Epidemiological Analysis of Changes in Clinical Practice for Full-Thickness Rotator Cuff Tears From 2010 to 2015

A two-step neural network-based guiding system for obtaining reliable radiographs for critical shoulder angle measurement

Background

The critical shoulder angle (CSA) has been reported to be highly associated with rotator cuff tears (RCTs) and an increased risk of RCT re-tears. However, the measurement of the CSA is greatly affected by the malpositioning of the shoulder. To address this issue, a two-step neural network-based guiding system was developed to obtain reliable CSA radiographs, and its feasibility and accuracy was evaluated.

Methods

A total of 1,754 shoulder anteroposterior (AP) radiographs were retrospectively acquired to train and validate a two-step neural network-based guiding system to obtain reliable CSA radiographs. The study included patients aged 18 years or older who underwent X-rays and/or computed tomography (CT) scans of the shoulder. Patients who had undergone shoulder surgery, had a confirmed fracture, or were diagnosed with a musculoskeletal tumor or glenoid defect were excluded from the study. The system consisted of a two-step neural network that in the first step, localized the region of interest of the shoulder, and in the second step, classified the radiography according to type [i.e., 'forward' when the non-overlapping coracoid process is above the glenoid rim, 'backward' when the non-overlapping coracoid process is below or aligned with the glenoid rim, a ratio of the transverse to longitudinal diameter of the glenoid projection (RTL) ≤0.25, or a RTL >0.25]. The performance of the model was assessed in an offline, prospective manner, focusing on the sensitivity and specificity for the forward, backward, RTL ≤0.25, or RTL >0.25 types (denoted as SensF, B, -, + and SpecF, B, -, +, respectively), and Cohen's kappa was also reported.

Results

Of 273 cases in the offline prospective test, the SensF, SensB, Sens-, and Sens+ were 88.88% [95% confidence interval (CI): 50.67-99.41%], 94.11% (95% CI: 82.77-98.47%), 96.96% (95% CI: 91.94-99.02%), and 95.06% (95% CI: 87.15-98.40%), respectively. The SpecF, SpecB, Spec-, and Spec+ were 98.48% (95% CI: 95.90-99.51%), 99.55% (95% CI: 97.12-99.97%), 95.04% (95% CI: 89.65-97.81%), and 97.39% (93.69-99.03%), respectively. A high classification rate (93.41%; 95% CI: 89.14-96.24%) and almost perfect agreement (Cohen's kappa: 0.903, 95% CI: 0.86-0.95) were achieved.

Conclusions

The guiding system can rapidly and accurately classify the types of AP shoulder radiography, thereby guiding the adjustment of patient positioning. This will facilitate the rapid obtainment of reliable CSA radiography to measure the CSA on proper AP radiographs.

Rotator Cuff Repair With Acromioplasty Is Associated With an Increased Rate of Revision and Subsequent Procedures

Purpose

To evaluate the mid-term rate of revision arthroscopic rotator cuff repair as well as ipsilateral shoulder reoperations after index rotator cuff repair performed with or without acromioplasty in the United States.

Methods

The Medicare Standard Analytic File, which encompasses the entire Medicare billing and payment data, was queried between 2005 and 2014. Patients undergoing arthroscopic rotator cuff repair were identified and stratified based on whether ipsilateral acromioplasty was concurrently performed using Current Procedural Terminology codes. Groups were matched by age, sex, year of index procedure, and Elixhauser index at a 2:1 ratio. Primary end point was defined as undergoing a repeat ipsilateral shoulder surgery related to the rotator cuff at 5 years of follow-up. Kaplan-Meier survival curves were constructed, and the 2 groups were compared using the log-rank test.

Results

After matching, 54,209 shoulders in the rotator cuff repair with acromioplasty group and 26,448 shoulders in the rotator cuff repair without acromioplasty group were identified. Shoulders undergoing concurrent acromioplasty at index rotator cuff repair had a significantly increased rate of repeat ipsilateral cuff repair at 5 years postoperatively (8.5% vs 6.8%, P < .001). Similarly, there was an increased rate of reoperation of all types to the ipsilateral shoulder in cases where concurrent acromioplasty was performed (9.6% vs 9.1%, P < .001).

Conclusions

Using a large, national database, concurrent acromioplasty at the time of rotator cuff tear was found to be associated with both an increase rate of overall subsequent procedures and revision rotator cuff repair.

Level of Evidence

III, retrospective comparative study.

Effect of Physical Therapy and Rehabilitation Timing on Rotator Cuff Repair Revisions and Capsulitis

INTRODUCTION

One variable that could potentially affect failure of a rotator cuff repair (RCR) is the timing of beginning physical therapy (PT) after the procedure. Although many studies have demonstrated decreased stiffness with beginning PT early, studies have also demonstrated that early PT increases repair failure. The goal of this study was to identify revision surgery and capsulitis rates after RCRs from an available database and determine whether an association was present with the timing of PT post-RCR.

METHODS

Medicare patients within the PearlDiver database who underwent RCR were stratified based on the timing of their first PT session postoperatively, and revision surgery and capsulitis rates were determined among the groups for both open and arthroscopic RCR. Demographics and comorbidities of the cohort were also used to formulate a multivariate analysis for revision surgery rate.

RESULTS

The cohort consisted of 64,842 patients who underwent RCR and started PT within 13 weeks of surgery. Starting PT within 1 week postoperatively resulted in a significantly higher revision surgery rate compared with starting PT in weeks 2 to 5, 6 to 9, or 10 to 13 (6.9% vs. 3.6% among all other groups, P = <0.001). The multivariate analysis for revision surgery further demonstrated that starting PT within 1 week postoperatively was associated with a significantly higher rate of revision surgery compared with beginning PT after 1 week (OR = 2.086, P < 0.001). No association was found between timing of beginning PT and capsulitis rates.

CONCLUSION

In the Medicare patient cohort, beginning PT within 1 week postoperatively was associated with a significantly higher revision surgery rate; however, no associated benefit was noted in capsulitis rates for beginning PT early. This calls into question the use of an early passive range of motion protocol for older patient cohort; however, further studies should be completed to conclusively determine the most efficacious time to begin rehabilitation post-RCR.

LEVEL OF EVIDENCE

Level III.

Diagnostic value of the hourglass biceps test for the detection of intra-articular long head of the biceps hypertrophy

Background

Shoulder surgeons performing tenodesis note a great variability in morphology of the proximal biceps. The hourglass biceps test measures the integrity of the intra-articular biceps tendon. The hourglass maneuver (HM) is positive when there is a passive flexion deficit compared to the contralateral shoulder in a relaxed patient in the supine position.

Hypothesis

Preoperative HM is correlated with an increased width of the biceps portion resected during tenodesis.

Methods

This prospective study evaluated all patients (N = 58) who underwent biceps tenodesis between January and September 2019. Two groups of patients were compared: group 1 (n = 20) had a positive HM and group 2 had a negative HM (n = 38). The smallest (s) and largest (L) width of the tendon were measured intraoperatively, and the L/s ratio was calculated. The HM was then evaluated as a diagnostic test by creating a contingency table and determining the sensitivity and specificity of the test for different L/s ratios. A receiver operating characteristic curve was created and the area under the curve (AUC) was calculated.

Results

A nonsignificant difference was found between the mean largest biceps width in group 1 compared to group 2 (11.65 mm [range: 5-21] vs. 9.71 mm [range: 6-20], respectively; P < .05). The AUC was 0.81; the sensitivity was 68.9% and specificity, 80.8%.

Conclusion

Preoperative positivity of the HM is linked to the increased width of the biceps portion resected during tenodesis. The hourglass biceps test should be predictive of intraoperative hourglass biceps according to our definition.

Morphologic and radiologic parameters correlating to shoulder function at diagnosis for patients with rotator cuff tear

BACKGROUND

The magnetic resonance imaging (MRI) parameters used to diagnose rotator cuff tears are weakly correlated to shoulder function. Our hypothesis was that adding 3-dimensional morphologic parameters resulting from biplanar radiographs (3DXR parameters) to the MRI parameters would improve this correlation.

METHODS

We assessed 52 patients with rotator cuff tears with an EOS Imaging radiographic examination, MRI study, and clinical evaluation of the shoulder, as well as the Constant score. The bones of the 52 shoulders were reconstructed 3-dimensionally, and eleven 3DXR parameters were automatically extracted. First, the trueness and reliability of these parameters were evaluated. Then, bivariate correlations between each parameter and the Constant score were made. A linear regression model was subsequently built to correlate the 11 parameters and 5 MRI findings with shoulder function at diagnosis, as assessed by the Constant score.

RESULTS

The parameters showed good trueness and reliability of most 3DXR parameters. Supraspinatus tear extension, muscle atrophy, and the distance between the greater and deltoid tuberosities were the only parameters with a statistically significant correlation to a lower Constant score (P < .05) in the bivariate study. These correlations were either weak or negligible. A regression model was successfully built with one MRI parameter and four 3DXR parameters. Correlation to function increased from 16.7% to 43.3% with this model.

CONCLUSION

For patients with rotator cuff tears, the combination of MRI and 3DXR parameters of the shoulder in a linear regression model improves the correlation with the Constant score (shoulder function) at diagnosis.

Anatomic total shoulder arthroplasty after healed rotator cuff repair: a matched cohort

BACKGROUND

Rotator cuff tears are a common cause of failure after anatomic total shoulder arthroplasty (TSA). The purpose of this study was to evaluate the effect of a healed prior rotator cuff repair (RCR) on outcomes and complications after primary TSA. We hypothesized that patients with a prior healed RCR would have equivalent outcomes and complication rates compared with patients without prior surgery.

METHODS

A retrospective review of all primary TSAs with a prior RCR was performed using a multicenter database between 2005 and 2017. Thirty shoulders with prior RCR were case matched on a 3:1 ratio with a minimum 2-year follow-up. Range of motion, strength, patient-reported outcome measures, complications, and reoperations were compared.

RESULTS

Thirty shoulders with a prior RCR were compared with 90 control patients without prior surgery at a mean follow-up of 43 months (range, 24-109 months). Groups demonstrated similar preoperative range of motion and patient-reported outcome measures. Postoperatively, TSAs with a prior healed RCR demonstrated less forward flexion (132° vs. 143°, P = .14) and strength (5.7 vs. 6.4 kg, P = .55) compared with control shoulders with no prior surgery; however, these did not meet statistical significance. Complications were significantly more common in patients with a prior RCR (17% vs. 7%, P = .01). Postoperative rotator cuff tears were significantly more common in TSA with a healed prior RCR (13% vs. 1%, P = .014).

CONCLUSIONS

TSA after RCR results in similar functional improvements compared with shoulders without prior surgery. However, the risk of a postoperative rotator cuff tear is significantly higher after prior successful RCR. Surgeons should consider this potential complication when indicating these patients for primary TSA.

Health Care Utilization and Costs in the Year Prior to Arthroscopic Rotator Cuff Repair

Background:

A majority of cost-control strategies in arthroscopic rotator cuff repair (RCR) have been concentrated on the perioperative and post–acute care periods, with the preoperative health care period being largely overlooked.

Purpose:

To report the distribution of costs associated with health care utilization within the year prior to arthroscopic RCR.

Study Design:

Economic and decision analysis; Level of evidence, 3.

Methods:

The 2007 through 2015 (third quarter) Humana Administrative Claims database was queried using Current Procedural Terminology code 29827 to identify patients undergoing arthroscopic RCR for only degenerative rotator cuff tears. The study cohort was divided into 2 distinct groups based on insurance plan: commercial or Medicare Advantage (MA). Total 1-year costs, per-patient average reimbursements (PPARs), and trends in utilization for the following preoperative health care resource categories were studied: office visits, radiographs, magnetic resonance imaging (MRI) scans, computed tomography (CT) scans, steroid injections, hyaluronic acid (HA) injections, physical therapy, and pain medications (opioids + nonopioids).

Results:

A total of 18,457 MA and 6530 commercial beneficiaries undergoing arthroscopic RCR over the study period were included. Total 1-year preoperative costs (in US$) amounted to $16,923,595 ($916/patient) and $8,397,291 ($1285/patient) for MA and commercial beneficiaries, respectively. The largest proportion of total 1-year costs for both MA and commercial beneficiaries was accounted for by MRI scans (36% and 56%, respectively). PPARs for each health care resource category were as follows: office visits (MA, $240; commercial, $249), radiographs (MA, $60; commercial, $93), MRI scans (MA, $385; commercial, $813), CT scans (MA, $223; commercial, $562), steroid injections (MA, $97; commercial, $137), HA injections (MA, $422; commercial, $602), physical therapy (MA, $473; commercial, $551), and pain medications (MA, $208; commercial, $136). High health care utilization within the past 3 months before surgery was noted for radiographs, physical therapy, opioids, steroid injections, and office visits, with up to 40% to 90% of 1-year PPARs being accounted for within this time period alone.

Conclusion:

Approximately $900 to $1300 per patient was spent in rotator cuff–related health care resource use in the year prior to undergoing arthroscopic RCR. As we begin to implement value in shoulder surgery, judicious use of nonoperative treatment modalities among patients who would not benefit from nonoperative care will be an effective way of reducing costs.