Publications

BACKGROUND: Margin convergence (MC) and superior capsular reconstruction (SCR) are common treatment options for irreparable rotator cuff tears in younger patients, although they differ in associated costs and operative times. The purpose of this study was to compare range of motion, patient-reported outcomes (PROs), and reoperation rates following MC and SCR. We hypothesized superior outcomes after SCR relative to MC regarding functional outcomes, subjective measures, and reoperation rates.

METHODS: This was a multicenter retrospective review of 59 patients from 3 surgeons treating irreparable rotator cuff tears with either MC (n = 28) or SCR (n = 31) and minimum 1-year follow-up from 2014-2019. Visual analog scale (VAS) for pain, Subjective Shoulder Value (SSV), active forward flexion (FF), external rotation (ER), retear rate, and conversion rate to reverse shoulder arthroplasty were evaluated. t tests and χ2 tests were used for continuous and categorical variables, respectively (P < .05).

RESULTS: Baseline demographics, range of motion, and magnetic resonance imaging findings were similar between groups. Average follow-up was 31.5 months and 17.8 months for the MC and SCR groups, respectively (P < .001). The MC and SCR groups had similar postoperative FF (151° ± 26° vs. 142° ± 38°; P = .325) and ER (48° ± 12° vs. 46° ± 11°; P = .284), with both groups not improving significantly from their preoperative baselines. However, both cohorts demonstrated significant improvements in VAS score (MC: 7.3 to 2.5; SCR: 6.4 to 1.0) and SSV (MC: 54% to 82%; SCR: 38% to 87%). There were no significant differences in postoperative VAS scores, SSV, and rates of retear or rates of conversion to arthroplasty between the MC and SCR groups. In patients with preoperative pseudoparesis (FF < 90°), SCR (n = 9) resulted in greater postoperative FF than MC (n = 5) (141° ± 38° vs. 67° ± 24°; P = .002).

CONCLUSION: Both MC and SCR demonstrated excellent postoperative outcomes in the setting of massive irreparable rotator cuff tear, with significant improvements in PROs and no significant differences in range of motion. Specifically for patients with preoperative pseudoparesis, SCR was more effective in restoring forward elevation. Further long-term studies are needed to compare outcomes and establish appropriate indications.

PURPOSE: To determine the comparative accuracy and precision of routine magnetic resonance imaging (MRI) versus magnetic resonance (MR) arthrogram in measuring labral tear size as a function of time from a shoulder dislocation.

METHODS: We retrospectively evaluated consecutive patients who underwent primary arthroscopic stabilization between 2012 and 2021 in a single academic center. All patients completed a preoperative MRI or MR arthrogram of the shoulder within 60 days of injury and subsequently underwent arthroscopic repair within 6 months of imaging. Intraoperative labral tear size and location were used as standards for comparison. Three musculoskeletal radiologists independently interpreted tear extent using a clock-face convention. Accuracy and precision of MR labral tear measurements were defined based on location and size of the tear, respectively. Accuracy and precision were compared between MRI and MR arthrogram as a function of time from dislocation.

RESULTS: In total, 32 MRIs and 65 MR arthrograms (total n = 97) were assessed. Multivariate analysis demonstrated that intraoperative tear size, early imaging, and arthrogram status were associated with increased MR accuracy and precision (P < .05). Ordering surgeons preferred arthrogram for delayed imaging (P = .018). For routine MRI, error in accuracy increased by 3.4° per day and error in precision increased by 2.3° per day (P < .001) from time of injury. MR arthrogram, however, was not temporally influenced. Significant loss of accuracy and precision of MRI compared with MR arthrogram occurred at 2 weeks after an acute shoulder dislocation.

CONCLUSIONS: Compared with MR arthrogram, conventional MRI demonstrates time-dependent loss of accuracy and precision in determining shoulder labral tear extent after dislocation, with statistical divergence occurring at 2 weeks.

LEVEL OF EVIDENCE: Level II, retrospective radiographic diagnostic study.

BACKGROUND: The glenoid track concept for shoulder instability primarily describes the medial-lateral relationship between a Hill-Sachs lesion and the glenoid. However, the Hill-Sachs position in the craniocaudal dimension has not been thoroughly studied.

HYPOTHESIS: Hill-Sachs lesions with greater inferior extension are associated with increased risk of recurrent instability after primary arthroscopic Bankart repair.

STUDY DESIGN: Case-control study; Level of evidence, 3.

METHODS: The authors performed a retrospective analysis of patients with on-track Hill-Sachs lesions who underwent primary arthroscopic Bankart repair (without remplissage) between 2007 and 2019 and had a minimum 2-year follow-up. Recurrent instability was defined as recurrent dislocation or subluxation after the index procedure. The craniocaudal position of the Hill-Sachs lesion was measured against the midhumeral axis on sagittal magnetic resonance imaging (MRI) using either a Hill-Sachs bisecting line through the humeral head center (sagittal midpoint angle [SMA], a measure of Hill-Sachs craniocaudal position) or a line tangent to the inferior Hill-Sachs edge (lower-edge angle [LEA], a measure of Hill-Sachs caudal extension). Univariate and multivariate regression were used to determine the predictive value of both SMA and LEA for recurrent instability.

RESULTS: In total, 176 patients were included with a mean age of 20.6 years, mean follow-up of 5.9 years, and contact sport participation of 69.3%. Of these patients, 42 (23.9%) experienced recurrent instability (30 dislocations, 12 subluxations) at a mean time of 1.7 years after surgery. Recurrent instability was found to be significantly associated with LEA >90° (ie, Hill-Sachs lesions extending below the humeral head equator), with an OR of 3.29 (P = .022). SMA predicted recurrent instability to a lesser degree (OR, 2.22; P = .052). Post hoc evaluation demonstrated that LEA >90° predicted recurrent dislocations (subset of recurrent instability) with an OR of 4.80 (P = .003). LEA and SMA were found to be collinear with Hill-Sachs interval and distance to dislocation, suggesting that greater LEA and SMA proportionally reflect lesion severity in both the craniocaudal and medial-lateral dimensions.

CONCLUSION: Inferior extension of an otherwise on-track Hill-Sachs lesion is a highly predictive risk factor for recurrent instability after primary arthroscopic Bankart repair. Evaluation of Hill-Sachs extension below the humeral equator (inferior equatorial extension) on sagittal MRI is a clinically facile screening tool for higher-risk lesions with subcritical glenoid bone loss. This threshold for critical humeral bone loss may inform surgical stratification for procedures such as remplissage or other approaches for at-risk on-track lesions.

Cadaveric and computer simulations suggest lateral humeral offset (LHO) and humeral retroversion (HR) are associated with strength and range of motion (ROM) after reverse total shoulder arthroplasty (rTSA), butin vivodata is lacking. This study aimed to evaluate the effects of implant parameters (i.e. LHO and HR) on strength and ROM. LHO and HR were measured using pre-operative and post-operative computed tomography (CT) scans. Postoperative strength was measured across three planes of motion using a Biodex isokinetic dynamometer. Postoperative active and passive ROM during forward elevation, external rotation (ER), and internal rotation (IR) were assessed using a goniometer or spinal level. 30 rTSA patients (14 M, 16F, age: 71.8 ± 6.7yrs) participated with an average postoperative follow-up of 2.4 ± 1.1 years. Regarding strength, higher post-op LHO values were predictive of greater postoperative strength across all movements. However, lateralization of the implant beyond pre-op values (i.e. post-op LHO > pre-op LHO) was associated with poorer strength performance across all ranges of motion. Similar to strength outcomes, greater deviations from pre-op LHO was predictive of poorer IR ROM. Lastly, patients with minimal deviations in HR (post-op HR within 10° of pre-op HR) and minimal deviations in LHO (post-op LHO ≤ pre-op LHO) displayed the greatest postoperative ER ROM. Anatomic restoration of LHO combined with anatomic restoration of HR may be ideal for maximizing strength and ROM following rTSA. Overlateralization beyond anatomic may have negative consequences. Optimal implant lateralization and version may need to be individualized based on preoperative values.

Lacus, ultrices in ultrices tellus odio nunc urna. Massa aenean sed ipsum praesent enim. Porttitor iaculis augue pulvinar nam feugiat. Aliquam morbi ut ultricies elementum adipiscing purus proin semper. Viverra accumsan tempus, vitae auctor a. Dictumst cras dui sit feugiat. Enim nulla pulvinar urna sit eu placerat.

Nascetur nisi, tortor velit et ipsum commodo. Tempor massa, non suscipit at sagittis morbi eget euismod.

BACKGROUND: Superior capsular reconstruction (SCR) is a procedure purported to restore stability of the glenohumeral joint after an irreparable rotator cuff tear, but the in vivo behavior of the graft is unknown. Previous work has not evaluated the relationship between graft deformation, kinematics, and healing.

PURPOSE: To (1) determine regional graft elongation after SCR, (2) determine if graft elongation is related to graft healing, and (3) identify associations between graft elongation and changes in kinematics from presurgery to postsurgery.

STUDY DESIGN: Case series; Level of evidence, 4.

METHODS: Ten patients who underwent SCR performed abduction and shoulder rotation with the arm at 90° of humerothoracic abduction before and 1 year after surgery while biplane radiographs were collected at 50 images per second. Kinematics was determined with submillimeter accuracy by matching patient-specific digitally reconstructed radiographs of the humerus and scapula to the biplane radiographs using a validated volumetric tracking technique. Graft elongation was calculated using motion of the graft anchors that were identified on postoperative magnetic resonance imaging. Differences in elongation between anterior and posterior regions of the graft, as well as associations between graft elongation, graft healing, and kinematics, were analyzed.

RESULTS: Peak graft elongation ranged from a 3% decrease in the anterior region during rotation to up to a 171% increase in the anterior region during abduction and the posterior region during rotation. Grafts that were healed at both anterior anchors reached the intraoperative length at lower abduction angles (60°) than grafts that were not healed at 1 or both of the anterior anchors (87°) (P = .005). The posterior anchor graft origin to insertion distances were 2.1 mm farther apart after surgery compared with before surgery during both abduction and rotation.

CONCLUSION: SCR dermal allografts are stretched well beyond their intraoperative length in vivo. Graft healing appears to be associated with less graft elongation. The posterior portion of the SCR graft does not appear to improve glenohumeral joint stability 1 year after surgery. Improved clinical outcomes after dermal allograft SCR may be because of the spacer effect of the graft rather than improved glenohumeral joint stability 1 year after surgery.

BACKGROUND: Proximal humerus fractures (PHFs) occur most commonly in an elderly and osteoporotic population, but a considerable proportion of these injuries occur in relatively younger individuals. Differences in treatment principles and outcomes in this younger population remain poorly understood. The purpose of this review was to characterize the treatment algorithms and outcomes for patients less than or equal to 60 years of age with PHFs.

METHODS: A comprehensive search of the Medline, Pubmed, Embase, and Cochrane databases for articles published between January 2005 and December 2020 was performed in January 2021. Levels of evidence I-IV analyzing outcomes (patient reported outcomes and/or complications) following PHFs in adult patients less than or equal to 60 years of age were included. The search was carried out in accordance with the preferred reported items for systematic reviews and meta-analyses guidelines. The risk of bias 2 tool and methodological index for nonrandomized studies score were utilized to evaluate included studies.

RESULTS: Fourteen studies met the inclusion criteria (open reduction internal fixation: 5, intramedullary nail: 4, hemiarthroplasty: 2, nonoperative: 1, and reverse total shoulder arthroplasty (RTSA): 1). Seven studies reported differences in outcomes between younger and older patient populations, with three studies noting separate management algorithms for those 60 years of age or younger. There were no studies comparing different treatments modalities in those less than 60 years of age, and the lone study on RTSA did not include patient-reported outcomes.

CONCLUSION: Treatment algorithms and outcomes following PHFs in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. However, evidence-based treatment recommendations for this younger population are limited by the lack of studies comparing treatment modalities and the absence of patient-reported outcomes for individuals undergoing RTSA.

PURPOSE: To compare various nonarthroplasty treatment options for massive, irreparable rotator cuff tears, including allograft bridging/augmentation, debridement, partial repair, superior capsule reconstruction (SCR), subacromial balloon spacer, and tendon transfer.

METHODS: A comprehensive search was conducted through the PubMed, MEDLINE, and EMBASE databases for all articles pertaining to nonarthroplasty treatment options for irreparable rotator cuff tears. Inclusion criteria included manuscripts published between 2009 and 2020 with at least 1 year follow-up and Level I-IV evidence. Articles were separated into six groups: debridement, arthroscopic and open repair, allograft bridging/augmentation, SCR, subacromial balloon spacer, and tendon transfer. Data points included range of motion (external rotation, abduction, forward flexion, and internal rotation), visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, rate of revision surgery, and rate of conversion to arthroplasty.

RESULTS: A total of 83 studies and 3363 patients were included. All treatment options had statistically significant improvements in postoperative range of motion and patient-reported outcomes. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. The SCR subgroup had the greatest improvement in ASES scores postoperatively. The overall revision rate was 7.2% among all surgical options, with the allograft bridging/augmentation group having the lowest rate of revision at 0-8.3%. The overall rate of conversion to arthroplasty was 7.2%, with debridement having the greatest rate of conversion at 15.4%.

CONCLUSION: All six nonarthroplasty treatment options for irreparable rotator cuff tears resulted in statistically significant improvements in range of motion and patient-reported outcomes at 1 year follow-up or more, with low rates of revision and conversion to arthroplasty. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. However, these conclusions should be interpreted with caution due to the heterogeneous nature of the data, lack of prospective randomized control trials, and short-term follow-up. The findings of this study highlight the complexity of irreparable, massive rotator cuff tears, and the need for an individualized approach when treating these patients.

LEVEL OF EVIDENCE: Level IV.