Comparison of arthroscopic and open revision decompression for failed anterior acromioplasty

Arthroscopic distal clavicle resection versus conservation in patients with combined rotator cuff tears and acromioclavicular joint osteoarthritis

PURPOSE

The most common cause of shoulder pain originating from the acromioclavicular (AC) joint is osteoarthritis, causing pain and disability. Operative Management of AC arthritis includes arthroscopic distal clavicle resection (DCR) and open clavicle resection. This study was conducted to evaluate the outcomes of isolated rotator cuff repair with conservative treatment of ACJ arthritis versus the combined resection of the distal clavicle with the repair of a rotator cuff tear, in cases with acromioclavicular arthritis.

METHODS

A total of 46 patients with unilateral or bilateral combined rotator cuff tear and acromioclavicular arthritis were included, they were classified into 2 independent groups: Conservative group (23 patients), and DCR group (23 patients). All patients were subjected to full history taking, examination, pre and post-operative University of California at Los Angeles shoulder scoring scale (UCLA), Antero-Posterior and Zanca X-rays views, early and late complications.

RESULTS

Mean age was (51 ± 9) years, males were predominant (56.5%). The average post-operative UCLA score was (31.1 ± 4.9), and the average time to return to work was (214 ± 22). (2.2%) of patients had early complications, (19.6%) had late complications, (32.6%) had > 24 h till 1st post-operative analgesia, and (87%) needed MgSO4 Injection. We found a highly significant increase in UCLA score measurements in the Conservative group, and a highly significant increase in UCLA score measurements in the DCR group (p < 0.01). But there was no difference between the 2 groups.

CONCLUSION

Conventional conservative approach with arthroscopic rotator cuff repair and subacromial decompression has proven to be as effective as arthroscopic rotator cuff repair and subacromial decompression with DCR, in terms of efficacy and safety profiles in short term, but with more risks of potential hazards and cost with the DCR.

Do Outcomes Differ After Proximal Hamstring Repair for Patients Receiving Workers' Compensation?

Background

Patients with workers' compensation (WC) insurance claims are often shown to experience inferior patient-reported outcomes (PROs) after an orthopaedic surgical intervention compared with patients without WC claims.

Purpose

To compare the postoperative PROs of patients with WC claims (WC patients) versus those without WC claims (non-WC patients) after proximal hamstring repair (PHR).

Study Design

Cohort study; Level of evidence, 3.

Methods

WC patients who underwent PHR between November 2011 and to September 2020 were propensity score matched at a 1:2 ratio to non-WC patients according to age, sex, and body mass index. Comorbidity data were collected as well as minimum 1-year postoperative PRO scores for the Lower Extremity Functional Scale (LEFS), the Hip Outcome Score (HOS), and the 12-Item Short From Health Survey (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS). The type of work was characterized according to national WC insurance guidelines as light (maximum 20 lbs [9.1 kg]), medium (maximum 50 lbs [22.7 kg]), or heavy (≥50 lbs) [>/=22.7 kg].

Results

A total of 30 patients (10 WC and 20 non-WC) were included. The work type and baseline demographic characteristics of patients did not differ between groups. There were no significant between-group differences in postoperative PRO scores as measured by the LEFS (P = .488), HOS (P = .233), or SF-12 PCS (P = .521). However, the WC cohort showed inferior SF-12 MCS scores compared with the non-WC group (49.28 ± 9.97 vs 54.26 ± 9.69, respectively; P = .032). The WC status was also associated with an increased time needed for patients to return to full-duty work capacity (21 ± 9 vs 9 ± 8 weeks; P = .005).

Conclusion

Our findings suggest that WC and non-WC patients who undergo PHR have comparable outcomes. Differences in SF-12 MCS scores and return to work time for full-duty capacity warrant further investigation.

Understanding Outcomes and the Ability to Return to Work After Rotator Cuff Repair in the Workers' Compensation Population

Introduction

Patients with a worker compensation claim are associated with a greater probability of continued symptoms and activity intolerance. This study aims to determine predictors of improved patient-reported outcomes in the workers’ compensation population.

Methods

Patients with workers’ compensation claims undergoing arthroscopic rotator cuff repair between 2010 and 2015 were included. Age, gender, dominant hand, occupation, and number of tendons involved were analyzed. At a minimum of two years, patients were contacted to complete American Shoulder and Elbow Surgeons (ASES) Survey, Simple Shoulder Test (SST), and return-to-work status (RTW). Preoperative characteristics and scores were then compared.

Results

Seventy patients were available for follow-up at an average of 5.4 years (range: 2.1-8.8 years). Average age was 55 years (range: 37-72); 55 (78.6%) were males, 23 (32.9%) were laborers; and 59 (84.2%) patients returned to work. The sole predictor for RTW was surgery on the non-dominant arm (96.5% versus 75.6%; p = 0.021). Laborers showed decreased RTW (p = 0.03). Patients who completed RTW had excellent outcomes with higher ASES (87 versus 50; p value < 0.001) and SST scores (10.4 versus 4.6; p < 0.001). Patients with three tendon tears had inferior ASES (p = 0.026) and SST (p = 0.023) scores than those with less.

Conclusion

Most workers’ compensation patients have excellent outcomes from rotator cuff repair. Patients with three tendon tear repairs demonstrated the worst functional outcomes. Laborers showed decreased ability to RTW with nearly one-third unable.

Preoperative Factors Associated With Subsequent Distal Clavicle Resection After Rotator Cuff Repair

Background:

Acromioclavicular osteoarthritis and rotator cuff tears are commonly coincident.

Purpose:

To determine the rate of subsequent distal clavicle excision (DCE) when rotator cuff repair (RCR) is performed without DCE and the risk factors for subsequent DCE after RCR.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

The operative logs of 2 surgeons from 2007 to 2016 were retrospectively reviewed for all patients who underwent RCR with or without DCE. Preoperative demographic data, symptoms, physical examination, and standardized outcomes (visual analog scale for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) were noted. Acromioclavicular (AC) arthritis was classified on preoperative radiographs. The rate of subsequent surgery on the AC joint was determined via chart review, and univariate and multivariate analyses were conducted to determine risk factors for revision.

Results:

In total, 894 patients underwent isolated RCR, and 46 underwent concomitant RCR and DCE. On retrospective chart review, of those who underwent isolated RCR, the revision rate for any reason was 7.5% (67 patients), and the rate of subsequent AC surgery was 1.1% (10 patients). Preoperatively, 88% of the total cohort was considered to have a radiographically normal AC joint. On multivariate analysis of patients who underwent isolated RCR, the risk factors for subsequent AC surgery included preoperative tenderness to palpation at the AC joint (10% vs 63%, P < .001), female sex (35% vs 80%, P < .001), and surgery on the dominant side (60% vs 100%, P = .002). On multivariate analysis, these 3 factors explained 50% of the variance in revision AC surgery. When these 3 factors were present in combination, there was a 40% rate of revision AC surgery.

Conclusion:

This records review found that 10 of 894 (1.1%) rotator cuff repairs underwent subsequent distal clavicle resection. Risk factors for subsequent DCE included tenderness to palpation at the AC joint, female sex, and surgery on the dominant side, with subsequent DCE performed in 40% of cases with a combination of these 3 factors. Because the duration of follow-up was short and the number of reoperations small, some caution is recommended in interpreting these results, as the analyses may be underpowered.

Predictive value of preoperative clinical examination for subacromial decompression in impingement syndrome

PURPOSE

Subacromial decompression is the standard surgical treatment of subacromial impingement syndrome. Unsatisfactory results have been reported for concomitant lesions as well as inadequate diagnosis. We sought to determine the predictive value of the preoperative examination for the results of arthroscopic subacromial decompression in impingement syndrome.

METHODS

Forty-nine shoulder joints in 47 patients receiving arthroscopic subacromial decompression were prospectively followed for a mean 3.7 ± 0.4 years. Prior to surgery, the impingement tests according to Neer, Hawkins-Kennedy (in the neutral as well as abducted position), and the Jobe test (empty can position) were evaluated as well as the presence of a painful arc. The association between the presence of these sings, success of the operation, and improvement in Constant scores as well as WORC indices was analysed.

RESULTS

Pre- to postoperative improvement in Constant scores as well as WORC indices was greater in case of a positive test result for every test studied. With the numbers available, significant greater improvements in Constant scores were observed only for patients with a positive Hawkins-Kennedy sign in the neutral position, Neer and Jobe tests, compared to patients with negative signs, respectively. No significant differences were observed for the improvement in WORC indices. Patients with at least four positive tests out of the five studied had greater improvement in Constant scores than patients with three or less positive test results. Five patients went on to receive subsequent shoulder surgery. There was no association between the necessity for revision surgery and the presence or absence of impingement signs.

CONCLUSION

The impingement tests according to Hawkins-Kennedy, Neer, and Jobe are valid predictors of outcome after subacromial decompression, as is the presence of multiple impingement tests. This study may aid in improving patient outcome and especially patient selection for subacromial decompression.

LEVEL OF EVIDENCE

Prognostic, Level I.

Is arthroscopic distal clavicle resection necessary for patients with radiological acromioclavicular joint arthritis and rotator cuff tears? A prospective randomized comparative study

BACKGROUND

The failure of subacromial decompression may be attributed to persistent symptoms of acromioclavicular joint (ACJ) arthritis, while inferior clavicular spurs of the ACJ may be associated with failed healing of repaired rotator cuffs.

PURPOSE

To evaluate the clinical effectiveness of arthroscopic distal clavicle resection (DCR) in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 78 patients with rotator cuff tears in addition to radiological and asymptomatic ACJ arthritis who were scheduled for arthroscopic rotator cuff repair were prospectively randomized into 2 groups. Patients underwent arthroscopic rotator cuff repair with acromioplasty. Patients in group 1 (39 patients) underwent additional arthroscopic DCR, while patients in group 2 (39 patients) did not. Clinical outcomes of the 2 groups were compared using the visual analog scale (VAS) for pain, range of motion, Constant score, and American Shoulder and Elbow Surgeons (ASES) score up to at least 24 months. The structural integrity of repaired rotator cuffs was assessed using ultrasonography, computed tomography arthrography, or MRI at least 6 months after surgery. To evaluate ACJ instability, weighted stress radiography of the ACJ was studied at 6 and 12 months postoperatively.

RESULTS

Patients in both groups showed significant improvement in the VAS score and all functional scores at final follow-up (mean, 29.2 months; range, 24-46 months) without significant differences between the 2 groups (P > .05). Results (mean ± SD) for preoperative group 1/group 2 and postoperative group 1/group 2 were as follows, respectively: 7.2 ± 1.8/6.1 ± 1.9 (P = .02) and 0.6 ± 1.8/0.6 ± 0.9 (P = .97) for the VAS score, 74.1 ± 5.7/73.8 ± 8.0 (P = .87) and 96.3 ± 5.7/95.7 ± 4.6 (P = .77) for the Constant score, and 47.0 ± 10.3/50.8 ± 14.1 (P = .22) and 91.5 ± 15.5/94.5 ± 11.8 (P = .55) for the ASES score. Failed cuff healing occurred in 9 patients (23%) in group 1 and 10 patients (26%) in group 2, with no significant difference (P = .95). In group 1, there were 2 patients (5.0%) with ACJ subluxation on weighted stress radiography at 6 months postoperatively. These patients complained of gross protrusion and ACJ tenderness.

CONCLUSION

Preventive arthroscopic DCR in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis did not result in better clinical or structural outcomes, and it did lead to symptomatic ACJ instability in some patients. Preventive arthroscopic DCR is not recommended in patients with radiological but asymptomatic ACJ arthritis. Further long-term follow-up is needed to confirm the development of symptoms in ACJ arthritis.

Outcomes of open subacromial decompression after failed arthroscopic acromioplasty

Aim. To prospectively assess the effectiveness of revision with open subacromial decompression in patients who had a previous unsatisfactory outcome with the arthroscopic procedure. Methods. 11 patients were identified for the study, who did not demonstrate expected improvement in symptoms after arthroscopic acromioplasty. All patients underwent structured rehabilitation. Functional evaluation was conducted using the Hospital for Special Surgery, New York, shoulder rating questionnaire. Results. M : F was 7 : 4. The mean age was 57 years. The average shoulder score improved from 49.6 preoperatively to 56 postoperatively at an average followup of 16 months. Two patients showed deterioration in their shoulder scores after revision while the rest showed only marginal improvement. All except one patient stated that they would opt for surgery again if given a second chance. Conclusion. In the group of patients that fail to benefit from the arthroscopic decompression, only a marginal improvement was noted after revision with open decompression.

The CARE technique: arthroscopic CoracoAcromial ligament RE-attachment

During standard acromioplasty, the inferior fibers of the coracoacromial ligament are inevitably detached. Partial or complete sectioning of the coracoacromial ligament results in secondary weakening of the deltoid muscle and an incremental risk of anterior-superior glenohumeral migration. This technique allows the re-attachment of the inferior fibers to the intact portion of the ligament and re-establishes mechanical continuity of the coracohumeral arc.

Difference in outcome of shoulder surgery between workers' compensation and nonworkers' compensation populations

The purpose of this study was to review the association between compensation status and surgical outcome especially of the shoulder. Given the high prevalence of shoulder injuries in the workplace and the large proportion of workers compensation (WC) claims involving such injuries, it is worth examining the correlation between WC status and surgical outcome of the shoulder. All studies published in journals (MEDLINE and PubMed) from 1980 through 2007 on surgical interventions performed on the shoulder in which workers compensation status was documented and the postoperative functional outcome was compared according to that status were pooled for meta-analysis. This systematic review shows that compensation status of an individual receiving shoulder surgery is a consistent positive predictor of poor functional outcome. The majority of questions posed in the most commonly adopted shoulder-specific functional outcome measurement tools were subjective in nature and may account for part of the phenomenon.

Radiofrequency-based plasma microtenotomy compared with arthroscopic subacromial decompression yields equivalent outcomes for rotator cuff tendinosis

PURPOSE

This study aimed to determine whether radiofrequency (RF)-based plasma microtenotomy (microdebridement) was effective for treating chronic supraspinatus tendinosis.

METHODS

The institutional ethics committee approved the study design, and all patients signed informed consent forms. Patients (age range, 30 to 70 years) were considered for enrollment if 6 months of active conservative treatment had failed and they had Neer stage II impingement syndrome, positive radiographic evidence of type II acromion, and magnetic resonance imaging or ultrasound evidence of supraspinatus tendinosis. Patients (N = 60) were randomly assigned to undergo arthroscopic subacromial decompression or RF-based plasma microtenotomy. For microtenotomy, a bipolar RF-based probe (TOPAZ; ArthroCare, Austin, TX) was used to perform microdebridement in the supraspinatus tendon; patients did not undergo acromioplasty. Outcomes evaluation consisted of self-reported pain via a visual analog scale, as well as functional assessment (American Shoulder and Elbow Surgeons [ASES] survey, Constant score, and University of California, Los Angeles [UCLA] questionnaire). Statistical analyses were performed by use of factorial dependent-measures analysis of variance tests.

RESULTS

Age and baseline scores on the visual analog scale (mean +/- SD) were 52.0 +/- 6.7 and 53.2 +/- 6.6 years and 8.4 +/- 0.9 and 8.2 +/- 0.8 points in the microtenotomy and arthroscopic subacromial decompression groups, respectively. A significant reduction in pain (P < .001) and improved function (P < .001 for all measures) were observed in both groups postoperatively. Both treatment groups had almost identical longitudinal recovery profiles for pain relief (P = .416) and restoration of function (P = .964 for ASES score, P = .978 for Constant score, and P = .794 for UCLA score). At 1 year, the median pain score was 1.0, and all patients had ASES, Constant, and UCLA scores of greater than 90, greater than 80, and greater than 30, respectively.

CONCLUSIONS

Both procedures were associated with significant improvement postoperatively, but the RF-based plasma microtenotomy procedure draws into question the need for a more extensive procedure such as subacromial decompression in this patient population.

LEVEL OF EVIDENCE

Level I, therapeutic randomized controlled study.

Management of rotator cuff disease: specific treatment for specific disorders

Disease of the rotator cuff is common. It is responsible for a high proportion of patients with shoulder pain presenting to general practice, causing work absenteeism and claims for sickness benefits. Rotator cuff disease (RCD) can often be managed in primary health care services, although some cases may require secondary referral. Both extrinsic and intrinsic factors to the cuff tendon are thought to be involved in the pathogenesis leading on to a spectrum of conditions ranging from sub-acromial bursitis to mechanical failure of the cuff tendon itself. Careful history and examination followed by pertinent investigation are essential to establish the correct diagnosis. The main aim of treatment is to improve symptoms and restore function of the affected shoulder. The majority of patients suffering from RCD can be managed by conservative means, but a shift in attitude has led to a significant number benefiting from invasive procedures ranging from decompression of the sub-acromial space to large, open procedures reconstructing the tendon itself.

Arthroscopic rotator cuff repair with and without subacromial decompression: a prospective randomized study

PURPOSE

Our purpose was to evaluate the role of subacromial decompression in the arthroscopic repair of full-thickness rotator cuff tears in a prospective randomized clinical study.

METHODS

Arthroscopic cuff repair was performed in 80 patients with a full-thickness rotator cuff tear. They were divided into 2 groups comprising 40 patients each. In group 1 arthroscopic rotator cuff repair was performed with subacromial decompression. In group 2 the repair was performed without decompression. Rotator cuff tears were repaired via metal suture anchors for tendon-to-bone repair, side-to-side repair, or a combination of the 2 techniques. Results were evaluated by use of the Constant score normalized for age and gender, as well as the Disabilities of the Arm, Shoulder and Hand (DASH) and Work-DASH self-administered questionnaires. On analyzing the results at 2 years' follow-up, we considered the following independent variables: age; gender; dominance; location, shape, area, retraction, and reducibility of cuff tear; fatty degeneration; involvement of subscapularis tendon; treatment of biceps tendon; rotator cuff repair technique; and type of acromion. A univariate and multivariate statistical analysis was performed to determine which variables were independently associated with the outcome.

RESULTS

Comparison between the groups did not show significant differences for each variable considered. The overall results for the Constant score were 103.6 points in group 1 and 96.1 points in group 2; those for the DASH score were 18.2 points and 23.1 points, respectively; and those for the Work-DASH score were 23.7 points and 26.2 points, respectively. Univariate and multivariate analysis showed that the following variables significantly and independently influenced the outcome: age; shape, retraction, and reducibility of cuff tear; fatty degeneration; involvement of subscapularis; and repair technique. Subacromial decompression did not influence the outcome significantly for each scoring system considered.

CONCLUSIONS

At short-term follow-up, subacromial decompression did not seem to significantly affect the outcome of arthroscopic rotator cuff repair. Longer follow-up studies will be necessary to confirm the clinical relevance of these observations.

LEVEL OF EVIDENCE

Level I, randomized controlled trial with no significant difference but narrow confidence intervals.

Long-term results of acromioclavicular joint coplaning

PURPOSE

Coplaning removes medial acromial spurs and portions of the distal clavicle with an arthroscopic subacromial decompression (ASD). Concerns exist that this violates inferior acromioclavicular (AC) ligaments and increases AC joint mobility, resulting in long-term problems. The purpose of this study was to re-evaluate 3 cohorts of patients who underwent ASD with various degrees of coplaning and to determine if late AC joint tenderness or reoperation had occurred.

TYPE OF STUDY

Nonrandomized control study.

METHODS

Eighty-one patients undergoing ASD were divided into 3 groups. Group 1 (24) underwent removal of inferior clavicle osteophytes, group 2 (34) had a distal clavicle hemiresection with up to 50% of the articular cartilage removed, and group 3 (23) had complete distal clavicle resection. Radiographs, charts, and arthroscopic videotapes were reviewed to determine the amount of clavicle removed. Follow-up evaluations included Constant-Murley, American Shoulder and Elbow Surgeons (ASES), SANE, and Rowe shoulder scores with special attention given to AC joint pain and additional procedures.

RESULTS

The average patient age was 46 years (range, 19 to 81 years) and follow-up was 73 months. At follow-up, the average Constant, ASES, Row, and SANE scores were: for group 1, 97.1, 97.5, 96.9, and 95.8, respectively; for group 2, 95.1, 97.4, 96, and 92.8, respectively; and for group 3, 96.3, 98.3, 96.1, and 95.7. No patient required additional shoulder surgery.

CONCLUSIONS

Coplaning did not increase AC joint symptoms, compromise clinical results, or lead to additional surgery at an average follow-up of 6 years.

LEVEL OF EVIDENCE

Level IV, therapeutic case series study.

Coplaning of the acromioclavicular joint

PURPOSE

Coplaning removes inferior spurs or portions of the distal clavicle to decrease injury to the rotator cuff. This study sought to determine if the presence or degree of coplaning influenced the results and if reoperations for distal clavicle symptoms were needed.

TYPE OF STUDY

Nonrandomized control study.

METHODS

A total of 76 patients undergoing arthroscopic subacromial decompression (ASD) followed for at least 25 months were divided into 3 groups. Group 1 included 28 patients who underwent ASD with removal of only an inferior clavicular osteophyte. Group 2 included 27 patients with resection of any inferior clavicle spur, violation of the inferior joint capsule, and removal of articular cartilage to a level adjacent with the resected acromion. As much as 50% of the articular cartilage was removed in some cases. Group 3 included 21 patients who underwent a complete distal clavicle excision. Radiographs, charts, and arthroscopic videotapes were reviewed and the degree of claviculectomy exactly determined. Follow-up evaluations included the Constant-Murley, American Shoulder and Elbow Surgeons (ASES), SANE, and Rowe shoulder scores, with special attention given to acromioclavicular (AC) joint pain and additional operations.

RESULTS

The average age of the patients was 49 years (range, 19 to 81 years) and follow-up averaged 40 months (range, 25 to 68 months). Follow-up Constant, ASES, Rowe, and SANE scores for the various groups were calculated. Group 1 scores were 99.4, 98.7, 98.6, and 98.1, respectively; group 2 scores were 96.8, 98.7, 98.5, and 95.7, respectively; and group 3 scores were 98.4, 99.4, 99.3, and 98.6, respectively. No patient required any additional AC joint surgery.

CONCLUSIONS

Violation of the AC joint capsule and partial distal clavicle resection to make it confluent with the resected acromion (coplaning), does not cause increased AC joint symptoms, compromise the results, or lead to additional surgery at an average 40-month follow-up.