Weight-bearing shoulder and rotator cuff tear

Upper Limb Function in People With Upper and Lower Limb Loss 8 Years Postinjury: The Armed Services Trauma Outcome Study (ADVANCE) Cohort Study

OBJECTIVE

Upper limb (UL) disability in people with UL loss is well reported in the literature, less so for people with lower limb loss. This study aimed to compare UL disability in injured (major trauma) and uninjured UK military personnel, with particular focus on people with upper and lower limb loss.

METHODS

A volunteer sample of injured (n = 579) and uninjured (n = 566) UK military personnel who served in a combat role in the Afghanistan war were frequency matched on age, sex, service, rank, regiment, role, and deployment period and recruited to the Armed Services Trauma Rehabilitation Outcome (ADVANCE) longitudinal cohort study. Participants completed the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire, scored from 0 (no disability) to 100 (maximum disability) 8 years postinjury. Mann-Whitney U and Kruskal-Wallis tests were used to compared DASH scores between groups. An ordinal model was used to assess the effect of injury and amputation on DASH scores.

RESULTS

DASH scores were higher in the Injured group compared to the Uninjured group (3.33 vs 0.00) and higher in people with lower limb loss compared to the Uninjured group (0.83 vs 0.00), although this was not statistically significant. In the adjusted ordinal model, the odds of having a higher DASH score was 1.70 (95% CI = 1.18-2.47) times higher for people with lower limb loss compared to the Uninjured group. DASH score was not significantly different between people with major and partial UL loss (15.42 vs 12.92). The odds of having a higher DASH score was 8.30 (95% CI = 5.07-13.60) times higher for people with UL loss compared to the Uninjured group.

CONCLUSION

People with lower limb loss have increased odds of having more UL disability than the Uninjured population 8 years postinjury. People with major and partial UL loss have similar UL disability. The ADVANCE study will continue to follow this population for the next 20 years.

IMPACT

For the first time, potential for greater long-term UL disability has been shown in people with lower limb loss, likely resulting from daily biomechanical compensations such as weight-bearing, balance, and power generation. This population may benefit from prophylactic upper limb rehabilitation, strength, and technique.

Shoulder arthroplasty in the upper extremity weight-bearing patient: a systematic review of clinical outcomes and complications

BACKGROUND

Patients who rely on their upper extremities for ambulation, or upper extremity ambulators (UEAs), place considerable stress on their shoulders through the use of assistive devices like walkers, crutches, canes, and wheelchairs. It has been postulated that UEAs may be at increased risk for complications following shoulder arthroplasty. This study aimed to systematically review the literature related to (1) patient-reported outcomes measures (PROMs), (2) functional outcomes, and (3) complications in UEAs who undergo shoulder arthroplasty.

METHODS

A systematic review of the PubMed/MEDLINE, Embase, and Cochrane databases was performed to identify studies reporting clinical outcomes of shoulder arthroplasty in UEAs. Patient demographics, clinical characteristics, patient-reported outcomes measures, radiographic outcomes, and postoperative range of motion were collected and compared to control patients (ie bipedal ambulators) from the constituent studies.

RESULTS

A total of eight studies evaluating 248 UEA cases and 206 control cases were included for review. Ambulatory assistive devices utilized by UEAs included walkers (39%), wheelchairs (38%), canes (22%), and a crutch (<1%). Among UEA cases, 197 (79%) reverse total shoulder arthroplasty (TSA), 37 (15%) anatomic TSA, and 14 (6%) hemiarthroplasty were performed. Overall, patients exhibited significant improvements in mean American Shoulder and Elbow Surgeons scores, Constant-Murley scores, Simple Shoulder Test scores, and Visual Analog Scale scores postoperatively. Among 3 studies that included comparison with control groups of bipedal ambulators, no significant differences in outcomes were identified. The overall clinical complication rate was 17% for UEAs compared to 9.1% for controls. The rate of revision surgery was 7.7% for UEAs and 4.9% for bipedal ambulators.

CONCLUSIONS

UEAs experience satisfactory pain relief, functional improvements, and good subjective outcomes following shoulder arthroplasty. However, complication and revision rates are higher compared to those for bipedal ambulators, and the majority of UEAs undergo reverse shoulder arthroplasty compared to anatomic TSA.

Clinical and radiological outcome after arthroscopic rotator cuff repair using PEEK-CF anchors

PURPOSE

The goal of this study was to evaluate the clinical and radiological outcome after arthroscopic rotator cuff repair using new carbonfiber reinforced polyetheretherketone (CF-PEEK) suture anchors.

METHODS

One hundred (n=100) patients with rotator cuff tears were enrolled at seven French hospitals between July 2019 and June 2020. Pain levels, Constant score and Subjective Shoulder Value (SSV) were taken preoperatively and 6months postoperatively. Ultrasonography (US) was performed at 6months postoperatively to evaluate tendon healing using the Sugaya classification. Statistical analysis was done with the Student t-test with 95% confidence intervals.

RESULTS

One hundred patients of the 100 patients were followed at 6months. The mean SSV and Constant score improved from 40.1% preoperatively to 78% at 6months (p<0.0001) and from 43 points preoperatively to 65 points at 6months (p<0.0001), respectively. The mean level of pain, as measured with the visual analogue scale, decreased from 5.9 to 1.6 (p<0.001). There were no postoperative complications that resulted in revision surgery.

CONCLUSION

The study showed good results at 6months follow-up using carbonfiber reinforced PEEK anchors with improved Constant and SSV scores as well as a high ultrasonographic tendon healing rate, making PEEK-CF anchors safe to use, comparable to commonly used anchors.

LEVEL OF EVIDENCE

IV.

Estimation of the carbon footprint of arthroscopic rotator cuff repairs in France

AIM

The main objective of this study was to estimate the carbon impact of arthroscopic rotator cuff repairs in France. The secondary objective was to assess the effectiveness of the following measures in reducing the carbon footprint associated with this technique: outpatient treatment, arthroscopic water filtration, surgery under locoregional anesthesia.

HYPOTHESIS

The hypothesis was that the carbon footprint could be significantly improved with the implementation of these three procedures.

METHODS

A continuous series of 26 patients who underwent surgery for a rotator cuff tear involving only one tendon between November 2020 and April 2021 were included. The evaluation protocol consisted of three parts: 1/ use of volatile anesthetic agents; 2/ electrical consumption linked to the procedure; 3/ emissions related to patient and staff travel, delivery of implants and waste management. Another series of 26 patients operated between November 2018 and April 2019 who had none of these three factors were matched.

RESULTS

The carbon impact of arthroscopic repair of the rotator cuff was estimated at 334.61±18.82kgCO2eq. The implementation of the three methods for improvement made it possible to significantly reduce emissions by 40.9±1.71kgCO2eq (12.2%) (p<0.001).

CONCLUSION

Performing surgery under locoregional anesthesia, on an outpatient basis with water purification, reduces the carbon impact of arthroscopic rotator cuff repair by more than 12%.

LEVEL OF EVIDENCE

III, retrospective case control.

History of mood and anxiety disorders does not affect the outcomes of arthroscopic rotator cuff repair

BACKGROUND

A pre-existing mood and anxiety disorder (MAD) is often present in patients with rotator cuff pathology, but its presumed negative effect on the outcomes has not been demonstrated.

AIM OF STUDY AND HYPOTHESIS

The primary objective of this study was to evaluate how a history of MAD affects the clinical outcomes 1 year after arthroscopic rotator cuff repair (RCR). The secondary objectives were to evaluate how a history of MAD affects tendon healing, analgesic consumption and the occurrence of complications.

MATERIALS AND METHODS

The study population consisted of 219 patients (mean age 54.5±6.6 years) who underwent arthroscopic repair for a distal supraspinatus tendon tear, with 17% (38/219) presenting an history of MAD (depression, unspecified mood disorder, anxiety, and bipolar disorder). Using univariate and multivariate analyses, the joint range of motion, Constant score, analgesic consumption, occurrence of complications during the first postoperative year and tendon healing at 1 year (MRI or CT arthrography) were compared between the two groups (with or without MAD).

RESULTS

The Constant score was lower preoperatively in patients with history of MAD (-4 points, p=.04) but there were no significant differences between the two groups at the various postoperative follow-up time points (p>.05). No significant difference was found between the two groups of patients in their analgesic consumption at the various postoperative time points (p>.05), tendon healing at 1 year (p=.17) or the occurrence of postoperative complications (p=.59).

DISCUSSION/CONCLUSION

Pre-existing MAD had no effect on the clinical outcomes after arthroscopic RCR at 1 year and no effect on tendon healing, analgesic consumption or the occurrence of complications in our study population.

LEVEL OF EVIDENCE

III; retrospective case-control study.

Finite element study of the biomechanical effects on the rotator cuff under load

Rotator cuff injuries account for 50% of shoulder disorders that can cause shoulder pain and reduced mobility. The occurrence of rotator cuff injury is related to the variation in shoulder load, but the mechanical changes in the rotator cuff caused by load remain unclear. Therefore, the mechanical results of the rotator cuff tissue during glenohumeral abduction and adduction were analyzed based on a finite element shoulder model under non-load (0 kg) and load (7.5 kg) conditions. The results showed that the maximum von Mises stress on the supraspinatus muscle was larger than that on the subscapularis, infraspinatus, and teres minor muscles during glenohumeral abduction. Compared with the non-load condition, the maximum von Mises stress on the supraspinatus muscle increased by 75% under the load condition at 30° abduction. Under the load condition, the supraspinatus joint side exhibited an average stress that was 32% greater than that observed on the bursal side. The von Mises stress on the infraspinatus muscle was higher than that in other rotator cuff tissues during adduction. The stress on the infraspinatus muscle increased by 36% in the load condition compared to the non-load condition at 30° adduction. In summary, the increased load changed the mechanical distribution of rotator cuff tissue and increased the stress differential between the joint aspect and the bursal aspect of the supraspinatus tendon.