Comparison of Short-term Complications After Rotator Cuff Repair: Open Versus Arthroscopic

Lower Risk of Postoperative Complications and Rotator Cuff Retear Associated with Semaglutide Use in Patients with Type II Diabetes Mellitus Undergoing Arthroscopic Rotator Cuff Repair

PURPOSE

To investigate the potential impact of preoperative semaglutide use (active agent in Ozempic® and Wegovy®) on ninety-day postoperative outcomes and two-year rotator cuff retear following arthroscopic rotator cuff repair (ARCR) for type II diabetes mellitus (T2DM) patients.

METHODS

T2DM patients undergoing primary ARCR were identified from the PearlDiver database using administrative billing codes. Exclusion criteria included: patients <18 years old, prior RCR, concurrent non-rotator cuff related arthroscopic shoulder procedures, any traumatic, neoplastic, or infectious diagnoses within 90-days before surgery, and <90-days follow-up. T2DM patients using semaglutide within one-year of ARCR ([+]semaglutide) were matched 1:4 with T2DM patients who did not ([-]semaglutide) by age, sex, Elixhauser Comorbidity Index (ECI), diabetes complications, obesity, tobacco, insulin, and metformin use. Occurrence of any, severe, and minor adverse events (AAE, SAEs, MAEs, respectively) within 90-days were compared by multivariable logistic regression. Two-year retear was assessed by Kaplan-Meier survival analysis and compared by log-rank test.

RESULTS

There were 1,094 ARCR (+)semaglutide and 4,110 ARCR (-)semaglutide patients meeting inclusion criteria after matching. The incidence of AAE for the ARCR (-)semaglutide vs. ARCR (+)semaglutide patients was 27.4% vs. 11.0%, SAE was 10.5% vs. 3.5%, and MAE was 22.0% vs. 8.5%, respectively (p<0.001 for all). ARCR (-)semaglutide patients had a higher odds ratio (OR) of AAE (3.65, p<0.001) and SAEs (3.62, p<0.001), including surgical-site infection (2.22, p=0.049), venous thromboembolism (3.10, p<0.001), sepsis (3.87, p<0.001), and cardiac events (3.96, p<0.001). Also, greater odds of MAEs (3.59, p<0.001), including urinary tract infection (3.27), pneumonia (3.88), acute kidney injury (3.91), and ED visits (2.51) (p<0.001 for all). Additionally, (-)semaglutide patients revealed higher 2-year retear vs (+)semaglutide patients (18.3% vs 12.5%, respectively) (p<0.001).

CONCLUSION

Preoperative semaglutide use for T2DM patients undergoing ARCR was associated with decreased odds of minor and serious 90-day adverse events, and lower 2-year rotator cuff retear.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Risk factors for infection in patients undergoing shoulder arthroscopy: a systematic review and meta-analysis

We conducted a meta-analysis to determine the risk of infection following shoulder arthroscopy and to identify risk factors for infection. We systematically searched the PubMed/Medline, Embase and Cochrane Library databases, as well as the reference lists of previous systematic reviews and meta-analyses; manual searches were also performed. A random-effects model was employed to estimate pooled odds ratios (ORs), based on sample size, the P-value of Egger's test and heterogeneity among studies. Of the 29,342 articles screened, 16 retrospective studies comprising 74,759 patients were included. High-quality evidence showed that patients with diabetes (OR, 1.30; 95% confidence interval (CI), 1.20-1.41) or hypertension (OR, 1.26; 95% CI, 1.10-1.44) had a higher risk of infection, while moderate quality evidence showed that patients with obesity (body mass index ≥30 kg/m2) (OR, 1.42; 95% CI, 1.28-1.57), those who were male (OR, 1.65; 95% CI, 1.12-2.44), those who had an American Society of Anesthesiologists (ASA) class ≥3 (OR, 2.02; 95% CI, 1.02-3.99) and those who had a history of smoking (OR, 2.44; 95% CI, 1.39-4.28) had a higher risk of infection. The meta-analysis revealed that there was no association between age, time of surgery, or alcohol consumption and infection. This meta-analysis identified six significant risk factors for infection following shoulder arthroscopy including diabetes, obesity, hypertension, male sex, ASA class, history of smoking. These patient-related risk factors may help identify postoperative patients at higher risk for infection following shoulder arthroscopy.

In Vivo Comparison of Positive Microbial Culture by Wound Irrigation Methods: Biportal Endoscopic Versus Open Microscopic Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

This study aimed to evaluate the risk factors and prevalence of intraoperative contamination (IoC) through the microbial culture of superficial and deep samples obtained during surgery.

SUMMARY OF BACKGROUND DATA

Surgical site infection (SSI) in spinal surgery is a serious complication. The prevalence of IoC may differ based on surgical approach and technique, even in the setting of the same procedure.

MATERIALS AND METHODS

In this in vivo study, microbial cultivation was performed with superficial (ligamentum flavum, LF) and deep (nucleus pulposus, NP) surgical specimens to evaluate IoC in 132 patients undergoing single-level transforaminal lumbar interbody fusion (TLIF). Biportal endoscopic -TLIF was performed under continuous wound irrigation (group A, n=66), whereas open microscopic (OM) TLIF was performed under intermittent wound irrigation (group B, n=66). LF and NP specimens were homogenized, gram stained, and cultured in aerobic and anaerobic media for 14 days. Microbial culture results and the occurrence of SSI in the two groups were assessed. The χ 2 test and Fisher exact test were used to determine significant differences among categorical variables. Logistic regression analysis was used to assess the influence of patient characteristics on the prevalence of positive microbial cultures.

RESULTS

Of the 132 patients, 34 (25.8%) had positive microbial cultures, and positive culture required an incubation period of 72 hours to 2 weeks in all these patients except for three. Overall, positive culture was significantly higher in group B than in group A ( P =0.029). The subgroups of LF- and NP-positive cultures were 18.18% (n=24) and 12.88% (n=17), respectively; the SSI was 0.76% (n=1). Group A had a significantly lower subgroup of NP-positive culture than group B ( P =0.035). OM technique was an independent risk factor associated with overall positive culture ( P <0.05). The most common microorganism was Cutibacterium acnes ( C. acnes ).

CONCLUSIONS

Biportal endoscopic-TLIF with continuous wound irrigation showed significantly lower overall and NP-positive cultures than OM-TLIF with intermittent irrigation. The most common strain of positive culture was C. acnes .

LEVEL OF EVIDENCE

2.

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.

Magnetic Resonance Imaging and Magnetic Resonance Arthrography Are Both Reliable and Similar When Measuring Hip Capsule Thickness in Patients With Femoroacetabular Impingement Syndrome

Purpose

To propose an accurate method of measuring hip capsular thickness in patients with femoroacetabular impingement syndrome and to compare the reliability of these measurements between magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA).

Methods

A previously established database of patients with femoroacetabular impingement syndrome (FAIS) was used to identify candidates with preoperative MRI or MRA from November 2018 to June 2021. Two reviewers independently examined preoperative imaging for 85 patients. Capsular thickness was measured in 12 standardized locations. Intraclass correlation coefficients (ICCs) were calculated using an absolute-agreement, 2-way random-effects model. Using the same method, 30 patients were randomly selected for repeat measurements by 1 reviewer following a washout period. Ten additional patients with preoperative MRI and MRA of the same hip were identified to compare measurements between modalities using paired samples t test.

Results

ICCs for measurements on MRIs and MRAs using these proposed measurements to compare inter-rater reliability were 0.981 and 0.985. ICCs calculated using measurements by a single reviewer following a washout period for intrarater reliability were 0.998 and 0.991. When comparing MRI and MRA measurements in the same patient, t test for all pooled measurements found no difference between modality (P = .283), and breakdown of measurements by quadrant found no difference in measurements (P > .05), with the exception of the inferior aspect of the capsule on coronal sequences (P = .023).

Conclusions

In patients with FAIS, both MRI and MRA have excellent reliability for quantifying hip capsular thickness. A difference in capsular thickness was found only when comparing MRI and MRA on inferior coronal aspects of the hip capsule, indicating interchangeability of these imaging modalities when measuring the clinically important aspects of the hip capsule.

Level of Evidence

Level IV, diagnostic case series.

While the Incidence of Venous Thromboembolism After Shoulder Arthroscopy Is Low, the Risk Factors Are a Body Mass Index Greater than 30 and Hypertension

Purpose

This study aims to determine the overall incidence of venous thromboembolism (VTE) following shoulder arthroscopy and to define potential risk factors associated with its development that may help define guidelines for the use of thromboprophylaxis.

Methods

A systematic review was performed using PubMed, Embase, Web of Science, CINAHL, and Cochrane databases per PRISMA guidelines. The search terms consisted of variations of "Venous Thromboembolism" and "Shoulder Arthroscopy." Information regarding arthroscopy indication, risk factors, outcomes, and patient demographics was recorded and analyzed, and pooled odds ratios were reported for each variable.

Results

Six hundred eighty-five articles were identified in the initial search, and 35 articles reported DVT, PE, or VTE incidence following shoulder arthroscopy. Seventeen nonoverlapping articles with a unique patient population incidence rates. Four articles were then used for subgroup meta-analysis. The incidence rate of VTE was 0.24%, ranging from 0.01% to 5.7%. BMI >30 (OR = 1.46; 95% CI = [1.22, 1.74]; I2 = 0%) and hypertension (OR = 1.64; 95% CI = [1.03, 2.6]; I2 = 75%) were significant risk factors (P < .05) for developing VTE following shoulder arthroscopy. Diabetes (OR = 1.2; 95% CI = [0.97, 1.48]; I2 = 0%), insulin-dependent diabetes (OR = 5.58; 95% CI = [0.12, 260.19]; I2 = 85%), smoking (OR = 1.04; 95% CI = [0.79, 1.37]; I2 = 12%), male sex (OR = 0.95; 95% CI = [0.49, 1.85]; I2 = 86%) and age over 65 (OR = 4.3; 95% CI = [0.25, 72.83]; I2 = 85%) were not associated with higher VTE risk.

Conclusion

The VTE incidence following shoulder arthroscopy is low at 0.24%. Patients with BMI >30 and hypertension are at a higher risk for VTE after shoulder arthroscopy.

Level of Evidence

Level IV, systematic review and meta-analysis of Level I-IV studies.

Diabetes status and postoperative complications for patients receiving open rotator cuff repair

Background

Diabetic patients are known to have poor wound healing and worse outcomes following surgeries. The purpose of this study is to evaluate diabetes status and complications for patients receiving open rotator cuff repair.

Methods

Patients undergoing open rotator cuff repair from 2006 to 2018 were identified in a national database. Patients were stratified into 3 cohorts: no diabetes mellitus, non-insulin dependent diabetes mellitus (NIDDM), and insulin dependent diabetes mellitus (IDDM). Differences in demographics, comorbidities, and complications were assessed with the use of bivariate and multivariate analyses.

Results

Of 7678 total patients undergoing open rotator cuff repair, 6256 patients (81.5%) had no diabetes, 975 (12.7%) had NIDDM, and 447 (5.8%) had IDDM. Bivariate analyses revealed that IDDM patients had increased risk of mortality, extended length of stay, and readmission compared to non-diabetic patients (p < 0.05 for all). IDDM patients had higher risks of major complications and readmission relative to NIDDM patients (p < 0.05 for both). On multivariate analysis, there were no differences in any postoperative complications between the non-diabetic, NIDDM, and IDDM groups.

Discussion

Diabetes does not affect postoperative complications following open rotator cuff repairs. Physicians should be aware of this finding and counsel their patients appropriately.Level of Evidence: III.

Systematic Review and Meta-analysis of Clinical Outcomes After Management of Posterior Cruciate Ligament Tibial Avulsion Fractures

Background

There is no consensus regarding the management of posterior cruciate ligament (PCL) avulsion fractures and the expected outcomes after treatment.

Purpose

To systematically review clinical outcomes and complications after management of tibial-sided avulsion fractures of the PCL.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search of Scopus, PubMed, Medline, and the Cochrane Central Register for Controlled Trials was performed in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included were studies with evidence levels 1 to 4 that reported clinical outcomes after treatment of PCL tibial-sided avulsion fractures in humans. The quality of the included studies was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. A meta-analysis was performed for patient-reported outcome measures using random-effects modeling with 95% CIs.

Results

A total of 58 studies published between 1999 and 2022 were identified. The mean MINORS score was 9.90 ± 4.12, indicating overall low-quality evidence with high risk of bias. The studies comprised 1440 patients (mean age, 32.59 ± 5.69 years; 75.2% males) with a mean follow-up of 26.9 ± 19.6 months (range, 5.3-126 months). Most patients were treated with open surgery (63.6%), followed by arthroscopic surgery (29.7%) and nonoperative treatment (6.7%). All patients reported significant posttreatment improvement in both subjective and objective outcomes (P < .05 for all). Arthroscopic surgery was associated with lower postoperative posterior tibial translation compared with open surgery (range, 0.6-3.2 vs 1.7-3.1 mm), greater preoperative to postoperative improvement in Lysholm score (54.6 vs 48.8; P < .0001), higher postoperative Tegner score (6.64 ± 1.03 vs 6.14 ± 2.29; P = .0448), and a higher rate of return to sport (100% vs 89.5%; P = .009). Nonoperative management was associated with a significantly lower fracture union rate (87% vs 99.1%; P < .0001) and greater postoperative side-to-side posterior translation (4.9 ± 4.3 mm) when compared with operative management.

Conclusion

Although nonoperative and surgical management of PCL tibial avulsion fractures resulted in high rates of fracture union and improvement in functional outcome scores and a low incidence of complications, nonoperative treatment yielded a high side-to-side posterior displacement (>4 mm) with a lower rate of fracture union compared to surgical treatment.

The Effect of the Overweight Condition on Arthroscopic Rotator Cuff Repair Outcomes

This study sought to investigate the influence of a preexisting overweight condition (body mass index [BMI], 25-29.9 kg/m2) on functional outcomes after arthroscopic rotator cuff repair surgery. A retrospective review was performed examining the outcomes of arthroscopic rotator cuff repair in a normal-weight (BMI, 18.5-24.9 kg/m2) and an overweight (BMI, 25-29.9 kg/m2) population. Functional outcomes were assessed to include the American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation score, and the visual analog scale (VAS) pain score, as well as range of motion in forward flexion, external rotation, and internal rotation. A total of 52 normal-weight patients (mean BMI, 23.7±2.1 kg/m2) and 57 overweight patients (mean BMI, 28.4±1.4 kg/m2) were included. Both groups demonstrated statistically and clinically significant improvements in VAS score, Single Assessment Numeric Evaluation score, and ASES score at final follow-up (P<.0001), with no difference in range of motion (P>.05). Overall, when comparing outcomes between the groups, there were significantly better outcomes in the normal-weight group's VAS scores (mean, 0.56±0.96 vs 1.3±1.7; P=.0064), ASES scores (mean, 96.1±5.8 vs 92.4±9.7; P=.0187), and internal rotation (mean thoracic vertebrae, 9.2±3.0 vs 10.4±2.6; P=.0289). However, these differences did not reach clinical significance regarding the threshold of patients meeting standard minimal clinically important difference, substantial clinical benefit, and patient-acceptable symptomatic state for rotator cuff repairs. Over-weight patients have improved outcomes after arthroscopic rotator cuff repair surgery with noninferior clinical results when compared with normal-weight patients. More data regarding outcomes of overweight patients will help physicians make better-informed decisions when considering rotator cuff repair. [Orthopedics. 2023;46(4):242-249.].

Risk Factors for Unexpected Admission Following Outpatient Rotator Cuff Repair: A National Database Study

Introduction  Rotator cuff repair (RCR) procedures are some of the most common orthopaedic surgeries performed in the United States. Compared to other orthopaedic procedures, RCRs are of relatively low morbidity. However, complications may arise that result in readmission to an inpatient healthcare facility. The purpose of this study is to identify the demographics and risk factors associated with unplanned 30-day readmission after RCR. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent elective RCR from 2015-2019. Univariate and multivariate analyses were utilized to assess patient demographics, comorbidities, and peri-operative variables predicting unplanned 30-day readmission. Results Of the identified 45,548 patients that underwent RCR, 597 (1.3%) required readmission within 30 days of the procedure. Multivariate analysis identified male sex (OR 1.36, 95% CI: 1.10, 1.67), hypertension (OR 1.29, 95% CI:1.03, 1.62), chronic obstructive pulmonary disease (COPD) (OR 2.07, 95% CI: 1.46, 2.93), American Society of Anesthesiologists (ASA) Class III (OR 1.85, 95% CI: 1.07, 3.18), ASA Class IV (OR 5.38, 95% CI: 2.70, 10.72), and total operative time (OR 1.002, 95% CI: 1.000, 1.004) as independent risk factors for unplanned readmission. Conclusion Unplanned 30-day readmission after RCR is infrequent. However, certain patients may be at increased risk for unplanned 30-day admission to an inpatient facility. This study confirmed male sex, COPD, hypertension, ASA Class III, ASA Class IV, and total operative time to be independent risk factors for readmission following outpatient RCR.

Metabolic Syndrome: Is Arthroscopic Rotator Cuff Repair Safe in This Patient Population?

Purpose Metabolic syndrome is associated with postoperative morbidity and mortality in surgical patients. With the increased use of arthroscopic techniques for rotator cuff repair (RCR), it is important to identify the impact this disorder has on surgical patients. The purpose of this study is to evaluate the clinical impact of metabolic syndrome on outcomes following arthroscopic RCR. Methods The 2006-2019 National Surgical Quality Improvement Program database was queried for adult patients who underwent arthroscopic RCR. Two patient groups were categorized: patients with metabolic syndrome and patients without metabolic syndrome. Demographics, comorbidities, and 30-day postoperative outcomes were compared using bivariate and multivariate analyses. Results Of 40,156 patients undergoing arthroscopic RCR, 36,391 did not have metabolic syndrome and 3,765 had metabolic syndrome. After adjusting for differences in baseline characteristics between the two groups, those with metabolic syndrome had an increased risk of developing renal complications and cardiac complications, as well as requiring hospital admission postoperatively and hospital readmission. Conclusion Metabolic syndrome is an independent risk factor for developing renal and cardiac complications, as well as requiring overnight hospital admission and hospital readmission. Providers should understand the need for preoperative evaluation and surveillance of these patients following their surgery to minimize the risk of poor outcomes.

Determinants of Operative Time in Arthroscopic Rotator Cuff Repair

Arthroscopic rotator cuff repairs have been reported to take between 72 and 113 min to complete. This team has adopted its practice to reduce rotator cuff repair times. We aimed to determine (1) what factors reduced operative time, and (2) whether arthroscopic rotator cuff repairs could be performed in under 5 min. Consecutive rotator cuff repairs were filmed with the intent of capturing a <5-min repair. A retrospective analysis of prospectively collected data of 2232 patients who underwent primary arthroscopic rotator cuff repair by a single surgeon was performed using Spearman's correlations and multiple linear regression. Cohen's f² values were calculated to quantify effect size. Video footage of a 4-min arthroscopic repair was captured on the 4th case. Backwards stepwise multivariate linear regression found that an undersurface repair technique (f² = 0.08, p < 0.001), fewer surgical anchors (f² = 0.06, p < 0.001), more recent case number (f² = 0.01, p < 0.001), smaller tear size (f² = 0.01, p < 0.001), increased assistant case number (f² = 0.01, p < 0.001), female sex (f² = 0.004, p < 0.001), higher repair quality ranking (f² = 0.006, p < 0.001) and private hospital (f² = 0.005, p < 0.001) were independently associated with a faster operative time. Use of the undersurface repair technique, reduced anchor number, smaller tear size, increased surgeon and assistant surgeon case number, performing repairs in a private hospital and female sex independently lowered operative time. A <5-min repair was captured.

Arthroscopic rotator cuff repair performed with intra-articular tranexamic acid: could it provide improved visual clarity and less postoperative pain? A prospective, double-blind, randomized study of 63 patients

BACKGROUND

Tranexamic acid (TXA) has been widely used in orthopedic surgery with the aim of reducing intraoperative and postoperative bleeding, as well as bleeding-related complications. The purpose of this study was to assess whether intra-articular use of TXA during arthroscopic rotator cuff tear (RCT) repair could improve visual clarity, shorten the duration of the operation, and provide superior pain management as compared with placebo.

METHODS

We conducted a prospective, randomized, double-blind, placebo-controlled study. Patients aged ≥18 years with a magnetic resonance imaging-confirmed RCT and a history of failed conservative treatment for ≥6 months were included. Patients with a history of coagulopathy; a history of cardiac, renal, or hepatic disease; a history of conservative treatment for <6 months; and/or acute RCTs were excluded. Visual clarity as the primary outcome was assessed using an arthroscopic visual scale comprising 5 grades-ranging from grade 1, best visual clarity, to grade 5, worst visual clarity (requiring conversion to open surgery)-after the procedure by the operating surgeon every 10 minutes throughout the video of the operation. Secondary outcomes were operative duration and postoperative pain scores.

RESULTS

A total of 63 patients with similar demographic data (age and sex) and intraoperative mean arterial pressure were enrolled and randomized into 2 groups: The TXA group comprised 32 patients with a mean age of 56.46 years, and the placebo group comprised 31 patients with a mean age of 57.83 years. The TXA group was reported to have significantly superior visual clarity (mean arthroscopic visual scale score, 1.5 ± 0.5 vs. 2.86 ± 1.7; P < .001), with a significantly higher percentage of grade 1 visual clarity (78.1% vs. 32.2%, P < .001) and a significantly lower percentage of grade 4 visual clarity (0% vs. 3.2%, P = .003). Grade 5 visual clarity was not recorded in any patient in either group. The TXA group showed a significantly shorter operative duration (55.73 minutes vs. 67.26 minutes, P = .001) and superior pain scores at 8 hours (2.3 vs. 3.6, P = .002) and 24 hours (1.6 vs. 2.4, P < .001) postoperatively. No complications were recorded in either group.

CONCLUSIONS

This study showed that during arthroscopic rotator cuff repair procedures, intra-articular use of TXA was able to provide superior arthroscopic visual clarity while shortening the total operative duration significantly and providing significantly superior pain management in the first 8 and 24 hours postoperatively as compared with placebo. This study underlines the safety and efficacy of intra-articular TXA use in arthroscopic rotator cuff repair.

Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty

BACKGROUND

Previous studies have indicated an increased risk of periprosthetic joint infection (PJI) in patients treated with reverse shoulder arthroplasty (RSA) compared with patients treated with anatomic total shoulder arthroplasty. The reason for this is unclear but may be related to a high prevalence of previous rotator cuff repair in patients who are treated with RSA. The purpose of this study was to determine previous non-arthroplasty surgery as a risk factor for revision owing to PJI after RSA for cuff tear arthropathy, massive irreparable rotator cuff tears, or osteoarthritis.

METHODS

Data were retrieved from the Danish Shoulder Arthroplasty Registry and medical records. We included 2217 patients who underwent RSA for cuff tear arthropathy, massive irreparable rotator cuff tears, or osteoarthritis between 2006 and 2019. PJI was defined as ≥3 of 5 tissue samples positive for the same bacteria or as definite or probable PJI evaluated based on criteria from the International Consensus Meeting. The Kaplan-Meier method was used to illustrate the unadjusted 14-year cumulative rates of revision. A Cox regression model was used to report hazard for revision owing to PJI. Results were adjusted for previous non-arthroplasty surgery, sex, diagnosis, and age.

RESULTS

Revision was performed in 88 shoulders (4.0%), of which 40 (1.8%) underwent revision owing to PJI. There were 272 patients (12.3%) who underwent previous rotator cuff repair, of whom 11 (4.0%) underwent revision owing to PJI. The 14-year cumulative rate of revision owing to PJI was 14.1% for patients with previous rotator cuff repair and 2.7% for patients without previous surgery. The adjusted hazard ratio for revision owing to PJI for patients with previous rotator cuff repair was 2.2 (95% confidence interval, 1.04-4.60) compared with patients without previous surgery.

CONCLUSION

There is an increased risk of revision owing to PJI after RSA for patients with previous rotator cuff repair. We recommend that patients with previous rotator cuff repair be regarded as high-risk patients when considering RSA.

Evaluation of Osteochondral Allograft Transplant Using In-Office Needle Arthroscopy

In-office needle arthroscopy (IONA) has been available in various iterations for decades. Studies have described it as comparable if not superior to magnetic resonance imaging for identifying intra-articular pathology with associated cost savings per patient. A new IONA system has been brought to market with a modernized user interface and disposable handpieces offering the opportunity to address intra-articular pathology. This article outlines the use of this IONA system for the postoperative evaluation of an osteochondral allograft transplant.

Venothromboembolism following shoulder arthroscopy: a systematic review

Background

Venous thromboembolic events (VTEs) following orthopedic surgery may lead to serious morbidity and mortality. Fortunately, VTEs following upper extremity procedures are uncommon. However, the true incidence is likely underreported. The aim of this study is to provide a systematic review, excluding large database studies, to report on the incidence of VTEs following shoulder arthroscopic procedures.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review of multiple databases was performed. A comprehensive search of several databases from inception to September 1, 2021, limited to English language and excluding animal studies, was designed and conducted. Studies were screened by 2 independent reviewers. A decision to exclude studies from large surgical or insurance claim databases was made to minimize the risk of including overlapping data points in this systematic review.

Results

Thirteen studies met inclusion and exclusion criteria and form part of this systematic review. A total of 32,407 patients were included in this study. Among these patients, the deep vein thrombosis, pulmonary embolism, and overall VTE rates were 0.15%, 0.08%, and 0.21%, respectively. Among the patients specified to have undergone arthroscopic rotator cuff repair, the rate of deep vein thrombosis, pulmonary embolism, and overall VTE was 0.71%, 0.37%, and 1.04%, respectively.

Conclusion

While symptomatic VTEs are rare following shoulder arthroscopic procedures, surgeons must be aware that they still account for a certain number of postoperative complications. Factors such as operative time, open procedures, obesity, and altitude may increase the risk of postoperative VTE although conflicting data exist. Current literature supports the idea that chemical antithrombotic prophylaxis likely provides no significant advantage over early mobilization in reducing VTEs following shoulder arthroscopy in low-risk patients.

Transosseous repair with a cortical implant for greater tubercle cyst-related rotator cuff tear results in good clinical outcomes, but significant implant migration

PURPOSE

To evaluate whether an arthroscopic transosseous technique (ATO) with cortical implants is effective for rotator cuff tear (RCT) repair in patients with cysts of the greater tuberosity (GTC).

METHODS

Patients treated with the ATO technique between January 2013 and October 2017 were evaluated. Inclusion criteria were patients treated for both cyst-related and non-cyst-related RCTs and patients with a moderate-sized tear (1-3 cm) according to the DeOrio and Cofield classification. A total of 39 patients were separated into two groups: Group 1 (n = 16) patients with cyst-associated RCT, and Group 2 (n = 23) patients with no cyst. Implant pull-out and migration were evaluated radiologically on standard antero-posterior shoulder radiographs and rotator cuff re-tear was assessed on magnetic resonance images at the final follow-up examination. Group 1 patients were separated into two subgroups according to cyst size (cyst < 5 mm and cyst ≥ 5 mm) and subgroup analysis was performed. Clinical assessment was performed using a visual analog scale, the Constant score and Oxford shoulder score.

RESULTS

The mean follow-up time was 33.7 ± 11.7 months. The mean cyst size was 5.4 ± 1.5 mm. There was no significant difference in re-tear rates between the cystic and non-cystic groups. The mean implant migration distance was 3.0 ± 2.2 mm in patients with a RCT -related cyst and 0.7 ± 0.8 mm in those without a cyst. A statistically significant difference was found between the groups (p = 0.002). There was no statistically significant difference between the groups in respect of clinical scores. No implant failure was observed.

CONCLUSION

The ATO method performed with a cortical implant in RCTs resulted in satisfactory recovery and clinical outcomes in the short to medium term with low failure rates. While no implant failures were observed, implant migration was associated with cyst presence. Therefore, judicious use is advocated in the choice of transosseous fixation for cyst-related RCTs and patients should be informed of the possibility of implant migration.

LEVEL OF EVIDENCE

III.

Alcohol Abuse, Morbid Obesity, Depression, Congestive Heart Failure, and Chronic Pulmonary Disease are Risk Factors for 90-Day Readmission After Arthroscopic Rotator Cuff Repair

Purpose

The purpose of this study was to report the rate and causes of 90-day readmissions after arthroscopic rotator cuff repair.

Methods

A retrospective query from January 2005 to March 2014 was performed using a nationwide administrative claims registry. Patients and complications were identified using International Classification of Disease, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Patients who underwent arthroscopic rotator cuff repair (RCR) and were readmitted within 90 days after their index procedure were identified. Patients not readmitted represented controls. Patients readmitted were stratified into separate cohorts depending on the primary cause of readmission, which included cardiac, endocrine, hematological, infectious, gastrointestinal, musculoskeletal (MSK), neoplastic, neurological or psychiatric, pulmonary, and renal. Risk factors assessed were comorbidities comprising the Elixhauser-Comorbidity Index (ECI). Primary outcomes analyzed and compared included cause for readmission, patient demographics, risk factors, in-hospital length of stay (LOS), and costs. Pearson’s chi-square was used to compare patient demographics, and multivariate binomial logistic regression was used to calculate odds ratios (OR) on patient-related risk factors for 90-day readmissions.

Results

10,425 readmitted patients and 301,625 control patients were identified, representing a 90-day readmission rate of 3.5%. The causes of readmissions were primarily related to infectious diseases (15%), MSK (15%), and cardiac (14%) complications. The most common MSK readmissions were osteoarthrosis of the leg or shoulder (24.8%) and spinal spondylosis (8.4%). Multivariate binomial logistic regression analyses demonstrated patients with alcohol abuse (OR, 1.42; P < .0001), morbid obesity (OR, 1.38; P < .0001), depression (OR, 1.35; P < .0001), congestive heart failure (OR, 1.34; P < 0.0001), and chronic pulmonary disease (OR, 1.28; P < .0001) were at the greatest risk of readmissions after RCR.

Conclusions

Significant differences exist among patients readmitted, and those patients who do not require hospital readmission within 90 days following arthroscopic rotator cuff repairs. Readmissions are associated with significant patient comorbidities and were primarily related to medically based complications.

Level of Evidence

Level III, prognostic, retrospective cohort study.

Increased Risk of Surgical-Site Infection and Need for Manipulation Under Anesthesia for Those Who Undergo Open Versus Arthroscopic Rotator Cuff Repair

Purpose

Methods

Results

Conclusions

Level of Evidence

Outcomes of Mini-Invasive Arthroscopic Arthrolysis Combined with Locking Screw and/or Intramedullary Nail Extraction after Osteosynthesis of the Proximal Humerus Fracture

Data on the effectiveness of arthroscopic arthrolysis and extraction of osteosynthetic material after osteosynthesis of the proximal humerus in patients with persisting problems are rare and insufficient. In this study, we performed arthroscopic arthrolysis and extraction of fixation screws, and, where protruding, extraction of the nail in 34 patients with problems persisting 12 months after osteosynthesis of the proximal humerus using an intramedullary nail. The effectiveness of the treatment was assessed using the Constant-Murley shoulder score and forward flexion difference between the treated arm and the contralateral one. A median increase of 16 points in CMS score and 30 degrees reduction in the arm forward flexion difference was recorded 12 months after the arthroscopy. The improvement was significantly higher in the patient group with intramedullary nail extraction (however, this group had worse pre-operative values and the screw was only extracted where likely to cause problems). The median time to heal was 11 weeks; no serious peri- or post-procedural complications occurred. Mini-invasive arthroscopic arthrolysis combined with extraction of osteosynthetic material proved to be a safe and effective method for treatment of patients after osteosynthesis of the proximal humerus using an intramedullary nail with persisting pain and/or mobility limitation.

Arthroscopic Rotator Cuff Repair Results in Lower Two-Year Reoperation Rates Compared With Open Rotator Cuff Repair in a Large Cross-sectional Cohort

PURPOSE

To use a large, contemporary database to perform a cross-sectional analysis of current practice trends in rotator cuff repair (RCR) for the treatment of full-thickness rotator cuff tear (RCT) and determine outcomes of arthroscopic and open RCR, including hospital readmissions and 2-year reoperation rates with accurate laterality tracking using International Classification of Diseases, Tenth Revision (ICD-10) codes.

METHODS

The PearlDiver Mariner dataset was used to query patients with full-thickness RCTs from 2010 to 2017. Propensity-score matching was performed to account for differences in age and comorbidities and allow for comparison between those undergoing open RCR and arthroscopic RCR. Subsequent procedures were tracked using ICD-10 codes to identify ipsilateral surgery within 2 years of index surgery. Hospital and emergency department admission within 30 days of surgery were investigated.

RESULTS

Of 534,076 patients diagnosed with full-thickness RCT, 37% underwent RCR; 73% of which were arthroscopic. From 2010 to 2017, arthroscopic RCRs increased from 65% to 80%, whereas open RCRs decreased from 35% to 20% (P < .0001). Younger patients underwent arthroscopic RCR more frequently, and patients who underwent open RCR had greater rates of 30-day emergency department (7.0%) and hospital readmission (2.0%) compared with arthroscopic RCR (6.3%, 1.0%, respectively) (P < .0001). For 24,392 patients with ICD-10 coding and 2-year follow-up, 10.4% of patients required reoperation, with the most common procedure being revision RCR, and 1.3% required conversion to arthroplasty. Open RCRs were more likely to require subsequent surgery (11.3%) compared with arthroscopic RCR (9.5%) (P < .0001). Patients aged 50 to 59 had the greatest rate of reoperation (14.0%), but no patients younger than age 40 years required reoperation, and no patients younger than age 50 years required conversion to arthroplasty.

CONCLUSIONS

The frequency of arthroscopic RCR has continued to increase compared to open RCR. In this large cross-sectional analysis, arthroscopic RCR demonstrated lower 2-year reoperation rates and 30-day readmission rates compared to open RCR.

LEVEL OF EVIDENCE

III, cross-sectional study.

Live Surgery: A retrospective study on the outcomes and complications of 7 orthopedic live surgery events

INTRODUCTION

Live surgery has always been an invaluable part of medical education. Live Surgery Events (LSE) have recently been criticized in France, arguing that unnecessary risks have been placed on the patients.

HYPOTHESIS

We want to report our experience in organizing the last 7 shoulder LSE over the past 12 years focusing on the results and complications during and after the surgeries performed during these courses.

MATERIAL AND METHODS

190 patients benefited from live shoulder surgery between 2005 and 2017. 11 of them were lost to follow up, thus 179 patients were included. The mean follow-up was 7,5 years for the instability group, 6,7 years for the rotator cuff group, 7,5 years for the arthroplasty group and 6,8 years for the nerve group. This study is a retrospective analysis of prospectively collected data. We report the epidemiology of the surgeries perfomed and analyzed the patient outcomes: peri and postoperative complications. We evaluated the educational benefit for the attendees of this shoulder LSE through a questionnaire.

RESULTS

There were 6 (3.1%) peri or immediate postoperative complications. There were 33 (18%) long term complications needing 26 (14%) revisions. 90% of the surgeons audience attending the events evaluated the educational benefit from good to very good.

DISCUSSION

Over the years, we have standardized the organization of the meeting to ensure maximum safety, while still respecting patient integrity and anonymity. Our complications rates seem within the ranges found in the current literature for each procedure. Our LSE has been an instrument for education, but also for matching patients with complex problems with experienced surgeons, to the benefit of the patient. Our experience has shown that LSE may induce potential dangers and complications can arise. However, these events should follow rigorous rules and not just recommendations.

LEVEL OF EVIDENCE

IV; retrospective analysis of prospectively collected data.

Functional outcomes of arthroscopic transosseous rotator cuff repair using a 2-mm tape suture in a 137-patient cohort

Background

Although being the historical gold standard for rotator cuff repair, open transosseous (TO) repair was largely replaced by anchor-based methods with the advent of arthroscopic surgery owing to their comparative ease of use. However, suture anchors are at risk of dislodgement, especially among older patients, who have more osteopenic bone or those presenting large tears. Considering the ever-increasing active life expectancy and associated increased quality of life expectations by older generations, the need to offer safe and efficient surgical treatments to these patients imposes itself. Arthroscopic TO repairs would combine the best of both worlds and be well adapted to these populations. The primary objective of this study was to evaluate the functional outcome and complication rate of the TO arthroscopic repair technique when using a 2-mm braided suture tape. The secondary objective of this study was to assess functional outcome of TO repair in older patients and patients with >3-cm tears.

Methods

One hundred thirty-seven consecutive patients with full-thickness rotator cuff tear who underwent arthroscopic TO (anchorless) rotator cuff repair between January 2011 and December 2013 were reviewed. The surgery was performed by a single surgeon with a reusable curved suture passer and 2-mm braided tape suture. Follow-up was 3 to 5 years (mean = 50 months). All patients underwent preoperative and postoperative functional assessments (American Shoulder and Elbow Surgeons and Quick Dash) and were questioned with their overall satisfaction.

Results

Thirty-eight (28%) of the 137 patients were 65 years and older, and 62 (45%) had a large or massive tear. One patient (0.7%) had early retear at the suture-tendon interface after trauma 3 weeks postoperatively. The average Quick Dash score improved by 55.6 points and the average American Shoulder and Elbow Surgeons score improved by 69.7 points 3.5 and 6.3 times their minimal clinically important differences, respectively. There was no significant difference in final functional outcomes between patients 65 years and older and younger patients or between patients with large and massive (>3 cm) and smaller tears (≤3 cm). Mean operative time was 68 min ± 16.

Conclusions

Arthroscopic TO repair using a 2-mm tape material has achieved significant mid-term functional improvement, with results statistically unaffected by larger tear size (>3 cm) or older age (≥65 years).

Level of obesity is directly associated with complications following arthroscopic rotator cuff repair

BACKGROUND

The purpose of this study was to investigate the association between increasing levels of obesity and postoperative complications within 30 days of arthroscopic rotator cuff repair (ARCR).

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent ARCR from 2015 to 2017. Patients were stratified into 3 cohorts according to their body mass index (BMI). Patients with a BMI < 30 kg/m² were placed in the non-obese cohort, patients with a BMI between 30 and 40 kg/m² were placed in the obese cohort, and patients with a BMI > 40 kg/m² were placed in the morbidly obese cohort. Postoperative complications within 30 days of the procedure were collected. Multivariate logistic regression was used to investigate the relationship between increasing levels of obesity and postoperative complications.

RESULTS

There were 18,521 patients included in this study. Of these patients, 9548 (51.6%) were non-obese, 7438 (40.2%) were obese, and 1535 (8.3%) were morbidly obese. A comparison among non-obese, obese, and morbidly obese patients showed increasing rates of medical complications (0.5% vs. 1.0% vs. 1.4%), pulmonary complications (0.1% vs. 0.3% vs. 0.5%), renal complications (0.0% vs. 0.1% vs. 0.2%), readmission (0.9% vs. 1.2% vs. 1.6%), nonhome discharge (0.4% vs. 0.5% vs. 1.2%), and overall complications (0.8% vs. 1.3% vs. 1.8%). In comparison to non-obesity, both obesity and morbid obesity were identified by multivariate analysis as significant predictors of medical complications (odds ratio [ORs] of 1.72 and 2.16, respectively), pulmonary complications (ORs of 2.66 and 4.06, respectively), and overall complications (ORs of 1.52 and 1.77, respectively).

CONCLUSION

This study used a large national database to identify increasing levels of obesity as a risk factor for medical complications, pulmonary complications, and overall complications within 30 days of ARCR.

Cost analysis and complication rate comparing open, mini-open, and all arthroscopic rotator cuff repair

Hypothesis/Background

Value-based healthcare delivery models are becoming increasingly common and are driving cost effectiveness initiatives. Rotator cuff repair (RCR) is a commonly performed procedure with some variations on the specific surgical technique. The purpose of this study was to perform a comprehensive analysis of the cost, complications, and readmission rates of 3 categories of RCR techniques (open [oRCR], combined arthroscopically assisted and mini-open [CRCR], and all arthroscopic [ARCR]) at a high-volume institution.

Methods

All RCR procedures performed by 2 fellowship-trained shoulder surgeons at a single institution between 2012 and 2017 were retrospectively identified. These consisted of oRCR, CRCR, and ARCR repair techniques. One surgeon performed oRCR and CRCR, and the second surgeon performed ARCR. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation.

Results

The cohort consisted of 95 oRCR, 233 CRCR, and 287 ARCR. Median standardized costs were as follows: preoperative evaluation $486.03; index surgical hospitalization oRCR $9,343.10, CRCR $10,057.20, and ARCR $10,330.60; and postoperative care $875.02. Preoperative and postoperative costs did not vary based on the type of RCR performed. However, significant differences were observed among index surgical costs (P = .0008). The highest standardized cost for hospitalization for both the CRCR group and the ARCR group was related to the cost of the operating room and the implants. The 90-day complication, reoperation, and readmission rates were 1.1%, 1.1%, and 2.1% in the open group; 0.8%, 0.8%, and 1.7% in the combination group; 0%, 0%, and 1.7% in the all arthroscopic group, respectively. There were no significant differences among the 3 surgical procedures with respect to complication (P = .26), reoperation (P = .26), and readmission rates (P = .96).

Discussion/Conclusions

In this investigation, the median standardized costs for RCR inclusive of 60-day workup and 90-day postoperative care were $10,704.15, $11,418.25, and $11,691.65 for oRCR, CRCR (average added cost $714.10), and ARCR (added cost $987.50), respectively. The group complication, reoperation, and readmission rate were 0.5%, 0.5%, and 1.8% with no significant differences between the varying techniques, respectively. This retrospective cost analysis and complication profile may serve as a useful reference as surgeons consider engaging in bundled payment for RCR. As value based initiatives continue to progress, implant cost may serve as an actionable area for cost reduction.

Diabetes is an independent risk factor for infection after non-arthroplasty shoulder surgery: a national database study

OBJECTIVES

Diabetes has been associated with poor healing and prior literature has shown worse functional outcomes in diabetic patients undergoing both open and arthroscopic shoulder surgery. However, the effects of diabetes on perioperative complications for patients undergoing non-arthroplasty type shoulder procedures are not well defined. The purpose of this study was to analyze the effects of diabetes on 30-day complications following non-arthroplasty shoulder surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent open and arthroscopic shoulder procedures (excluding arthroplasty) from 2011 to 2018. Diabetic patients were identified and compared to a non-diabetic cohort. Demographic data and postoperative complications within 30 days were analyzed. Multivariable regression was used to determine the effect of diabetes on shoulder surgery.

RESULTS

We identified 99,970 patients who underwent shoulder surgery in our cohort and 13.9% (13,857 patients) of these patients were diabetics. Within the diabetic cohort, 4,394 (31.7%) were insulin dependent. Diabetics were more likely to be older, female, and have a higher body mass index (P < 0.01). Diabetics had a higher rate of associated medial comorbidities (P < 0.05). Diabetics were less likely to be smokers and on average had shorter surgeries (P < 0.05). Univariate analysis showed that diabetes was associated with increased risk for infectious and other major and minor complications; however, multivariate regression revealed that diabetes was only independently associated with infection (OR 1.33, P = 0.38).

CONCLUSION

While diabetes is associated with increased likelihood of infection following shoulder surgery, absent commonly associated comorbidities, they are not at increased risk for other 30-day postoperative complications.

The Relevance of Open Rotator Cuff Repair in 2021

BACKGROUND

The last decade has seen a large increase in rotator cuff surgery and arthroscopic surgery. We were asked to define the relevance of open rotator cuff repair in 2021.

PURPOSE

To define whether there are proven advantages to arthroscopic or open rotator cuff repair surgery.

METHOD

We reviewed the recent literature regarding recent trends, anaesthetic time, rehabilitation, post-operative pain, complications, economic considerations, the learning curve and outcomes. We outlined the senior authors' technique preferences, rationale and patient reported outcomes.

RESULTS

There is no clear evidence of proven advantage in arthroscopic rotator cuff repair compared to open rotator cuff repairs, with regard to outcomes or the other aspects reviewed. There were no differences in the outcomes of arthroscopic and open repairs in the senior authors practice with his procedure indications.

CONCLUSIONS

Open rotator cuff repair surgery remains a valid option and has some appeal in specific indications and in settings where arthroscopic resources are limited. We believe surgeons should learn both techniques and the principles of good patient selection, tissue handling, and fixation techniques are of paramount importance in both arthroscopic and open rotator cuff surgery.

Reassessment of Relative Value in Shoulder and Elbow Surgery: Do Payment and Relative Value Units Reflect Reality?

BACKGROUD

Many U.S. health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. A major determinant of payment and wRVU assignments is operative time. We sought to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common shoulder/elbow procedures.

METHODS

We collected data on wRVUs, payments, and operative times from CMS for 29 types of isolated arthroscopic and open shoulder/elbow procedures. Using regression analysis, we compared relationships between these variables, in addition to median operative times reported by NSQIP (2013-2016). We then determined the relative valuation of each procedure based on operative time.

RESULTS

Seventy-nine percent of CMS operative time were longer than NSQIP time (R2 = 0.58), including, but not limited to, shoulder arthroplasty and arthroscopic shoulder surgery. The correlation between payments and operative times was stronger between CMS data (R2 = 0.61) than NSQIP data (R2 = 0.43). Similarly, the correlation between wRVUs and operative times was stronger when using CMS data (R2 = 0.87) than NSQIP data (R2 = 0.69). Nearly all arthroscopic shoulder procedures (aside from synovectomy, debridement, and decompression) were highly valued according to both datasets. Per NSQIP, compensation for revision total shoulder arthroplasty ($10.14/min; 0.26 wRVU/min) was higher than that for primary cases ($9.85, 0.23 wRVU/min) and nearly twice the CMS rate for revision cases ($5.84/min; 0.13 wRVU/min).

CONCLUSIONS

CMS may overestimate operative times compared to actual operative times as recorded by NSQIP. Shorter operative times may render certain procedures more highly valued than others. Case examples show that this can potentially affect patient care and incentivize higher compensating procedures per operative time when less-involved, shorter operations have similar patient-reported outcomes.

Arthroscopic rotator cuff repair in patients over 70 years of age: a systematic review

Background

Failure of conservative treatment in patients over 70 years of age with a rotator cuff tear makes surgery a possible option, considering the increase in life expectancy and the high functional demands of elderly patients. The purpose of this systematic review of the literature was to evaluate the subjective and objective outcomes after arthroscopic rotator cuff repair in patients over 70 years of age.

Methods

A systematic review was performed to identify all the studies reporting subjective and objective outcomes in patients aged 70 years or older undergoing arthroscopic rotator cuff repair. Constant Murley Score (CMS), visual analog scale (VAS), American Shoulder and Elbow Surgeons Score (ASES), and Simple Shoulder Test (SST) were used to detect any clinical improvement after surgery. Retear and satisfaction were also analyzed.

Results

Out of 941 studies identified, only 6 papers have been included in the review. All studies reported improvements in postoperative functional outcome scores that exceed the minimal clinically relevant difference. The mean retear rate amounts to 21.9%, which is in line with the failure rate of rotator cuff repair in general population. Moreover, postoperative satisfaction is very high (95%).

Conclusion

This systematic review suggests that arthroscopic rotator cuff repair in patients over 70 years of age could be a valid treatment option after failure of conservative approach.

Level of evidence: 4

Trial registration The study was registered on PROSPERO (registration ID: CRD42018088613)

Smoking as a risk factor for complications following arthroscopic rotator cuff repair

Background

The purpose of this study was to investigate the association between smoking status and postoperative complications within 30 days of arthroscopic rotator cuff repair (ARCR).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients who underwent ARCR from 2015 to 2017. Smokers were defined as patients who reported smoking cigarettes in the year prior to rotator cuff repair. Patients who used chewing tobacco, cigars, or electronic cigarettes were not included in the smoking cohort. Postoperative complications were reported within 30 days of the procedure. Multivariate logistic regression was performed to investigate the relationship between smoking status and postoperative complications.

Results

There were 18,594 patients included in this study. Of these patients, 2834 (15.2%) were current smokers. Smokers were more likely to be men, to be aged < 65 years, and to have a body mass index < 30. Smokers were also more likely to have chronic obstructive pulmonary disease, to be functionally dependent, and to have an American Society of Anesthesiologists (ASA) class ≥ 3. After adjustment for all significantly associated patient demographic characteristics and comorbidities, smoking was identified as a significant predictor of surgical complications (odds ratio [OR], 1.955; P = .022), return to the operating room (OR, 2.547; P = .003), readmission (OR, 1.570; P = .014), and sepsis or septic shock (OR, 4.737; P = .021). Smoking was not a significant predictor of medical complications (OR, 1.105; P = .687) or surgical-site infections (OR, 1.216; P = .713).

Conclusion

Smoking may be a risk factor for surgical complications, readmission, and sepsis or septic shock within 30 days of ARCR.

Post-operative septic arthritis after arthroscopy: modern diagnostic and therapeutic concepts

PURPOSE

Septic arthritis is a significant complication following arthroscopic surgery, with an estimated overall incidence of less than 1%. Despite the low incidence, an appropriate diagnostic and therapeutic pathway is required to avoid serious long-term consequences, eradicate the infection, and ensure good treatment outcomes. The aim of this current review article is to summarize evidence-based literature regarding diagnostic and therapeutic options of post-operative septic arthritis after arthroscopy.

METHODS

Through a literature review, up-to-date treatment algorithms and therapies have been identified. Additionally, a supportive new algorithm is proposed for diagnosis and treatment of suspected septic arthritis following arthroscopic intervention.

RESULTS

A major challenge in diagnostics is the differentiation of the post-operative status between a non-infected hyperinflammatory joint versus septic arthritis, due to clinical symptoms, (e.g., rubor, calor, or tumor) can appear identical. Therefore, joint puncture for microbiological evaluation, especially for fast leukocyte cell-count diagnostics, is advocated. A cell count of more than 20.000 leukocyte/µl with more than 70% of polymorphonuclear cells is the generally accepted threshold for septic arthritis.

CONCLUSION

The therapy is based on arthroscopic or open surgical debridement for synovectomy and irrigation of the joint, in combination with an adequate antibiotic therapy for 6-12 weeks. Removal of indwelling hardware, such as interference screws for ACL repair or anchors for rotator cuff repair, is recommended in chronic cases.

LEVEL OF EVIDENCE

IV.

Time Required to Achieve Clinically Significant Outcomes After Arthroscopic Rotator Cuff Repair

BACKGROUND

Recent literature has focused on correlating statistically significant changes in outcome measures with clinically significant outcomes (CSOs). CSO benchmarks are being established for arthroscopic rotator cuff repair (RCR), but more remains to be defined about them.

PURPOSE

To define the time-dependent nature of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptomatic State (PASS) after RCR and to define what factors affect this time to CSO achievement.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

An institutional registry was queried for patients who underwent arthroscopic RCR between 2014 and 2016 and completed preoperative, 6-month, 1-year, and 2-year patient-reported outcome measures (PROMs). Threshold values for MCID, SCB, and PASS were obtained from previous literature for the American Shoulder and Elbow Surgeons score (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant score. The time in which patients achieved MCID, SCB, and PASS was calculated using Kaplan-Meier analysis. A Cox multivariate regression model was used to identify variables correlated with earlier or later achievement of CSOs.

RESULTS

A total of 203 patients with an average age of 56.19 ± 9.96 years and average body mass index was 30.29 ± 6.49 were included. The time of mean achievement of MCID, SCB, and PASS for ASES was 5.77 ± 1.79 months, 6.22 ± 2.85 months, and 7.23 ± 3.81 months, respectively. The time of mean achievement of MCID, SCB, and PASS for SANE was 6.25 ± 2.42 months, 7.05 ± 4.10 months, and 9.26 ± 5.89 months, respectively. The time of mean achievement of MCID, SCB, and PASS for Constant was 6.94 ± 3.85 months, 7.13 ± 4.13 months, and 8.66 ± 5.46 months, respectively. Patients with dominant-sided surgery (hazard ratio [HR], 1.363; 95% CI, 1.065-1.745; P = .014) achieved CSOs earlier on ASES, while patients with workers' compensation status (HR, 0.752; 95% CI, 0.592-0.955; P = .019), who were current smokers (HR, 0.323; 95% CI, 0.119-0.882; P = .028), and with concomitant biceps tenodesis (HR, 0.763; 95% CI, 0.607-0.959; P = .021) achieved CSOs on ASES at later timepoints. Patients with distal clavicle excision (HR, 1.484; 95% CI, 1.028-2.143; P = .035) achieved CSOs earlier on SANE. Patients with distal clavicle excision (HR, 1.689; 95% CI, 1.183-2.411, P = .004) achieved CSOs earlier on Constant, while patients with workers' compensation insurance status (HR, 0.671; 95% CI, 0.506-0.891; P = .006) and partial-thickness tears (HR, 0.410; 95% CI, 0.250-0.671; P < .001) achieved CSOs later on Constant. Greater preoperative score was associated with delayed achievement of CSOs for ASES, SANE (HR, 0.993; 95% CI, 0.987-0.999; P = .020), and Constant (HR, 0.941; 95% CI, 0.928-0.962; P < .001).

CONCLUSION

A majority of patients achieved MCID by 6 months after surgery. Dominant-sided surgery and concomitant distal clavicle excision resulted in faster CSO achievement, while workers' compensation status, concomitant biceps tenodesis, current smoking, partial-thickness rotator cuff tears, and higher preoperative PROMs resulted in delayed CSO achievement.

Single-Incision Rotator Cuff Repair With a Needle Arthroscope

Arthroscopy frequently has been used to treat a variety of shoulder conditions, including rotator cuff tears. Arthroscopic techniques, when compared with open techniques, are associated with less morbidity, leading to lower complication rates, easier recovery, and improved outcomes. As technology improves, we continue to develop less-invasive surgical techniques to treat rotator cuff pathology. With the development of the NanoScope (Arthrex, Naples, FL), we have the opportunity to view through a small cannula without making a standard viewing portal. This technique combines this small viewing portal with standard repair techniques through only a single lateral incision to provide a less-invasive rotator cuff repair technique.

The 5-Factor Modified Frailty Index Predicts Complications, Hospital Admission, and Mortality Following Arthroscopic Rotator Cuff Repair

INTRODUCTION

The purpose of this study is to evaluate the utility of the modified frailty index-5 (mFI-5) as a predictor for postoperative complications in patients undergoing arthroscopic rotator cuff repair (RCR).

METHODS

The National Surgical Quality Improvement Program database was queried for patients undergoing arthroscopic RCR between 2006 and 2016. The mFI-5, a 5-factor score comprising comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status limiting independence, was calculated for each patient. Multivariate logistic regression models were used to evaluate the mFI-5 score as a predictor for complications including medical complications, surgical-site infections, hospital admission, discharge to a facility, and mortality.

RESULTS

In total, 24,477 patients met criteria for inclusion. The mFI-5 was a strong predictor for medical complications (P < .001), hospital admission (P < .001), length of stay (P = .007), and discharge to a facility (P = .001) but not surgical-site infections (P = .153). For each point increase in mFI-5 score, the risk for a medical complication increased by 66%, readmission by 52%, and adverse discharge by 45%. However, of all the measured complications, the mFI-5 was the strongest predictor for mortality, with the risk more than doubling for each increase in mFI-5 point (odds ratio 2.66, P = .025).

CONCLUSIONS

The mFI-5 is a sensitive tool for predicting life-threatening medical complications, hospital admission, increased length of stay, adverse discharge, and mortality following arthroscopic RCR. The 5 comorbidities comprising the mFI-5 are easily obtained through the patient history, making it a practical clinical tool for identifying high-risk patients, informing preoperative counseling, and improving value-based health care.

LEVEL OF EVIDENCE

Level III, prognostic.

Medialization of medial row anchor via the Nevasier portal yield enhanced footprint and outcomes in medium-to-large rotator cuff tears

PURPOSE

To evaluate clinical and radiological outcomes of medial row anchor insertion between 90° or 45° (deadman) angle in the suture-bridge rotator cuff repair of medium-to-large rotator cuff tears.

METHODS

This retrospective analysis included 113 consecutive patients undergoing arthroscopic suture-bridge repair for medium-to-large rotator cuff tears (mean tear size: 2.8 × 2.3 cm) between 2010 and 2013. The patients were divided into two groups: group I (53 patients) and group II (60 patients) involving 90° and 45° medial row anchors, respectively. The conventional lateral row anchors were inserted in the suture-bridge repair. The clinical outcomes at 2 years and radiological outcomes including re-tear or footprint coverage (anteroposterior length and mediolateral width) of the repaired tendon using postoperative MRI were evaluated.

RESULTS

Clinical outcome scores were significantly improved in both groups. However, Group I (90° anchor insertion group) showed better clinical scores without the difference of range of motion. The postoperative MRI revealed enlarged footprint coverage with 90° medial row anchor. The repaired footprint cuff size (mediolateral width) in the coronal plane MRI showed a statistically significant difference (45°: 19 mm vs. 90°: 24 mm) (p < 0.05).

CONCLUSIONS

Enhanced clinical outcomes and additional anatomical footprint coverage (coronal width of repaired tendon) in the suture-bridge repair are obtained with the 90° medial row anchors compared with the 45° medial row anchors. These findings would guide clinical application of 90° medial row anchor insertion for further medialization in the medium-to-large rotator cuff tears.

LEVEL OF EVIDENCE

Level III (retrospective comparative trial).

Preoperative Mental Health Scores and Achieving Patient Acceptable Symptom State Are Predictive of Return to Work After Arthroscopic Rotator Cuff Repair

Background:

The incidence of rotator cuff repairs has risen dramatically over the past 10 years, most notably in the working-class population. Return to work (RTW) is a valuable outcome measure to set patient expectations before surgery.

Purpose:

To establish the rate of RTW after rotator cuff repair with respect to stratified levels of occupational demand (sedentary, light, moderate, and heavy) and to identify clinical factors significantly associated with postoperative RTW.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who received rotator cuff repair between 2014 and 2017 were queried from a prospectively maintained institutional registry. Work status was evaluated from clinical and physical therapy notes, and RTW was stratified based on duty level. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) values were calculated for American Shoulder and Elbow Surgeons (ASES) score and subjective Constant score through use of an anchor-based approach. Patient demographic factors, preoperative ASES scores, Constant scores, and health-related quality of life scores, as well as change in postoperative scores exceeding the thresholds for MCID, SCB, and PASS, were analyzed to determine significant associations with RTW without restriction.

Results:

In total, 89 patients with documented pre- and postoperative work status underwent surgery. Rates of RTW for sedentary, light, moderate, and heavy duties were 100%, 84.0%, 77.4%, and 63.3%, respectively, within return at less than 7 postoperative months on average. RTW was associated with achieving PASS (P = .004) but not achieving MCID and SCB (P = .429 and .452, respectively). Injury to a patient’s dominant side had reduced odds (0.057; 95% CI, 0.004-0.763; P = .030) for RTW at full duty. Tear characteristics and type of insurance were not associated with RTW. Preoperative Veterans RAND Mental Component Score (>53.3; area under the curve, 70.4%) was predictive of returning to work.

Conclusion:

A vast majority of patients undergoing rotator cuff repair can expect to return to work within 8 months of surgery. Preoperative mental health scores can predict future return to work, which supports the concept that mental health status plays an important role in the outcomes after rotator cuff repair surgery.

Influence of vitamin C on the incidence of CRPS-I after subacromial shoulder surgery

PURPOSE

The primary aim of this study was to determine whether postoperative administration of vitamin C (VC) is associated with reduced risk of complex regional pain syndrome type I (CRPS-I) after subacromial shoulder surgery (SaSS). The secondary objective of the study was to identify risk factor for the development of CRPS-I after SaSS.

MATERIALS AND METHODS

A retrospective cohort study was performed to evaluate 542 patients undergoing SaSS from January 2015 to December 2016. The cohort was divided into two groups based on VC administration [Group I (no VC) and Group II (500 mg/day oral VC for 50 days postoperatively)]. The relationship between VC administration and development of CRPS-I was assessed. Demographics, preoperative clinical parameters, and operative variables were evaluated to determine their effect on the incidence of CRPS-I.

RESULTS

A total of 267 patients (Group II) undergoing SaSS received VC, and 266 patients (Group I) did not. The incidence of CRPS-I was significantly different between two groups (36(13%) vs 18(7%), p = 0.009). Multivariable regression, however, demonstrated that VC reduced the risk of CRPS-I after SaSS by > 50% (aOR = 0.49; 95% CI 0.27-0.91). Patients undergoing open surgery (aOR = 2.19; 95% CI 1.2-4.0) were more likely to develop CRPS-I postoperatively. Higher preoperative Constant score (aOR = 0.94; 95% CI 0.91-0.98) was associated with lower risk for CRPS-I development.

CONCLUSIONS

The present study found that VC administered prophylactically for 50 days postoperatively is effective in preventing CRPS-I development after SaSS. CRPS-I is a common complication following SaSS, especially in the setting of an open approach. The authors recommend preventive management with VC and arthroscopic approaches when possible for SaSS.

LEVEL OF EVIDENCE III

Retrospective comparative study.

The effect of age on short-term postoperative complications following arthroscopic rotator cuff repair

Hypothesis

The purpose of this study was to assess short-term outcomes, including the rates of medical complications, non-home discharge, overnight hospital stay, and 30-day readmission, associated with patient age at the time of rotator cuff repair.

Methods

This study used National Surgical Quality Improvement Program data from 2005 to 2016 to analyze patients who underwent arthroscopic rotator cuff repair (ARCR). Patients were stratified into age cohorts of younger than 55 years, between 55 and 65 years, or older than 65 years. Outcomes including postoperative complications, discharge destination, and readmission were compared between the age cohorts using multivariate analysis.

Results

We identified 23,974 patients undergoing ARCR: 8344 patients (34.8%) were younger than 55 years, 9166 (38.4%) were aged between 55 and 65 years, and 6434 (26.8%) were older than 65 years. Older patients were more likely to be female patients and to have a lower body mass index, more medical comorbidities, shorter operative duration, dependent functional status, and higher American Society of Anesthesiologists classification. Patients older than 65 years had a higher rate of total complications (odds ratio [OR], 1.99; P = .003), respiratory complications (OR, 2.99; P = .023), urinary tract infections (OR, 6.94; P < .001), overnight hospital stay (OR, 1.49; P < .001), and unplanned hospital readmission (OR, 1.50; P = .040) relative to patients younger than 55 years. There was no increase in complication rates for patients aged between 55 and 65 years.

Conclusions

Patients older than 65 years have nearly double the odds of having a postoperative complication following ARCR and nearly 3 and 6 times the odds of having a respiratory complication and a urinary tract complication, respectively. Thorough preoperative optimization, including respiratory and urinary care, may be able to decrease complications in select, high-risk patients.

A 15-Minute Incremental Increase in Operative Duration Is Associated With an Additional Risk of Complications Within 30 Days After Arthroscopic Rotator Cuff Repair

Background:

Operative time is a risk factor for short-term complications after orthopaedic procedures; however, it has yet to be investigated as an independent risk factor for postoperative complications after arthroscopic rotator cuff repair.

Purpose:

To determine whether operative time is an independent risk factor for complications, readmissions, and extended hospital stays within 30 days after arthroscopic rotator cuff repair.

Study Design:

Descriptive epidemiology study.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program was queried for all hospital-based inpatient and outpatient arthroscopic rotator cuff repairs (Current Procedural Terminology code 29827) from 2005 to 2016. Concomitant procedures such as subacromial decompression, biceps tenodesis, superior labrum anterior and posterior (SLAP) repair, labral repair, and distal clavicle excision were also included, whereas patients undergoing arthroplasty were excluded from the study. Operative time was correlated with patient demographics, comorbidities, and concomitant procedures. All adverse events were correlated with operative time, while controlling for the above preoperative variables, using multivariate Poisson regression with a robust error variance.

Results:

A total of 27,524 procedures met inclusion and exclusion criteria. The mean age of patients was 58.4 ± 10.9 years, the mean operative time was 86.9 ± 37.4 minutes, and the mean body mass index was 30.4 ± 7.0 kg/m². Concomitant biceps tenodesis, glenohumeral debridement, SLAP repair, labral repair, and distal clavicle excision significantly increased operative time (P < .001) but not the risk of adverse events (P > .05). The overall rate of adverse events was 0.88%. After adjusting for demographic and procedural characteristics, a 15-minute increase in operative duration was associated with an increased risk of anemia requiring transfusion (relative risk [RR], 1.27 [95% CI, 1.14-1.42]; P < .001), venous thromboembolism (RR, 1.17 [95% CI, 1.02-1.35]; P = .029), surgical site infection (RR, 1.13 [95% CI, 1.03-1.24]; P = .011), and extended length of hospital stay (RR, 1.07 [95% CI, 1.00-1.14]; P = .036).

Conclusion:

Although the rate of short-term complications after arthroscopic rotator cuff repair is low, incremental increases in operative time are associated with an increased risk of adverse events such as surgical site infection, pulmonary embolism, transfusion, and extended length of hospital stay. Efforts should be made to maximize surgical efficiency in the operating room through optimal coordination of the staff or increased preoperative planning.

A comparison of continuous interscalene block versus general anesthesia alone on the functional outcomes of the patients undergoing arthroscopic rotator cuff repair

PURPOSE

The aim of this prospective and randomized study was to compare the effects of general anesthesia to the combination of general anesthesia and continuous interscalene block on postoperative pain and functional outcomes in patients undergoing arthroscopic rotator cuff repair.

METHODS

This study included a total of 85 patients aged 45-74 years, who were scheduled for elective arthroscopic rotator cuff repair. One group consists of patients who underwent only general anesthesia (GA, N = 43), and the other group consists of patients who underwent a combination of continuous interscalene brachial plexus block and general anesthesia (CISB + GA, N = 42). Pain levels of the patients were evaluated postoperatively by a visual analog scale. Shoulder function was evaluated preoperatively and postoperatively using the Constant score.

RESULTS

Patients in the CISB + GA group had lower postoperative visual analog scores and less additional analgesic needs during the early postoperative period than those in the GA group. Constant scores of the patients in the CISB + GA group at postoperative week 6 were higher than those in the GA group. Evaluation of the functional outcomes at 6 months postoperatively showed that there were no significant differences between the two groups.

CONCLUSION

Although CISB significantly improved postoperative pain control and early (in the first 6 weeks) functional outcomes following arthroscopic rotator cuff repair, there was no significant difference between the CISB group and CISB + GA group at 6 months.

LEVEL OF EVIDENCE

Level II, Randomized Controlled Trial, Treatment Study.

Open Biceps Tenodesis Associated With Slightly Greater Rate of 30-Day Complications Than Arthroscopic: A Propensity-Matched Analysis

PURPOSE

To compare the early complication risk associated with open biceps tenodesis (OBT) and arthroscopic biceps tenodesis (ABT) and determine which preoperative factors may influence complication rate.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively queried from 2008 to 2016 for all procedures with CPT codes for ABT (29828) and OBT (23430). Patients were excluded if they received concomitant rotator cuff repair or shoulder arthroplasty. Patients undergoing OBT and ABT were matched by propensity scores based on age, body mass index, operative time, proportion of smokers, and proportion of concomitant subacromial decompression, distal clavicle excision, SLAP, and debridement. The incidence of adverse events in the 30-day postoperative period was compared.

RESULTS

A total of 8,032 patients met the inclusion and exclusion criteria. Prior to propensity match, patients receiving OBT and ABT, respectively, differed with respect to age (49.4 ± 13.8 vs 51.4 ± 13.2; P < .001), body mass index (29.6 ± 6.8 vs 29.9 ± 7.0; P = .029), and operative time (91.2 ± 51.3 vs 85.3 ± 43.4; P < .001). Following propensity match, 6,330 remained in the study (3,165 ABT and 3,165 OBT). OBT had significantly greater incidence of any adverse events (1.58% vs 0.95%; P = .032) and anemia requiring transfusion (0.35% vs 0%; P = .001). Multivariate analysis suggested that OBT (relative risk [RR] = 1.7, 95% confidence interval [CI], 1.1-2.7; P = .020), old age (RR = 1.6, 95% CI, 1.0-2.5), history of dyspnea (RR = 3.8, 95% CI, 1.8-7.7; P < .001), and congestive heart failure (RR = 5.5, 95% CI, 1.3-22.7; P = .019) were associated with developing a postoperative adverse event within 30 days of surgery.

CONCLUSIONS

Both procedures were found to have a low rate of complications, although OBT had a slightly greater (1.58% vs 0.95%) rate of 30-day complications than ABT. Early complication rate should not serve as impetus to direct surgical technique as number needed to treat is high, although ABT may be considered in more high-risk individuals.

LEVEL OF EVIDENCE

Level III, retrospective comparative database study.

Superior Capsular Reconstruction for Massive Rotator Cuff Tear Leads to Significant Improvement in Range of Motion and Clinical Outcomes: A Systematic Review

PURPOSE

To determine if arthroscopic superior capsular reconstruction for massive irreparable rotator cuff tears results in statistically significant and clinically significant improvement in patient-reported outcomes and shoulder range of motion with low graft failure, complication, and reoperation rates.

METHODS

A systematic review was registered with PROSPERO and performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane databases were searched. Studies investigating superior capsular reconstruction in adults were included. Animal, cadaveric, and review studies, letters to the editor, and technique papers were excluded. Study methodological quality was analyzed using the Modified Coleman Methodology Score. Shoulder motion and patient-reported outcome scores were analyzed. Statistical significance was defined by P < .05, and clinical significance was defined by the minimal clinically important difference.

RESULTS

Six articles (286 subjects, 292 shoulders, 67.7% males, mean age 63.4 ± 4.1 years, mean follow-up 25.7 ± 14.5 months) were analyzed. The methodological quality was fair (59.7 ± 13.8). Five studies reported significant improvement in the American Shoulder and Elbow Surgeons (ASES) score (mean range: 30-55, P < .001 for all). Visual analog scale (VAS) scores significantly improved in 3 studies (mean range: 2.5-5.9, P < .001 for 2 and P = .005 for 1). Shoulder forward flexion (mean range: 28°-56°, P < .001 for 2 and P = .04 for 1) significantly increased in 3 studies. One hundred percent of subjects from 2 studies had clinically significant improvement in ASES and VAS scores and shoulder forward flexion. Thirty-six subjects (14.2% of 254) had graft failure on magnetic resonance imaging (MRI). Eleven subjects (3.8%) had complications, and 34 (11.7%) underwent reoperation.

CONCLUSIONS

Arthroscopic superior capsular reconstruction for massive irreparable rotator cuff tears results in statistically significant and clinically significant improvement in patient-reported outcomes and shoulder range of motion with low graft failure, complication, and reoperation rates at short-term follow-up in fair-quality studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Contribution of arthroscopy in the treatment of anterior glenoid rim fractures: a comparison with open surgery

BACKGROUND

This study assessed the clinical and radiologic outcomes of Ideberg type IA glenoid fractures treated using conventional open surgery compared with those treated with arthroscopic surgery.

MATERIALS AND METHODS

This was a retrospective, multicenter study of anterior glenoid rim fractures (Ideberg IA) treated with conventional open surgery (group O) or arthroscopic surgery (group A). Included were 56 patients: 10 in group O and 46 in group A. The patients were reviewed after a minimum of 12 months of follow-up. The Constant score was used as an objective clinical outcome. Radiographs were reviewed to assess the quality of the postoperative reduction, fracture healing, complications, and whether osteoarthritis was present at the last follow-up.

RESULTS

At a mean follow-up of 30 months (range, 12-115 months), there was no significant difference between the groups based on the Constant Score (group O: 74 points; group A: 84 points, P = .07). None of the shoulders showed signs of instability. Conversely, the rate of postoperative complications was higher in group O than in group A (30% vs. 4%; P = .03). Glenohumeral osteoarthritis was found in 10% of group O patients and 18% of group A patients (P = .65).

CONCLUSIONS

This study shows that anterior glenoid rim fractures have similar functional outcomes, whether treated using conventional open surgery or arthroscopic surgery. Arthroscopic surgery appears to reduce the complication and reoperation rate.

Rotator Cuff Repair: Single Row Repair Versus Double Row Repair and Superior Capsular Reconstruction

The surgical management of rotator cuff (RC) tears has progressed considerably in recent decades. Arthroscopic procedures now represent the mainstay of contemporary treatment approaches. The success of repair is predicated upon the achievement of a secure, durable repair that promotes tendon-to-bone healing. Both single and double row (DR) suture anchor configurations have been described to achieve stable fixation. Although consensus is lacking with regard to the clinical superiority of one configuration over another, trends in the literature suggest that DR repairs may optimize the likelihood of tendon healing and restoration of shoulder strength. In cases of truly irreparable RC tears, superior capsular reconstruction is a promising alternative to open tendon transfer and arthroplasty procedures. The purposes of this concise review are to: (1) explain our preference for a DR repair configuration in almost all circumstances; and (2) advocate superior capsular reconstruction as a viable treatment tactic for truly irreparable RC tears in the absence of significant glenohumeral arthritis.

Editorial Commentary: Don't Throw Away the Retractors: Complications of Open Versus Arthroscopic Rotator Cuff Repair Could Be Influenced by Indications

Shoulder surgeons must carefully interpret literature that compares outcomes and complications of open and arthroscopic rotator cuff repair techniques. It is important for shoulder surgeons to be facile with both techniques.