Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery

Superior capsular reconstruction vs. Latissimus dorsi transfer for posterosuperior irreparable rotator cuff tears without arthritic change: Mid-term Crossover study

Background

Latissimus dorsi transfer (LDT) is a well-known tendon-transfer technique with long-term clinical follow-up results, whereas superior capsular reconstruction (SCR) has recently emerged as a treatment option for posterosuperior irreparable rotator cuff tears (PSIRCTs). However, only a few small short-term comparative studies have evaluated SCR and LDT. We evaluated the clinical and radiological outcomes of SCR and LDT in PSIRCTs without arthritic changes.

Methods

This retrospective clinical comparative study evaluated patients who underwent SCR or LDT for PSIRCTs and had a mid-term (at least 5 years) follow-up. 28 patients in the SCR group and 31 in the LDT group were included. The visual analog scale (VAS) score, patient-reported clinical outcome scores, and active range of motion (aROM) were used for assessing clinical outcomes. The radiologic outcomes including progression of glenohumeral osteoarthritis and graft integrity were evaluated using Hamada grade and Sugaya classification, respectively.

Results

Significant improvements in VAS scores and aROM were observed in both groups. The LDT group reported significant improvements in all patient-reported outcome scores. However, SCR group showed no significant improvement in patient-reported outcome scores except for American Shoulder and Elbow Surgeons score. In radiologic outcomes, AHD was significantly decreased, and the Hamada grade was significantly increased postoperatively in both groups. Moreover, the progression of arthritic change was significantly greater in the LDT group, while the rate of graft retear was markedly higher in the SCR group.

Conclusions

Although both SCR and LDT improved clinical outcomes, LDT was superior to SCR in terms of patient-reported outcome scores. However, progression of osteoarthritis is more common in LDT whereas graft retear is more common in SCR. Therefore, SCR or LDT could be considered as a surgical treatment in PSIRCTs without arthritic changes, but clinical outcomes as well as complications (osteoarthritis and graft re-tear) must be considered.

Level of evidence

Level of evidence, III.

Adding Teres Major Transfer to Arthroscopic-Assisted Posterior Latissimus Dorsi Transfer Provides Superior Outcomes for Posterosuperior Irreparable Rotator Cuff Tears

PURPOSE

The purpose of this study is to compare the clinical and radiologic outcomes of arthroscopic-assisted latissimus dorsi transfer (LDT) and arthroscopic-assisted posterior latissimus dorsi and teres major (pLDTM) transfer in posterosuperior irreparable rotator cuff tears (PSIRCTs).

METHODS

We retrospectively reviewed patients with PSIRCTs who underwent LDT or pLDTM transfer between January 2017 and December 2020 and were followed for at least 2 years. Clinical outcomes were evaluated based on pain, patient-reported outcome scores, active range of motion (aROM) and aROM strength. Radiological outcomes were evaluated by arthritic changes of glenohumeral joints and transferred tendon integrity. The acromiohumeral distance and Hamada classification were evaluated on the true anteroposterior radiograph. Hamada grades 3, 4, 5 at last follow-up indicated the progression of osteoarthritis (OA). Transferred tendon integrity was evaluated with Sugaya classification on MRI.

RESULTS

In LDT group and pLDTM group, 48 and 32 patients were included, respectively, with no difference in the mean follow-up period (LDT group, 59.0±9.6 (range, 48-72) months vs pLDTM group, 56.5±8.4 (range, 42-72) months, p=0.697) Significant improved clinical outcomes were observed in both groups. The postoperative activities of daily living requiring active external rotation (ADLER) score (20.2±6.7 vs 24.5±6.3, p=0.002), achievement of MCID for ADLER score (56.3% vs 81.3%, p=0.029), postoperative ER (33.8±5.4 vs 39.4±5.9, p=0.043), and postoperative ER strength (19.5±4.6 vs 23.5±4.1, p<0.001) were significantly better in pLDTM group. Regarding radiologic outcomes, the rate of OA progression (42.3% vs 18.8%, p=0.049) was significantly higher in LDT group. There was no significant difference in transferred tendon re-tear rate between the two groups.

CONCLUSION

At medium term follow-up, pLDTM transfer for PSIRCTs results in improved ADLER scores, ER, and ER strength with slower OA progression compared to LDT.

LEVEL OF STUDY

Level III.

No Short-Term Effects of Acromioclavicular Joint Augmentation in Acute Acromioclavicular Joint Stabilization Surgery: A Randomized Controlled Clinical Trial on 70 Patients

Background: Optimal treatment for high-grade acromioclavicular (AC) joint dislocations is still not unanimous. Improving horizontal AC stability has been emphasized in recent years. Biomechanical studies and computer simulations have demonstrated that adequate horizontal stability could be restored with an additional AC fixation. We aim to prospectively investigate if AC augmentation leads to better clinical and radiological results. Methods: A total of 70 patients with a mean (± SD) age of 42 ± 11 years with acute AC joint dislocation Rockwood type IIIb and V were prospectively randomized into two equal groups. All patients underwent arthroscopically assisted stabilization using a double coracoclavicular (CC) suspensory system. Group N (No-augmentation group) had no additional fixation across the AC joint, while group T (tape-augmentation group) had additional fixation with tape. Patients were evaluated at 3, 6, and 12 months postoperatively. Primary clinical outcome measures included the Constant-Murley score and the Specific AC Score (SACS). Secondary outcome measures included the Subjective Shoulder Value (SSV), the Simple Shoulder Test (SST), the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure, and the AC Joint Instability (ACJI) Score. Horizontal stability was radiologically measured with overlapping length (OL) and overlapping area (OA). Vertical alignment was measured with the CC distance. All radiological measurements were compared to the uninjured side and expressed in percentages as relative values. Results: There were no significant differences found between groups regarding the Constant score (p = 0.664), SACS (p = 0.518), or any other outcome measure at the one-year follow-up. Pain level (p = 0.635) and strength (p = 0.217) at the one-year mark also showed no significant differences. Clinical drawer testing for residual horizontal instability was non-significant (p = 0.061), but showed a tendency for a more stable AC joint in group T. The CC distance was smaller in group T at 6 and 12 months (p = 0.047 and p = 0.046, respectively). A two-way mixed factorial ANOVA test showed significantly lower CC differences for group T (p = 0.032); however, the gradual increase in CC distance was similar for both groups over time (p = 0.869). No significant differences were found in OL (p = 0.619) or OA (p = 0.236). Conclusions: The results of our study show that both CC stabilization with the double suspensory system alone and with additional AC fixation are effective surgical treatment options for acute AC joint dislocations, without any important clinical differences. CC distance similarly increased over one year in both groups but was better retained in the AC-augmented group, which showed a tendency toward a more stable fixation.

Outcomes of Latissimus Dorsi Tendon Transfer for Posterosuperior Massive Rotator Cuff Tears and Failed Rotator Cuff Repair

BACKGROUND

Although a recent systematic review found that latissimus dorsi tendon transfer (LDTT) granted comparable outcomes in shoulders with massive rotator cuff tears (mRCTs) versus those with failed rotator cuff repair (RCR), some studies found inferior outcomes after failed RCR.

PURPOSE

To compare the clinical and functional outcomes, as well as complication rates, of patients who underwent LDTT for the treatment of mRCTs or failed RCR.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors retrieved the records of a consecutive series of 258 patients (n = 150, arthroscopically assisted; n = 108, all-arthroscopic) who underwent LDTT by the same senior surgeon between 2014 and 2021. A total of 136 patients underwent LDTT for irreparable posterosuperior mRCTs without previous RCR, whereas 122 underwent LDTT for failed RCR. All intra- and postoperative complications were noted, as well as whether patients required conversion to reverse shoulder arthroplasty. At a minimum follow-up of 24 months, an independent observer collected the range of motion and clinical scores including the Constant score, Subjective Shoulder Value (SSV), Simple Shoulder Test, Activities of Daily Living requiring Active External Rotation (ADLER) score, American Shoulder and Elbow Surgeons (ASES) score, and pain on visual analog scale (VAS).

RESULTS

At a minimum follow-up of 2 years after LDTT, no significant differences were noted between shoulders treated for mRCTs versus failed RCR in terms of rates of conversion to reverse shoulder arthroplasty (3% vs 3%, respectively), LDTT tear (8% vs 10%), or other complications (10% vs 11%). Shoulders treated for mRCTs had significantly better outcomes than those treated for failed RCR, in terms of ASES score (75.8 ± 19.5 vs 65.6 ± 24.2, respectively; P = .002), ADLER score (26.3 ± 5.7 vs 24.8 ± 6.4; P = .003), SSV (72.3 ± 19.8 vs 63.6 ± 24.0; P = .004), and pain on VAS (1.8 ± 2.0 vs 2.7 ± 2.7; P = .018) but not in terms of Constant score (69.2 ± 13.4 vs 66.4 ± 16.3, P = .520) and range of motion (P = .360-.700). Multivariable analysis confirmed that ASES score was worse for shoulders with previous RCR (β, -9.90; 95% CI, -15.94 to 3.86; P = .001) and that Constant score was better for men (β, 3.91; 95% CI, -0.06 to 7.88; P = .044).

CONCLUSION

At a minimum follow-up of 24 months, LDTT granted better outcomes for the treatment of mRCTs than of failed RCR, notably in terms of activity and pain.

Constant-Murley score categorization to assess outcomes after reverse shoulder arthroplasty following complex proximal humeral fracture

BACKGROUND

The Constant-Murley (CM) score is considered the gold standard of shoulder scoring systems. However, it does not include scoring categorization, and in some acute traumatic processes, a paired comparative analysis is not feasible. The purpose of this study was to determine cutoff values for the CM score that indicate a specific category on the outcome score following reverse total shoulder arthroplasty (rTSA) for fracture.

METHODS

Consecutive patients with complex proximal humeral fracture who underwent rTSA from 2010 to 2022, were included in the study. Two years of postoperative follow-up was required. Postoperative clinical evaluations were conducted using the CM and University of California, Los Angeles (UCLA) scores. The correlation between CM and UCLA scores was analyzed. Then, the receiver-operating characteristic (ROC) curve was utilized to determine the cutoff points in CM scores that most effectively distinguished between categories. The UCLA categories were used as the external criterion.

RESULTS

132 patients completed the evaluations at the 2-year follow-up. Among them, 112 (84.8 %) were females and 20 (15.2 %) were males, with a mean age of 73.5 years. The UCLA score showed a strong correlation with the CM score (r = 0.936; 95% CI 0.911-0.954; p = 0.000). For the CM score, the cutoff for an excellent outcome was 67.5 (AUC 0.963, 95% CI 0.925-1.000), 56.5 (AUC 0.920, 95% CI 0.872-0.969) for good, 41.5 (AUC 0.701, 95% CI 0.617-0.784) for fair, and <41.5 (AUC 0.965, 95% CI 0.939-0.990) for poor.

DISCUSSION

According to the cut-off values in the CM score used to categorize the outcomes after rTSA in proximal humeral fractures, an excellent outcome was considered a score equal to or greater than 68, good between 57 and 67 points, fair between 41 and 56 points, and a poor outcome with a score equal to or less than 40 points.

LEVEL OF EVIDENCE

III.

Efficacy of reverse shoulder arthroplasty compared with superior capsular reconstruction in patients with posterosuperior irreparable rotator cuff tears without arthritis: a propensity score matching study

INTRODUCTION

Superior capsular reconstruction (SCR) and reverse shoulder arthroplasty (RSA) are viable treatment options for active patients with posterosuperior irreparable rotator cuff tears (PSIRCTs). In this study, we aimed to compare the clinical outcomes and recovery of muscle strength following RSA and SCR in PSIRCTs patients without arthritis.

MATERIAL AND METHODS

Fifteen patients were included in the RSA and SCR groups using propensity score matching, which was performed to minimize selection bias among the surgical treatments, RSA or SCR. Clinical outcomes were evaluated based on the degree of pain and patient-reported clinical scores. Functional outcomes were assessed with active range of motion of the shoulder and muscle strength. Radiological outcomes were assessed with acromiohumeral distance and Hamada grade.

RESULTS

Both groups showed significant improvement in postoperative clinical and functional outcomes; there was no significant difference between the groups. However, mean improvement in the Constant score, American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) score, forward elevation, and abduction was significantly better in the RSA group. Moreover, the achievement of MCID for ASES score and UCLA score was significantly better in the RSA group (p = 0.001 and 0.009, respectively). Although the muscle strength was improved following SCR or RSA, it was not statistically significant. In the SCR group, five patients (30%) showed postoperative progression of arthritic change, and seven patients (46.7%) had graft re-tear.

CONCLUSIONS

Our findings suggest that RSA provides greater improvements in functional outcomes and a higher likelihood of achieving MCID compared to SCR in patients with PSIRCTs without arthritis. However, given the small sample size, the potential for indication bias, and the high variability in patient selection criteria, these results should be interpreted with caution.

LEVEL OF EVIDENCE

III.

An additional rehabilitation program to improve postoperative outcomes in patients with rotator cuff tear and scapular dyskinesis: a propensity score-matched study

BACKGROUND

General scapular exercises have been included in traditional postoperative rehabilitation for rotator cuff tears, but patients with concomitant scapular dyskinesia do not have identical scapular muscle imbalances, and general scapular exercises make it difficult to improve scapular movement. We hypothesized that identifying weak scapular muscle groups and strengthening training would improve scapular movement.

METHODS

A total of 60 rotator cuff tear patients with scapular dyskinesia were included in the study, 20 in the experimental group and 40 in the control group. Patients in the control group received traditional rehabilitation following rotator cuff repair, while patients in the experimental group performed additional selective scapular muscle rehabilitation exercises. Constant-Murley Score (CMS), shoulder mobility, VAS scores, SF-12 scores, and scapular motion were assessed in both groups at 16 weeks postoperatively.

RESULTS

At 16-week follow-up, the experimental group showed better CMS (87.2 ± 4.4 vs. 83.9 ± 4.8) and shoulder anteflexion (137 ± 13.0 vs. 127.9 ± 12.2°) and abduction mobility (133.1 ± 15.4 vs. 121.4 ± 13.8°) compared to the control group. The experimental group had better improvements in scapular upward rotation (42.8 ± 11.7 vs. 35.3 ± 9.6°) and anterior tilt (12.9 ± 4.2 vs. 6.4 ± 2.0°) during shoulder anteflexion versus the control group. During shoulder abduction, the experimental group had better improvements in scapular anterior tilt (12.8 ± 3.3 vs. 9.1 ± 3.0°) versus the control group.

CONCLUSIONS

This study provides an additional exercise program targeting the scapular muscle groups for postoperative rehabilitation in rotator cuff tear patients with scapular dyskinesis. By identifying imbalanced muscles through electromyographic testing, and performing selective muscle strengthening exercises, better shoulder mobility and scapular motion performance can be achieved.

TRIAL REGISTRATION

(Chinese Clinical Trial Registry ( https://www.chictr.org.cn ), ChiCTR2400087465, July 29, 2024, prospectively registered.).

Arthroscopic Bankart Repair Versus Arthroscopic Latarjet for Anterior Shoulder Instability: A Matched-Pair Long-Term Follow-up Study

Background

The Bankart and the Latarjet procedures are 2 of the most commonly utilized surgical techniques to treat anterior shoulder instability. However, the long-term outcomes after these procedures remain unclear, and there is not enough information regarding arthroscopic Latarjet.

Purpose

To analyze long-term outcomes of patients with anterior glenohumeral instability managed with an arthroscopic Bankart or Latarjet procedure.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent an arthroscopic Latarjet were matched-paired in a 1:1 ratio with patients who underwent an arthroscopic Bankart procedure at a single institution between 2007 and 2012. Recurrence at the time of follow-up as well as intraoperative and postoperative complications were recorded and compared between the 2 groups. Postoperative status was assessed at the final follow-up using the Rowe score, the Western Ontario Shoulder Instability Index (WOSI), the Subjective Shoulder Value, and the return-to-sport rate.

Results

A total of 80 patients, 40 patients in each group, were included (overall mean age, 26.5 ± 15.4 years). The mean follow-up was 13.2 years (range, 10-17 years). The recurrence rate was significantly higher in the Bankart group compared with the Latarjet group (35% vs 10%, respectively; P = .009). The mean estimate for the cumulative proportion of stable shoulders at 15-year follow-up was 64.4% in the Bankart group and 89.6% in the Latarjet group (P = .008). Revision surgery because of instability was necessary in 8 (20%) patients in the Bankart group and 2 (5%) in the Latarjet group (P = .41). There was no significant group difference in complication rate (15% in the Bankart group vs 17.5% in the Latarjet group; P = .48). The WOSI score was significantly better in patients treated with arthroscopic Latarjet (P = .004). More than half of the patients were able to completely return to their previous sport (52.5%), with no significant difference between groups.

Conclusion

Arthroscopic Latarjet was associated with a significantly lower recurrence rate and better postoperative WOSI score and sports activity level at long-term follow-up compared with arthroscopic Bankart, without any greater risk of complications.

A Systematic Review of Functional Donor-Site Morbidity in Scapular Bone Transfer

BACKGROUND

Despite the general perception of minimal donor-site morbidity associated with scapular free flaps, the surgical harvest of scapular bone and subsequent reattachment of parascapular muscle have the potential to compromise postoperative shoulder function. A comprehensive assessment of functional impairment remains undocumented in the literature. Therefore, this systematic review was conducted to thoroughly explore both subjective and objective donor-site morbidity following free flap surgery.

METHODS

Searches were conducted on PubMed, Embase, and CENTRAL to locate articles addressing functional donor-site morbidity after the transfer of scapular bone. Qualifying articles reported scapular free flaps which utilized bone, including lateral border, medial border, and scapular tip. Each measured donor-site morbidity using at least one of these measures: Constant-Murley score (CM), Disabilities of Arm, Shoulder, and Hand questionnaire (DASH), shoulder range of motion (ROM), and shoulder strength.

RESULTS

The search culminated in 16 eligible studies, incorporating data from 316 cases. The CM was employed in five studies, yielding mean values from 60.6 to 95, while the DASH was utilized in nine studies, with means ranging from 10.44 to 46.7. Compared to normative values, these CM and DASH scores reflected negligible to mild impairment in shoulder function. Additional evaluations of shoulder ROM, conducted in four studies, revealed modest yet statistically significant reductions in flexion, abduction, and external rotation. Three studies measuring shoulder strength reported associated mild weakening of these motions.

CONCLUSIONS

This systematic review enables healthcare providers to characterize the probable scope of shoulder dysfunction following scapular bone harvest. Patient-reported outcomes imply a high tolerance for the procedure, while objective measures denote the potential for substantial restoration of shoulder function approaching preoperative levels. To augment the understanding of functional recovery, future research should incorporate a comparative analysis of preoperative and postoperative functional metrics for each subject.

Spin is Prevalent in the Abstracts of Systematic Reviews and Meta-Analyses Comparing Biceps Tenodesis and Tenotomy Outcomes

PURPOSE

This study aimed to assess the presence of spin in abstracts of systematic reviews and meta-analyses comparing biceps tenodesis and tenotomy outcomes and to explore associations between spin and specific study characteristics.

METHODS

Using Web of Science and PubMed databases, systematic reviews and meta-analyses comparing outcomes of biceps tenodesis and tenotomy were identified. Abstracts were evaluated for the nine most severe types of spin as described by Yavchitz et al. and appraised using the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Study characteristics were extracted, including adherence to PRISMA guidelines,funding status, and impact metrics such as journal impact factor, total number of citations, and average annual citations.

RESULTS

A total of 16 studies were included, with spin detected in 81.3% of the abstracts. Type three spin was the most frequent (56.3%), followed by types six (43.8%), five (37.5%), nine (25.0%), two (12.5%), and four (6.3%). Spin types one, seven, and eight were not observed. AMSTAR 2 appraised 75% of the studies as 'low' quality, and 25% as 'critically low' quality. All studies had at least one critical flaw, with item 15 (investigation of publication bias) being the most frequent (93.8%). A strong positive correlation was found between AMSTAR 2 scores and citation counts (r = 0.821, p < 0.001). Studies with a higher number of spin incidents were significantly more likely to have an associated letter to the editor (p = 0.0043).

CONCLUSION

Severe types of spin were prevalent in the abstracts of systematic reviews and meta-analyses comparing biceps tenodesis and tenotomy. Data analysis suggests that abstracts with a higher incidence of spin tend to attract more scrutiny from the academic community. These findings highlight the need to enhance reporting standards.

Early versus delayed mobilisation for non-surgically treated proximal humerus fractures: a systematic review and meta-analysis of randomised trials

BACKGROUND

Proximal humerus fractures (PHFs) are among the commonest bony injuries and the majority of them can be managed non-surgically. The aim of our systematic review and meta-analysis was to compare the effectiveness and safety of early versus delayed mobilisation in conservatively treated PHFs.

METHODS

A literature search was performed in Medline, EMBASE and clinicaltrials.gov in Januray 2025 aiming to identify all randomised controlled trials (RCTs) comparing early versus delayed (conventional) mobilisation as part of the non-surgical management of PHFs. Primary outcomes were patient-reported function and pain at short-term (3 months), mid-term (6 months) and long-term (12 months) follow-up, and secondary outcomes included secondary fracture displacement and total complications. Meta-analyses produced mean differences (MDs) or standardised MDs (SMDs) for continuous outcomes and odds ratios (ORs) for binary outcomes, with 95% confidence intervals (CI). Certainty of evidence was assessed using the GRADE tool. Recommendations for clinical practice were given only based on results of high or moderate certainty of evidence.

RESULTS

Six (6) RCTs were included that compared early mobilisation (EM; within one week from injury) to delayed mobilisation (DM; after 3 or 4 weeks of immobilisation) with a total of 470 patients with PHFs. There were no differences in patient-reported function (combined or Constant score) or pain between the EM and DM groups at any follow-up time points except for a significant difference in combined function scores favouring EM [SMD 0.4 CI (0.1,0.7), P = 0.006] at 3 months follow-up. There were no significant differences in the incidence of secondary fracture displacement and total complications in the two groups [OR 3.5 CI (0.7,18.2), P > 0.05, and OR 1.2 CI (0.5,2.9), P > 0.05, respectively]. All results were based on moderate or high strength of evidence. The most significant limitations of our study were the small number of pooled studies and inability to perform subgroup analyses for specific fracture types.

CONCLUSIONS

Our meta-analysis of RCTs showed that commencement of mobilisation within one week from injury for non-surgically managed PHFs is safe and may confer short-term functional benefits compared to delayed mobilisation.

Rate of graft retear is higher in over-the-top superior capsular reconstruction for massive posterosuperior rotator cuff tears with subscapularis tear

PURPOSE

To compare side-to-side superior capsular reconstruction (SCR) with over-the-top SCR in terms of functional outcomes, pain relief and allograft survival rates.

METHODS

Patients who had undergone arthroscopic dermal allograft SCR for massive irreparable rotator cuff tears and clinical follow-up for ≥2 years were recruited. All patients underwent postoperative assessment with routine radiographic analysis for acromiohumeral distances, ultrasound imaging 1 and 3 months after SCR and magnetic resonance imaging (MRI) at least 12 months after SCR. The outcome measures were visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES), Constant and Single Assessment Numeric Evaluation (SANE) scores.

RESULTS

SCR was performed in 56 patients including side-to-side SCR in 32 and over-the-top SCR in 24. Postoperative MRI showed that the grafts were intact in 46 patients (82.1%; 26 who underwent side-to-side SCR and 20 who underwent over-the-top SCR). The proportion of nonhealing grafts in the over-the-top group was significantly higher with concomitant subscapularis tears (60% vs. 5.3%; p = 0.02). VAS scores and functional outcomes improved postoperatively in both groups and postoperative VAS (1.4 vs. 1.7; n.s.), Constant (74.8 vs. 76.0; n.s.), mean ASES (87.4 vs. 89.1; n.s.) and mean SANE (81.7 vs. 84.3; n.s.) scores did not differ significantly.

CONCLUSION

For massive rotator cuff tears, over-the-top and side-to-side SCR achieve similar pain relief and functional improvement, and the rate of healing allografts is high. However, over-the-top SCR is not recommended for massive posterosuperior rotator cuff tears with repairable subscapularis tendon tears due to a higher nonhealing rate.

LEVEL OF EVIDENCE

Level III.

Preoperative subjective assessment of disease-specific quality of life significantly influenced the likelihood of achieving the minimal clinically important difference after surgical stabilization for recurrent lateral patellar instability

PURPOSE

To evaluate which factors exert a predictive value for not reaching the minimal clinically important difference (MCID) in patients who underwent a tailored operative treatment for recurrent lateral patellar dislocation (RLPD).

METHODS

A total of 237 patients (male/female 71/166; 22.4 ± 6.8 years) were included. The Banff Patellofemoral Instability Instrument 2.0 (BPII 2.0) and subjective rating of knee function and pain (numeric analogue scale [NAS]; 0-10) were used to evaluate patients' outcomes from pre- to postoperatively. Gender, age at the time of surgery, body mass index (BMI), nicotine abuse, psychiatric diseases, cartilage status and pathoanatomic risk factors were evaluated as potential predictors for achieving the MCID using univariate logistic regression analysis.

RESULTS

The MCID for the BPII 2.0 was calculated at 9.5 points. Although the BPII 2.0 and NAS for knee function and pain improved significantly in the total cohort from pre- to postoperatively (all p < 0.001), 29 patients did not reach the MCID at the final follow-up. The analysis yielded that only the preoperative NAS for function and BPII 2.0 score values were significant predictors for reaching the MCID postoperatively. The optimal threshold was calculated at 7 (NAS function) and 65.2 points (BPII 2.0). Age at the time of surgery should be considered for patients with a preoperative BPII 2.0 score >62.5.

CONCLUSION

The probability of reaching BPII 2.0 MCID postoperatively depends only on the preoperative BPII 2.0 value and subjective rating of knee function, as well as age at the time of surgery for patients undergoing surgical treatment of RLPD. Here, presented results can assist clinicians in advising and presenting patients with potential outcomes following treatment for this often complex and multifactorial pathology.

LEVEL OF EVIDENCE

Level III.

Functional Improvements by Controlled Suture Tension in Arthroscopic Rotator Cuff Repair

Background

Although a certain degree of tension in bridging sutures is required for proper tendon healing following suture-bridge rotator cuff repair, excessive suture tension may be detrimental to tendon healing. This study aimed to investigate the effects of bridging suture tension on clinical outcomes and tendon healing. We hypothesized that fixed, low tension of the bridging sutures would improve the tendon healing rate and clinical outcomes compared with maximum manual tensioning.

Methods

A group of 39 patients with a rotator cuff tear were treated with arthroscopic suture-bridge rotator cuff repair, in which the bridging sutures were uniformly tensioned to 20 N (group A). A separate group of 37 patients was treated with the same suture construct, but the sutures were tensioned by maximum manual pulling (mean tension, 36.1 N; group B). The visual analog scale (VAS) score for pain, active anterior elevation, external and internal rotation, and Constant score were compared between the groups preoperatively and at 1, 3, and 6 months and 1 and 2 years postoperatively. Anatomical healing was evaluated using magnetic resonance imaging (MRI) at 1 year after surgery.

Results

At 6 months postoperatively, all clinical values had improved in both groups. The Constant score (p < 0.001), VAS pain score (p < 0.001), and anterior elevation (p = 0.004) were significantly better in group A than in group B. Two years postoperatively, there was no significant difference between groups A and B in the Constant score (p = 0.847), VAS pain score (p = 0.991), and anterior elevation (p = 0.855). Group A demonstrated a significantly lower retear rate (3 of 39, 7.7%) than group B (9 of 37, 24.3%) (p = 0.0467).

Conclusions

Double-row suture-bridge repairs with fixed, low tension led to superior clinical outcomes at 6 months and a superior tendon healing rate at 1 year compared with repairs with higher suture tension. However, the clinical outcomes did not differ significantly at 2 years between the 2 tensioning methods.

Level of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparing Conventional Double-Row With Transosseous Equivalent Suture Bridge Fixation in Arthroscopic Rotator Cuff Repairs: A Multicenter Retrospective Cohort Study

Background

Biomechanical studies have shown that the transosseous equivalent suture bridge (TOE-SB) rotator cuff repair technique improves contact areas and pressure between the tendon and footprint, which may facilitate healing. However, few studies have directly compared its outcomes with traditional double-row (DR) repair.

Purpose/Hypothesis

The primary objectives of this study were to (1) compare the functional outcomes of DR with TOE-SB fixation in patients undergoing arthroscopic rotator cuff repairs and (2) compare healing rates between the 2 groups and investigate whether any factors were associated with healing. It was hypothesized that arthroscopic rotator cuff repair using DR repair would demonstrate no difference in disease-specific quality of life, patient-reported outcomes, or healing rates compared with TOE-SB repair.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a cohort study conducted as a subanalysis of 2 larger randomized controlled trials. Patients ≥18 years old with degenerative rotator cuff tears confirmed by magnetic resonance imaging who had persistent symptoms of pain and functional impairment after 6 months of nonoperative management were enrolled in prospective randomized controlled trials and underwent either a traditional DR repair or a TOE-SB rotator cuff repair. Functional outcomes were assessed using the Western Ontario Rotator Cuff index, the American Shoulder and Elbow Surgeons score, and the Constant score at baseline and 3, 6, 12, and 24 months postoperatively. Healing rates were determined using ultrasound at 24 months postoperatively.

Results

A total of 184 patients were included in this study; 34 patients underwent conventional DR repair and 150 underwent TOE-SB repair. Postoperative changes in the outcome measures from baseline were statistically significant for all outcomes in both groups (P < .0001). No statistically significant differences were found between outcomes at any of the follow-up times, except a significant difference in the Constant score at 24 months in favor of the DR group (mean ± SE, 80.5 ± 1.1 [95% CI, 78.4-82.7]) and TOE-SB and DR, respectively (mean ± SE, 85.7 ± 2.2 [95% CI, 81.2-90.1]) (P = .041). Healing rates were 77.8% for DR and 83% for TOE-SB (odds ratio, 1.34 [95% CI, 0.53-3.38]; P = .53). Multivariable regression analysis showed a positive correlation between nonhealing rates and the rotator cuff tear size in the sagittal plane (odds ratio, 1.97 (95% CI, 1.02-3.78); P = .042).

Conclusion

No difference was found between DR and TOE-SB rotator cuff repair in the Western Ontario Rotator Cuff index, the American Shoulder and Elbow Surgeons score, Constant strength subscore, or the healing rate. The Constant score at the 24-month follow-up favored DR repair but did not reach the minimal clinically important difference. An association was found between higher healing rates and smaller sagittal plane tear sizes.

Outcomes of arthroscopic coracoclavicular management for acromioclavicular joint injuries: A systematic review

Introduction

Various surgical procedures for coracoclavicular (CC) ligament repair have been described for symptomatic acromioclavicular joint dislocations, with none emerging as a clear gold standard. There has been increased interest in arthroscopic approaches. This systematic review evaluates clinical outcomes after arthroscopic surgeries used to treat chronic and acute AC joint dislocations.

Methods

We searched three databases (PubMed, EMBASE, and OVID [MEDLINE]) from database inception to December 20, 2022. Studies were included if they met the following criteria: studies evaluating humans, English language studies, level of evidence I to IV, and studies investigating clinical outcomes in patients following arthroscopic surgery for coracoclavicular ligament reconstruction. Studies on open reconstruction techniques only were excluded. Primary outcomes included function/pain scores, coracoclavicular distances, complications, and revision rates.

Results

Fifty-two studies were included. In 33 studies, postoperative Constant-Murley scores ranged from 82.8 to 99 points. Postoperative VAS scores ranged from 0.3 to 4.1 in 16 studies. In 46 studies, revision rates ranged from 0 % to 44.4 %. We did not observe a difference in revision rates between chronic and acute cases (P = 0.268). Complications were more common in chronic than acute cases (25.5 % vs. 16.4 %; P < 0.001).

Conclusions

Arthroscopic surgery for chronic and acute CC ligament injuries exceeds the MCID and PASS for several outcomes, with low failure rates. Arthroscopic CC reconstruction is a safe and effective alternative for chronic AC joint dislocations.

Level of evidence

IV (Systematic Review of Level I-IV Studies).

One-Year Follow-Up Is Sufficient Time for Patient-Reported Outcomes Following Rotator Cuff Repair: A Systematic Review and Meta-analysis

PURPOSE

To perform a systematic review to determine whether there were clinically significant differences in patient-reported outcome measures from 1- to 2-year follow-up following rotator cuff repair (RCR).

METHODS

A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs) reporting on patient-reported outcomes at the 1- and 2-year follow-up following RCR were included. Meta-analysis was performed, and a P value <.05 was considered statistically significant.

RESULTS

Nineteen randomized controlled trials with 2,110 patients were included. There was a statistically significant difference in American Shoulder and Elbow Score score between the 1-year (mean, 87) and 2-year (mean, 89.4) follow-up (P < .00001), but this did not reach the minimal clinically important difference. There was no statistically significant difference in visual analog scale pain score between the 1-year (mean, 0.9) and 2-year (mean, 0.8) follow-up (P = .10). Additionally, the differences in Simple Shoulder Test; University of California, Los Angeles score; Constant score; and Western Ontario Rotator Cuff index between the 1- and 2-year follow-up did not reach the minimal clinically important difference despite statistically significant differences.

CONCLUSIONS

Statistically significant differences in patient-reported outcomes are reported between the 1- and 2-year follow-up points, although these differences fail to reach minimally clinically important differences. As a result, the 1-year follow-up may be sufficient to determine clinical outcomes from RCR.

STUDY DESIGN

Level II, systematic review of randomized control trials.

Good clinical outcomes and low recurrence rate in patients undergoing arthroscopic revision Latarjet for failed arthroscopic Bankart repair

BACKGROUND

The role of arthroscopic Latarjet stabilization after failed arthroscopic Bankart repair has yet to be definitively established and merits further investigation.

OBJECTIVE

To assess clinical and radiological outcomes after arthroscopic Latarjet stabilization as a revision procedure for failed Bankart repair, as well as the return to athletic activity and complication rates.

METHODS

Between 2009 and 2020, patients with a previous failed arthroscopic Bankart repair who were treated with an arthroscopic Latarjet were retrospectively evaluated. Clinical outcomes at a minimum of 24 months postoperatively included the Rowe score, Western Ontario Shoulder Instability Index, Constant-Murley Shoulder Outcome score, and Single Assessment Numeric Evaluation. Dislocations, subluxations, complications, pre- and postoperative levels of activity, and degree of osteoarthritis were also assessed.

RESULTS

A total of 77 patients, with a mean age at revision surgery of 31.2 ± 9.1 years and with either 1 (n = 59), 2 (n = 13), or 3 (n = 4) previous arthroscopic stabilizations, who underwent revision surgery using an arthroscopic Latarjet procedure were studied. Postoperatively, the mean Rowe and Constant-Murley Shoulder Outcome scores increased from 41.8 ± 16 to 90.7 ± 14.3 (P < .001) and from 50.5 ± 13.8 to 90.5 ± 10.3 (P < .001), respectively. Western Ontario Shoulder Instability Index decreased from 1247 ± 367.6 to 548.9 ± 363 at the final follow-up (P < .001). After a mean follow-up of 39.6 ± 23.1 months, 64 shoulders (83.1%) were subjectively graded as good to excellent using the Single Assessment Numeric Evaluation score. Grade 1, 2, and 3 osteoarthritis, according to Ogawa et al, was found in 18 (23.4%), 6 (7.8%), and 3 (3.9%) shoulders, respectively. Six (7.8%) dislocations after revision surgery were reported. In 4 failed cases, an Eden-Hybinette procedure was conducted, and in the remaining 2 patients, an arthroscopic extra-articular anterior capsular reinforcement was performed. A significantly decreased level of athletic activity was observed postoperatively (P = .01).

CONCLUSIONS

Arthroscopic Latarjet for the revision of failed arthroscopic Bankart repair provides satisfactory patient-reported subjective outcomes with a low rate of recurrences and complications. However, a decreased level of athletic activity is expected.

Bioinductive patch as an augmentation for rotator cuff repair, a systematic review and meta-analysis

BACKGROUND

Rotator cuff tears are a prevalent cause of shoulder pain and dysfunction. For those who fail initial conservative treatment, operative intervention can be pursued. A significant and common complication after rotator cuff repair (RCR) is retearing or nonhealing. Numerous augmentations to traditional suture RCR have been studied. Of these, the Smith + Nephew Regeneten bioinductive collagen patch has had promising initial results; however, analytic data for its use are lacking, and there is no meta-analysis comparing the available data to historical RCR outcomes.

METHODS

A PRISMA-guided literature search was conducted using Ovid MEDLINE, PubMED, Cochrane, and ClinicalTrials.gov. Thirteen studies met inclusion and exclusion criteria. Only clinical trials on full and partial-thickness tears were included. American Shoulder and Elbow Surgeon score, Constant-Murley Score, the visual analog scale for pain, the minimal clinically important difference (MCID), tendon thickness, and complication rates were primary outcomes of interest. A meta-analysis was performed to determine the overall complication and retear rate from the included studies.

RESULTS

American Shoulder and Elbow Surgeon score, Constant-Murley Score, and visual analog scale for pain improved significantly in all studies that reported them, and most patients achieved MCID. Patient-reported outcome measure improvements were similar to historical improvements in standard RCR, and a similar proportion of patients achieved MCID after standard repair. Tendon thickness improved significantly and to a similar degree as standard RCR. Overall retear rate after full thickness RCR augmented with the bioinductive patch was 8.3%. For partial thickness RCR, total retear rate was of 1.1% across all patients. The overall complication rate with the bioinductive patch was 15.5% across all full-thickness RCR studies and 16.2% in partial thickness RCR. We found overall retear rate to be lower after augmentation with the bioinductive patch compared to traditional repair; however, the overall complication rate was similar for full-thickness tears and higher for partial-thickness tears. Lastly, adverse reactions to the bioinductive patch were noted at 0.2%.

CONCLUSIONS

The bioinductive collagen patch appears to be a safe augmentation for rotator cuff repair. Patients are likely to experience significant subjective improvement in patient-reported outcome measures and significant increases in tendon thickness. Retear rate has been a concern after RCR for decades, and the bioinductive patch may help mitigate this risk. There is lack of case-control studies comparing the bioinductive patch to traditional suture RCR. Such data are needed to better determine the role of the bioinductive patch in the treatment of full and partial-thickness rotator cuff repairs.

Reverse shoulder arthroplasty or nothing for patients with displaced proximal humeral fractures: a randomized controlled trial

BACKGROUND

The benefits of reverse shoulder arthroplasty compared to nonoperative treatment for patients presenting with complex proximal fractures have been rarely explored. The aim of this prospective study was to compare the functional results of reverse shoulder arthroplasty with those of nonsurgical treatment in patients with displaced proximal humeral fractures.

METHODS

A multicentric prospective randomized control trial of patients older than 70 years who sustained an acute proximal humeral fracture (3 or 4 parts), with less than 3 weeks of evolution, and had no previous condition or surgery on the affected shoulder was conducted. Patients were randomly assigned to the intervention group (implantation of a reverse shoulder arthroplasty and tuberosities reattachment) or the control group (nonoperative treatment). Functional outcome was assessed using the Constant-Murley score (CMS) at the 1-year follow-up. Complications and reinterventions were considered secondary outcomes. The power of the study relied on the inclusion of 81 patients to recognize a statistically significant difference of 10 points between CMS scores in the groups. Analysis was performed based on the intention to treat principle.

RESULTS

Eighty-one patients were randomized to surgical treatment or nonoperative treatment, while 66 patients completed the 1-year follow-up evaluation. There was no significant difference between the groups in terms of age (76.1 yo vs. 77.43 yo, P = .43), sex (81.08% women in the surgical group vs. 84.09% in the nonoperative group, P = .72), or type of fracture according to Neer's classification system (P = .06). At the 1-year follow-up, the group assigned to undergo the intervention had better functional outcomes than the nonoperative treatment group (mean CMS; 61.24, SD: 13.33 vs. mean CMS: 52.44, SD: 16.22, P: .02), with a mean difference of 8.84 points, 95% CI (1.57, 16.11). Two patients in the intervention group (6.5%) suffered major complications (periprosthetic joint infection and axillary nerve palsy). No major complications were observed in the nonoperative group. One patient in the intervention group underwent secondary surgery for a periprosthetic joint infection.

CONCLUSIONS

Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. The difference in CMS is close to the clinically significant thresholds, and some harms are associated with the operative treatment.

Preoperative magnetic resonance imaging rotator cuff tendon stump classification correlates with the surgical outcomes following superior capsular reconstruction

HYPOTHESIS

This study aimed to investigate the correlation between rotator cuff stump classification and postoperative outcomes after superior capsular reconstruction (SCR).

METHODS

A total of 75 patients who underwent SCR between June 2013 and May 2021 were included in this study. Based on stump classification using the signal intensity ratio of the tendon rupture site to the deltoid muscle in the coronal view of preoperative T2-weighted, fat-suppressed magnetic resonance imaging scans, the patients were classified into types 1, 2, and 3 with ratios of <0.8, 0.8-1.3, and >1.3 (44, 17, and 14 patients, respectively). The American Shoulder and Elbow Surgeons (ASES), Constant, and visual analog scale (VAS) scores for pain and range of motion were evaluated at a minimum of 1 year of follow-up postoperatively. The acromiohumeral distance and rotator cuff arthropathy according to the Hamada classification were assessed on plain radiography. The graft integrity was evaluated by magnetic resonance imaging at 3 and 12 months postoperatively and annually thereafter.

RESULTS

Clinical and radiological outcomes were significantly improved after SCR. In comparison with type 2 and 3 patients, type 1 patients had significantly higher ASES scores (type 1, 2, and 3 = 84 ± 10, 75 ± 15, and 76 ± 14; all P = .014), Constant scores (type 1, 2, and 3 = 65 ± 5, 61 ± 9, and 56 ± 13; all P = .005), and forward flexion (type 1, 2, and 3 = 155 ± 10, 154 ± 15, and 145 ± 13; all P = .013). However, these statistical differences between groups were below the established minimum clinically important difference values for the ASES and Constant scores after rotator cuff repair. The graft failure rate after surgery was lower in the type 1 group than that in the other 2 groups; however, the difference was not statistically significant (P = .749).

CONCLUSION

Patients with stump classification type 1 showed significantly better functional scores (ASES and VAS scores) and forward flexion; however, the clinical importance of these differences may be limited. Stump classification may be useful for predicting postoperative clinical outcomes.

Muscle Advancement During Arthroscopic Rotator Cuff Repair as a Treatment Option for Irreparable Rotator Cuff Tears

Background

The management of irreparable rotator cuff tears presents a surgical dilemma. However, supraspinatus muscle advancement (MA) could be used to convert irreparable to reparable tears without requiring a graft.

Purpose

To compare the outcomes of patients with an irreparable tear who underwent rotator cuff repair with MA with those with a reparable large to massive cuff tear who underwent rotator cuff repair.

Study Design

Cohort study; Level of evidence, 3.

Methods

We enrolled 62 patients who underwent rotator cuff repair for a large to massive tear between January 2020 and May 2022. Among them, 29 patients underwent an MA procedure due to an inability to repair despite releases (MA group), whereas the other 33 patients did not require the procedure (NMA group). At 1 year postoperatively, follow-up assessments including magnetic resonance imaging were performed to evaluate group outcomes.

Results

Despite there being more revision surgery cases and a poorer potential for cuff healing in the MA group, the retear rates in the MA and NMA groups were similar (31.0% vs 21.2%, respectively; P = .401), as were clinical outcomes, including the visual analog scale for pain (2.9 vs 1.9; P = .076), University of California, Los Angeles (27.0 vs 29.1; P = .185), Constant (70.1 vs 74.9; P = .063), and American Shoulder and Elbow Surgeons (74.5 vs 81.8; P = .168) scores. Postoperative muscle power during forward elevation was weaker in the MA group than in the NMA group (35.1 vs 45.8 N; P = .052), but external rotation power was comparable (49.3 vs 59.0 N; P = .121). Progress in fatty degeneration of the supraspinatus was not significantly different in the 2 groups (P = .43), although the MA group showed a nonsignificant decrease in supraspinatus atrophy (P = .092) due to the lateral shift produced by the procedure.

Conclusion

The MA procedure for irreparable tears produced outcomes comparable with reparable tears, offering a valuable perspective on the efficiency of the procedure. The comparable but relatively high retear rates emphasize the need for further studies to compare with other treatment options for irreparable tears.

Acromioplasty combined with arthroscopic rotator cuff repair can reduce the risk of reoperation: a systematic review and meta-analysis

BACKGROUND

Whether to perform acromioplasty in arthroscopic rotator cuff repair (ARCR) is controversial, and the optimal surgical approach for rotator cuff tear repair is unknown. The purpose of this study was to compare the reoperation rate, retear rate and patient-reported outcomes (PROs) of ARCR with those of ARCR combined with acromioplasty (ARCR-A).

METHODS

PubMed, Embase and Cochrane Library were searched for relevant literature dated between database inception and 4 December 2023. The primary outcomes of this study were the reoperation rate and the retear rate. The secondary outcomes were PROs, including the visual analogue scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, the University of California-Los Angeles (UCLA) score, the Constant score and the Western Ontario Rotator Cuff (WORC) score. The quality of the included studies was evaluated by using the risk of bias assessment tool. RevMan 5.3 software was used for meta-analysis. Fixed (I2 <50%) or random (I2 ≥50%) effects models were applied to calculate the effect size.

RESULTS

Meta-analysis revealed that ARCR-A had a lower reoperation rate (OR = 0.35, 95%CI: 0.15-0.85, p = 0.02), but the difference in the retear rate between ARCR-A and ARCR was not significant (p = 0.25). In type 2 acromion patients, the reoperation rate was not significantly different between ARCR and ARCR-A (p = 0.12), but, for type 3 acromion patients, the retear rate was lower for ARCR-A than for ARCR (OR = 0.12, 95%CI: 0.01-0.94, p = 0.04). There were statistically significant differences in the 6-month postoperative Constant scores (p < 0.001), VAS pain scores (p = 0.003) 12-month postoperative ASES scores (p = 0.02) and 24-month postoperative WORC scores (p = 0.04), but these differences were not clinically significant.

CONCLUSIONS

Combining ARCR with acromioplasty can reduce the rate of reoperation, especially in patients with type 3 acromion, but it provides no clinically important change in the retear rate and postoperative PRO compared with ARCR.

Early Postoperative Stiffness After Arthroscopic Rotator Cuff Repair Correlates With Improved Tendon Healing

PURPOSE

To assess whether early postoperative stiffness predicts long-term stiffness and its relationship with repair integrity in patients who undergo arthroscopic rotator cuff repair (ARCR).

METHODS

This was a single-center retrospective study; 427 patients undergoing primary ARCR by a board-certified orthopaedic surgeon over 4 years were considered. Patients with at least 1 year of follow-up were categorized into stiff and non-stiff groups based on their range of motion (ROM) at 3 months' postoperatively. Stiffness was defined as passive forward flexion <120°, external rotation <30°, or internal rotation below L3. We evaluated clinical outcomes using demographics, ROM, Constant Shoulder (CS) score, University of California, Los Angeles (UCLA) score, and visual analog scale (VAS) for pain preoperatively and at 3, 6, and 12 months' postoperatively. Stiffness, retear rates, and tendon integrity were assessed via magnetic resonance imaging at 12 months.

RESULTS

Of 155 patients meeting the inclusion criteria, 68 (43.9%) were stiff, and 87 (56.1%) were non-stiff. The stiff group had significantly lower preoperative CS and UCLA scores (P = .013/.014) and greater VAS score (P = .034). At 3 months, this group showed lower ROM and functional scores (P < .001), persisting at 6 and 12 months (except internal rotation) (P < .001). Their 12-month VAS score was greater (P = .024). Postoperative stiffness occurred in 10.3% of the stiff group and 2.3% of the non-stiff group (P = .035). The 12-month retear rate was 5.9% in the stiff group and 17.2% in the non-stiff group (P = .032). Minimal clinically important difference analysis indicated ROM changes but limited functional score changes in the 2 groups.

CONCLUSIONS

This study showed that early postoperative shoulder stiffness correlates with lower preoperative functional scores and greater pain levels. Shoulder stiffness at 3 months' post-ARCR predicts 12-month shoulder stiffness but indicates better tendon integrity. While early stiffness is linked to lower functional scores and more pain, its long-term clinical impact seems limited.

LEVEL OF EVIDENCE

Level III, retrospective comparison study.

Defining minimal clinically important difference, patient acceptable symptomatic state and substantial clinical benefit for the visual analog scale pain score after arthroscopic rotator cuff repair

INTRODUCTION

Patient satisfaction after arthroscopic rotator cuff repair (RCR) is commonly assessed with patient-reported outcome measures (PROMs), and there is an increased need to establish clinical relevance within these measures. The purpose of this study was to (1) define minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) for the visual analog scale (VAS) pain score in patients undergoing arthroscopic RCR, and (2) identify preoperative predictors of achieving each of these threshold values.

METHODS

Data from consecutive patients who underwent primary arthroscopic rotator cuff repair study between 2010 and 2016 were prospectively collected. Baseline data and VAS pain scores were collected preoperatively and at 1 year and 2 years postoperatively. MCID, PASS and SCB were determined using an anchor-based approach, with anchor questions assessing postoperative satisfaction and expectation fulfillment. Multivariate logistic regression analysis was also used to identify preoperative predictors for achieving MCID, PASS, and SCB.

RESULTS

A total of 286 patients were included in the final analysis, with an average age of 60.2 ​± ​10.4 and the majority being female (61.2%). The values for the VAS pain score identified to represent MCID, PASS, and SCB, respectively, at 1-year postoperatively were: 5, 2, and 1. The rates of achieving clinically significant improvement based on VAS were 60.5%, 63.3%, and 57.2%, respectively. A higher preoperative VAS was predictive for achieving MCID (odds ratio [OR], 1.84; P ​< ​0.01).

CONCLUSION

This study identified threshold VAS pain scores of 5, 2, and 1 for achieving MCID, PASS, and SCB, respectively, at 1-year follow-up after arthroscopic rotator cuff repair. A higher preoperative VAS pain score was also identified as a statistically significant predictor of attaining MCID after arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

II.

Biceps Rerouting Regardless of a Biceps-Labral Lesion During Rotator Cuff Repair Results in Lower Retear Rates and Comparable Clinical Outcomes to Subpectoral Biceps Tenodesis

PURPOSE

To evaluate the radiographic and clinical outcomes when rerouting a pathologic biceps during arthroscopic rotator cuff repair by comparing it with concomitant subpectoral biceps tenodesis (SPBT).

METHODS

This retrospective, historical cohort study was conducted with patients who underwent an arthroscopic repair of a full-thickness rotator cuff tear, with intraoperative confirmation of biceps pathology including partial tears, subluxation, pulley lesions, or type II SLAP lesions. Until May 2018, such patients were treated with concomitant subpectoral tenodesis (group SPBT). Afterward, biceps rerouting (BR) was done regardless of biceps pathology (group BR) without biceps or SLAP repair. Radiographic parameters, including fatty degeneration, acromiohumeral distance, Sugaya classification, and retears, were evaluated using preoperative and 1-year postoperative magnetic resonance imaging results. Clinical evaluation with a minimum 2-year follow-up included pain visual analog scale, American Shoulder and Elbow Surgeons, Simple Shoulder Test, and Constant-Murley scores. Whether individual patients exceeded these scores' minimal clinically important difference also was determined.

RESULTS

A total of 64 patients (group SPBT = 32; group BR = 32) were included in the final analysis. The duration of clinical follow-up was 36.2 ± 9.3 months in group SPBT and 29.4 ± 6.9 months in the BR group (P = .002). Compared with group SPBT, group BR demonstrated a significantly lower retear rate (SPBT vs BR: 34.4% vs 12.5%, P = .039). In the BR group, 8 of 32 (25%) patients demonstrated a postoperative LHBT tear. The 4 cuff retears in group BR only took place within these patients. Other postoperative radiographic and clinical outcomes were comparable between the groups. Within each group, significant postoperative improvements were demonstrated (P < .05 for all clinical scores).

CONCLUSIONS

Even in the presence of a pathologic LHBT and/or a type II SLAP lesion, augmenting the rotator cuff repair with BR significantly reduced retear rates while achieving clinical scores comparable with SPBT in a minimum 2-year follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Type III acromioclavicular dislocation: Mid term results after operative and non-operative treatment

INTRODUCTION

Controversy exists in the literature about the best treatment for type III acromioclavicular dislocations. The aim of this study is to compare functional results between surgical and conservative treatment in type III acromioclavicular joint dislocations.

MATERIAL AND METHOD

We retrospectively evaluated the records of 30 patients from our area with acute type III acromioclavicular dislocations that were treated from January 1st, 2016 to December 31st, 2020. Fifteen patients were treated surgically and 15 conservatively. Follow up mean time was 37.93 months in operative group and 35.73 months in non-operative group. Results obtained on the Constant score was the main variable analysed and results obtained on the Oxford score and the Visual Analogue Scale for pain were the secondary variables. Epidemiological variables were analysed, as well as range of mobility in injured shoulder and subjective and radiological variables (distance between the superior border of the acromion and the superior border of the clavicle's distal end and presence of osteoarthritis in the acromioclavicular joint).

RESULTS

Functional evaluation scores did not show differences between the two groups (Constant: operative 82/non-operative 86.38, p 0.412; Oxford: operative 42/non-operative 44.80, p 0.126) nor did Visual Analogue Scale (operative 1/non-operative 0.20, p 0.345). Subjective evaluation of the injured shoulder was excellent or good in 80% of the patients in both groups. Measurement of the distance between the superior border of the acromion and the superior border of the clavicle's distal end were significantly higher in non-operative group (operative 8.95/non-operative 14.21, p 0.008).

CONCLUSIONS

Although radiographic results were better in the surgical treatment group, functional evaluation scores did not show significant differences between the two groups. These results do not support the routine use of surgical treatment for grade III acromioclavicular dislocations.

Variability of MCID, SCB, and PASS Thresholds in Studies Assessing Patient-Reported Outcomes After Rotator Cuff Repair: A Systematic Review

BACKGROUND

An increasing reliance on patient-reported outcomes has led to greater emphasis on minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) thresholds in assessing rotator cuff repairs.

PURPOSE

To review the MCID, SCB, and PASS thresholds reported for patient-reported outcome measures (PROMs) after rotator cuff repair.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PubMed, Embase, Ovid, Cochrane, and Google Scholar databases were queried for full-text journal articles in English published between January 1, 2000, and May 31, 2022. Studies with MCID, SCB, and PASS thresholds reported for patients with rotator cuff repair and a minimum of 12 months of follow-up were included. Reported MCID, SCB, and PASS thresholds and associated calculation methods were extracted.

RESULTS

There were 41 unique studies (6331 shoulders) that met the inclusion criteria. Of these, 37 (90%) reported MCID; 16 (39%), PASS; and 11 (27%), SCB values. The most common PROMs were the American Shoulder and Elbow Surgeons score and the Constant-Murley score. In total, 71% (29/41) of these studies referenced values in the literature, usually studies of patients undergoing rotator cuff repair (21/29). Twelve studies calculated MCID, SCB, or PASS thresholds using anchor-based approaches, whereas 6 studies also calculated thresholds using distribution-based methods. The use of MCID, SCB, and PASS in the rotator cuff repair literature is increasing, with half of the included studies published within the final 17 months of the studied period.

CONCLUSION

Significant variability was seen in the reporting of MCID, SCB, and PASS threshold values after rotator cuff repair. Researchers should prioritize studies that report clinical outcome thresholds calculated using anchor-based methods and should critically review both the anchor question and its response choices. Standardization of MCID, SCB, and PASS values and calculation methods will allow for a more reliable assessment of PROMs in rotator cuff repair moving forward.

[Translated article] Type III acromioclavicular dislocation: Mid term results after operative and non-operative treatment

INTRODUCTION

Controversy exists in the literature about the best treatment for type III acromioclavicular dislocations. The aim of this study is to compare functional results between surgical and conservative treatment in type III acromioclavicular joint dislocations.

MATERIAL AND METHOD

We retrospectively evaluated the records of 30 patients from our area with acute type III acromioclavicular dislocations that were treated from January 1st, 2016 to December 31st, 2020. Fifteen patients were treated surgically and 15 conservatively. Follow-up mean time was 37.93 months in operative group and 35.73 months in non-operative group. Results obtained on the Constant score was the main variable analysed and results obtained on the Oxford score and the Visual Analogue Scale for pain were the secondary variables. Epidemiological variables were analysed, as well as range of mobility in injured shoulder and subjective and radiological variables (distance between the superior border of the acromion and the superior border of the clavicle's distal end and presence of osteoarthritis in the acromioclavicular joint).

RESULTS

Functional evaluation scores did not show differences between the two groups (Constant: operative 82/non-operative 86.38, p 0.412; Oxford: operative 42/non-operative 44.80, p 0.126) nor did Visual Analogue Scale (operative 1/non-operative 0.20, p 0.345). Subjective evaluation of the injured shoulder was excellent or good in 80% of the patients in both groups. Measurement of the distance between the superior border of the acromion and the superior border of the clavicle's distal end were significantly higher in non-operative group (operative 8.95/non-operative 14.21, p 0.008).

CONCLUSIONS

Although radiographic results were better in the surgical treatment group, functional evaluation scores did not show significant differences between the two groups. These results do not support the routine use of surgical treatment for grade III acromioclavicular dislocations.

Revision Surgery for Shoulder Infection after Arthroscopic Rotator Cuff Repair: Functional Outcomes and Eradication Rate-A Systematic Review

The outcomes after arthroscopic rotator cuff repair (RCR) have been reported to be successful. The incidence of deep infections (defined as an infection involving any part of the anatomy other than the skin and subcutaneous tissue) after surgery ranges between 0.03% and 3.4%. This systematic review aims to investigate the outcomes of revision surgery for infection following arthroscopic RCR. Clinical outcomes and eradication rates among patients treated with different surgical and antibiotic therapies are analyzed. A total of five studies were eligible for systematic review. A total of 146 patients were treated and evaluated, of whom 71 (48%) and 75 (52%) underwent arthroscopic and open surgery to manage the infection, respectively. The most common causative bacterium was Cutibacterium acnes (50.4%). Two studies reported the pre-and postoperative ASES score and Constant-Murley score (CMS), and a statistically significant improvement was found after surgery (p < 0.001 for both). Eradication was observed in a total of 138 patients (94.5%); no difference was found between arthroscopic and open revision surgery (92.8% and 96%, respectively, p = 0.90). The frequency-weighted mean duration of the intravenous antibiotic therapy was 6.6 ± 5.4 days, while the overall mean duration of antibiotic therapy, considering intravenous and oral administration, was 43.5 ± 40 days. Patients with infection following arthroscopic RCR undergoing revision surgery experienced a high rate of eradication. A significant improvement in shoulder functionality and less residual pain can be expected.

Clinical and Structural Outcomes of Arthroscopic Rotator Cuff Repair in Patients Over 75 Years Are Comparable to Those in Younger Patients: A Propensity Score-Matched Comparative Study

PURPOSE

To compare clinical and structural outcomes of arthroscopic rotator cuff repair (ARCR) in patients over 75 years and those under 75 years and to analyze the factors associated with retear and clinical outcomes after ARCR.

METHODS

This retrospective study reviewed patients who underwent ARCR between 2011 and 2021 with at least 2 years of follow-up. Using propensity score matching for sex, tear size, subscapularis involvement, and follow-up time, this study included 54 patients older than 75 years (group A) and 54 patients younger than 75 years (group B). Cuff integrity was evaluated using magnetic resonance imaging (MRI). Structural and clinical outcomes were compared between the 2 groups.

RESULTS

The mean improvements in external rotation (P = .030) and the American Shoulder and Elbow Surgeons (ASES) score (P = .043) were significantly higher in group A. Visual analog scales for pain and function, ASES score, and Constant score were significantly improved in both groups (all P = .001). On routine postoperative MRI at 6 months, the retear rate was 20.4% (11/54) in group A and 18.5% (10/54) in group B with no statistical difference between the 2 groups (P = .808). Factor analysis in group A showed that follow-up duration (P = .019), tear size in mediolateral dimension (P = .037), occupation ratio (P = .036), and incomplete repair (P = .034) were associated with retear, and mild glenohumeral arthritis (P = .003) and subscapularis involvement (P = .018) were associated with inferior Constant score.

CONCLUSIONS

Clinical and structural outcomes after ARCR in patients aged 75 years or older are comparable to those in patients younger than 75 years.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Early functional improvements using continuous passive motion therapy after angular-stable plate osteosynthesis of proximal humerus fractures - results of a prospective, randomized trial

BACKGROUND

The use of continuous passive motion therapy (CPM) has led to promising results in the early phase of rehabilitation after surgical treatment of rotator cuff tears and arthrolysis of the elbow. However, its use has not been proven in other pathologies of the upper extremity. Therefore, the aim of the underlying study was to evaluate the use of CPM therapy after plate osteosynthesis of proximal humeral fractures.

METHODS

95 patients with isolated proximal humerus fractures were enrolled in a prospective, randomized study. Patients were assigned to a treatment group with (n = 48, CPM) or without CPM therapy (n = 47, CG). Four patients (2 of each cohort) violated the study protocol and were excluded. CPM therapy was used for 6 weeks after surgery 2-3 times daily. Functional (range of motion) and patient reported outcomes (PROM, Constant Score [CSS], QuickDASH, subjective shoulder value [SSV], pain on visual analogue scale [VAS]) were evaluated at 6 weeks, 3 and 12months. 60 patients completed the 1-year follow-up.

RESULTS

The average patient age was 65.3 years (min: 27, max: 88, SD: ± 14.7). Seventy-two patients were female (79%). There was no difference regarding injury severity (2/3/4 part-fracture: 6/32/7 vs. 9/26/11, p = 0.867) and sex (p = 0.08). However, patients in the CPM group were significantly younger (CPM: 67 [min: 34, max: 82], CG: 74 [min: 27, max: 88], p = 0.032). After 6 weeks we observed a better range of motion for forward flexion (CPM: 90° [min: 50°, max: 180°] vs. CG: 80° [min: 20°, max: 170°] p = 0.035) and abduction (CPM: 80° [min: 40°, max: 180°] vs. CG: 70° [min: 20°, max: 180°], p = 0.048) in the CPM group. There was no difference regarding the further planes of motion or the assessed PROMs at 6 weeks. At 3 and 12 months the results between the treatment groups equalized with no further significant differences.

CONCLUSION

The treatment with CPM increases the range of motion after plate osteosynthesis of proximal humerus fractures in the first 6 weeks after surgery. This effect is not sustained after 3 and 12months. The evaluated PROMs are not being influenced by CPM therapy. Hence the results of this prospective randomized study suggest that CPM can be a beneficial asset in the early period of rehabilitation after proximal humerus plate osteosynthesis.

TRIAL REGISTRATION

The study protocol was registered in the US National Institutes of Health's database ( http://www.

CLINICALTRIALS

gov ) registry under NCT05952622.

Effect of Porcine-Derived Absorbable Patch-Type Atelocollagen for Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Trial

BACKGROUND

Even though arthroscopic rotator cuff repair is recognized as a standard treatment option, the risk of postoperative retear is a major concern.

PURPOSE

To evaluate the effect of porcine-derived absorbable patch-type atelocollagen during arthroscopic rotator cuff repair.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 64 patients with rotator cuff tears diagnosed on magnetic resonance imaging (MRI) were enrolled prospectively from November 2020 to December 2021. Both groups had repairs using the suture bridge technique. For the atelocollagen group, before securing the lateral anchors, we inserted porcine-derived absorbable patch-type atelocollagen between the footprint and the tendon. On postoperative day 2, the patients underwent MRI to confirm containment of the patch-type atelocollagen. At 6 months and 1 year postoperatively, the signal intensity of the repaired tendon was assessed using MRI. Patients were evaluated using the Constant score as the primary outcome, along with the visual analog scale for pain; range of motion; American Shoulder and Elbow Surgeons score; University of California, Los Angeles, score; and Korean Shoulder Score preoperatively and at 2, 3, 6, and 12 months postoperatively.

RESULTS

No significant changes in the Constant score as primary outcome, pain or other functional scores, and range of motion were observed between the groups at 1 year postoperatively. The patch-type atelocollagen was confirmed to be contained by the time-zero MRI scan taken 2 days postoperatively. Among the 55 patients included in final analysis, 12 retear cases were recorded (21.8% retear rate). A significantly lower retear rate was found in the atelocollagen group, as 3 cases were observed in this group (10.3%) and 9 cases were observed in the conventional repair group (34.6%) (P = .048).

CONCLUSION

The Constant score was not different between the groups. The retear rate after rotator cuff repair was significantly lower in the group that received porcine-derived absorbable patch-type atelocollagen compared with in the conventional group.

REGISTRATION

KCT0005184 (Clinical Research Information Service [CRIS]; https://cris.nih.go.kr).

Determining minimal clinically important difference and patient-acceptable symptom state after arthroscopic isolated subscapularis repair

Background

Minimal Clinically Important Difference (MCID) and Patient-Acceptable Symptomatic State (PASS) have emerged as patient-based treatment assessments. However, these have not been investigated in patients undergoing arthroscopic isolated subscapularis repair (AISR). The primary purpose of this study was to determine the MCID and PASS for commonly used patient-reported outcomes in individuals who underwent AISR. The secondary purpose was to assess potential associations between preoperative and intraoperative patient characteristics and the MCID and PASS.

Methods

A retrospective analysis was conducted on prospectively collected data for patients who underwent primary AISR between 2011 and 2021 at a single institution, with minimum 2-year postoperative follow-up. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and Visual Analog Scale (VAS) pain scale. The MCID was determined using the distribution-based method, while PASS was evaluated using area under the curve analysis. To investigate the relationship between preoperative variables and the achievement of MCID and PASS thresholds, Pearson and Spearman coefficient analyses were employed for continuous and noncontinuous variables, respectively.

Results

A total of 77 patients with a mean follow-up of 58.1 months were included in the study. The calculated MCID values for VAS pain, ASES, and SSV were 1.2, 10.2, and 13.2, respectively. The PASS values for VAS pain, ASES, and SSV were 2.1, 68.8, and 68, respectively. There was no significant correlation between tear characteristics and the likelihood of achieving a MCID or PASS. Female sex, worker's compensation status, baseline VAS pain score, and baseline ASES score, exhibited weak negative correlations for achieving PASS for VAS pain and ASES.

Conclusion

This study defined the MCID and PASS values for commonly used outcome measures at short-term follow-up in patients undergoing AISR. Tear characteristics do not appear to impact the ability to achieve a MCID or PASS after AISR. Female sex, worker's compensation claim, and low baseline functional scores have weak negative correlations with the achievement of PASS for VAS pain and ASES scores.

Effectiveness of a joint mobilizations protocol for shoulder subacromial pain syndrome: A pilot study

BACKGROUND

Subacromial pain syndrome (SPS) is the most frequent shoulder pathology. The aims of this prospective randomized study were to evaluate the effects of some specific shoulder joint mobilizations ("spin correction"), and the effectiveness of a rehabilitation program, named Shoulder Global Concept, in SPS patients.

METHODS

45 patients with SPS were randomly assigned to two groups, to benefit from a different first session of mobilizations: the experimental group received all specific mobilizations, while the control group received the same program but without the spin correction mobilizations. The second session was identical for both groups, with all specific mobilizations. Before and after the first two sessions, range of motion (ROM) in flexion, abduction, external and internal rotations, pain and functional status with Constant score and Quick Dash were evaluated. Evaluation was repeated with 24 patients after 11 rehabilitation sessions. Rehabilitation with Shoulder Global Concept included 13 mobilizations aiming at improving the ROM with passive and active-assisted mobilizations, static stretching, and muscle strengthening.

RESULTS

All ROM were improved at the end of the first session for both groups, but significantly more in the experimental group for glenohumeral (GH) abduction and external rotation (p < 0.05). Functional scores, pain and strength were significantly improved after 11 rehabilitation sessions with the Shoulder Global Concept.

CONCLUSION

This manual therapy method was able to improve shoulder mobility in one session. The additional joint mobilizations (spin correction) specifically increased GH abduction and external rotation. Rehabilitation of SPS with Shoulder Global Concept allowed to improve functional capacity and decrease pain.

Full arthroscopic vs. arthroscopically assisted posterosuperior latissimus dorsi tendon transfer for shoulders with failed and irreparable rotator cuff repair: matched case-control study

PURPOSE

To compare clinical outcomes and complication rates of full arthroscopic latissimus dorsi tendon transfer (LDTT) vs. arthroscopically assisted LDTT, for the treatment of irreparable posterosuperior massive rotator cuff tears (mRCTs) in shoulders that had failed rotator cuff repair (RCR).

METHODS

We evaluated a continuous series of 191 patients who underwent LDTT over 4 consecutive years. A total of 107 patients did not have previous shoulder surgery, leaving 84 patients who had prior surgical procedures. All procedures performed over the first 2 years were arthroscopically assisted (n = 48), whereas all procedures performed over the last 2 years were full arthroscopic (n = 36). We noted all complications, as well as clinical scores and range of motion at ≥24 months. To enable direct comparison between the 2 techniques, propensity score matching was used to obtain 2 groups with equivalent age, sex, and follow-up.

RESULTS

Compared with the 48 patients who underwent arthroscopically assisted LDTT, the 36 patients who underwent full arthroscopic LDTT had comparable complications (13% vs. 11%) and conversions to RSA (8.3% vs. 5.6%). Propensity score matching resulted in 2 groups, each comprising 31 patients, which had similar outcomes in terms of clinical scores (except mobility component of Constant score, which was better following fully arthroscopic LDTT; P = .037) and range of motion at a minimum follow-up of 2 years.

CONCLUSION

At a minimum follow-up of 24 months, for the treatment of irreparable posterosuperior mRCTs in shoulders that had surgical antecedents, full arthroscopic LDTT had significantly better mobility component of the Constant score than arthroscopically assisted LDTT, although there were no significant differences in the other clinical or functional outcomes. Arthroscopically assisted LDTT and full arthroscopic LDTT had comparable rates of complications (8.3% vs. 13%) and conversion to RSA (5.6% vs. 8.3%).

Estimating the minimal clinically important difference of shoulder functional scores after arthroscopic rotator cuff repair: a prospective study

INTRODUCTION

The minimal clinically important difference (MCID) is a valuable tool for patient-based outcome analysis, for which limited data is available in the literature, especially after arthroscopic rotator cuff repair (ARCR). Although several studies have reported MCID after ARCR, few have studied the impact of various clinical factors such as Diabetes, pseudoparalysis, type of cuff repair, and retear over MCID. This study attempts to determine the MCID in shoulder functional scores after ARCR and the impact of various factors on MCID.

METHODS

144 patients undergoing ARCR were prospectively evaluated at six and 12 months by ASES and UCLA scores. MCID for American Shoulder and Elbow Surgeons (ASES) and the University of California and Los Angeles (UCLA) scores were calculated using an anchor-based and distribution-based approach. MCID was also calculated for diabetic and non-diabetic patients, smokers vs. non-smokers, presence or absence of pseudoparalysis, type of cuff repair (single row vs. suture bridge), and presence of retears. Uni- and multivariate analysis was performed to identify factors affecting the MCID of both scores.

RESULTS

Mean MCID for ASES score was 13.3 and 16.6 using an anchor-based and distribution-based approach, respectively. For the UCLA score, the mean MCID was 10.0 and 12.6 by anchor-based and 12.6 by distribution-based approach, respectively. Patients with higher pre-operative ASES scores demonstrated lower MCID values. No significant difference was observed in MCID scores of diabetic vs. non-diabetic patients, smoker vs. non-smoker, patients with or without pseudoparalysis, and type of cuff repair. The age, gender, and presence of retear did not affect MCID values.

CONCLUSION

This study establishes the MCID values of ASES and UCLA scores for rotator cuff repair by anchor and distribution methods. No patient or surgical factors appear to affect the MCID except pre-operative ASES scores.

STUDY DESIGN

Prospective cohort, Level II.

Arthroscopic Suprapectoral Biceps Tenodesis for Isolated Biceps Tendinopathy: Results From 23 Patients

INTRODUCTION

Pathology affecting the long head of the biceps tendon (LHB) is a common cause of shoulder pain. When conservative treatment fails to resolve symptoms, surgical treatment is the modality of choice. The literature describes many arthroscopic and open techniques using different implants. However, no consensus exists on which procedure yields the greatest improvement. The purpose of this study was to evaluate the effectiveness and safety of arthroscopic suprapectoral biceps tenodesis for treating isolated LHB pathology.

MATERIALS AND METHODS

We present a case series of 23 patients with isolated LHB pathology who were treated with arthroscopic suprapectoral tenodesis between 2016 and 2022. All surgeries were performed by the same senior surgeon, and patients were assessed preoperatively and one year after the procedure, using the simple shoulder test (SST), Constant score (CS), and visual analog scale (VAS) by the senior surgeon. Statistical analysis was performed using the Wilcoxon Signed Rank test, with significance defined as p < 0.05.

RESULTS

The CS improved from 68.52 (SD = 1.59) to 98 (SD = 7.1; p < 0.001), the SST improved from 8.78 (SD = 0.998) to 11.21 (SD = 0.42; p < 0.001), and the VAS improved from 8.26 (SD = 0.54) to 0 (SD = 0; p < 0.001) at one-year follow-up. No complications were reported postoperatively or during the follow-up period.

CONCLUSIONS

Arthroscopic suprapectoral biceps tenodesis significantly improved outcomes at one-year follow-up and can be considered an effective and safe choice when treating LHB pathology.

Comparable results of superior vs antero-inferior plating for the treatment of displaced midshaft clavicle fractures. A comparative study

BACKGROUND

Clavicle fractures represent up to 10 % of all fractures, affecting mainly a young population. Open reduction and internal plate fixation provide good results, but evidence on the best plate positioning is still unclear. Aim of this retrospective study was to compare superior and antero-inferior plating positioning in the surgical treatment of displaced midshaft clavicle fractures.

MATERIALS AND METHODS

104 patients aged > 18 years, treated surgically with plate fixation (51 superior, 53 antero-inferior) for a midshaft clavicle fracture from January 2010 to April 2021 were included. At the time of the visit, mean follow-up time was 6.6 ± 2.6 years. Shoulder function was evaluated with the use of Constant-Murley Score (CMS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Return to sport, aesthetic satisfaction, operative time, radiological outcomes, rate of implant removal, and overall patient satisfaction were documented as well.

RESULTS

Mean CMS was 94.1 ± 10.0 points in the superior plating group and 93.4 ± 11.6 points in the antero-inferior plating group. DASH score: 4.6 ± 11.0 superior, 5.1 ± 10.5 antero-inferior. Return to sport: 8.2 ± 2.9 superior, 8.2 ± 3.0 antero-inferior. Aesthetic satisfaction: 8.9 ± 1.6 superior, 8.8 ± 2.1 antero-inferior. Overall satisfaction: 9.1 ± 1.5 superior, 8.9 ± 1.7 antero-inferior. The comparison between groups showed no statistically significant differences (p = n.s.) for all outcome measures. Operative time: 101.6 ± 27.3 min superior, 113.0 ± 31.6 min antero-inferior (p = 0.05). Radiological follow-up documented one non-union and one mal-union in the antero-inferior plating group. Overall, 63 patients underwent plate removal: 58.8 % in the superior plating group and 62.3 % in the antero-inferior plating group (p = n.s.). Main reason for plate removal was pain/discomfort.

CONCLUSIONS

Both superior and antero-inferior plating provided excellent clinical, functional, and radiological results for the treatment of displaced midshaft clavicle fractures, without significant differences between groups. The superior plating group showed a statistically shorter operative time. High rate of re-interventions with implant removal was documented in both groups.

LEVEL OF EVIDENCE

III.

Mid- to long-term outcomes of latissimus dorsi tendon transfer for massive irreparable posterosuperior rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

This study aims to analyze the mid-to long-term results of the latissimus dorsi tendon for the treatment of massive posterosuperior irreparable rotator cuff tears as reported in high-quality publications and to determine its efficacy and safety.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, and EMBASE databases were searched until December 2022 to identify studies with a minimum 4 year follow-up. Clinical and radiographic outcomes, complications, and revision surgery data were collected. The publications included were analyzed quantitatively using the DerSimonian Laird random-effects model to estimate the change in outcomes from the preoperative to the postoperative condition. The proportion of complications and revisions were pooled using the Freeman-Tukey double arcsine transformation.

RESULTS

Of the 618 publications identified through database search, 11 articles were considered eligible. A total of 421 patients (432 shoulders) were included in this analysis. Their mean age was 59.5 ± 4 years. Of these, 277 patients had mid-term follow-up (4-9 years), and 144 had long-term follow-up (more than 9 years). Postoperative improvements were considered significant for the following outcome parameters: Constant-Murley Score (0-100 scale), with a mean difference (MD) = 28 points (95% confidence interval [CI] 21, 36; I2 = 89%; P < .001); visual analog scale, with a standardized MD = 2.5 (95% CI 1.7, 3.3; P < .001; I2 = 89%; P < .001); forward flexion, with a MD = 43° (95% CI 21°, 65°; I2 = 95% P < .001); abduction, with a MD = 38° (95% CI 20°, 56°; I2 = 85%; P < .01), and external rotation, with a MD = 8° (95% CI 1°, 16°; I2 = 87%; P = .005). The overall reported mean complication rate was 13% (95% CI 9%, 19%; I2 = 0%), while the reported mean revision rate was 6% (95% CI: 3%, 9%; I2 = 0%).

CONCLUSIONS

Our pooled estimated results seem to indicate that latissimus dorsi tendon transfer significantly improves patient-reported outcomes, pain relief, range of motion, and strength, with modest rates of complications and revision surgery at mid-to long-term follow-up. In well-selected patients, latissimus dorsi tendon transfer may provide favorable outcomes for irreparable posterosuperior cuff tears.

Nitrous oxide provided during intensive physiotherapy for shoulder adhesive capsulitis does not improve function: A randomised controlled trial

BACKGROUND

There is no consensus on treatment for adhesive capsulitis of the shoulder. Physiotherapy is often used to increase range of motion but individuals may experience pain during mobilisation.

OBJECTIVES

The objective of this study was to determine whether rehabilitation under N2O for shoulder AC improved pain and function more than rehabilitation alone (with placebo gas).

METHOD

A randomised, 1:1 parallel arm, double-blind study in 4 university hospital outpatient centres. Adults with adhesive capsulitis for at least 3 months with intact cartilage were included. Participants were randomised in blocks of 4 and stratified by centre to receive 20 sessions of intensive physiotherapy over 10 days; the 10 morning sessions were performed with either nitrous oxide (intervention) or sham gas (placebo).

PRIMARY OUTCOME

improvement in shoulder function at day 14 (D14) (Constant-Murley score).

RESULTS

Seventy-five participants were included, and data from 69 were analysed: 37 in the placebo group and 32 in the intervention group. Improvements occurred in both groups after the intervention. No significant difference in the Constant-Murley score was found between groups at D14 (median score increase of 12.0, IQR 5.6; 19.5 points in placebo group vs. 13.7, 5.2; 18.2 in the N20 group, p = 0.78). Pain score during sessions reduced in the intervention group from the first to final session (-11.6, p = 0.053) but not for the placebo group (-4.2, p = 0.414). Seven serious adverse events were recorded, 4 in the intervention group and 3 in the placebo group, with 11 minor adverse events only in the intervention group (mostly shortness of breath).

CONCLUSION

Nitrous oxide gas associated with intensive physiotherapy for shoulder adhesive capsulitis did not improve function, pain or quality of life more than physiotherapy alone. zHowever, pain experienced during physiotherapy sessions appeared lower.

TRIAL REGISTRATION

Clinical Trial registration number NCT01087229.

Arthroscopic rotator cuff repair in patients over 65 years of age: successful functional outcomes and a high tendon integrity rate can be obtained after surgery

Background

Although interest in studies evaluating the outcomes of rotator cuff repair is steadily increasing, the results and tendon integrity after arthroscopic rotator cuff repair in elderly patients have only been minimally investigated. The aim of this study was to evaluate clinical outcomes and repair integrity in patients over 65 years of age who underwent arthroscopic repair of full-thickness rotator cuff tears.

Methods

A retrospective study was conducted with the following inclusion criteria: (1) elective shoulder arthroscopy for rotator cuff repair for full-thickness posterosuperior tears; (2) age over 65 years at surgery; and (3) participation in 24 months of follow-up. Preoperatively, the range of motion (ROM) and the Constant-Murley Score (CMS) and at follow-up, the ROM, the 12-Item Short Form Survey, the American Shoulder and Elbow Surgeons, and the CMS were evaluated; an ultrasonographic assessment of tendon integrity was performed according to the adapted Sugaya classification.

Results

The final sample consisted of 110 patients with an average age of 69.2 ± 3.5 years. The mean duration of nonoperative management before surgery was 2.6 ± 0.8 months. The mean period of preoperative physical therapy was 0.6 ± 0.9 months. ROM and CMS showed statistically significant improvement (all P < .001) after a mean follow-up time of 54.5 ± 22.3 months. The ultrasonographic assessment showed tendon integrity (types I and II) in 75% of cases; 21% were type III repair, and rotator cuff retear (types IV and V) was recorded in 4% of cases. All scores directly correlated with the integrity of the tendon. In the multivariate analysis, higher postoperative CMS was associated with male sex (P < .001, β = -6.085) and lower age (P = .004, β = -0.533). Higher postoperative American Shoulder and Elbow Surgeons were associated with lower age (P = .020, β = -0.414). Higher postoperative 12-Item Short Form Survey physical component score and mental component score were associated with lower age (P = .013, β = -0.550 and P < .001, β = -0.520, respectively) and shorter preoperative physical therapy period (P = .013, β = -2.075 and P = .006, β = -1.093, respectively).

Conclusion

A significant ROM and CMS recovery and a rotator cuff integrity rate of 75% can be expected in patients over 65 years of age who undergo arthroscopic repair for full-thickness rotator cuff tears. Better functional, physical, and mental health outcomes correlate with rotator cuff integrity and are predicted by male sex and a shorter period of preoperative physical therapy.

Hydrotherapy after Rotator Cuff Repair Improves Short-Term Functional Results Compared with Land-Based Rehabilitation When the Immobilization Period Is Longer

Background: The evidence of hydrotherapy after rotator cuff repair (RCR) is limited as most studies either used it as an adjuvant to standard land-based therapy, or have different initiation timing. This study aimed to compare hydrotherapy and land-based therapy with varying immobilization time. Methods: Patients who underwent RCR with a 10-days or 1-month immobilization duration (early or late rehabilitation) were prospectively randomized. Results: Constant scores significantly differed at three months only, with the best score exhibited by the late hydrotherapy group (70.3 ± 8.2) followed by late land-based (61.0 ± 5.7), early hydrotherapy (55.4 ± 12.8) and early land-based (54.6 ± 13.3) groups (p < 0.001). There was a significant interaction between rehabilitation type and immobilization duration (p = 0.004). The effect of hydrotherapy compared to land-based therapy was large at three months when initiated lately only (Cohen's d, 1.3; 95%CI, 0.9-1.7). However, the relative risk (RR) of postoperative frozen shoulder or retear occurrence for late hydrotherapy was higher compared to early hydrotherapy (RR, 3.9; 95%CI, 0.5-30.0). Conclusions: Hydrotherapy was more efficient compared to land-based therapy at three months only and if initiated lately. Even though initiating hydrotherapy later brought greater constant scores at three months, it might increase the risk of frozen shoulders or retear compared to early hydrotherapy.

A Virtual Assistant to Guide Early Postoperative Rehabilitation after Reverse Shoulder Arthroplasty: A Pilot Randomized Trial

INTRODUCTION

Rehabilitation can improve outcomes after reverse shoulder arthroplasty (RSA). However, low adherence to rehabilitation and compliance rates are some of the main barriers. To address this public health issue, the goal of this research was to pilot test and evaluate the effectiveness of a chatbot to promote adherence to home rehabilitation in patients undergoing RSA.

METHODS

A randomized pilot trial including patients undergoing RSA and early postoperative rehabilitation was performed. The control group received standard home rehabilitation; the experimental group received the same intervention supervised with a chatbot, with automated interactions that included messages to inform, motivate, and remember the days and exercises for 12 weeks. Compliance with rehabilitation and clinical measures of shoulder function, pain, and quality of life were assessed.

RESULTS

31 patients (17 experimental) with an average age of 70.4 (3.6) completed the intervention. Compliance was higher in the experimental group (77% vs. 65%; OR95% = 2.4 (0.5 to 11.4)). Statistically significant between-group differences with a CI of 95% were found in the QuickDASH questionnaire and self-reported quality of life. No differences were found in the rest of the measures.

CONCLUSIONS

This pilot study suggests that the chatbot tool can be useful in promoting compliance with early postoperative home rehabilitation in patients undergoing RSA. Future randomized trials with adequate power are warranted to determine the clinical impact of the proposal.

Quantifying Threshold Scores for Patient Satisfaction After Massive Rotator Cuff Repair for the Interpretation of Mid-Term Patient-Reported Outcomes

PURPOSE

To establish minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) values for 4 patient-reported outcomes (PROs) in patients undergoing arthroscopic massive rotator cuff repair (aMRCR): American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), Veterans Rand-12 (VR-12) score, and the visual analog scale (VAS) pain. In addition, our study seeks to determine preoperative factors associated with achieving clinically significant improvement as defined by the MCID and PASS.

METHODS

A retrospective review at 2 institutions was performed to identify patients undergoing aMRCR with minimum 4-year follow-up. Data collected at the 1-year, 2-year, and 4-year time points included patient characteristics (age, sex, length of follow-up, tobacco use, and workers' compensation status), radiologic parameters (Goutallier fatty infiltration and modified Collin tear pattern), and 4 PRO measures (collected preoperatively and postoperatively): ASES score, SSV, VR-12 score, and VAS pain. The MCID and PASS for each outcome measure were calculated using the distribution-based method and receiver operating characteristic curve analysis, respectively. Pearson and Spearman coefficient analyses were used to determine correlations between preoperative variables and MCID or PASS thresholds.

RESULTS

A total of 101 patients with a mean follow-up of 64 months were included in the study. The MCID and PASS values at the 4-year follow-up for ASES were 14.5 and 69.4, respectively; for SSV, 13.7 and 81.5; for VR-12, 6.6 and 40.3; and for VAS pain, 1.3 and 1.2. Greater infraspinatus fatty infiltration was associated with failing to reach clinically significant values.

CONCLUSIONS

This study defined MCID and PASS values for commonly used outcome measures in patients undergoing aMRCR at the 1-year, 2-year, and 4-year follow-up. At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Massive and irreparable rotator cuff tear treatment by arthroscopic partial repair with long head of the biceps tendon augmentation provides better healing and functional results than partial repair only

BACKGROUND

The aim of this study was to compare the clinical and radiologic outcomes of 2 treatment methods for massive and irreparable rotator cuff tears (RCTs): partial repair (PR) and PR with long head of the biceps tendon (LHBT) augmentation. Biceps tendon augmentation is believed to promote better healing at the bone-tendon junction, leading to improved clinical and radiologic outcomes.

METHODS

This retrospective comparative study included patients with chronic, massive and irreparable RCTs involving both the supraspinatus (SSP) and infraspinatus muscles. Only patients with failure of nonoperative treatment and at least 1 year of follow-up between 2013 and 2018 were analyzed. The patients were divided into 2 groups based on the chosen treatment method. Irreparability was defined intraoperatively as the inability to achieve sustainable repair of the SSP after complete release, typically corresponding to a Goutallier classification of stage ≥ 3 and Patte classification of stage 3. The clinical assessment protocol involved measurements of range of motion and shoulder strength, as well as the Constant-Murley score (CMS) and Simple Shoulder Test score. Radiologic assessment comprised measurements of the acromiohumeral distance, Hamada classification, Sugaya classification, and Goutallier classification of both the SSP and infraspinatus.

RESULTS

The study included data from 60 patients (30 in each group) with a mean age of 62.5 years and a mean follow-up period of 34.5 months. The retear rate was 43.3% for PR with LHBT augmentation and 73.3% for PR alone (P = .036). During the final examination, statistically significant differences in favor of PR with LHBT augmentation were observed for the CMS (76.2 ± 10.9 vs. 70.9 ± 11.5, P = .034), Sugaya classification (3.5 ± 1.1 vs. 4.1 ± 0.9, P = .035), and acromiohumeral distance (5.8 ± 2 mm vs. 4.7 ± 1.3 mm, P = .021). There were no significant differences between the groups in range of motion, shoulder strength, Hamada classification, Simple Shoulder Test score, and postoperative Goutallier stage.

CONCLUSION

PR with LHBT augmentation for patients with irreparable, massive RCTs provides a lower retear rate and better humeral head centralization, as well as improved results measured by the CMS, compared with PR alone.

Postoperative Graft Volume Reduction Is Associated With Inferior Clinical Outcomes of Superior Capsule Reconstruction Using an Acellular Dermal Matrix Allograft

PURPOSE

To evaluate whether postoperative graft volume reduction is associated with clinical outcomes after superior capsule reconstruction (SCR) and to identify factors related to graft volume change.

METHODS

Between May 2018 and June 2021, patients who underwent SCR with acellular dermal matrix allograft for irreparable rotator cuff tear with a minimum 1-year follow-up and who had intact graft continuity in postoperative 6-month magnetic resonance imaging were retrospectively reviewed. The lateral half to the medial half of the graft volume ratio was defined as lateral half graft volume ratio. The difference between the preoperative and postoperative lateral half graft volume ratio was defined as lateral half graft volume change. Patients were divided into 2 groups: those with preserved graft volume (group I) and those with reduced graft volume (group II). Intergroup differences in clinical and radiological characteristics were analyzed.

RESULTS

A total of 81 patients were included, with 47 (58.0%) in group I and 34 (42.0%) in group II. Group I showed significantly lower lateral half graft volume change (0.018 ± 0.064 vs 0.370 ± 0.177; P < .001) than group II. Group II showed significantly greater preoperative Hamada grade (1.3 ± 0.5 vs 2.2 ± 0.6, P < .001), an anteroposterior distance of the graft at the greater tuberosity (APGT) (30.3 ± 4.8 vs 35.2 ± 3.8, P < .001), and fatty infiltration of infraspinatus (2.3 ± 0.9 vs 3.1 ± 0.8, P < .001) and subscapularis (0.9 ± 0.9 vs 1.6 ± 1.3, P = .009) than group I. Group II had a significantly lower proportion of patients achieving MIC in Constant score than group I (70.2% vs 47.1%, P = .035). The Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were independent factors of graft volume change.

CONCLUSIONS

Although SCR improved pain and shoulder function, postoperative graft volume reduction was related to a lower rate of minimal important change achievement in the Constant score compared with preserved graft volume. The preoperative Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were associated with graft volume reduction.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Subacromial Balloon Spacer Does Not Reduce the Retear Rate for Massive Rotator Cuff Tears: A Comparative Study

PURPOSE

To determine whether a subacromial spacer decreases the recurrent rotator cuff tear rate in arthroscopically managed massive rotator cuff tears (MRCTs) with 1 year of follow-up.

METHODS

We selected all patients who met the following criteria: (1) an MRCT excluding Collin type A, (2) Goutallier stage equal or less than 2, and (3) complete arthroscopic repair of the MRCT. Patients were allocated into 2 groups: A (without subacromial spacer) or B (with subacromial spacer) for a prospective evaluation 1 year after surgery. The primary outcome was the retear rate, determined with magnetic resonance imaging (MRI) according to the classification of Sugaya. Secondary outcome measures were the functional outcomes using visual analog score, Shoulder Subjective Value, and Constant-Murley Score. Preoperative rotator cuff characteristics such as number of tendons involved and the tear retraction also were evaluated. Patient-related data such as sex, age, laterality, history of smoking, and diabetes mellitus were analyzed.

RESULTS

In total, 31 patients were included in group A and 33 in group B. Preoperatively, only 2 differences were found between both groups: a significant (but not clinical) greater Constant score in group A (P = .034) and a slightly greater retraction of the supraspinatus in group B (P = .0025). The overall retear rate between the 2 groups was similar regarding the number of patients (P = .746) and the total number of tendons involved in the recurrent tear (P = .112). At 1-year follow-up, no differences were found in VAS (P = .397), SSV (P = .309), and Constant score (P = .105).

CONCLUSIONS

In reparable massive rotator cuff tears (excluding Collin type A), the augmentation of repair with a subacromial spacer did not significantly reduce the number of patients with recurrent rotator cuff tears identified by MRI. It was also ineffective in reducing the number of re-ruptured tendons in these patients. No patient-reported or clinically significant findings were noted in Constant, SSV, and VAS scores at 1-year postoperative follow-up. Patients with MRI findings of a healed rotator cuff (Sugaya 1-3) had better clinical outcomes compared with those without.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Different types of rotator cuff tear morphology do not affect post-repair clinical outcomes in large to massive tears

OBJECTIVES

The primary aim of this current study is to evaluate the effects of rotator cuff tear morphology on clinical outcomes in large to massive tears, using a modified version of the existing classification system, with specific focus on tear symmetry and use of margin convergence.

METHODS

Patients who underwent arthroscopic repair of large to massive, full thickness rotator cuff tears were retrospectively analysed. The tear pattern was classified at the time of surgery as Type IA, Type IB, Type IIA, and Type IIB according to tear symmetry and direction of maximum tear diameter, with Type I being symmetrical and Type II being asymmetrical. Type IA (U-shaped) had greater mediolateral (ML) than anteroposterior (AP) diameter while Type IB (crescent shaped) had greater AP than ML diameter. Type IIA tears have an anterior extension towards the rotator interval while IIB tears have a posterior extension into the infraspinatus, similar to AP L-shaped tears established in the literature. Type I tears were typically repaired from medial to lateral while Type II tears were repaired diagonally. All types were repaired using double row technique, with the addition of margin convergence for Types IA and IIB, which had larger tears in the medial and lateral directions. Primary outcome measures were Oxford Shoulder Score, Constant Shoulder Score, University of California at Los Angeles Shoulder Score followed-up at 6, 12, and 24-months as well as retear rates at latest follow-up.

RESULTS

In total, 109 patients were included in the study with a mean age of 65.5 ​± ​9.4. The prevalence of each tear morphologies from Type IA to IIB was 22.0 ​%, 34.9 ​%, 27.5 ​%, and 15.6 ​%, respectively. All four groups showed statistically significant improvement from pre-operative scores in all 3 outcome measures at 24 months (p ​< ​0.001 for all). No significant difference in primary outcome measures or retear rates was detected between all 4 groups.

CONCLUSION

This study found that different types of cuff tear morphology, despite affecting surgical repair technique, does not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up.

LEVEL OF EVIDENCE

Retrospective Cohort study, Level III.

Subacromial Balloon Spacer Implantation Is a Promising Alternative for Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

To provide an overview of the existing literature on subacromial balloon spacers for the treatment of massive irreparable rotator cuff tears, in an effort to inform surgeons of the procedure's clinical effectiveness.

METHODS

The PubMed, Scopus, and Ovid EMBASE databases were queried to identify studies evaluating the clinical, radiographic, and patient-reported outcomes of patients indicated for subacromial balloon spacer implantation. The following datapoints were extracted: study demographics, patient baseline characteristics, and postoperative outcomes of interest. Outcomes were evaluated at baseline and at the longest available follow-up period.

RESULTS

A total 766 patients were included among 22 included studies, with an average follow-up of 27.54 months. Improvements were seen for all clinical and patient-reported outcomes: forward elevation (ranging from 9.20 to 90.00° improvement), external rotation (ranging from 2.00 to 22.00°), abduction (ranging from 14.00 to 95.00°), Total Constant Score (ranging from 7.70 to 50.00), American Shoulder and Elbow Surgeons score (ranging from 24.60 to 59.84), Oxford Shoulder Score (ranging from 7.20 to 22.20), and pain score (ranging from 3.57 to 6.50). Minimal differences were seen in acromiohumeral interval (ranging from -2.00 to 1.27). Reoperation and complication rates ranged from 0% to 33% and 0% to 19.64%, respectively.

CONCLUSIONS

The short-term results of subacromial balloon spacers for management of massive rotator cuff tears demonstrate clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures. Of note, minimal change in acromiohumeral interval was seen on postoperative radiography, and wide variations in complication and reoperation rates were reported across studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.