Asymptomatic acromioclavicular joint arthritis in arthroscopic rotator cuff tendon repair: a prospective randomized comparison study

Evaluating the Effect of Rotator Cuff Repair With Concomitant Distal Claviculectomy on 2 and 4 Year Reoperation Rates

BACKGROUND

The current literature has differing views on the efficacy of concomitant distal claviculectomy (DC) during rotator cuff repair (RCR) in preventing revision surgery. Our aim was to investigate the revision surgery rate between RCR with DC and RCR without DC.

METHODS

A retrospective cohort analysis was conducted using a national claims database. Patients undergoing open or arthroscopic primary RCR with or without concomitant DC were identified. The primary outcome was 4-year revision surgery rates. Univariate analysis was conducted using chi-square or Student t tests. Multivariable analysis was conducted using logistic regression, and an adjusted number needed to harm was calculated.

RESULTS

A total of 131,232 patients met inclusion criteria. After logistic regression, patients undergoing RCR with DC had higher odds of requiring a subsequent DC procedure [OR; 95% CI; P-value (1.49; 1.35-1.64; P < 0.001)] but lower odds of any revision surgery (0.87; 0.80-0.91; P < 0.001) within 4 years than those who underwent RCR without DC.

CONCLUSION

Although associated with a lower rate of overall revision surgeries within 2 and 4 years of RCR, those who underwent RCR with DC were 85% more likely at 2 years and 49% more likely at 4 years to undergo revision surgery of the distal clavicle than those without concomitant DC.

Outcomes of Secondary Arthroscopic Distal Clavicle Resection for Shoulders With Symptomatic Acromioclavicular Joint Arthropathy After Isolated Rotator Cuff Repair With Complete Tendon Healing

Background

Recent meta-analyses have advised against distal clavicle resection (DCR) as an adjuvant procedure during rotator cuff repair (RCR), whether performed routinely or in shoulders diagnosed with symptomatic acromioclavicular joint (ACJ) arthropathy. However, the efficacy of DCR as a secondary procedure in patients with persistent pain attributed to symptomatic ACJ arthropathy remains unknown.

Purpose

To evaluate outcomes of secondary DCR in patients with failed nonoperative treatment of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing.

Study Design

Case series; Level of evidence, 4.

Methods

Between 2008 and 2018, the senior surgeon performed isolated RCR in 1935 patients, of which 23 (1.2%) presented with ACJ pain and discomfort at ≥12 months after the index RCR, despite complete healing of repaired tendons. Those 23 patients underwent secondary DCR, as ACJ arthropathy was confirmed clinically and radiographically. Clinical assessment before DCR included the Subjective Shoulder Value (SSV) and pain at rest. Clinical assessment at >12 months after DCR included the SSV, pain at rest, Constant-Murley score, range of motion, and satisfaction. Pre- and post-DCR SSV and pain scores were compared.

Results

Of the initial cohort, 5 patients did not consent to the use of their data, leaving 18 patients aged 53.3 ± 7.6 years (mean ± SD; range, 39-68 years) for outcome assessment. At a mean follow-up of 7.0 ± 3.1 years after DCR, the SSV significantly improved from 58.7 ± 17.2 to 76.1 ± 20.2 (P < .001), and the pain at rest significantly decreased from 4.7 ± 1.5 to 2.8 ± 1.9 (P < .001). At final follow-up, the Constant-Murley score was 70.2 ± 21.0. Of 18 patients, 15 had none or mild residual pain (0-2; 83%), while 3 had substantial residual pain (5 or 6; 17%). Only 1 of the 3 patients with substantial residual pain had a poor SSV score (20 points) and was against opting for DCR in retrospect. No patient had infections or gross ACJ instability after DCR.

Conclusion

Secondary DCR for cases of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing reduced pain in 83% of patients, and 94% were satisfied and would undergo secondary DCR again.

Risk factors for failure to achieve minimal clinically important difference and significant clinical benefit in PROMIS computer adaptive test domains in patients undergoing rotator cuff repair

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) has emerged as a valid and efficient means of collecting outcomes in patients with rotator cuff tears. The purpose of this study was to establish threshold score changes to determine minimal clinically important difference (MCID) and substantial clinical benefit (SCB) in PROMIS computer adaptive test (CAT) scores following rotator cuff repair (RCR). Additionally, we sought to identify potential risk factors for failing to achieve MCID and SCB.

METHODS

Patients undergoing arthroscopic RCR were identified over a 24-month period. Only patients who completed both preoperative and postoperative PROMIS CAT assessments were included in this cohort. PROMIS CAT forms for upper extremity physical function (PROMIS-UE), pain interference (PROMIS-PI), and depression (PROMIS-D) were used with a minimum of 1.5-year follow-up. Statistical analysis was performed to determine threshold score changes to determine anchor-based MCID and SCB, as well as risk factors for failure to achieve significant clinical improvement following surgery.

RESULTS

Of 198 eligible patients, 168 (84.8%) were included in analysis. ΔPROMIS-UE values of 5.8 and 9.7 (area under the curve [AUC] = 0.906 and 0.949, respectively) and ΔPROMIS-PI values of -11.4 and -12.9 (AUC = 0.875 and 0.938, respectively) were identified as threshold predictors of MCID and SCB achievement. On average, 81%, 65%, and 55% of patients achieved MCID for PROMIS-UE, PROMIS-PI, and PROMIS-D whereas 71%, 61%, and 38% of patients in the cohort, respectively, achieved SCB. MCID achievement in PROMIS-UE significantly differed according to risk factors, including smoking status (likelihood ratio [LR]: 9.8, P = .037), tear size (LR: 10.4, P < .001), distal clavicle excision (LR: 6.1, P = .005), and prior shoulder surgery (LR: 19.2, P < .001). Factors influencing SCB achievement for PROMIS-UE were smoking status (LR: 9.3, P = .022), tear size (LR: 8.0, P = .039), and prior shoulder surgery (11.9, P < .001). Significantly different rates of MCID and SCB achievement in PROMIS-PI for smoking status (LR: 7.0, P = .030, and LR: 5.2, P = .045) and prior shoulder surgery (LR: 9.1, P = .002, and LR: 7.4, P = .006) were also identified.

DISCUSSION AND CONCLUSION

The majority of patients showed clinically significant improvements that exceeded the established MCID for PROMIS-UE and PROMIS-PI following RCR. Patients with larger tear sizes, a history of prior shoulder surgery, tobacco users, and those who received concomitant distal clavicle excision were at risk for failing to achieve MCID in PROMIS-UE. Additionally, smokers and patients who underwent prior shoulder surgery demonstrated significantly lower improvements in pain scores following surgery.

Shoulder Pathology on Magnetic Resonance Imaging in Asymptomatic Elite-Level Rock Climbers

Background:

The prevalence of findings on shoulder magnetic resonance imaging (MRI) is high in asymptomatic athletes of overhead sports.

Purpose/Hypothesis:

The purpose of this study was to determine the prevalence of atypical findings on MRI in shoulders of asymptomatic, elite-level climbers and to evaluate the association of these findings with clinical examination results. It was hypothesized that glenoid labrum, long head of the biceps tendon, and articular cartilage pathology would be present in >50% of asymptomatic athletes.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 50 elite climbers (age range, 20-60 years) without any symptoms of shoulder pain underwent bilateral shoulder examinations in addition to dedicated bilateral shoulder 3-T^† MRI. Physical examinations were performed by orthopaedic sports medicine surgeons, while MRI scans were interpreted by 2 blinded board-certified radiologists to determine the prevalence of abnormalities of the articular cartilage, glenoid labrum, biceps tendon, rotator cuff, and acromioclavicular joint.

Results:

MRI evidence of tendinosis of the rotator cuff, subacromial bursitis, and long head of the biceps tendonitis was exceptionally common, at 80%, 79%, and 73%, respectively. Labral pathology was present in 69% of shoulders, with discrete labral tears identified in 56%. Articular cartilage changes were also common, with humeral pathology present in 57% of shoulders and glenoid pathology in 19% of shoulders. Climbers with labral tears identified in this study had significantly increased forward elevation compared with those without labral tears in both active (P = .026) and passive (P = .022) motion.

Conclusion:

The overall prevalence of intra-articular shoulder pathology detected by MRI in asymptomatic climbers was 80%, with 57% demonstrating varying degrees of glenohumeral articular cartilage damage. This high rate of arthritis differs significantly from prior published reports of other overhead sports athletes.

Bony Edema and Clinical Examination Findings Predict the Need for Distal Clavicle Excision at the Time of Shoulder Arthroscopy

Background: Deciding to perform a distal clavicle excision for acromioclavicular joint arthritis, especially in conjunction with other arthroscopic shoulder procedures, is challenging for surgeons. Studies have reported mixed results on the value of magnetic resonance imaging (MRI) in decision making. Purpose: We sought to correlate MRI findings with clinical symptoms and the surgeon's decision to perform a distal clavicle excision. Methods: We compared MRI, clinical examination, and MRI findings of 200 patients who underwent distal clavicle excision for symptomatic acromioclavicular joint arthritis with 200 patients who underwent arthroscopic shoulder procedures for other reasons. Univariate statistics were used to determine correlations between physical examination findings, MRI findings, and the decision to perform distal clavicle excision. A binary logistic regression model was used to determine independent predictors of need for distal clavicle excision. Results: There was no difference in mean age, sex, and race between groups. Advanced acromioclavicular joint osteoarthritis was strongly correlated with positive physical examination findings. Bony edema correlated strongly with tenderness at the acromioclavicular joint but not pain with cross-body adduction testing. There was no association between higher MRI grade of osteoarthritis and the need for distal clavicle excision. Regression analysis identified both physical examination findings and bony edema on MRI as independent predictors of the need for distal clavicle excision. Conclusion: In the setting of positive clinical examination findings and bony edema of the distal clavicle, surgeons should feel reassured that distal clavicle excision is likely indicated.

Acromioclavicular joint arthritis is not an indication for routine distal clavicle excision in arthroscopic rotator cuff repair

PURPOSE

To evaluate the significance of untreated primary acromioclavicular joint (ACJ) osteoarthritis, encountered during arthroscopic rotator cuff repair (RCR), as a cause of persistent symptomatology and need for revision surgery.

METHODS

In a cohort of 811 consecutive patients older than 55 years who underwent RCR, the effect of primary ACJ osteoarthritis presence was prospectively examined. A total of 497 patients with mild/moderate and severe ACJ osteoarthritis based on preoperative MRI evaluation were allocated to Group A (n = 185, symptomatic ACJ) and Group B (n = 312, asymptomatic ACJ). Distal clavicle excision was not performed regardless of the presence of pain. The minimum follow-up was 28 months (28-46). The visual analogue scale (VAS) pain scores were assessed for ACJ pain on palpation, the cross body adduction test, the Constant-Murley, and the American Shoulder and Elbow Surgeons (ASES).

RESULTS

The overall loss to follow-up rate was 3.82% (19 patients: 11 in Group A and eight in Group B). The mean ASES score at the latest follow-up was 91.16 ± 9.3 and 92.37 ± 10.44 in Groups A and B, respectively, and the mean Constant-Murley score was 96.36 ± 5.7 and 95.76 ± 4.6 in Groups A and B, respectively. There was no statistical significance between regarding both scores. Localised ACJ pain on palpation and pain on cross body adduction were diminished in both the symptomatic and asymptomatic group. There were five cases (1%: two in Group A and three in Group B) with persistent ACJ pain who had failed the conservative treatment, and ACJ excision was necessary to alleviate the symptoms. All revision operations were uncomplicated with symptom resolution.

CONCLUSION

Untreated ACJ osteoarthritis, symptomatic or not, encountered during arthroscopic RCR is associated with a low percentage of failure. Routine distal clavicle excision is not absolutely necessary, even in patients with symptomatic ACJ osteoarthritis.

LEVEL OF EVIDENCE

II, Prospective cohort study.

Management of Acromioclavicular Osteoarthritis in Rotator Cuff Tears: A Scoping Review

Purpose  The treatment of acromioclavicular joint (ACJ) osteoarthritis during shoulder arthroscopy is a discussed topic. The aim of this scoping review is to report the current recommendations regarding the management of this disorder in patients undergoing surgery for rotator cuff tears.

Methods  A scoping review was performed in Pubmed\Medline and Embase in March 2017, restricted to English language literature. The following keywords were used: (“rotator cuff tear” OR ” rotator cuff” OR “rotator cuff repair”) AND (“acromioclavicular joint arthritis” OR “ac joint arthritis” OR “ac joint” OR “acromioclavicular joint”). Inclusion criteria were randomized controlled trials, prospective cohort studies, retrospective trials, and therapeutic case series. Exclusion criteria were reviews, meta-analyses, and expert opinions.

Results  Two retrospective studies and three randomized controlled trials were identified. Clinical studies reported results of 443 shoulders, with an average age of 60.48 years and a mean follow-up of 31.7 months. Many differences were found regarding the design of the studies, patient's selection, surgical procedures, and instrumental and clinical evaluations. No statistically significant differences were found in clinical outcome scores between patients that underwent rotator cuff repair in association with distal clavicular resection and patients with isolated rotator cuff repair.

Conclusion  Results of this scoping review underline a lack of evidence-based recommendations about the management of ACJ osteoarthritis in association with arthroscopic rotator cuff repair. Surgical procedures such as distal clavicle resection (DCR) should be performed carefully in this cohort of patients. More prospective randomized studies are needed to reach a consensus about the correct surgical approach to DCR in patients with signs of ACJ osteoarthritis and rotator cuff tears.

Level of Evidence  Level III.

Is conventional radiography still relevant for evaluating the acromioclavicular joint?

INTRODUCTION

Conventional radiography using an anteroposterior view of the acromioclavicular (AC) joint is the gold standard for evaluating arthritic degeneration.

OBJECTIVE

Based on a standardised AP view of the AC joint, the objective of this study was to determine whether this radiographic view is reliable and reproducible for evaluating the AC joint space.

METHODS

A cadaver scapula-clavicle unit, free of osteoarthritis, was used for this study. The scapula was positioned in a stand; and then with fluoroscopy guidance, a strict AP view of the AC joint was taken. Starting from this "0" position, a radiograph was taken by varying the angle by 5°, 10°, and 15° in every plane in space. All radiographs were taken during a single session to ensure the distance between the X-ray tube and scapula did not change. The images were then exported to OsiriX for processing; the superior and inferior AC distance and the joint area were measured.

RESULTS

There was no reproducibility in the AC joint measurements as a function of the incidence angle relative to a strict AP view.

CONCLUSION

Conventional radiography using an AP view of the AC joint cannot be used to do a fine analysis of arthritic degeneration of this joint. It is likely that only CT scan or MRI is sufficient to analyse osteoarthritis in this joint.

LEVEL OF EVIDENCE

IV, basic science study.

Benefits of distal clavicle resection during rotator cuff repair: Prospective randomized single-blind study

INTRODUCTION

Rotator cuff tears often occur in combination with acromioclavicular (AC) arthropathy. But it can be difficult to separate pain caused by the rotator cuff tear from pain caused by the AC joint, despite clinical and other examinations. Distal clavicle resection (DCR) is increasingly being done at the same time as arthroscopic rotator cuff repair. The aim of this study was to compare the functional outcomes 1 year after arthroscopic rotator cuff repair between patients who simultaneously undergo DCR and patients who do not. The primary hypothesis was that DCR improves the clinical outcomes.

MATERIAL AND METHODS

This was a prospective, multicenter, randomized, single-blind study of 200 patients who underwent isolated supraspinatus repair using the same technique. The patients were randomized into two groups: 97 patients who also underwent DCR and 103 patients who did not. The patients were followed until 1 year postoperative according to a standardized radiological and clinical review protocol.

RESULTS

At 1 year postoperative, all the clinical outcomes were worse in the DCR group, although only external rotation with elbow at side (53° vs. 59°, p=0.04) and the SSV (86.5 vs. 90.1, p=0.04) were statistically different. Overall shoulder pain was higher in the DCR group during the first 3 months postoperative (p=0.04). At 1 year, the DCR group had more residual pain; this pain was mainly located on the superior side of the shoulder (p=0.03), especially when more than 11 mm was resected (p=0.01). More of the shoulders in the DCR group had failures in rotator cuff healing based on ultrasonography (p=0.5).

CONCLUSION

Our hypothesis was not confirmed. We do not recommend doing routine DCR with arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

I, prospective randomized simple blind study.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

Histologic and magnetic resonance image evaluation in acromioclavicular joint osteoarthritis

Introduction

Little is known about the development of specific acromioclavicular joint osteoarthritis. Its histologic alterations are controversial, and radiologic alterations are seen in asymptomatic people. The objective of this study was to evaluate histologically the distal clavicle subchondral bone and to analyze magnetic resonance images in patients with painful and nonpainful acromioclavicular joint osteoarthritis.

Methods

An observational, analytical, and cross-sectional study with a control group was conducted. Between August 2018 and June 2019, we analyzed a total of 41 patients. Group 1 consisted of patients with pain in the acromioclavicular joint (symptomatic osteoarthritis), and group 2 consisted of patients without pain in the acromioclavicular joint (asymptomatic osteoarthritis).

Results

Twelve of the 15 patients with acromioclavicular joint pain (group 1) were female, 13 presented distal clavicle edema on magnetic resonance imaging, and 9 had subchondral bone edema on histologic examination. Patients with acromioclavicular joint pain had longer shoulder pain duration than patients without pain. Women were more likely to have acromioclavicular joint pain compared with men. Patients with edema on magnetic resonance imaging showed a greater chance of presenting pain in the acromioclavicular joint in comparison with patients without edema.

Conclusion

Women had a higher chance of presenting with acromioclavicular joint pain than men. Patients with edema on magnetic resonance imaging were more likely to present with pain than patients without edema. Patients with acromioclavicular joint pain had longer shoulder pain duration than patients without pain, and subchondral bone edema on histologic examination was more frequent in patients with pain.

Seven-year course of asymptomatic acromioclavicular osteoarthritis diagnosed by MRI

BACKGROUND

Asymptomatic acromioclavicular osteoarthritis (AC-OA) is a frequent finding in shoulder magnetic resonance imaging (MRI). Its natural course is unknown. Therefore, the question arises whether a resection should be performed simultaneously with shoulder surgery for another reason to prevent future pain and reoperation. The purpose of this study was to investigate the mid-term course of asymptomatic AC-OA.

METHODS

Overall, 114 asymptomatic AC-OA diagnosed on MRI were followed for 7 years between 2011 and 2018. At baseline, MRI signal enhancement in the clavicle and acromion, OA grade, physical demand as well as the parameters (1) Constant Score Visual Analogue Scale, (2) pain on AC-joint compression, and (3) cross-body adduction test were measured. All patients were followed up after 7 years by interview, and in case of symptoms by clinical examination. The endpoint "deterioration" was reached if 2 of the 3 parameters turned worse.

RESULTS

Asymptomatic AC-OA remained asymptomatic in 83% of cases, 7% turned better, 10% turned worse. Physical demand and osteoarthritis grade increased the risk of deterioration, whereas MRI signal enhancement in the clavicle or acromion had no influence on outcome. During follow-up, the frequency of pain on AC-joint compression increased from 11% to 16% (P = .24), the frequency of a positive cross-body adduction test increased from 6% to 20% (P = .017), and the mean Constant Score Visual Analogue Scale increased from 10 to 13 points (P < .001) indicating less pain.

CONCLUSIONS

Asymptomatic AC-OA remained asymptomatic in 90% over 7 years. A simultaneous resection of an asymptomatic AC-OA during shoulder surgery for another reason is not indicated in every patient.

The Natural History of Full-Thickness Rotator Cuff Tears in Randomized Controlled Trials: A Systematic Review and Meta-analysis

BACKGROUND

Rotator cuff tears are the most common tendon injury in the adult population, resulting in substantial morbidity. The optimum management for these patients is not known.

PURPOSE

To assess the overall treatment response to all interventions in full-thickness rotator cuff tears among patients enrolled in randomized clinical trials.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Randomized controlled trials (RCTs) were identified from a systematic search of Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials. Patients were aged ≥18 years with a full-thickness rotator cuff tear. The primary outcome measure was change in Constant shoulder score from baseline to 52 weeks. A meta-analysis to assess treatment response was calculated via the standardized mean change in scores.

RESULTS

A total of 57 RCTs were included. The pooled standardized mean change as compared with baseline was 1.42 (95% CI, 0.80-2.04) at 3 months, 2.73 (95% CI, 1.06-4.40) at 6 months, and 3.18 (95% CI, 1.64-4.71) at 12 months. Graphic plots of treatment response demonstrated a sustained improvement in outcomes in nonoperative trial arms and all operative subgroup arms.

CONCLUSION

Patients with full-thickness rotator cuff tears demonstrated a consistent pattern of improvement in Constant score with nonoperative and operative care. The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively.

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.

Is routine distal clavicle resection necessary in rotator cuff repair surgery? A systematic review and meta-analysis

BACKGROUND

The objective of the present study was to perform a systematic review and meta-analysis of randomized controlled trials looking at the effect of distal clavicle resection in patients undergoing rotator cuff repair (RCR).

METHODS

A systematic literature search was undertaken to identify randomized controlled trials looking at RCR +/- distal clavicle resection. Primary clinical outcome measures included in the meta-analysis were American Shoulder Elbow Society (ASES) score, pain on visual analogue scale and range of motion in forward elevation.

RESULTS

The systematic review identified three studies with a total of 203 participants. Those who underwent distal clavicle resection in conjunction with RCR had worse pain and acromioclavicular joint tenderness at 3-month follow-up. This difference, however, was not observed at the 24-month follow-up. The mean difference (95% confidence interval) for the ASES score was 0.45 (-3.67 to 4.58) and pain on visual analogue scale was - 0.27 (-0.70 to 0.16).

CONCLUSIONS

Routine distal clavicle resection in the setting of rotator cuff repair does not result in improved outcomes for patients with no difference being observed at 24 months post surgery. The results of our systematic review and meta-analysis do not support routine distal clavicle resection when performing RCR.

Does Distal Clavicle Resection Decrease Pain or Improve Shoulder Function in Patients With Acromioclavicular Joint Arthritis and Rotator Cuff Tears? A Meta-analysis

BACKGROUND

Acromioclavicular joint arthritis is a common, painful, and often missed diagnosis, and it often accompanies other shoulder conditions such as rotator cuff disease. Whether distal clavicle resection is important to perform in patients undergoing surgery for rotator cuff tears and concomitant acromioclavicular joint arthritis is controversial.

QUESTIONS/PURPOSES

The purpose of this study was to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of distal clavicle resection on (1) outcome scores; (2) shoulder ROM, joint pain or tenderness, and joint instability; and (3) risk of reoperation among patients treated surgically for rotator cuff tears who had concomitant acromioclavicular joint arthritis.

METHODS

We systematically searched the PubMed, EMBASE, and Cochrane databases to find RCTs that met our eligibility criteria, which, in summary, (1) compared rotator cuff repair plus distal clavicle resection with isolated rotator cuff repair for patients who sustained a full- or partial-thickness rotator cuff tear and concomitant acromioclavicular joint arthritis; and (2) the followup period was at least 2 years. Two reviewers screened the studies, extracted the data and evaluated the methodological quality, and performed data analysis. Statistical heterogeneity among studies was quantitatively evaluated with the I index. No heterogeneity was detected (I = 0%; p = 0.75) in terms of acromioclavicular joint pain or tenderness, Constant score, forward flexion, external rotation, and risk of reoperation, so fixed-effect models were used in these endpoints. Heterogeneity was moderate for the American Shoulder and Elbow Surgeons (ASES) score (I = 53%; p = 0.12) and low for the visual analog scale (VAS) score (I = 35%; p = 0.22), so random-effect models were used in these endpoints. Subgroup analysis was stratified by the symptom of acromioclavicular joint arthritis. Three RCTs with 208 patients were included. We evaluated the risk of bias using the Cochrane risk-of-bias tool; in aggregate, the three RCTs included showed low to intermediate risk, although not all parameters of the Cochrane tool could be assessed for all studies.

RESULTS

There was no difference between the distal clavicle resection plus rotator cuff repair group and the isolated rotator cuff repair group in ASES score (mean difference =1.41; 95% confidence interval [CI], -3.37 to 6.18; p = 0.56) nor in terms of the VAS score and Constant score. Likewise, we found no difference in ROM of the shoulder (forward flexion, internal rotation, and external rotation) or acromioclavicular joint pain or tenderness between the groups (pooled results of acromioclavicular joint pain or tenderness: risk ratio [RR], 1.59; 95% CI, 0.67-3.78; p = 0.30). Acromioclavicular joint instability was only detected in the rotator cuff repair plus distal clavicle resection group. Finally, we found no difference in the proportion of patients undergoing repeat surgery between the study groups (pooled results of risk of reoperation for the rotator cuff repair plus distal clavicle resection and isolated rotator cuff repair: one of 52 versus two of 78; RR, 0.86; 95% CI, 0.11-6.48; p = 0.88).

CONCLUSIONS

Distal clavicle resection in patients with rotator cuff tears did not result in better clinical outcome scores or shoulder ROM and was not associated with a lower risk of reoperation. Distal clavicle resection might cause acromioclavicular joint instability in patients with rotator cuff tears and concomitant asymptomatic acromioclavicular joint arthritis. Arthroscopic distal clavicle resection is not recommended in patients with rotator cuff tears and concomitant acromioclavicular joint arthritis. Additional well-designed RCTs with more participants, long-term followup, and data on patient-reported outcomes are needed.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Editorial Commentary: The "Mumford" & Sons: For Distal Clavicle Excisions, What Are Our Young Surgeons Doing, and How Well Are They Doing It?

The distal clavicle excision (DCE, also known as the "Mumford" procedure), either open or arthroscopic, is a time-honored procedure with generally excellent and predictable results. Surgeons have a choice to make regarding which technique to perform, and most surgeons choose the arthroscopic approach. This choice is justified, as complication rates are lower for arthroscopic DCE than for open DCE. A well-performed arthroscopic DCE should have a very low complication rate and high success rate.

Is there sufficient evidence to support intervention to manage shoulder arthritis?

BACKGROUND

We explore the nature, extent and validity of research studies concerning the management of shoulder arthritis to identify whether current management recommendations are adequate.

METHODS

A full electronic search for relevant studies published between 2002 and 2012 was performed. The search focused on level 1 and level 2 studies. Full texts of selected articles were retrieved and assessed for quality against validated criteria.

RESULTS

Four hundred and eleven studies were identified on the initial search and screened. Sixteen studies were selected for inclusion in the review. The studies identified were unable to provide a clear indication of best intervention for shoulder arthritis. The inclusion of a range of shoulder pathologies in some studies and the diversity in outcome measures used made it difficult for systematic reviews to effectively pool data. Better outcomes have been shown with total shoulder replacement over hemiarthroplasty for shoulder osteoarthritis; however, primary studies were often of limited quality. Sparse evidence is available for all other interventions, regardless of whether operative or non-operative.

CONCLUSIONS

The present review highlights the need for standardization of outcome assessment following treatment of shoulder arthritis. More rigorous and robust primary studies are needed to guide clinical practice on the best interventions for arthritis of the shoulder.

Outcome of distal clavicle resection in patients with acromioclavicular joint osteoarthritis and full-thickness rotator cuff tear

PURPOSE

The purpose of this study was to examine the impact of distal clavicle resection (DCR) on subjective and objective outcome measures in patients with acromioclavicular (AC) joint osteoarthritis (OA) and rotator cuff tear.

METHODS

Prospectively collected data of consecutive patients with arthroscopic evidence of OA of the ACJ with complete data at 2 years were used for the data analysis. Patients with moderate-to-severe OA of the AC joint underwent a DCR in conjunction with rotator cuff repair, while patients with mild OA of the ACJ underwent surgery related to concomitant rotator cuff tear without a DCR.

RESULTS

Data of 184 (72 females, 112 males, mean age: 62) patients with rotator cuff tear and varying degrees of OA of the AC joint were used for the analysis. Of 184 patients, 144 (78 %) had a resection of distal clavicle (resection group) and 40 (22 %) did not have a resection (no-resection group). Both groups showed a statistically significant (p < 0.0001) improvement in the American Shoulder and Elbow Surgeons (ASES) scores, Constant Murley score, and strength. Multivariable analysis showed that lower pre-operative ASES scores (higher disability), having a larger tear, an active compensation claim, and not having a DCR, had a negative impact on post-operative ASES scores.

CONCLUSION

When untreated surgically, even mild arthroscopic findings of AC joint OA may lead to a poorer outcome after rotator cuff repair. Further characterisation of patients in whom mild arthroscopic findings of OA of AC joint are clinically significant and warrant resection is needed.

LEVEL OF EVIDENCE

Retrospective outcome study, Level II.

[Arthroscopic resection of the acromioclavicular joint]

OBJECTIVE

Arthroscopic resection of the painful and degenerative altered acromioclavicular (AC) joint without destabilization of the joint and therefore pain relief and improvement in function.

INDICATIONS

Conservative failed therapy of painful AC joint osteoarthritis. Impingement caused by caudal AC joint osteophytes. Lateral clavicular osteolysis.

CONTRAINDICATIONS

General contraindications (infection, local tumor, coagulation disorders), higher grade instability of the AC joint (resection only together with stabilization).

SURGICAL TECHNIQUE

Diagnostic glenohumeral arthroscopy. Treatment of accompanying lesions (subacromial impingement, rotator cuff, long head of biceps). Subacromial arthroscopy with bursectomy (partial) and visualization of the AC joint. Resection of caudal osteophytes. Localization of the anterior portal using a spinal needle in the outside-in technique. Resection of 2-3 mm of the acromial side and the 3-4 mm of the clavicular side with shaver/acromionizer.

RESULTS

An isolated open AC joint resection was performed in 9 studies and an arthroscopic resection in 6 studies. Good and very good results were obtained in 79% (range 54-100%) in open resection and 91% (range 85-100%) in arthroscopic resections. Patients were able to return to activities of daily life more quickly after arthroscopic resections than after open surgery.

Clinical examination of the rotator cuff

Rotator cuff tears are the leading cause of shoulder pain and shoulder-related disability and account for 4.5 million physician visits in the United States annually. A careful history and structured physical examination are often sufficient for diagnosing rotator cuff disorders. We are not aware of a clinical review article that presents a structured physical examination protocol of the rotator cuff for the interested clinician. To fill this void, we present a physical examination protocol developed on the basis of review of prior literature and our clinical experience from dedicated shoulder practices. Our protocol includes range of motion testing by using a goniometer, strength testing by using a dynamometer, and select special tests. Among the many tests for rotator cuff disorders that have been described, we chose ones that have been more thoroughly assessed for sensitivity and specificity. This protocol can be used to isolate the specific rotator cuff tendon involved. The protocol can typically be completed in 15 minutes. We also discuss the clinical implications and limitations of the physical examination maneuvers described in our protocol. This protocol is thorough yet time efficient for a busy clinical practice. It is useful in the diagnosis of rotator cuff tears, impingement syndrome, and biceps pathology.