Hawkins, Richard J.

Purpose We create a viable, mechanically expanded autograft long head biceps tendon (LHBT) scaffold for biologically augmenting the repair of torn rotator cuffs. Methods The proximal aspect of the tenotomized LHBTs was harvested from patients during rotator cuff repair surgery and was mechanically formed into porous scaffolds using a surgical graft expander. LHBT scaffolds were evaluated for change in area, tensile properties, and tenocyte viability before and after expansion. The ability of endogenous tenocytes derived from the LHBT scaffold to promote tenogenic differentiation of human adipose‐derived mesenchymal stromal cells (ADMSCs) was also determined. Results Autograft LHBTs were successfully expanded using a modified surgical graft expander to create a porous scaffold containing viable resident tenoctyes from patients undergoing rotator cuff repair. LHBT scaffolds had significantly increased area (length: 24.91 mm [13.91, 35.90] × width: 22.69 mm [1.87, 34.50]; P = .011) compared with the native LHBT tendon (length: 27.16 mm [2.70, 33.62] × width: 6.68 mm [5.62, 7.74]). The structural properties of the autograft were altered, including the ultimate tensile strength (LHBT scaffold: .56 MPa [.06, 1.06] vs. native LHBT: 2.35 MPa [1.36, 3.33]; P = .002) and tensile modulus (LHBT scaffold: 4.72 MPa [−.80, 1.24] versus native LHBT: 37.17 MPa [24.56, 49.78]; P = .001). There was also a reduction in resident tenocyte percent viability (LHBT scaffold: 38.52% [17.94, 59.09] vs. native LHBT: 68.87% [63.67, 74.37]; P =.004). Tenocytes derived from the LHBT scaffold produced soluble signals that initiated ADMSC differentiation into an immature tenocyte‐like phenotype, as indicated by an 8.7× increase in scleraxis ( P = .040) and a 3.6× increase in collagen type III mRNA expression ( P = .050) compared with undifferentiated ADMSC controls. Conclusions The ability to produce a viable autologous scaffold from the proximal biceps tendon having dimensions, porosity, mechanical characteristics, native ECM components, and viable tenocytes that produce bioactive signals conducive to supporting the biologic augmentation of rotator cuff repair surgery has been demonstrated. Clinical Relevance This biologically active construct may help to improve the quality of healing and regeneration at the repair site of rotator cuff tears, especially those at high risk for retear.

Background: Functional bracing is often used as an adjunct to nonoperative treatment of anterior shoulder instability, but no study has evaluated the effectiveness of in-season bracing. The purpose of this study was to examine successful return to play in a nonoperative cohort of adolescent athletes with in-season shoulder instability and compare those athletes treated with bracing to those who were not. Hypothesis: The use of functional bracing will improve success rates in a cohort of athletes treated nonoperatively for in-season shoulder instability. Study Design: Cohort study. Level of Evidence: Level 3. Methods: A total of 97 athletes with anterior shoulder instability were followed for a minimum of 1 year. The mean age was 15.8 ± 1.4 years (range, 12.0-18.0 years). All athletes were treated with initial nonoperative management. Twenty athletes (21%) were also treated with bracing while 77 (79%) were not. The athlete completing the current season and 1 subsequent season without surgery or time lost from shoulder injury was defined as a successful outcome. Results: There was no statistical difference in nonoperative success rates between the braced and nonbraced athletes ( P = 0.33). Braced athletes (n = 20) returned to play 80% of the time, while nonbraced athletes (n = 77) returned at a rate of 88%. Of the braced athletes, 85% were football players (n = 17). A football-only comparison demonstrated no difference between braced failures (26%) and nonbraced failures (16%) ( P = 0.47). Conclusion: This is the first study to evaluate the utility of functional bracing in returning an athlete to sport and completing a full subsequent season without surgery or time loss due to injury of the shoulder. In adolescent athletes with shoulder instability treated nonoperatively, functional bracing did not result in increased success rates when compared with no bracing. Clinical Relevance: The data from this study indicate that functional bracing may not improve success rates for athletes with shoulder instability.

Background: Young age and contact sports have been postulated as risk factors for anterior shoulder instability. Management after shoulder instability is controversial, with studies suggesting that nonoperative management increases the risk of recurrence. Several studies examined return to play after an in-season instability episode, and few followed these patients to determine if they were able to successfully compete in a subsequent season. No study has evaluated this question in a high school athlete population. Purpose: To compare the likelihood of return to scholastic sport and complete the next full season without an additional time-loss injury among athletes with anterior shoulder instability in terms of treatment, instability type, and sport classification. Study Design: Cohort study; Level of evidence, 2 Methods: Athletes were included in this study as identified by a scholastic athletic trainer as experiencing a traumatic time-loss anterior shoulder instability injury related to school-sponsored participation. The cohort was predominantly male (n = 108, 84%) and consisted mostly of contact athletes (n = 101, 78%). All athletes had dislocation or subluxation diagnosed by a board-certified physician who determined the athlete’s course of care (nonoperative vs operative). Successful treatment was defined as completion of care and return to the athlete’s index sport, with full participation for the following season. Chi-square and relative risk analyses were completed to compare success of treatment (nonoperative vs operative care) and instability type. Separate logistic regressions were used to compare the effect of sex and sport classification on the athletes’ ability to return to sport. Statistical significance was set a priori as α = .05. Results: Scholastic athletes (N = 129) received nonoperative (n = 97) or operative (n = 32) care. Nonoperatively treated (85%) and operatively treated (72%) athletes successfully returned to the same sport without injury for at least 1 full season ( P = .11). Players sustaining a dislocation were significantly more likely to fail to return when compared with those sustaining a subluxation (26% vs 89%, P = .013). Sex ( P = .85) and sport classification ( P = .74) did not influence the athlete’s ability to return to sport, regardless of treatment type. Conclusion: A high percentage of athletes with shoulder instability achieved successful return to sport without missing any additional time for shoulder injury. Those with subluxations were at almost 3 times the odds of a successful return compared with those sustaining a dislocation.

Background: Movement toward a value-based health-care system necessitates the development of performance measures to compare physicians, hospitals, and health-care systems. Patient-reported outcomes (PROs) are a potential metric. However, valid use of PROs hinges on the ability to risk-adjust for baseline patient differences across a surgeon’s panel of patients. The purpose of this study was to propose an approach for baseline risk adjustment and evaluate the importance of risk adjustment when comparing surgeons’ performance of rotator cuff repair. Methods: Patients (n = 995) treated with arthroscopic rotator cuff repair by 34 surgeons from 2010 to 2017 were identified from a large sports medicine clinical data registry. A linear regression model was used to adjust for baseline PROs, patient demographics, and clinical characteristics to predict American Shoulder and Elbow Surgeons (ASES) change scores for each surgeon. A risk-adjusted performance measure was calculated as the difference between the average unadjusted ASES change scores and the risk-adjusted predicted ASES change scores across all patients treated by a surgeon. Results: The differences between unadjusted and risk-adjusted performance scores varied widely across surgeons (range, −13.8 to 10.3 ASES points). Use of the risk-adjusted performance scores resulted in a dramatic change in the relative ranking of surgeons, compared with the ranking based on the observed ASES change scores, with 31 of the 34 surgeons’ rank changing following risk adjustment. On average, the observed ASES scores improved from 49.5 ± 17.5 at baseline to 78.0 ± 22.5 at 6 months across all surgeons. In the risk-adjustment model (R 2 = 0.44), male sex, Workers’ Compensation status, higher scores on the Veterans RAND 12-item Health Survey (VR-12), lower baseline ASES scores, fair and poor tendon quality, and night pain all had a significant effect on the predicted ASES change scores (p < 0.05). Conclusions: Our results show wide variation of nearly 25 points in the risk-adjusted 6-month ASES performance difference from the highest to the lowest-performing surgeons. Additionally, 91% of surgeons’ rank changed following risk adjustment. This suggests that performance measurement that does not account for baseline patient characteristics would likely result in incorrect conclusions about a surgeon’s relative performance based on PROs. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: There is an ever-increasing demand for widespread implementation of patient-reported outcomes. However, adoption is slow owing to limitations in clinical infrastructure and resources within busy orthopaedic practices. Prior studies showed the single alpha-numeric evaluation (SANE) score to correlate at a single point in time with the American Shoulder and Elbow Surgeons (ASES) score. However, no study has validated the SANE in terms of test-retest reliability, responsiveness, or clinical utility. Purpose: To validate SANE with the ASES across a sample of patients with common orthopaedic shoulder diagnoses. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Patients undergoing rotator cuff repair (n = 77), total shoulder replacement (n = 55), or physical therapy (n = 80) for signs and symptoms of subacromial impingement syndrome (n = 61) or adhesive capsulitis (n = 19) were administered the SANE and ASES at baseline and again at their 3-month follow-up from initial care or surgery (N = 212, mean ± SD age = 52.6 ± 1.2 years, n = 145 women). Interclass correlation coefficient (ICC 2,1 ) and standard error of the measurement (SEm) were used to evaluate the test-retest reliability of the SANE and the validity between the SANE and ASES scores. Analysis of variance (treatment group × time) was used to evaluate the responsiveness to treatment, and a receiver operating characteristic curve was used to establish the minimal clinically important difference (MCID) for the SANE as compared with the ASES (α = .05). Floor and ceiling effects were evaluated as the percentage of patients who scored the highest or lowest score on each tool. Results: The SANE demonstrated good pretreatment reliability (ICC 2,1 = 0.84, SEM = 3.8), similar to the ASES (ICC 2,1 = 0.82, SEM = 3.4). The SANE also showed good agreement with the ASES before and after treatment across all treatment groups (rotator cuff repair, ICC 2,1 = 0.85, SEM = 3.4; total shoulder replacement, ICC 2,1 = 0.72, SEM = 5.2; physical therapy: ICC 2,1 = 0.82, SEM = 2.9). The SANE and ASES displayed similar responsiveness after treatment, with similar mean change and SD within each treatment group. The receiver operating characteristic curve revealed an area under the curve of 0.79 (SE, 0.62; P < .001) and a cutoff of 15% on the SANE, with a sensitivity of 85% to establish the MCID. Acceptable and similar floor and ceiling effects were observed for the ASES (4%) and SANE (9%). Conclusion: The study demonstrates that the SANE is valid for a range of common shoulder diagnoses to assess patient outcomes across operative and nonoperative treatment for shoulder complaints. The MCID of 15% is similar to that of the ASES (11%), suggesting that the SANE is a simple and efficient tool to assess treatment effects for shoulder disorders. Future studies are warranted to confirm these results and compare across other body parts and diagnoses.

Objectives: Early results following arthroscopic superior capsular reconstruction(SCR) in patients with massive, irreparable rotator cuff tears are promising. However, no studies have compared patient reported outcomes between SCR or reverse total shoulder(rTSA) and rotator cuff debridement for these patients. Therefore, the purpose of this study was to compare 1-year outcomes between patients with massive irreparable rotator cuff tears who underwent a SCR, rTSA, or rotator cuff debridement with a concurrent biceps tenotomy or tenodesis. Methods: Patients(n=63) who underwent either SCR(n=21), rTSA(21), or cuff debridement(n=21) and biceps tenotomy or tenodesis for a massive, irreparable rotator cuff tear treated with a minimum 1-year follow up were retrospectively reviewed. Age, sex, BMI, smoking status, Charlson Index, Hamada classification, and ASES scores were recorded and compared using a multivariate ANOVA were used to compare between surgical approaches. A Chi Square analyses were used to compare sex distribution and the Charlson Deyo Index between groups (α=0.05). Results: Overall, patients across the 3 groups were not statistically different in age or follow up ASES score at minimum 14 month follow up ( P> 0.05). There was a significant interaction effect between surgery group and sex (P=0.02) on ASES score but not age ( P=0.08). Univariate F tests revealed that male patients who received an SCR displayed a 10-14% better outcome at follow up compared to other groups (Table 1) which exceeds the reported ASES score MCID. Conclusion: Our results show comparable results across surgical options for massive irreparable cuff tears with good patient reported outcomes. Male patients displayed clinically important greater ASES scores at 1 year follow up. Future studies should evaluate these preliminary results to assess if these preliminary results hold up at longer follow up times.

Background: Controversy exists as to whether the subscapularis should be repaired after reverse shoulder arthroplasty. The purpose of the present study was to evaluate the utility of repairing the subscapularis after reverse shoulder arthroplasty with regard to complications, objective findings, and patient-reported outcome measures. Methods: We retrospectively reviewed the records for 99 patients who had undergone a lateralized reverse shoulder arthroplasty with (n = 58) or without (n = 41) subscapularis repair. Outcomes were compared with the Single Assessment Numeric Evaluation (SANE), Penn shoulder score (PSS), Veterans RAND (VR)-12, and American Shoulder and Elbow Surgeons (ASES) score at a minimum of 2 years of follow-up. Demographics, range of motion, and complications were also compared. A 1-way analysis of variance was performed to determine differences in performance and outcome scores, and a chi-square analysis was performed to compare the frequency of complications between groups. Results: There were no significant differences between the repair and no-repair groups in terms of SANE, PSS, ASES, or VR-12 scores. There also were no significant differences between the 2 groups in terms of postoperative ranges of forward elevation (128° versus 123°; p = 0.44) and external rotation (33° versus 29°; p = 0.29), the dislocation rate (5% versus 2%; p = 0.49), or the overall complication rate (9% versus 5%; p = 0.47). Conclusions: The results of the present study suggest that repair of the subscapularis tendon after lateralized reverse shoulder arthroplasty may not be necessary. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Total shoulder arthroplasty remains an effective procedure for shoulder pain relief. Despite the negative effect of abnormal glenoid morphology and specifically retroverted and posteriorly subluxated glenoids, there is no consensus for management of B2 glenoids in total shoulder arthroplasty. The purpose of this study was to compare the outcomes and complication rates for B2 glenoid techniques so as to provide a baseline understanding of the current state of treatment of this pathology. Methods: A systematic review evaluating outcomes of total shoulder arthroplasty with biconcave glenoids using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology included searches up to December 31, 2015, of PubMed, Embase, MEDLINE, Cochrane Reviews, and Google Scholar. Nine articles met inclusion and exclusion criteria. Results: In this study, 239 total shoulder arthroplasties with B2 glenoids with a mean follow-up of 55.5 months (range, 24 to 91 months) were included. The mean patient age was 63.3 years (range, 55.8 to 68.7 years). Asymmetric reaming was performed in 127 glenoids, posterior bone-grafting was included in 53 glenoids, and 34 received an augmented glenoid component to correct glenoid retroversion and bone loss. Overall, the mean Constant and Neer scores improved from preoperative measures. Fifty-eight percent of patients had no loosening, and 42% had some loosening, although not all of these patients were symptomatic. Despite variation in outcome measures hindering treatment approach comparison, the posteriorly augmented glenoid was generally reported to provide better outcomes with few complications. Although posterior glenoid bone-grafting results in acceptable outcomes, it also represents the highest rate of complications. The revision rate was 15.6% for asymmetric reaming, 9.5% for posterior glenoid bone-grafting, and 0% for posteriorly augmented glenoids. Conclusions: Surgical treatment of the B2 glenoid remains a challenge to the shoulder surgeon, with worse outcomes and higher complication rates. Longer follow-up, consistent outcome measures, and result stratification based on glenoid type may allow for direct comparison in the future. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.