The Ases Open Meeting/Specialty Day Abstracts, March 28, 2015

THE ASES OPEN MEETING/SPECIALTY DAY ABSTRACTS, MARCH 28, 2015

1 MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS FOR physis comminution combined with poor bone quality in the prox- PROXIMAL HUMERAL FRACTURES: A PROSPECTIVE STUDY OF imal humerus, additional procedures using either a long CLINICAL AND RADIOLOGICAL OUTCOMES ACCORDING TO inferomedial screw insertion in the third or fourth row of the plate FRACTURE TYPE or fibular strut bone allograft were performed to maintain proper Sang-Jin Shin, MD, Jae Kwang Kim, MD, Young Won Koh, MD, reduction. Results: No patients were converted to open reduction Department of Orthopaedic Surgery, Ewha Womans University, during the MIPO procedure in this study. The clinical outcomes Mokdong Hospital, Seoul, South Korea such as time to union and satisfaction for the operation showed no Introduction: Various methods of surgical treatment for displaced statistical difference between the 3 fracture types. However, statisti- proximal humeral fractures have been introduced. Amongst them, cally significant differences were found in the Constant score for the clinical outcomes of proximal humeral fractures after open plate four-part fractures compared with three-part fractures (p¼0.041). fixation have improved rapidly with the development of the angular At final follow-up, the neck-shaft angle was measured at 12963 stable locking plate. However, open reduction and plating through (range, 122 to 133), 12969 (range, 110 to 147), and the traditional deltopectoral approach may lead to several con- 121610 (range, 110 to 135) in two-, three-, and four-part frac- cerns, including nonunion from extensile soft tissue stripping, deltoid tures, respectively. The neck-shaft angle in four-part fractures at final muscle injury, or infection. The minimal invasive plate osteosynthesis follow-up was significantly lower compared with other fracture types (MIPO) technique was developed to achieve biologic fixation and (p¼0.036 with two-part and p¼0.031 with three-part). Complica- minimize the complications of an open reduction. The application tion rates (72.7%) of four-part fractures were significantly higher of the MIPO technique has recently been extended to proximal hu- than other fracture types (two-part; 7.4%, three-part; 20.8%, meral fractures as an alternative to open reduction and internal fix- p¼0.001). Sixteen fractures were fixed using an additional infero- ation. Although several studies reported excellent clinical results medial screw and 3 patients underwent fibular allograft. Discussion: after the MIPO technique in the treatment of proximal humeral frac- Satisfactory clinical and radiological outcomes in terms of bony tures, few studies have analyzed the clinical and radiological out- union and anatomical restoration of the proximal humerus were ob- comes according to the fracture pattern in patients with proximal tained using the MIPO technique in patients with displaced proximal humeral fractures treated using the MIPO technique. The purpose humeral fractures. Additionally, medial cortical support might be of this study was to evaluate functional results prospectively and to considered using an inferomedial screw or fibular strut allograft analyze the clinical and radiological outcomes according to the augmentation in the MIPO technique. However, the MIPO technique type of fracture in patients with proximal humeral fractures treated for four-part fractures of the proximal humerus showed relatively un- using the MIPO technique. Material and Methods: This is a prospec- satisfactory clinical and radiological outcomes compared with two- tive case-series of 62 patients with proximal humeral fractures and three-part fractures. Conversion to open plating is also consid- treated with the MIPO technique. There were 23 men and 39 ered, if adequate reduction such as neck-shaft angle over 120 is women with an average age of 57 years (range, 29-85 years). not able to be obtained in MIPO technique for four-part fractures All of the fractures were classified according to the Neer classifica- of the proximal humerus. tion: 27 patients were two-part (44%), 24 were three-part (39%), and 11 were four-part fractures (17%). In all patients, a 3.5-mm proximal humerus anatomical locking plate was used. Clinical outcomes were assessed at the final follow-up visit using the active 2 A SIMPLER TECHNIQUE FOR THE TREATMENT OF range of motion of the shoulder joint and the Constant score. Radio- VALGUS-IMPACTED PROXIMAL HUMERUS FRACTURES graphic evaluations were performed at 2 weeks, and every 2 O. Alton Barron, MD, Frank J. Gerold, MD, Joseph months thereafter until union was obtained. Surgical Technique: Un- P. Donahue, MD, Louis W. Catalano III, MD, CV Starr Hand der an image intensifier, closed reduction was attempted with a lon- Surgery Center, Roosevelt Hospital, New York, NY, USA gitudinal and a varus or valgus force to the humeral shaft and two or Introduction: Valgus-impacted fractures comprise approximately three 2.0 mm Kirschner wires were inserted for temporary fixation. 14% of all proximal humerus fractures. We report a simple repair The proximal skin incision for deltoid splitting approach started from technique performed via a lateral mini-open deltoid split in which the anterolateral corner of the acromion and extended to approxi- coral is used as a strut allograft to support the articular segment of mately 4 cm distally. Tuberosity fragments were reduced using su- the humeral head following disimpaction/elevation, preceding tures. The axillary nerve could be palpated blindly by the index compression-free tuberosity reduction. The fracture fragments are finger approximately 2-3 cm below the inferior margin of the prox- stabilized with non-absorbable suture, and temporary supplemental imal window. While an index finger protected the axillary nerve, percutaneous pins are used infrequently to augment fixation. The a sub-deltoid extraperiosteal tunnel was made with blunt dissection coral strut fills the cancellous impaction void preventing collapse using a periosteal elevator. The plate was inserted from the proximal back into valgus and re-displacement of the tuberosities. Passive mo- window distally while protecting the axillary nerve. The location of tion is initiated 1-3 weeks after surgery, and active motion begun at the distal incision, which usually started from the oblong-shaped 4-5 weeks postop. This procedure yields a stable anatomic or near- combi-hole for the positional cortical screw and extended to the anatomic fracture construct through a mini-open rotator cuff saber last hole of the plate, was determined using an image intensifier. incision with less post-operative stiffness, no retained hardware, The distal portion of the plate was easily found when the interval be- and no additional disruption of the humeral head blood supply. tween the deltoid and biceps muscles was developed. A cortical This case series reports the radiographic and patient outcomes at screw was inserted in the combi-hole in order to reduce the dis- a minimum of one year post-op. Methods: Nineteen patients with placed neck-shaft angle indirectly along the anatomical shape of either 3 or 4-part valgus impacted proximal humerus fractures the plate. Four 3.5 mm locking screws were inserted in the proximal treated with the described technique were included in the study. holes of plate in the head of humerus. If a patient had medial meta- Range of motion and strength measurements were taken. We used

e229 e230 ASES Abstracts J Shoulder Elbow Surg August 2015

the Visual Analog Scale (VAS), DASH questionnaire, American humerus fracture. The average age was 61 years old. The proximal Shoulder and Elbow Surgeons Shoulder score (ASES), as well as humerus fractures were treated by a single surgeon with a precon- the Constant score as outcome measures. Patients were examined toured proximal humerus locking plate. Using the Neer Classifica- by a non-treating physician to determine shoulder motion and tion, there were 8 2-part fractures, 19 3-part fractures, and 8 strength of both the injured and contralateral upper extremity. A 4-part fractures. All patients completed a structured physical therapy radiograph of the operated shoulder was obtained at the time of program postoperatively. Patients were indicated for arthroscopic final follow up to measure the head-neck angle as well as to deter- plate removal after radiographic evidence of healing combined mine the presence or absence of post traumatic arthritis and avas- with a plateau in progression with regards to range of motion in cular necrosis (AVN) in the humeral head. Results: The mean age physical therapy. All patients underwent arthroscopic hardware of our patients at the time of surgery was 66.8 years (40.5 to removal, capsular release, and subacromial decompression. 85.4). There were no intra-operative complications. Mean esti- Figures 1 Additional findings included rotator cuff tear (n¼5), mated blood loss (EBL) was 109 ml (10 to 300) and the mean oper- glenohumeral arthritis (n¼6), heterotopic ossification (n¼5). Post- ative time was 119 min (70 to 236). All patients were able to return operatively, patients were evaluated by physical exam, Constant to their pre-injury level of activity and all were satisfied with their and DASH Scores, SF-36 assessment, a subjective satisfaction result. The mean follow-up time was 5.9 years (1 to 13.5). The mean external rotation of the injured versus uninjured shoulder was 49 deg (25 to 85) vs. 59 deg (20 to 90) p¼0.003, internal rotation was to T10 (L5 to T6) vs. T9 (L1 to T4) p¼0.65, forward flexion was 143 deg (90 to 180) vs. 158 deg (110 to 180) p¼0.019, and abduction was 113 deg (60 to 180) vs. 120 deg (85 to 180) p¼0.07. The mean ASES score was 88.2 (33 to 100), DASH score 13.9 (0 to 73.3), and Constant score 68.9 (37.9 to 86.3). The mean head-neck angle was 129 deg (106-140). Post-operative complications included one case of subacromial impingement, 2 cases of avascular necrosis, one of which involved less than twenty-five percent of the articular segment with no collapse, and one with articular collapse that required revision to hemiarthroplasty. There was one case of capsular contracture requiring manipulation under anesthesia and arthroscopic capsular release 38 months after the index procedure. There were two cases of heterotopic ossification of which one required excision 5 months after the index procedure. There was one pin tract infection that resolved with oral antibiotics. Conclusion: The use of coral as a strut allograft is a simple, safe, and effective technique for the surgical treatment of 3 and 4-part valgus-impacted proximal humerus fractures leading to consistently high patient satisfaction. questionnaire. Results: All patients were available for follow-up at an average of 1.5 years postoperatively. Range of motion significantly increased in all planes (p<0.05). Average Postoperative mo- 3 OUTCOMES OF ARTHROSCOPIC HARDWARE REMOVAL tions were: Forward Elevation 166 ,ER68,IR50. Average FOLLOWING LOCKED PLATING OF PROXIMAL HUMERUS Constant score improved from 70 to 91 (p<0.05). The presence FRACTURES: A PROSPECTIVE STUDY of heterotopic ossification had no effect on outcomes. No difference Joshua S. Dines, MD, Matthew R. Garner, MD, was noted based on fracture type. Patients with concomitant gleno- Asheesh Bedi, MD, Kristofer Jones, MD, Dean G. Lorich, MD, David humeral arthritis or rotator cuff tears improved significantly; however M. Dines, MD, The Hospital for Special Surgery, New York, they still had the most functional limitations relative to their contralat- NY, USA eral, uninjured arm. Subjectively, 34/35 patients were very satis- Introduction: Results of Open Reduction and Internal Fixation of fied with their outcome. There were no intraoperative or Proximal Humerus Fractures with locked plates have provided good postoperative complications. Conclusion: Arthroscopic removal of outcomes in the majority of patients, but plating of these fractures is proximal humerus locking plates can safely improve subjective not without complications. Pain, decreased motion or function, and/ and functional outcomes in patients treated for proximal humerus or impingement have all been reported after plate fixation of prox- fractures. Performing the hardware removal arthroscopically allows imal humerus fractures. Hardware removal can be successful for for treatment of concomitant intraarticular pathology while mini- such issues; however, these procedures have their own associated mizing morbidity to the patients. risks. Typically the previous surgical incision needs to be reopened. Neurovascular injury, particularly with regard to the axillary nerve, is a significant risk during hardware removal through these ap- 4 REVERSE TOTAL SHOULDER ARTHROPLASTY PATIENTS proaches. Several studies have shown that removal of proximal hu- WITH A PROXIMAL HUMERUS FRACTURE HAVE meral locking plates can improve functional results. In this study we SIGNIFICANTLY WORSE PERIOPERATIVE OUTCOMES THAN describe a technique of removing proximal humeral locking plates OTHER INDICATIONS: AN ANALYSIS OF 5644 CASES arthroscopically. Though technically demanding, benefits include Jimmy J. Jiang, MD, Aneet S. Toor, MD, Lewis L. Shi, MD, Jason smaller incisions, decreased risk of infection, and the ability to visu- L. Koh, MD, NorthShore University HealthSystem (a teaching alize and protect the axillary nerve throughout the course of the pro- affiliate of University of Chicago), Pritzker School of Medicine, cedure. Furthermore, arthroscopy affords the surgeon with the Evanston, IL, USA ability to address concomitant intraarticular pathology at the time Background: Proximal humerus fracture is becoming an of surgery. We hypothesized that arthroscopic removal of hardware increasingly common indication for reverse total shoulder arthro- following ORIF of proximal humerus fractures would improve subjec- plasty (RTSA). There is limited data that compare the demographic tive and objective outcomes in this patient group. Materials and data and the perioperative complication rate for these patients Methods: This was a prospective study of 35 patients who under- against those with other surgical indications. We analyzed the im- went arthroscopic plate removal following ORIF of a proximal mediate perioperative complications and hospitalization data of J Shoulder Elbow Surg ASES Abstracts e231 Volume 24, Number 8

5644 patients who underwent a RTSA and compared short term p<0.001) and hospital charge ($82,887 vs $63,135, outcomes between those with a fracture versus nonfracture diag- p<0.001). They also had significantly increased rates of deep nosis (osteoarthritis, rotator cuff disease, avascular necrosis, or venous thrombosis (odds ratio (OR)¼4.4, p¼0.001), pulmonary rheumatoid arthritis). Methods: The Nationwide Inpatient Sample embolism (OR¼3.9, p¼0.04), myocardial infarction (OR¼4.4, (NIS) database was evaluated from 2010-2011 for all patients p¼0.001), pneumonia (OR¼3.5, p<0.001), cerebrovascular acci- who underwent a RTSA (ICD-9 procedure code ¼ 81.88). The dent (OR¼7.0, p¼0.01), urinary tract infection (OR) ¼4.4, NIS is a statistically representative sample of hospitals from across p<0.001), blood transfusions (OR¼3.3, p<0.001), non-routine the United States that includes data on approximately 20% or 8 discharge (OR¼2.2, p<0.001), and overall perioperative compli- million inpatient admissions per year. A total of 5644 patients cation (OR¼3.7, p<0.001). Multivariate analyses, which adjusted were included in our retrospective study and all proximal humerus for all significant differences in preoperative variables and comor- fracture patients were identified based on ICD-9 coding (812.0x- bidities, showed that having a fracture was independently associ- 812.1x). The demographic data, comorbidities, complications, ated with increased risk of perioperative complication (Relative and perioperative inpatient data were compared between patients risk (RR) ¼3.2, p<0.001), pneumonia (RR¼4.6, p<0.001), with a fracture diagnosis versus those without a fracture diagnosis. myocardial infarction (RR¼4.6, p¼0.01), deep venous thrombosis Results: Fracture was the indication for RTSA in 10.4% of patients (RR¼4.6, p¼0.001), pulmonary embolism (RR¼3.9, p¼0.04), ce- (n¼ 567) compared to 89.6% of patients (n¼4899) with a nonfrac- rebrovascular accident (RR¼6.4, p¼0.02), and urinary tract infec- ture diagnosis. Patients who underwent a RTSA for a proximal hu- tion (RR¼2.9, p<0.001). Having a proximal humerus fracture merus fracture were significantly older (75.6 vs 72.3 years, was also associated with increased length of stay (difference ¼ p<0.001), more likely to be female (83.2% vs 61.8%, p<0.001), 1.95 days, p<0.001), proportion of non-routine discharge and more likely to be Caucasian (93.3% versus 88.8%, p¼0.02) (RR¼3.0, p<0.001), blood transfusion rates (RR¼2.2, p<0.001), compared to patients who underwent a RTSA for a nonfracture diag- and increased total hospitalization charges ($20,782, p<0.001). nosis. There was also a greater proportion of fracture patients who Conclusion: The overall perioperative complication rate following were in the lowest income quartile (p¼0.05) and treated at a large RTSA was 16.8% in the fracture group and 5.1% in the nonfracture hospital (p¼0.05). Patients with fractures also had significantly group. Patients with a proximal humerus fracture were also noted to increased rates of comorbidities including alcoholism (OR¼3.7, have higher rates of comorbidities. After adjustment of these differ- p<0.001), chronic anemia (OR¼2.3, p<0.001), hypertension ences in preoperative variables and comorbidities, fracture patients (OR¼1.3, p¼0.01), hypothyroidism (OR¼1.3, p¼0.01), and were still independently associated with having a longer hospital chronic renal failure (OR¼1.7, p¼0.001). Patients with a fracture stay (+ 2 days), higher costs (+ $20,000), and higher perioperative had a statistically significant longer hospital stay (4.5 vs 2.4 days, complication rates.

Reverse TSA 95% Conﬁdence Fracture No FractureP-value Relative Risk Lower Upper Age <0.001 Mean 75.6 72.3 Standard Deviation 9.33 9.14 Gender <0.001 Male 95 (16.8%) 1866 (38.2%) Female 472 (83.2%) 3020 (61.8%) Length of Stay (Days) <0.001 Mean 4.5 2.4 Standard Deviation 4.17 1.9 Hospital Charges (Dollars) <0.001 Mean 82,887.00 63,135.00 Standard Deviation 60,300.00 30,655.00 Discharge to Home <0.001 4.12 3.44 4.93 Yes 279 (49.2%) 933 (19.0%) No 288 (50.8%) 3966 (81.0%) Blood Transfusions <0.001 3.25 2.62 4.03 Yes 140 (24.7%) 449 (9.2%) No 427 (75.3%) 4450 (90.8%) Irrigation and Debridement 0.087 5.78 0.96 34.65 Yes 2 (0.4%) 3 (0.1%) No 565 (99.6%) 4896 (99.9%) Hematoma 0.73 1.24 0.37 4.16 Yes 3 (0.5%) 21 (0.4%) No 564 (99.5%) 4878 (99.6%) Death 0.12 2.89 0.78 10.7 Yes 3 (0.5%) 9 (0.2%) No 564 (99.5%) 4889 (99.8%) Pneumonia <0.001 3.52 1.88 6.58 Yes 14 (2.5%) 35 (0.7%) No 553 (97.5%) 4864 (99.3%) Deep Vein Thombosis 0.001 4.37 1.96 9.78 Yes 9 (1.6%) 18 (0.4%) No 558 (98.4%) 4881 (99.6%) (continued on next page) e232 ASES Abstracts J Shoulder Elbow Surg August 2015

(continued )

Reverse TSA 95% Conﬁdence Fracture No FractureP-value Relative Risk Lower Upper Pulmonary embolism 0.038 3.86 1.19 12.58 Yes 4 (0.7%) 9 (0.2%) No 563 (99.3%) 4890 (99.8%) Acute mental status changes 0.13 2.31 0.77 6.99 Yes 4 (0.7%) 15 (0.3%) No 563 (99.3%) 4884 (99.7%) Cerebrovascular Accident 0.009 6.95 1.86 25.97 Yes 4 (0.7%) 5 (0.1%) No 563 (99.3%) 4894 (99.9%) Myocardial Infarction 0.001 4.37 1.96 9.78 Yes 9 (1.6%) 18 (0.4%) No 558 (98.4%) 4881 (99.6%) Ileus 1 0.54 0.071 4.07 Yes 1 (0.2%) 16 (0.3%) No 566 (99.8%) 4883 (99.7%) Urinary Tract Infection <0.001 4.36 3.2 5.94 Yes 64 (11.3%) 139 (2.8%) No 503 (88.7%) 4760 (97.2%) Total Complications <0.001 3.73 2.89 4.81 Yes 95 (16.8%) 251 (5.1%) No 472 (83.2%) 4648 (94.9%)

Analysis of perioperative outcomes and complications in patients with and without a proximal humerus fracture who underwent reverse total shoulder arthroplasty.

5 THE COST-EFFECTIVENESS OF OPEN REDUCTION AND were robust on sensitivity analysis. Conclusion: Compared to hemi- INTERNAL FIXATION COMPARED WITH HEMIARTHROPLASTY arthroplasty, ORIF is the more cost-effective approach for surgical IN THE MANAGEMENT OF COMPLEX PROXIMAL HUMERUS management of complex proximal humerus fractures. This data is FRACTURES limited by patient selection which would impact the relative utility Robert J. Thorsness, MD, James C. Iannuzzi, MD, MPH, Edward scores. These results suggest that ORIF should be considered the J. Shields, MD, Katia Noyes, PhD, MPH, Ilya Voloshin, MD, preferable surgical approach given both payer and patient per- University of Rochester Medical Center, Surgical Health Outcomes spectives. & Research Enterprise, Rochester, NY, USA Background: Complex proximal humerus fractures are a challenging problem and are often managed with either open reduction and internal ﬁxation (ORIF) or hemiarthroplasty. Each approach has advantages, but there is little data to help guide de- cisions on surgical approach. This study evaluates the cost-effectiveness of each approach to surgical management of complex proximal humerus fractures. We hypothesize that ORIF would be more cost-effective. Methods: A decision analytic tree was developed using TreeAge Pro (Figure 1) to compare ORIF to hemiarthroplasty in the management of complex proximal humerus fractures. The tree incorporated 30-day post-operative complications and long term orthopaedic-speciﬁc complications most likely to require revision, including avascular necrosis or hardware complications in the ORIF group, and tuberosity complications in the hemiarthroplasty group. Cost was modeled from the payers perspective using 2013 US dollars derived from Medicare charges. Effective- ness was assessed from the patient perspective using quality adjusted life years (QALY). QALY were derived from patient re- sponses to the SF-36 survey and were converted to utility weights considered over a 1 year time horizon. Results: Given the baseline assumptions (Table 1) ORIF was slightly more costly ($10,950 versus $10,514), but more effective (0.75 QALY versus 0.67 QALY) than hemiarthroplasty. The incremental cost-effectiveness ratio (ICER) was $5,319/QALY for ORIF compared to hemiarthroplasty, which is less than the cost-effectiveness standard utilized Figure 1 Decision Analytic Tree comparing ORIF to Hemiarthro- based on a willingness to pay of $50,000/QALY. These results plasty in Complex Proximal Humerus Fractures. J Shoulder Elbow Surg ASES Abstracts e233 Volume 24, Number 8

Table 1 Baseline Assumptions ment in forward elevation (24 vs. 70,p¼0.001), lower final self- rated function (4 vs. 8 of 10, p<0.001), and lower final satisfaction Root (5 vs. 8 of 10, p<0.0001). The value of reverse shoulder arthro- Variable Definition Sensitivity range plasty (DASES/$10,000) for cases was 0.8 compared with 17.5 30-Day Complication, ORIF 6.9% 0-1 for controls (p<0.0001). Conclusions: One post-operative and three 30-Day Complication, Hemi 8.4% 0-1 pre-operative risk factors associated with a poor functional improve- Orthopaedic Complication, ORIF 30% 0-1 ment after reverse shoulder arthroplasty for massive rotator cuff tear Revision Rate, ORIF 58% 0-1 without glenohumeral arthritis were identified. Surgeons should be Orthopaedic Complication, Hemi 34% 0-1 aware of these associations in patient counseling and selection for Revision Rate, Hemi 6.4% 0-1 this operation. Neurological deficits should be carefully investigated Baseline Cost, ORIF $8,792 $7412-$10840 during history taking physical examination. In addition, younger, Baseline Cost, Hemi $9,853 $9174-$14304 higher functioning patients should be considered for alternative Complication Cost, ORIF $6,436 $1049-$17743 treatment options. As defined by condition specific outcome Complication Cost, Hemi $4,313 $1259-$16752 improvement per hospital cost, the value of reverse shoulder arthro- Utility, ORIF 0.81 0-1 plasty in the case group was very low in comparison with controls. Utility, Hemi 0.70 0-1 Utility of complication, nonop, ORIF 0.69 0-1 Utility of Revision, ORIF 0.60 0-1 Utility of complication, nonop, Hemi 0.64 0-1 7 TESTING OF A NOVEL GUIDING DEVICE FOR GLENOID Utility of Revision, Hemi 0.47 0-1 COMPONENT PLACEMENT IN TOTAL SHOULDER ARTHROPLASTY Gregory Lewis, PhD, Nicole Stevens, BS, April Armstrong, MD, FRCSC, Penn State Milton S. Hershey Medical Center and College of Medicine, Hershey, PA, USA 6 REVERSE SHOULDER ARTHROPLASTY FOR MASSIVE Background: Shoulder osteoarthritis leads to a complex anatomy ROTATOR CUFF TEAR: RISK FACTORS FOR POOR of the glenoid, including retroversion, biconcavity and/or increased FUNCTIONAL IMPROVEMENT surface area of the glenoid face. This altered anatomy often coin- Robert U. Hartzler, MD, Brandon Steen, MD, Michael cides with posterior subluxation of the humeral head, eventual M. Hussey, MD, Michael Cusick, MD, Benjamin J. Cottrell, BS, changes in joint kinematics and increasing instability of the joint. Rachel Clark, BA, CCRC, Mark A. Frankle, MD, Florida The alignment of the glenoid component is determined by the first Orthopaedic Institute, Foundation for Orthopaedic Research and central drill hole into the glenoid. The surgeon must take into account Education, Tampa, FL, USA glenoid wear, version and inclination, all with limited visibility [1]. Background: Reverse shoulder arthroplasty has been reported to Standard technique to orient the first drill hole includes running a have success in treating massive rotator cuff tears without glenohum- finger along the anterior surface of the glenoid vault to estimate eral arthritis. However, some patients have been observed to have the anatomy of the vault in order to align the drill. Three dimensional unexpectedly poor functional improvements after this operation. imaging has played a role in improving placement of the glenoid, Since alternative treatment options exist for the rotator cuff deficient but current techniques still have up to a 10% incidence of implant shoulder, our aim is to identify risk factors for poor functional loosening. We hypothesized that placement of a glenoid implant improvement after reverse arthroplasty in order to guide patient se- by an experienced surgeon with the aid of a novel customizable lection. Furthermore, we sought to assess the overall value of reverse guiding device, tailored to individual patients’ anatomy, will shoulder arthroplasty in cases with poor functional improvement decrease errors in version and inclination compared to finger- versus controls. Methods: The study design was a retrospective guided and image assisted techniques. Methods: A novel guiding case-control analysis of prospectively collected patient outcome device was developed based on the concept of a pin screen. The de- data. Inclusion criteria included primary reverse shoulder arthro- vice includes a grid of adjustable screws, with lengths adjusted ac- plasty performed for massive rotator cuff tear without glenohumeral cording to a 3-D computer reconstruction of the patient’s scapulae, arthritis (Hamada grade I-III) between 2007 and 2011 with mini- so that the guide will fit snugly on the glenoid face intraoperatively mum 2 year follow-up. Cases were defined as patients with pre- to final postoperative improvement in Simple Shoulder Test (SST) of 1 or less, and controls were defined as patients who improved SST $ 2 and had at least 2 year follow up. Risk factors previously sug- gested in the literature to be associated with poor outcome after reverse arthroplasty were analyzed: prior rotator cuff repair, preoperative active elevation > 90 degrees, workers compensation, upper extremity neurological dysfunction resulting in deltoid muscle weakness, age < 60, high preoperative functional score (SST $7), low mental health component score for SF-36 (<50), intraoperative elevation #90 degrees, and a major postoperative complication. Value was defined as improvement in ASES score per $10,000 hospital cost. Results: Thirteen cases and sixty-one controls met inclusion criteria and were included in the analysis. Risk factors associated with SST improvement of 1 or less included major complication (OR ¼ 5.0, 95% CI [1.1, 22.1], p¼0.045), neurological dysfunction (OR ¼ 18.0, 95% CI [1.7,190.7], p¼0.016), age less than 60 (OR ¼ 8.8, 95% CI [1.3, 59.8], p¼0.035), and high preoperative SST score (OR ¼ 18.0, 95% CI [1.7,190.7], p¼0.016). In the multivariate binomial logistic regression analysis, neurological dysfunction (p¼0.006), age less than 60 (p¼0.017), Figure 1 Shoulder replacement simulator with series of 3D printed and high preoperative SST score (p¼0.026) were independent pre- arthritic scapula positioned at adjustable orientation. During testing dictive variables. Compared with the control patients, the cases had all portions were shrouded, except for the glenoid face, and the sur- less improvement in ASES score (3 vs. 37, p<0.0001), less improve- geon positioned the drill on the face. e234 ASES Abstracts J Shoulder Elbow Surg August 2015

of pins based on automated software calculations. This method may ultimately provide a cost effective solution enabling surgeons to obtain desired orientation of the glenoid.

Reference

1. Hendel MD, Bryan JA, Rodriguez EJ, Brems JJ, Evans PJ, Iannotti JP. J Bone Joint Surg Am 2012;94:21-67-75

8 A RANDOMIZED, PROSPECTIVE EVALUATION ON THE EFFECTIVENESS OF TRANEXAMIC ACID IN REDUCING BLOOD LOSS AFTER TOTAL SHOULDER ARTHROPLASTY Robert J. Gillespie, MD, Yousef Shishani, MD, Shane Hanzlik, MD, Jonathan J. Streit, MD, Reuben Gobezie, MD, Case Western Reserve University, Department of Orthopaedic Surgery, Cleveland Shoulder Institute, University Hospitals of Figure 2 Points on the drill were 3D digitized and transferred to cor- Cleveland, Cleveland, OH, USA responding glenoid 3D image. Introduction: Tranexamic Acid(TA) is an antifibrinolytic agent that significantly reduces blood loss and transfusion requirements af- to align the central hole as desired by the surgeon. For this study we ter total knee and hip arthroplasty. The use of TA in shoulder arthro- tested a configuration which has the screws placed at the four gle- plasty has been limited to date. Aim: To evaluate the ability of TA to noid poles and two central points of the glenoid face. A surgical reduce postoperative blood loss after shoulder arthroplasty. simulator (Fig. 1) was used for testing that mounted 3D printed Methods: We performed a blinded, prospective randomized study arthritic scapulae and allowed for variability in scapula positioning of 88 patients(mean age 67 years, 58% female) in which patients (hidden from the surgeon). Physical models of glenoids were created received either 100mL normal saline or 100mL normal saline with from de-identified CT scans from nine arthritic patients. Three drill 2g TA by topical wound application at the completion of primary to- alignment methods were tested: using only the finger guided tech- tal (37 patients) or reverse (51 patients) shoulder arthroplasty. Blood nique along anterior glenoid vault, with the aid of 3D reconstructed loss during surgery (EBL), day-one drain output after surgery (DO), images, and using the novel drill guide. The alignment of the drill and change in hemoglobin were recorded for all patients. Results: relative to the glenoid face was collected using a 3D coordinate digi- Overall DO was 46mL635mL for TA and 55mL640mL for placebo tizer arm and transferred to a digital model to determine orientation (p¼0.29), mean change in hemoglobin was 2.161.0 for TA and of the drill relative to standard anatomical planes (Fig. 2). Error in 2.760.8 for placebo (p¼0.007), and mean EBL during surgery version and inclination were compared among alignment methods was not different (p¼0.20) between the TA and placebo groups. using a linear mixed effects model with repeated measures. Results: For TSA, mean DO was 42mL637 mL for TA and 57mL632mL for Errors in version and inclination of the glenoid, using the three placebo (p¼0.22), mean change in hemoglobin was 2.361.3 for different drill alignment methods, are shown in Fig. 3. Errors in drill TA and 2.760.5 for placebo (p¼0.23), and mean EBL was similar line orientation using no assistance avg 9.1 6 6.7 in version and between groups (p¼0.76). For RTSA, mean DO was 50mL634mL 8.7 65.9 inclination, errors using preop 3D imaging avg 7.8 for TA and 54mL644mL for placebo (p¼0.73), mean change in he- 66.1 version and 6.6 64.5 inclination, whereas errors using moglobin was 1.960.8 for TA and 2.660.9 for placebo the Pin Guide avg 2.6 61.7 version and 2.9 6 2.4 inclination. (p¼0.004), although the placebo group experienced greater surgi- Version errors using the pin guide were significantly lower than cal EBL (137mL694mL vs 91mL645mL, p¼0.03). There were no version errors associated with the other 2 methods. Conclusions: transfusions or complications recorded. All clinical parameters The new pin guide method reduced errors in orientation of the cen- improved (p¼0.05 or better) for the group overall. Conclusion: Tra- tral drill line. The guide method is patient specific, but does not nexamic acid appears to decrease blood loss following shoulder ar- require rapid prototyping and instead uses adjustments to an array thoplasty, however further study utilizing more patients is warranted.

9 ANALYSIS OF CYTOKINE PROFILES IN THE DIAGNOSIS OF PERIPROSTHETIC JOINT INFECTIONS OF THE SHOULDER Salvatore J. Frangiamore, MD, MS, Anas Saleh, MD, Matthew J. Grosso, MD, Mario Farias-Kovac, MD, Xiaochun S. Zhang, MD, PhD, Thomas M. Daly, MD, Thomas W. Bauer, MD, PhD, Joseph P. Iannotti, MD, PhD, Eric T. Ricchetti, MD, Orthopaedic & Rheumatologic Institute, Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, OH, USA Introduction: Periprosthetic joint infection (PJI) following shoulder arthroplasty can present both a diagnostic and therapeutic challenge due to the indolent nature of the most common offending organisms. Newer markers of infection have shown potential for increased sensitivity in diagnosis of PJI of the shoulder, in particular, synovial levels of Figure 3 Mean version and inclination errors for the three drill pro-inflammatory cytokines such as interleukin-6 (IL-6). The purpose alignment methods *indicates sign decrease using Pin Guide of this study was to evaluate the efficacy of broader synovial fluid compared to No assistance, # indicates sign decrease using Pin cytokine analysis in the diagnosis of PJI of the shoulder. Methods: Thir- Guide compared to Preop Image (p<0.05). Error bars indicate stan- ty-seven consecutive patients that underwent revision surgery (n¼40 dard error of mean. cases) for a painful shoulder arthroplasty were prospectively J Shoulder Elbow Surg ASES Abstracts e235 Volume 24, Number 8

Table 1 Comparison of cytokine levels across infection categories. Median and interquartile ranges (pg/mL) are presented for each cytokine in each infection category. Infection Category Statistics No Infection-Probable Cytokine Contaminant Probable Infection Deﬁnite Infection Correlation p-value IL-6 95.5 [28.8, 276.69] 1,400.19 [400.89, 13,411.25] 25,000 [24,241.9, 33,439.7] 0.5 <0.001 GM-CSF 0.6 [0.6, 0.6] 2.65 [1.57, 3.18] 15.7 [7.2, 18.6] 0.65 <0.001 IFN-g 2.4 [2.4, 6.25] 18.65 [4.97, 38.6] 32.85 [19.38, 77.67] 0.46 0.001 IL-1b 0.6 [0.6, 0.6] 6.4 [2.48, 64.57] 227.3 [218.1, 1,692.3] 0.64 <0.001 IL-12 0.6 [0.6, 1.57] 3 [0.6, 13.72] 57.2 [7.1, 64.1] 0.51 0.001 IL-2 0.6 [0.6, 1.4] 3.55 [0.88, 6.33] 18.8 [4.8, 23.7] 0.5 <0.001 IL-8 104.55 [27.02, 294.7] 2,190.8 [753.92, 3,969.95] 53,296.3 [39,239.5, 126,841.1] 0.55 <0.001 IL-10 9.55 [5.95, 14.12] 35.95 [22.65, 50] 87.35 [69.3, 115.17] 0.43 0.001 TNF-a 3.95 [2.38, 7.43] 7.25 [5.55, 8.82] 8.8 [4.67, 14.27] 0.27 0.019

enrolled. Cases were categorized into Definite Infection (n¼5), Prob- Purpose: Body Mass Index (BMI) is known to affect outcome in able Infection (n¼11), Probable Contaminant (n¼2), and No Infec- some orthopaedic surgical procedures. There are relatively few tion (n¼22) groups based on objective preoperative and studies that have analyzed the influence of BMI on complications after intraoperative findings; including serum ESR and CRP, synovial fluid total shoulder arthroplasty (TSA). We compare the 30-day complica- aspirate, tissue cultures, and frozen section analysis. P.acnes and/or tion rates and hospitalization outcomes following TSA among pa- coagulase-negative Staphylococcus species grew in 13/16 (81%) tients in different BMI categories. Methods: The American College cases of definite or probable infection. Twenty patients undergoing of Surgeons National Surgical Quality Improvement Program arthroscopic rotator cuff repair were also enrolled to serve as a (ACS-NSQIP) database for the 2006-2012 years was queried to non-infected control group. Synovial fluid was obtained in all pa- identify all patients who underwent a primary TSA (CPT¼23472) tients from preoperative aspiration and/or intraoperative aspiration for a diagnosis of osteoarthritis of the shoulder (ICD-9¼715.x1). prior to arthrotomy. Synovial fluid levels of nine different pro-inflam- The ACS-NSQIP is a statistically representative sample of prospec- matory cytokines (IL-6, GM-CSF, IL-1b, IL-12, IL-2, IL-8, IFN-g, IL-10, tively collected perioperative surgical data from participating hospi- TNF-a), were measured using a cytokine immunoassay that utilizes tals across the United States. Exclusion criteria included revision TSA, electrochemiluminescent detection. Elevations in each cytokine infection, tumor, or fracture. Patients who underwent a TSA were were evaluated across the infection categories and associations divided into four BMI categories: normal (18.5-25 kg/m2), over- with infection category and between individual cytokines were deter- weight (25-30 kg/m2), obesity class 1 (30-35 kg/m2), and obesity mined using Kendall’s rank correlation. Results: All nine cytokines class $ 2(>35 kg/m2). Perioperative hospitalization data and 30- showed significant positive correlations with infection category, day postoperative complications, as well as demographics, comor- with increasing cytokine levels seen as the likelihood of infection bidities, and preoperative laboratory values, were compared among increased (Table 1). GM-CSF and IL-1b demonstrated the strongest patients in different BMI classes. Results: There were a total of 3200 correlations, while TNF-a demonstrated the weakest. IL-6 and IL-8 patients from this database who underwent a TSA during 7 consecu- showed the largest magnitude of elevations. The Probable Contami- tive years. After implementing the exclusion criteria, we analyzed nant group did not demonstrate obvious differences in cytokine pro- 2121patients who underwent a primary TSA for osteoarthritis of files from the No Infection group, but this comparison was limited by the shoulder. The average age of the patients decreased with the small number of cases (n¼2). Within the No Infection group, increasing BMI (p<0.001), from 71.8 years in the normal BMI group cytokine levels were similarly low in the cases of arthroscopic rotator to 66.9 years in the obesity class $ 2 group. The overall complication cuff repair and aseptic revision shoulder arthroplasty. Pairwise com- rates for the normal, overweight, obesity class 1, and obesity class $ parisons of cytokines demonstrated positive correlations across all 2 were 4.5%, 3.7%, 2.8%, and 3.9% respectively (p¼0.59). There cytokines, with the strongest associations seen between IL-1b and was a statistical trend towards increased risk of DVT (p¼0.06) with a IL-8 (0.68), IL-1b and IFN-g (0.65), IL-1b and IL-10 (0.64), and IL-6 higher BMI. There were no difference among the BMI groups in rates and IL-10 (0.62). Conclusions: Elevated synovial fluid levels of pro-in- of wound complications (p¼0.33), blood transfusions (p¼0.14), re- flammatory cytokines are significantly associated with increased turn to the operating room (p¼0.81), mortality (p¼0.87), postopera- likelihood of infection in revision shoulder arthroplasty. Cytokine pro- tive length of stay (p¼0.53), and discharge to home (p¼0.13). The file analysis may lead to improved diagnostic accuracy of PJI in the operative time of surgery increased from 114.7 minutes in the normal shoulder and cytokine profile patterns may ultimately help to guide BMI group to 122.1 minutes in the obesity class $ 2 group (p¼0.02). decision-making in the management of PJI of the shoulder, including General anesthesia rates increased from 93.5% in the normal BMI the need to proceed with one- versus two-stage revision and the group to 98.7% in the obesity class $ 2 group (p¼0.001). There optimal postoperative antibiotic course. were statistically significant differences between the distribution of gender (p<0.001) and race (p<0.001) among the different BMI groups. Preoperative comorbidities that were more commonly seen in the higher BMI groups include diabetes (p<0.001), hypertension 10 THE IMPACT OF BMI ON SHORT TERM (p<0.001), dyspnea (p¼0.001), history of cerebrovascular acci- COMPLICATIONS FOLLOWING TOTAL SHOULDER dent or transient ischemic attack (p¼0.05), and a higher American ARTHROPLASTY Society of Anesthesiologists physical status classification Jimmy J. Jiang, MD, Pranay B. Patel, MD, Jason L. Koh, MD, Douglas (p<0.001). Conclusion: While the surgical time increased for pa- R. Dirschl, MD, Lewis L. Shi, MD, NorthShore University tients with greater BMI, the 30-day complication rates following HealthSystem (a teaching affiliate of University of Chicago), TSA were not significantly different in patients with increased BMI Pritzker School of Medicine, Evanston, IL, USA levels. Level of Evidence: Therapeutic Level III. e236 ASES Abstracts J Shoulder Elbow Surg August 2015

Body Mass Index (BMI) 18.5-25 25-30 30-35 >35 (N¼337) (N¼727) (N¼573) (N¼460) P-value Age (years) <0.001 Mean 72.5 70.8 68.7 67.1 Standard Deviation 10.5 10.4 9.5 9.5 Gender (%) <0.001 Male 32.1 53.2 51.4 36.7 Female 67.9 46.8 48.6 63.3 Race (%) 0.001 White or Hispanic 87.8 86.5 90.4 85.7 Black 1.8 2.8 2.6 6.1 Asian 1.2 0.3 0.5 0.2 American Indian 0.0 0.0 0.0 0.2 Other/Unknown 31.0 76.0 37.0 35.0 ASA Classiﬁcation(%) <0.001 1 or 2 59.9 59.7 54.8 35.9 3 38.9 39.1 43.6 59.2 4 1.2 1.2 1.6 5.0 Diabetes (%) 7.7 9.8 16.4 28.7 <0.001 Hypertension (%) 43.9 36.0 26.9 21.5 <0.001 Dyspnea (%) 0.001 At rest 0.6 0.3 0.2 0.7 Moderate Exertion 4.5 5.5 7.0 11.7 No 95.0 94.2 92.8 87.6 Surgical Time (minutes) 0.02 Mean 114.7 116.5 122.4 122.1 Standard Deviation 44.3 46.0 46.4 44.7 General Anesthesia (%) 93.5 95.0 96.3 98.7 0.001 Postoperative Length of Stay (days) 0.53 Mean 2.2 2.2 2.0 2.1 Standard Deviation 1.4 3.8 1.2 1.2 Blood Transfusion (%) 4.5 3.2 5.1 2.6 0.14 Total Wound Infection (%) 0 0 0.3 0.2 0.33 Pneumonia (%) 0 1 0.3 0.2 0.11 Pulmonary embolism (%) 0.6 0.3 0.3 0.1 0.81 Myocardial infarction (%) 0.6 0.6 0.3 0 0.44 CVA (%) 0.0 0.1 0.2 0.0 0.05 UTI (%) 1.5 0.8 0.9 2.2 0.17 DVT (%) 0.6 0.1 0 0.9 0.06 Total number of patients with a complication (%) 4.5 3.7 2.8 3.9 0.59

Comparison of Hospitalization data and 30-day Complication Rates of TSA among Different BMI Categories.

11 USE OF THE REVERSE PROSTHESIS IN PATIENTS IN disease of the shoulder who remain dependent on either wheelchair WHEELCHAIRS OR WALKERS or walker for mobility. All underwent reverse total shoulder arthro- Lucas B. Romine, MD, Filippo Familiari, MD, MBBS, plasty and had a minimum of one year of follow-up. All patients Alan Gonzalez-Zapata, MD, Uma Srikumaran, MD, Edward were studied prospectively and evaluated preoperatively with a G. McFarland, MD, Division of Shoulder Surgery, Department of physical examination, VAS for pain and multiple shoulder specific Orthopaedic Surgery, the Johns Hopkins University, Baltimore, outcome measures (viz. WOOS, ASES score, L’Insalata score, modi- MD, USA fied Constant score). These examinations were repeated at one year Introduction: The treatment of osteoarthritis of the shoulder in postoperatively and each subsequent year. Postoperative radio- patients who are restricted to the use of walkers or wheelchairs re- graphs at follow up were evaluated for baseplate loosening and mains a challenge. These patients are more dependent upon their notching was graded using the classification of Sirveaux et al. All upper extremities for ambulation, transfers, and are consistently patients were followed monthly after surgery for three months then bearing total body weight through the upper extremities. To our three months thereafter for the first year. Full weight bearing was knowledge there are no previous studies examining shoulder ar- not permitted on the operative extremity until 3 months postopera- throplasty in this unique population. Due to concern with long tively. Results: There were 6 patients (8 RTSAs) who were confined term rotator cuff failure with the use of anatomical total shoulder to wheelchairs and 5 (5 RTSAs) who were walker dependent for replacement in this patient population, we have utilized reverse to- ambulation. There were 3 men and 8 women with an average tal shoulder arthroplasty in select patients who are dependent age of 63.2 (range 44 to 81). The indications for the wheelchair upon walkers for ambulation or who are restricted to wheelchair were debilitating osteoarthritis in multiple joints in 3 patients, an use only. The goal of this study is to evaluate the short term results arthritic shoulder in a patient with cerebral palsy in 1, quadriplegia of the reverse total shoulder arthroplasty in this challenging group at C6-C7 in 1, Kniest syndrome with arthritis in both shoulders, and of patients. Materials and Methods: This is a retrospective case se- debilitating lower extremity fractures which did not allow ambula- ries of 11 patients (13 shoulders) with debilitating degenerative joint tion in 1. For the walker dependent patients the diagnosis was L4 J Shoulder Elbow Surg ASES Abstracts e237 Volume 24, Number 8

injury causing motor impairment in 1 patient, debilitating and multi- ment of shoulder pain and function using the VAS, the Simple Shoul- ple joint osteoarthritis in 1, nerve injury causing motor impairment der Test, and the American Shoulder and Elbow Surgeons score. and weakness at a spinal level of L4/L5 in 1, nerve injury causing Longitudinal follow-up is warranted to clarify the relationship be- motor impairment at the level of L5/S1 in 1, and cerebral palsy in tween distress and self-perceived disability and the impact of distress 1. Nine of 11 patients (11 of 13 shoulders) (84%) went to a rehabil- on postoperative outcomes after arthroscopic rotator cuff repair. itation facility postoperatively for an average of 32 days (range 8 to 90). At last follow up (average 19 months, range 12-37 months), there was no radiographic evidence of baseplate loosening in this 13 FULL THICKNESS ROTATOR CUFF TEARS SUMMARY cohort. There were 6 cases with no notching, 5 cases with grade RECOMMENDATIONS OF THE APPROPRIATE USE CRITERIA 1 notching, and 2 cases with grade 2 notching. There was a statis- Christopher C. Schmidt, MD, Bernard F. Morrey, MD, tically significant decrease in VAS for pain from preoperatively to Jayson Murray, MA, James O. Sanders, MD, Orthopaedic postoperatively (p¼.026). There was a significant increase in active Specialists – UPMC, the University of Pittsburgh Medical School, elevation of the arm postoperatively (p¼.042). There was a signifi- Pittsburgh, PA, USA; Department of Orthopaedic Surgery, Mayo cant improvement in SF36 physical component score (mean 46.2, Clinic, MN, USA; American Academy of Orthopaedic Surgery, SD 8.31, p¼.045) but not in SF36 mental component score Rosemont, IL, USA; Department of Orthopaedic Surgery, (mean 50.3, SD 7.25, p¼.074). There was a statistically significant University of Rochester Medical Center, School of Medicine and difference in the modified Constant score (p¼.041) and a trend to- Dentistry, Rochester, NY, USA ward a significant difference on ASES (p¼.057) and WOOS Introduction: The Full Thickness Rotator Cuff Appropriate Use (p¼.057). VAS for satisfaction revealed that satisfaction with the sur- Criteria (RCT AUC) process was designed to determine when it is gery was 84.6% overall (range 60 to 100). Conclusion: RTSA can reasonable to recommend non-operative, partial repair and/or debridement, repair, reconstruction (muscle transfer or graft), or ar- be performed successfully in this population of patients who are up- 1,2 per extremity dependent for transfers and mobility. This study is throplasty (hemi or RSA) following a cuff tear . The AUC methodol- limited by short term follow up, the use of one prosthetic system ogy consisted of writing, review, and voting panels that created 432 unique patient scenarios and graded the 5 above treatment options and the restriction of use of the arm for three months postoperatively. 1,2 Further study is needed to determine if use of the extremity can begin for each scenario. The level of appropriateness was ranked into earlier and if the implants will withstand long term stress due to pro- three groups: 1. Appropriate - benefits clearly outweigh risks, 2. longed upper extremity weight bearing. Maybe appropriate - benefit equals risks, and 3. Rarely appropriate - risks greater than benefit.1 Our hypothesis is that AUC methodology can determine the appropriateness of each treatment choice by care- ful considerations of the literature, patient/rotator cuff factors, and 12 PSYCHOLOGICAL DISTRESS NEGATIVELY IMPACTS evaluators’ expertise. The study’s goal was to generalize the detailed SELF-ASSESSMENT OF SHOULDER FUNCTION IN PATIENTS results of the process, to stratify the relative importance of the pa- WITH ROTATOR CUFF TEARS tient/RCT factors, and to describe these findings in clinically relevant Michael Q. Potter, MD, James D. Wylie, MD, Robert terms. Methods: This study generalized the AUC’s raw voting data1 T. Burks, MD, Patrick E. Greis, MD, Robert Z. Tashjian, MD, by analyzing patient/rotator cuff factors that were determine to influ- Department of Orthopaedics, University of Utah School of ence outcome and the indications for each treatment choice by sum- Medicine, Salt Lake City, UT, USA marizing the circumstances that make each treatment appropriate, Introduction: In many areas of orthopaedics, patients with maybe appropriate,orrarely appropriate. A multiple regression greater levels of psychological distress report inferior self-assess- analysis was performed on the final appropriateness ratings. Further, ments of pain and function. This effect can lead to lower than ex- Comparison Tables were created as an aid to clarify the clinical ef- pected baseline scores on common patient-reported outcome fect each patient/RCT factors had on the ranking of each of the scales, even those not traditionally considered to have a psycholog- five treatment choices. Results: Response to conservative treatment ical component. The purposes of this study were to determine (1) had the greatest statistical influence on the voting panel (p<0.05, whether higher levels of psychological distress are associated with b¼2.259). The Comparison Tables showed that when patients clinically significant differences in baseline scores on the Visual respond to conservative measures then non-operative treatment is Analog Scale (VAS) for pain, the Simple Shoulder Test, and the Amer- indicated. The only treatment choice that was considered maybe ican Shoulder and Elbow Surgeons score in patients undergoing appropriate in patients that responded to conservative care was a ro- arthroscopic rotator cuff repair; and (2) whether psychological tator cuff repair in healthy patients. ASA score statistically (p<0.05) distress would remain a significant negative predictor of baseline and clinically impacted the voting pattern for all treatment groups. shoulder scores when other clinical variables were controlled. Mate- Surprisingly, identifiable factors for healing failure and identifiable rials and Methods: Eighty-five patients with full-thickness rotator cuff patient factors affecting outcome were not clinically significant fac- tears were prospectively enrolled. Psychological distress was quan- tors in predicting levels of appropriateness. Rotator cuff repair was tified using the Distress Risk Assessment Method questionnaire. Pa- appropriate or maybe appropriate in virtually all circumstances in tients completed baseline self-assessments including the VAS for which the patient was more than mildly symptomatic. Partial pain, the Simple Shoulder Test, and the American Shoulder and repair/debridement and reconstructions were maybe appropriate Elbow Surgeons score. Age, sex, BMI, smoking status, and Amer- for large, chronic tears. Arthroplasty was only maybe appropriate ican Society of Anesthesiologists classification were recorded for in healthy patients with severe symptoms, psudeoparalysis, and a each patient. Bivariate correlations and multivariate regression chronic massive tear. Summary: This study is the first attempt to sum- models were used to assess the effect of psychological distress on pa- marize the clinical relevance of the RTC AUC. It showed that the tient self-assessment of shoulder pain and function. Results: Dis- AUC’s scenario specific recommendations could be simplified into tressed patients reported higher baseline VAS scores (6.7 versus meaningful treatment guidelines as discussed in the results section. 2.9, p ¼ 0.001) and lower baseline Simple Shoulder Test (3.7 versus However, AUC treatment groups were heterogeneous because the 5.7, p ¼ 0.001) and the American Shoulder and Elbow Surgeons categories included procedures with different indications and ex- scores (39 versus 58, p < 0.0001). These differences were statisti- pected outcomes. It is not possible to determine which of these treat- cally and clinically significant. Distress remained significantly associ- ments is more appropriate for a specific patient. The lack of ated with higher VAS scores (p ¼ 0.02) and lower Simple Shoulder importance given to some of the known patient and healing vari- Test (p ¼ 0.01) and American Shoulder and Elbow Surgeons scores ables make it incumbent on the treating physician to carefully ac- (p ¼ 0.01) when other clinical variables (age, sex, bmi, ASA classi- count for the individual patient’s pathology and preferences. fication, smoking status) were controlled. Conclusions: Psychological Therefore, each surgeon should consider the AUC as a useful refer- distress has a negative correlation with baseline patient self-assess- ence tool and not an authoritative document on treatment. e238 ASES Abstracts J Shoulder Elbow Surg August 2015

References 15 PRIMARY VS. REVISION ARTHROSCOPIC ROTATOR CUFF REPAIR: AN ANALYSIS IN 360 CONSECUTIVE PATIENTS 1. Murray J and Gross L. JAAOS: 2013: 21:767-71. Aminudin Shamsudin, MD, MMed(Ortho), Patrick 2. Pappou IP, Schmidt CC, Jarrett CD, Steen BM, and Frankle MA. H. Lam, PhD, Karin Peters, MD, Imants Rubenis, Lisa Hackett, AMS, JAAOS: 2013: 21:772-5. George A.C. Murrell, MD, DPhil, Orthopaedic Research Institute, St. George Hospital Campus, Sydney, NSW, Australia Aim: The aim of this study was to evaluate the outcome of revision 14 EFFECT OF ARTHROSCOPIC CAPSULAR RELEASE ON arthroscopic rotator cuff surgery when compared with primary SHOULDER STIFFNESS CONCOMITANT WITH A ROTATOR arthroscopic rotator cuff surgery in a large cohort of patients. CUFF TEAR -DIABETES AS A PREDISPOSING FACTOR Method: A consecutive series of 360 (310 primary and 50 revision) ASSOCIATED WITH TREATMENT OUTCOME arthroscopic rotator cuff repairs performed by a single surgeon with Seok Won Chung, MD, Kyung-Soo Oh, MD, Jong Pil Yoon, MD, minimum of two years follow-up were retrospectively reviewed using Jin-Young Park, MD, Department of Orthopaedic Surgery, Konkuk prospectively collected data. With the 50 revision cases (revision University School of Medicine, Konkuk University Medical Center, group) as a reference, three primary repair cases (primary group) Seoul, South Korea; Kyungpook University Hospital, Dae-gu, were chosen immediately before and three after each revision South Korea case. Standardized, patient-ranked outcomes, examiner determined Introduction: In spite of the high prevalence,optimal manage- assessments, and ultrasound determined rotator cuff integrity was as- ment of shoulder stiffness during rotator cuff repair remains un- sessed pre-operatively at six months and two years after surgery. Re- clear. The purpose of this study was to identify the effect of sults: The revision group were older (mean: 63 years, range 43 - 80) capsular release during rotator cuff repair on the outcomes of pa- compared to the primary group (mean: 60 years, range 18 – 88) (p < 2 6 2 6 tients with both shoulder stiffness and a rotator cuff tear using sub- 0.05) and had larger tear size (4.1 cm 0.5 cm )(mean SEM) 2 6 2 < group analyses. Methods: Forty-nine consecutive patients (mean compared to the primary group (3.0 cm 0.2 cm )(p 0.05). age, 61.568.3 years) who underwent arthroscopic repair of a Two years after surgery the primary group reported less pain at < < small-to-large sized full-thickness rotator cuff tear and manipulation rest (p 0.02), during sleep (p 0.05) and with overhead activity < for concomitant shoulder stiffness (FF#120 and ER at side#45 ) (p 0.01) compared to the revision group. The primary group had < were enrolled. The first 21 consecutive patients underwent manip- better passive forward flexion (+13o, p 0.05), abduction (+18o, p < < ulation alone to treat stiffness, and the second 28 consecutive pa- 0.01), internal rotation (+2 vertebral levels, p 0.001) and also < tients underwent capsular release with manipulation. Among the significantly greater abduction strength (+15 N, p 0.001), lift-off < < 49 patients, 25 showed severe stiffness (FF#100 and ER at strength (+9.3 N, p 0.05) and adduction strength (+22 N, p side#30: 11 in the first series and 14 in the second series) and 0.01) compared to the revision group at two years. When compared 15 (30.6%: 6 in the first series and 9 in the second series) had dia- to the primary group, the revision group was less satisfied with the < betes mellitus (DM). The postoperative ROM was measured 6 overall shoulder function before surgery ( p 0.001) but was weeks, 3 months, 6 months, and 1 year postoperatively and at final equally satisfied with the primary group at 6 months post operatively. follow-up visit. Simultaneously, functional outcome was evaluated However the revision group’s satisfaction deteriorated and were less from pain VAS, ASES score, Constant score, and muscle strength satisfied with their shoulder function than the primary group at two < ratio (involved/uninvolved), and cuff integrity was assessed ultra- years (p 0.005). The re-tear rate for primary rotator cuff repair sonographically at least 1 year postoperatively. Results: All was 16% at 6 months and 21% at two years; while the re-tear rate ROM, functional scores, and muscle strength ratios significantly for revision rotator cuff repair was 28% at six months and deterio- < improved postoperatively in all patients (all p<0.01). No outcome rated to 40% at two years (p 0.05). The overall shoulder satisfac- measure differed significantly between patients who did and did tion corresponded with a decline in rotator cuff integrity at two years. not undergo capsular release. However, among patients with se- Conclusion: The short term clinical outcomes of patients undergoing vere stiffness, those who underwent capsular release showed revision rotator cuff repair were similar to primary rotator cuff repair. greater improvement in ER at side 3 months postoperatively However, these results did not persist and by two years patients who (p¼0.036) despite the lack of significant difference in the final had revision rotator cuff repair were twice as likely to have re-torn outcome. Moreover, among patients with DM, those who under- compared to those undergoing primary repair. The increase re-tear went capsular release showed greater improvement in FF after 3 rate in the revision group at two years was associated with increased months and 1 year and in ER atside at all timepoints, except 6 pain, impaired overhead function, weaker strength, less passive mo- weeks postoperatively (all p<0.05) and also a significantly higher tion excursion and less overall satisfaction with shoulder function. final ASES score (p¼0.030). Two of 21 patients who underwent manipulation alone and 1 of 28 who underwent capsular release and manipulation developed retears. Conclusions: Both manipulation and capsular release with manipulation significantly improved 16 ARTHROSCOPIC ANCHORLESS VS. ANCHORED ROM and produced satisfactory functional outcomes. However, in ROTATOR CUFF REPAIR: ARE THE COST SAVINGS WORTH THE patients with severe stiffness, capsular release at the time of rotator HASSLE? cuff repair increased ER in early postoperative period. Capsular Eric M. Black, MD, Luke S. Austin, MD, Alexa Narzikul, BA, release was also beneficial in patients with diabetes, especially Kelly Martens, MD, Mark D. Lazarus, MD, The Rothman Institute, for ER and final postoperative function. Thomas Jefferson University Hospital, Philadelphia, PA, USA

TOE Cost TOE Time n Transosseous Cost Transosseous time n Small $813.00 1:32 (0:00) 1 $659.75 1:41 (0:13) 4 Medium $946.67 1:34 (0:20) 118 $671.39 1:34 (0:20) 116 Large $1,104.56 1:45 (0:22) 52 $695.55 1:47 (0:21) 44 Massive $1,507.29 2:07 (0:15) 7 $716.00 1:50 (0:07) 2 TOTAL $1,014.10 1:39 (0:22) 178 $678.05 1:38 (0:21) 166 J Shoulder Elbow Surg ASES Abstracts e239 Volume 24, Number 8

Introduction: Improvements in arthroscopic fixation methods for logically matched group of four rotator cuff repair-only patients rotator cuff repair surgery have led to substantial increases in implant before and after each stiffness patient were chosen from the consec- related costs. As facility reimbursements for rotator cuff repair have utive list of rotator cuff repairs. Twenty-five patients from the stiffness decreased, techniques to make the procedure more cost effective group and 170 patients from the non-stiffness group met the inclu- are warranted. We sought to investigate the cost savings associated sion criteria, leaving a total cohort of 195 patients. Patients with arthroscopic transosseous (anchorless) double-row rotator cuff completed modified L’Insalata Questionnaires for patient-ranked repair when compared to double-row anchored (transosseous-equiv- pain and function scores pre-operatively, intra-operatively, and at alent) repair. Materials/Methods: Between January 2009 and one week, six weeks, 12 weeks, six months and two-years post-oper- September 2012, patients undergoing double-row arthroscopic ro- atively, while examiners recorded range of motion, strength, and tator cuff repair by a single surgeon were eligible for inclusion. presence of impingement signs. Results: Patients from both groups Two consecutive series of patients undergoing arthroscopic transoss- had significantly improved clinical outcomes at the two-year eous-equivalent (TOE) repair or arthroscopic transosseous double- follow-up as compared to pre-operative values. Range of motion row repair were included in the study. Revision repairs, subscapula- was similar between groups at two-years for forward flexion, abduc- ris repairs, patients with poor tendon quality or excursion requiring tion and external rotation, while the non-stiffness group had a supe- medialized repair, and partial repairs were excluded from the study. rior range of internal rotation (p < 0.02). Stiffness patients had 0/ Rotator cuff implant costs (paid by the institution) and surgical times 25 (0%) re-tears at two years, significantly less (p ¼ 0.009) than were compared between the two groups, controlling for rotator cuff the non-stiffness patients (34/170 [20%]) [Fig. 1]. Conclusions: tear size and additional procedures performed. Results: 344 pa- This study showed that patients who have an arthroscopic rotator tients were included in the study, 178 TOE repairs and 166 transoss- cuff repair concomitantly with a glenohumeral joint capsule release eous repairs. The average implant cost for TOE double-row repairs for frozen shoulder experience very similar clinical outcomes to ro- was $1014.10 ($813.00 for small, $946.67 for medium, tator cuff repair-only patients with the exception that their repairs $1104.56 for large, and $1507.29 for massive tears). This was heal with superior integrity. The good outcomes of rotator cuff repair significantly more expensive than the average implant cost for trans- with capsular release suggest that there is no advantage in delaying osseous repairs, $678.05 ($659.75 for small, $671.39 for me- surgical repair of a rotator cuff tear to allow for stiffness to resolve. In dium, $695.55 for large, and $716.00 for massive tears). contradistinction, the data presented in this paper suggests that Average total operative time from case start to dressing application shoulder stiffness with glenohumeral joint capsule release, confers did not significantly differ between the two groups, 99 vs. 98 minutes an advantage in terms of repair integrity. in the TOE and transosseous groups, respectively. There was larger (though not statistically significant) case time variation in the TOE group, where case time was shorter in small tears and longer in 18 ANTHROPOMETRIC STUDY OF THE RADIO-CAPITELLAR massive tears. Conclusion: Compared with arthroscopic TOE repair, JOINT arthroscopic transosseous rotator cuff repair provides substantial Matthias Vanhees, MD, Dave R. Shukla, MBBCh, James implant related cost savings with no significant differences in surgical S. Fitzsimmons, BSc, Kai-Nan An, PhD, Shawn time for medium and large rotator cuff tears. Case time varied more W. O’Driscoll, PhD, MD, Biomechanics Laboratory, Department of with extremes in tear size for TOE repair. Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA Introduction: When a radial head implant is indicated because of a fracture, the preoperative measurements of the capitellum could 17 THE EFFECT OF CONCOMITANT GLENOHUMERAL help to decide which radial head implant size would be most appro- JOINT CAPSULE RELEASE DURING ROTATOR CUFF REPAIR: priate. Also, if a lateral hemiarthroplasty is needed because of iso- A COMPARATIVE STUDY OF 195 ARTHROSCOPIC ROTATOR lated lateral elbow osteoarthritis, radiographic measurements of the CUFF REPAIRS contralateral, intact side could help in pre-operative planning. The Jordan P. McGrath, Patrick H. Lam, PhD, Martin T.S. Tan, purpose of this study is to investigate the correlation between the George A.C. Murrell, MD, DPhil, Orthopaedic Research Institute, St. George Hospital Campus, Sydney, NSW, Australia Background: There is debate as to whether to operate or defer surgery on patients with concomitant rotator cuff tear and shoulder stiffness. The purpose of this study was, therefore, to compare the outcomes in those patients who had both their rotator cuff tear and shoulder stiffness treated with patients who had a rotator cuff repair but no stiffness. Methods: 1232 primary arthroscopic rotator cuff repairs were performed during the study period, including 44 patients who received a concomitant glenohumeral joint capsule release for Figure 1 (A) Lateral view showing the vertical height of the capitel- ipsilateral shoulder stiffness, forming the stiffness group. A chrono- lum: V. (B) A-P view showing the anterior width of the capitellum: W. (C) Measurements of the radial head. L-O: Long Outer. L-I: Long In- ner. S-O: Short Outer. S-I: Short Inner.

Table 1 Average, SD, and range of measurements Average SD Range Capitellum Vertical height 23 2 20-27 Anterior width 22 3 18-28 Radial head diameter Long outer 24 3 21-30 Long inner 18 2 15-23 Short outer 23 3 19-29 Figure 1 Repair integrity. xp < 0.05, xxp < 0.01, xxxp < 0.001, Short inner 17 2 15-22 xxxxp < 0.0001 for comparisons between groups. e240 ASES Abstracts J Shoulder Elbow Surg August 2015

size of the capitellum and that of the radial head, and to investigate if the correlation between the capitellum in the left and right elbow of the same subject. Methods: Eight pairs of elbows (8 right, 8 left), including 2 males and 6 females (average age 78.5 years, range 59-92); and 12 single (non-paired) elbows, including 6 males and 6 females (average age 77.5 years, range 60-89), from fresh frozen cadavers were obtained for this study. Measurements were done using a digital caliper. Each of the two observers made three measurements (Fig. 1). The Pearson’s correlation coefficient (r) and inter-rater correlation coefficient (ICC) were obtained for all measurements. Re- sults: The ICC was in the excellent range for all measurements (range: 0.91 – 0.99). For the paired elbows, all the correlations for the capitellar measurements were in the excellent (range: 0.95 – 0.96). The correlation for the radial head measurements was in the good to excellent range (range: 0.77-0.98). The long axis of the radial head was strongly correlated with the vertical height (V) of the capitellum (R¼0.8; p<0.0001) and the anterior width (W) of the capitellum (R¼0.9; p<0.0001). The correlations between other radial head and capitellum measurements was in the high to excellent range for 6 out of 8 combinations. The average, standard deviation, and range Figure 1 A-D. Intraoperative pictures demonstrating suture anchor Discussion: of all measurements are shown in Table 1. We found a placement (A) and fixation of olecranon fracture (B). Preoperative high correlation between the vertical height and all dimensions of (C) and seven month postoperative (D) X-Rays demonstrate appro- the radial head, but the strongest correlation was with the long outer priate fracture consolidation in anatomic position. diameter of the radial head. For the anterior width, an excellent correlation existed with the long outer diameter and the long inner diam- was 5.2 days 6 3.4 days. The average time from operation to long- eter. Because of the high correlation between several dimensions of term follow-up was 5.1 years 6 2.5 years (range: 0.8 – 7.4 years). the capitellum and radial head, we will be able to estimate the size Six patients were available for long-term follow-up. One patient had of the radial head based on the size of the capitellum and vice versa. deceased, and two patients were unable to be contacted despite mul- This information can be very helpful for radio-capitellar prosthetic tiple attempts. There were no intraoperative complications or reoper- design. The data might be even more helpful in clinical trauma setting ations. Eight of nine patients healed uneventfully in acceptable where the capitellum and/or the radial head are totally destroyed. In position without displacement. Postoperatively, the average Oxford case the radial head is totally destroyed, the size of the vertical height Elbow Score (OES) was 47.17 6 2.04; the average QuickDASH and anterior width can be used to determine the optimal size of the score was 6.43 6 9.47; and the average Short-Form Health Survey radial head prosthesis. If the capitellum and radial head are both de- (SF-12) scores were 49.02 6 16.59 and 55.38 6 4.05 for the phys- stroyed, but the other parts of the elbow were left intact, the opposite ical and mental component scales, respectively. Discussion and elbow could be used to determine the optimal size of the radio-capi- Conclusion: Suture anchor fixation of olecranon fractures in the tellar prosthesis. There is a high correlation between some dimen- elderly population provides excellent long-term radiographic and sions of the radial head and the capitellum, and there is also a high clinical outcomes. Importantly, this technique reduces complications correlation between the left and right elbow. and reoperations for symptomatic hardware, as compared with traditional surgical treatments. Reference

1. Pooley, J., Unicompartmental Elbow Replacement: Development of a Lateral Replacement Elbow (LRE) Arthroplasty. Techniques in 20 EFFECT OF INSERTION ANGLE ON LOCKING Shoulder & Elbow Surgery 2007;8:204-212. MECHANISM STRENGTH IN POLYAXIAL PLATES Ghita Bouzarif, BS, Michelle H. McGarry, MD, Martin Tynan, MD, Thay Q. Lee, PhD, Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System and University of 19 SUTURE ANCHOR FIXATION OF DISPLACED California, Irvine, Irvine, CA, USA OLECRANON FRACTURES IN THE ELDERLY Background: Distal elbow fractures tend to involve poor bone Dexter Bateman, BS, Jonathan D. Barlow, MD, MS, quality and are intra-articular, compromising stability. Locking plate Corinne VanBeek, MD, Joseph A. Abboud, MD, and screw constructs have higher pull-out strength which is instru- Introduction: Olecranon fractures are common in elderly patients, mental in repairing osteoporotic bone or comminuted fractures; how- causing significant morbidity and functional impairment. Traditional ever, the screw insertion angle is fixed relative to the plate. To address surgical treatments are often complicated by hardware failure and the limitation of monoaxial locking plates, polyaxial plates have al- prominence, frequently requiring reoperation. These difficulties often lowed surgeons greater freedom in screw angulation to accommo- arise secondary to the marked comminution and osteoporotic nature date complex fractures. The objective of this study was to evaluate of these patients’ bones. To address these concerns, a suture anchor the effect of screw angle insertion on the screw-plate fixation strength fixation technique was developed and clinically evaluated. Methods: of polyaxial locking plates. We hypothesized the angle of insertion of A consecutive series of elderly patients treated with this technique the locking screw is inversely proportional to the fixation strength of from January 1, 2006 to December 31, 2013 at a single institution the locking mechanism. Methods: Twenty-four screws with a diam- was studied. All cases were surgically repaired using biocomposite eter of 3.5mm were inserted into twenty-four locking holes of polyax- fully threaded suture anchors in a double row fashion. Each patient ial plates with identical locking mechanisms. A custom drill guide was evaluated with a physical examination, radiographs, and the was used to insert screws at 0, 5, 10 and 15 degrees relative to following clinical outcome measures: the Quick Disabilities of the the plate. Six holes were tested at each insertion angle. To determine Arm, Shoulder and Hand (QuickDASH) score; the Oxford Elbow strength of the locked screw construct, the screws were loaded a dis- Score (OES); and the Short-Form Health Survey (SF-12). Results: tance of 10mm from the plate with an Instron machine at 5mm/min Nine female patients with Mayo IIA or IIB fractures were identified. until screw failure occurred (Figure 1). Statistical analysis was con- The mean patient age at time of operation was 73.6 6 10.0 years ducted using ANOVA with a Tukey post hoc test with p < 0.05 for (range 59.3 – 88.8 years). The average time from injury to operation significance. Results: There were no significant differences in linear J Shoulder Elbow Surg ASES Abstracts e241 Volume 24, Number 8

Table 1 Fixation strength characteristics of polyaxial plate locking mechanism for 0, 5, 10 and 15 degree insertion angle. 0 degree 5 degrees 10 degrees 15 degrees Linear Stiffness (N/mm) 137.4 6 48.6 165.4 6 64.4 196.3 6 19.1 170.8 6 42.6 Yield Load (N) 94.8 6 45.4 115.5 6 39.7 100.6 6 9.1 87.7 6 15.5 Displacement at Yield Load (mm) 0.9 6 0.6 0.9 6 0.6 0.6 6 0.1 0.6 6 0.1 Ultimate Load (N) 200.8 6 45.9 233.4 6 40.0 199.8 6 22.0 106.0 6 27.1* Displacement at Ultimate Load (mm) 2.1 6 0.7 2.2 6 0.6 1.5 6 0.2 1.3 6 0.5+

*P<0.05 vs. 0,5,10 degrees; +P<0.05 vs. 5 degrees.

distinguish the nerves from the heterotopic bone and 3) precisely measure distances from the respective nerve to the most clinically relevant HO. Materials and Methods: 188 patients who had HO removed from the elbow by one surgeon were reviewed retrospectively. Based on preoperative CT scans, 22 were identified as likely having HO along the pathway of the radial or median nerve. These cases were evaluated by an expert elbow surgeon, two practicing orthopedic surgeons, and an orthopedic surgery resident. Each of the 4 observers was asked to determine, independently and blindly, answers to the following questions concerning the radial and median nerves: (1) Can the location of the nerve be adequately seen on sequential images to permit tracing its path for surgical planning (yes/no)? (2) Can the nerve be distinguished from the HO accu- rately enough to permit measuring its distance from the bone (yes/no)? The observers were allowed to use axial cuts or sagittal reconstructions to make their determinations and measurements. For each of these questions, consensus was defined as agreement among three or four of the observers, including the expert. If 2 or more observers disagreed, the final response was recorded as un- sure. In addition to answering the above 2 qualitative questions, each observer also measured the shortest distance between the radial and median nerve and the HO (example shown below).

Figure 1 Instron testing setup. Results: Overall utility of the CT images for visualizing the nerves was high. The radial and median nerves could be visualized and their stiffness, yield load or displacement at yield load between the inser- paths traced on sequential CT images adequately for preoperative tion angles (P > 0.02) (Table 1). The ultimate load decreased signif- planning purposes in 21/22 (95%) and 22/22 (100%) of the elbows icantly for the 15 degree insertion angle compared to 0, 5 and 10 respectively. In only one case was the location or path of the radial degree insertion angle (P < 0.001), disproving our hypothesis. nerve not well defined. Although both nerves could be traced well Displacement at ultimate load was significantly decreased with 15 on the CT images, the radial nerve was more readily distinguished degree insertion angle compared to 5 degree insertion angle (P ¼ from the HO (21/22 cases, 95%) than the median nerve (17/22 0.03). Conclusion: The fixation strength of polyaxial locking screws cases, 77%). The shortest distance from the radial or median nerve does not decrease until the angulation is greater than 10 degrees. to the HO was significantly more likely to be determined using This decrease is due to the effective locking contact area decreasing sequential axial cuts than using sagittal reconstructions (42/44 versus at higher screw angulations. 28/44 respective measurements from 22 elbows, p ¼ 0.0002). This distance measured on axial slices was also significantly less for the radial nerve (3 6 0.2 mm, range 0 to 9) than for the median nerve 21 THE RELATIONSHIP BETWEEN HETEROTOPIC (9 6 0.7, range 0 to 28) (p < 0.0001). Conclusion: This study dem- OSSIFICATION (HO) AND NERVES OF THE ANTERIOR ELBOW: onstrates the usefulness of CT imaging for determining the spatial rela- A STUDY BASED ON COMPUTED TOMOGRAPHY FINDINGS tionship between the radial and median nerves and the HO. Daniel R. Bachman, MD, Saygin Kamaci, MD, Sutee Thaveepunsan, MD, Sangeun Park, MD, George I. Vasileiadis, MD, PhD, Shawn W. O’Driscoll, PhD, MD, 22 DECREASED LOWER EXTREMITY FUNCTIONAL Department of Orthopaedics, Mayo Clinic, Rochester, MN, USA MOVEMENT SCORES AS A PREDICTOR FOR ELBOW INJURY IN Objective: The purpose of this study was to evaluate the useful- PROFESSIONAL BASEBALL PITCHERS ness of CT imaging for preoperative planning of HO excision, spe- Braden K. Mayer, MD, Ellen Shanley, PhD, PT, OCS, Charles cifically the spatial relationship between the HO and the radial and A. Thigpen, PhD, PT, ATC, Thomas J. Noonan, MD, Steadman median nerves. Our hypotheses were that CT imaging of the elbow Hawkins Clinic – Denver, Greenwood Village, CO, USA; Proaxis can be used to: (1) trace the paths of the radial and median nerves 2) Therapy, Greenville, SC, USA e242 ASES Abstracts J Shoulder Elbow Surg August 2015

Background: The Functional Movement Screen (FMSTM) has ogy Scores (MCMS) and Quality Appraisal Tool (QAT) scores. To been used as a screening instrument to help predict injuries in ath- quantify the structured review of observational data, meta-ana- letes. The purpose of this study was to correlate stance limb and lytic statistical methods were utilized. Results: Sixty-four studies stride limb lower extremity functional movement screening scores (38 BC, 26 LD) met inclusion criteria. A total of 3668 shoulders with elbow injuries in professional baseball pitchers. Methods: were included, with 2211 (average age 26.763.8 years, Select lower extremity FMS tests were performed on 88 asymptom- 84.5% male) in the BC position and 1457 (average age atic professional baseball pitchers (mean age 23.6 +/- 2.5 years) 26.063.0, 82.7% male) in the LD position. The average follow- over 2 spring trainings (2012-2013). Three component tests (Hurdle up was 49.8629.5 months in the BC group compared to Step (HS), In-line Lunge (ILL), and Active Straight Leg Raise (ASLR)) 38.7623.3 months in the LD group. Average overall recurrent were selected based on their ability to detect asymmetrical differ- instability rates were 14.668.4% in the BC group (range, 0 to ences in LE function between the stance and stride limb. Pitchers 38%) compared to 8.567.1% in the LD group (range, 0 to were classified into two groups based on their scores where normal 30%, P¼0.002). Using a mixed-regression model and converting movement (score ¼ 3) versus a compensatory movement pattern the data using the average follow-up duration to turn the result into (score # 2). Prospective injuries were tracked over the two subse- a ‘‘rate of incidence per 100 person-years,’’ the average recur- quent baseball seasons recording any overuse elbow injury sus- rence rate for the BC was 3.60 (95% CI: 2.88, 4.51) while that tained during club sponsored activities. Chi square and relative for the LD position was 2.30 (95% CI: 1.76, 3.00, P¼0.0122) risk analysis was performed to compare elbow injury rates between (Figure 1). The average postoperative loss in external rotation mo- the two groups (a< 0.05). Results: A total of 16 time-loss elbow in- tion (in abduction) was reported in 19 studies in the BC group and juries were recorded during the study period. Pitchers demonstrating 13 studies in the LD group, with an average loss of 2.461.0 de- compensatory movement patterns while performing the HS test on grees and 3.662.6 degrees in each group, respectively their stride limb presented with a greater frequency of elbow injury (P>0.05). The average MCMS score of all 64 studies was than pitchers completing the movement without compensatory pat- 44.1612.9 (maximum score 77) and the average QAT score terns. (24.5 vs 8.6%; p¼0.05). These pitchers demonstrated a was 13.764.5 (maximum score 22). There were no significant 2.9 times increased risk for developing overuse elbow injuries as differences between the BC and LD studies with regard to compared with those demonstrating normal movement patterns. A MCMS score (BC 43.3614.6, LD 44.8611.0, P¼0.656). similar relationship was found during ILL and ASLR testing. Pitchers Conclusions: Excellent clinical outcomes with low recurrence rates demonstrating compensatory patterns on the stance limb during ILL can be obtained following arthroscopic anterior shoulder stabili- and ASLR had increased frequencies of elbow injury as compared zation in either the BC or the LD positions, however lower recur- to pitchers with normal movement patterns (34.5 vs10.3%; renceratesarenotedintheLDposition.Additional,long-term, p ¼ 0.006 and 31.3 vs 10.7%; p ¼ 0.02). Pitchers with a score randomized clinical trials comparing these positions are needed # 2 on the ILL and ASLR test on the stance limb showed a 3.3 times to better understand the potential advantages and disadvantages and 2.9 times increased risk of injury, respectively. Conclusion: Our of each position. Level of Evidence: IV, Systematic Review of data suggests that professional baseball pitchers with scores indica- studies with Level I through IV Evidence tive of decreased stride limb flexibility (HS test) or decreased stability in their stance limb (ILL and ASLR test) are at significantly increased risk of overuse elbow injuries.

23 OUTCOMES OF ARTHROSCOPIC ANTERIOR SHOULDER INSTABILITY IN THE BEACH CHAIR VS. THE LATERAL DECUBITUS POSITION: A SYSTEMATIC REVIEW AND META- REGRESSION ANALYSIS Rachel M. Frank, MD, Maristella F. Saccomanno, MD, Lucas S. McDonald, MD, Mario Moric, MS, Anthony A. Romeo, MD, Matthew T. Provencher, MD, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA; Department of Orthopedics, Catholic University, Rome, Italy; Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA; Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA Introduction: Arthroscopic anterior shoulder stabilization can be performed in either the beach chair (BC) position or the lateral decubitus (LD) position, however the potential effect of patient positioning and its relationship to clinical outcomes has not yet been evaluated. The purpose of this study was to systematically review the clinical outcomes and recurrence rates following arthroscopic anterior shoulder stabilization in the BC and LD positions. The authors hypothesized that clinical outcomes and recurrent instability rates would be similar regardless of the choice of patient positioning. Methods: The authors performed a systematic review of multiple medical databases using PRISMA guidelines. All English-language literature from 1990 to 2013 reporting clinical outcomes following arthroscopic anterior shoulder stabilization with suture anchors or tacks with a minimum two-year follow-up period were reviewed by two independent reviewers. Data on recurrent instability rate, return to activity/sport, range of motion, and subjective outcomes measures was collected. Study method- ological quality was evaluated with Modiﬁed Coleman Methodol- J Shoulder Elbow Surg ASES Abstracts e243 Volume 24, Number 8

24 GLENOID MORPHOLOGY AFTER ARTHROSCOPIC loss can expect successful outcome without recurrence once bony OSSEOUS BANKART REPAIR FOR CHRONIC TRAUMATIC union is obtained. Glenoid morphology can be normalized during ANTERIOR GLENOHUMERAL INSTABILITY: A 5 TO 8 YEAR mid to long term postoperative period. FOLLOW-UP Hiroyuki Sugaya, MD, Soichiro Kitayama, MD, Norimasa Takahashi, MD, Nobuaki Kawai, MD, 25 EMG ANALYSIS OF ROTATOR CUFF FUNCTION Kazutomo Onishi, MD, Yusuke Ueda, MD, Shoulder & Elbow DURING DRIVING Center, Funabashi Orthopaedic Hospital, Funabashi, Japan Sameer H. Nagda, MD, Megan C. Paulus, MD, Introduction: An osseous Bankart lesion, which retains an Lauren Bierman, BS, Kevin Fitzpatrick, MD, Brent B. Wiesel, MD, osseous fragment inside the Bankart lesion, is frequently observed Georgetown University School of Medicine, Washington, DC, in shoulders with chronic traumatic anterior glenohumeral insta- USA; Inova Fairfax Hospital, Fairfax, VA, USA; Anderson bility. In addition, glenoid bone loss in shoulders with osseous Bank- Orthopaedic Clinic, Arlington, VA, USA art lesion is more significant than those without a bony fragment. In Introduction: A common concern of patients after rotator cuff the meantime, arthroscopic osseous Bankart repair has been intro- repair (RCR) is when they can drive. To date, no study has evaluated duced and reported as less invasive and effective procedure with the function of the rotator cuff during driving. Knowledge of this may promising short term outcome even in shoulders with significant gle- help guide recommendations regarding if and when a patient noid bone loss. However, due to the lack of mid to long term should drive after RCR. The purpose of this study was to evaluate outcome report, not a few surgeons are still skeptical about the ben- the activation of the supraspinatus, infraspinatus, and biceps while efits of this surgery. The purpose of this study is to report mid to long driving. Methods: A computerized driving simulator, (Drivesquare, term clinical outcome and glenoid morphologic change after arthro- Alexandria, VA) was used in a standard 4-door sedan, after IRB scopic osseous Bankart repair in patients with significant glenoid approval. Sixteen healthy volunteers, eight males and eight females bone loss. Methods: A consecutive series of 85 patients with chronic ages 24 to 29, performed a series of driving maneuvers while mus- traumatic anterior glenohumeral instability associated with osseous cle activity of the supraspinatus, infraspinatus, and biceps was re- Bankart lesion underwent arthroscopic osseous Bankart repair dur- corded and interpreted by a board-certified electromyographer ing January 2005 through December 2006. In all shoulders, a dis- using needle EMG. Muscle activity was recorded while closing the placed osseous fragment together with adjacent labroligamentous door, fastening the seatbelt, and turning a key in the ignition. During complex was separated and reattached using suture anchors, the driving portion, muscle activity was recorded while making a se- providing adequate tension to the entire inferior glenohumeral liga- ries of right and left turns. First, the hands were placed in the 9 and 3 ment, by a single surgeon. Glenoid bone loss was measured using o’clock positions. Next the left hand was placed in the 12 o’clock en face view of 3DCTand defect rate was calculated as percentage position with the right hand in the 6 o’clock position. Then the right loss of the diameter in the assumed inferior circle, which was the hand was placed in the 12 o’clock position and the left hand in the 6 method described in literatures. Forty-six patients with more than o’clock position. All maneuvers and positions were performed sepa- 15% glenoid defect were selected as a candidate and 35 patients rately for each muscle tested. EMG activity was graded as 0-4, with (76%), including 32 males and 3 females with an average age of 0 being no contraction and 4 being full EMG interference pattern. 24.0 years (range, 15 - 34) at the time of surgery, were followed Each turn was repeated 5 times and the average EMG activity for 6.2 years (range, 5.0 - 8.1) after surgery on average. During was calculated. Statistical comparisons were made using the one- the final follow-up, each patient underwent clinical and radio- sample Wilcoxon-Mann-Whitney test applied to within-subject dif- graphic examinations with X-rays and 3DCT. Clinical outcome ferences in EMG activity. Results: For the right supraspinatus, infra- was assessed using Rowe and Western Ontario Shoulder Instability spinatus, and biceps muscles, EMG analysis demonstrated a (WOSI) scoring systems. Results: One patient suffered re-dislocation statistically higher level of activation when the right hand was in by a traffic accident 5 months after surgery before obtaining bony the 12 o’clock position and the 3 o’clock position as compared union. Otherwise none of the patients experienced re-dislocation with the 6 o’clock positions. This was the same for the left side as or subluxation after surgery. The mean postoperative Rowe score high levels of activation were noted with the left hand in the 12 and WOSI significantly improved from 31.2 to 97.8 and from o’clock and 9 o’clock positions compared to the 6 o’clock positions 42.7 to 91.7%, respectively. Regarding radiographic examination, [Table 1]. Activity of all muscles was minimal when the car door was none of the patients demonstrated osteoarthritic change in plain-X- closed with the opposite hand (0.6-1.63). Fastening the seatbelt re- rays and bony union was confirmed with 3DCT images in all shoul- sulted in high activity in all the muscles bilaterally (2.7-3.1). Placing ders. The mean postoperative glenoid bone loss, calculated using en the key in the ignition to start the car mildly activated the right supra- face view of 3DCT, was improved from preoperative 20.6% (range, spinatus (2.1) and infraspinatus (2.4) with slightly higher activity in 15.1 to 29.7) to postoperative -1.1% (range, -10.9 to 6.0) the biceps muscle (2.8). Conclusions: Statistically higher levels of ac- (p<0.0001) on average (Table 1, Fig. 2). Conclusion: Arthroscopic tivity in the supraspinatus, infraspinatus, and biceps were noted with osseous Bankart repair for shoulders with significant glenoid bone the hands in the 12 o’clock, 9 o’clock, and 3 o’clock positions. This

Table 1 Muscle activation during driving HAND POSITIONS 12 o’clock (left) & 6 o’clock 12 o’clock (right) & 6 o’clock 9 o’clock & 3 o’clock (right) (left) RIGHT TURN LEFT TURN RIGHT TURN LEFT TURN RIGHT TURN LEFT TURN R SUPRASPINATUS 2.79 2.77 0.76* 1.00* 2.95 2.99 R INFRASPINATUS 2.73 2.92 0.65* 0.70* 3.13 3.1 R BICEPS 2.46 2.81 1.15* 1.24* 3.23 3.18 L SUPRASPINATUS 2.92 2.75 3.15 3.00 0.90* 0.64* L INFRASPINATUS 2.92 2.96 3.27 3.14 0.88* 0.97* L BICEPS 2.94 2.8 2.91 3.01 1.10* 1.19*

*Statistical signiﬁcance noted for all comparisons (p<0.003) e244 ASES Abstracts J Shoulder Elbow Surg August 2015

level of activation can compromise the integrity of a RCR. This activ- performed in the beach-chair position. We believe this approach ity was minimized on each side by placing the hand at the 6 o’clock minimizes adverse effects from anesthesia, provides excellent post- position. Based on the results, the following recommendations can operative pain control, and allows safe and efficient patient posi- minimize activation of the rotator cuff during driving: 1) Close the tioning while the patient is awake. The three cases of emergent door and fasten seatbelt using the non-operative arm. 2) Drive airway compromise due to rapid spread of subcutaneous arthro- with the non-operative arm in the 12 o’clock position with the oper- scopic irrigation fluid underscore the need for vigilance and commu- ative arm supinated and at the side while holding the steering wheel nication with the surgeon. CNS injury has been very rare, with no at the 6 o’clock position. Further evaluation will focus on the safety of acute injury to suggest intra-operative hypoperfusion, whereas driving in this position. commonly cited frequency of perioperative stroke in the general surgical population is approximately 0.5%4. The majority of our cases are performed under regional anesthesia with preserved sponta- 26 SAFETY OF SHOULDER SURGERY IN THE BEACH-CHAIR neous ventilation. We set routine treatment thresholds for hypoten- POSITION UNDER INTERSCALENE NERVE BLOCK WITH sion at SBP < 90 mmHg or MAP < 60 mmHg, and for SPONTANEOUS RESPIRATION: A SINGLE CENTER SERIES bradycardia < 40 BPM. In settings where general anesthesia and Mark W. Rodosky, MD, Brian A. Williams, MD, positive pressure ventilation are used, the combination of upright po- Michael Kentor, MD, Steven Orebaugh, MD, University of sition, volatile anesthetic induced vasodilatation and cardiosuppres- Pittsburgh, Pittsburgh, PA, USA sion, and increased intrathoracic pressure could lead to decreased Introduction: 3 The beach-chair position offers many surgical and cerebral blood flow and more CNS morbidity than in this series . anesthetic advantages for shoulder procedures1. Pohl reported several cases of devastating neurologic injury linked to anesthesia References in the seated position for shoulder surgery under general anesthesia 2 with positive pressure ventilation in otherwise healthy patients . 1. Arthroscopy. 2009;25(8):891-896. These and other provided little perspective about the overall fre- 2. J Clin Anesth. 2005;17(6):463-469. quency of such events. For beach-chair shoulder procedures, our 3. J Trauma. 2005;58(3):571-576. routine approach is preoperative interscalene block, followed by 4. Barash. Clinical Anesthesia. 6th ed. 2009:886. intravenous (IV) sedation with propofol, oxygen by facemask, and spontaneous respiration. Here we present our experience encom- passing 17471 cases over 12.5 years. Methods: The total number 27 ESTABLISHING A MOUSE MODEL TO EVALUATE of shoulder surgeries performed in beach-chair position was ex- MESENCHYMAL STEM CELLS AS A POTENTIAL PREOPERATIVE tracted from our de-identified billing records, and compared to the ADJUVANT IN THE MANAGEMENT OF MASSIVE ROTATOR complication rate from our existing quality improvement (QI) data- CUFF TEARS base over the same period. From April 2001 to December 2013 Adam Z. Khan, BS, Tomasz J. Kowalski, MD, PhD, Cameron we documented 17,471 cases of shoulder surgery in the beach- A. Garagozlo, Claire D. Eliasberg, BS, Owen J. McBride, BS, Peter chair position. Adverse events are shown in the table. Confidence I. Cha, BA, Kyle M. Natsuhara, BS, Kunal Sukhija, MD, Frank intervals were calculated using the adjusted Wald method. Results A. Petrigliano, MD, Department of Orthopaedic Surgery, David -Table 1: Serious Complications Occurring During Shoulder Sur- Geffen School of Medicine at UCLA, Los Angeles, CA, USA gery in the Beach-Chair Position. Discussion: This is the largest re- Background: Following a massive rotator cuff tear, fatty-fibrous ported series of anesthetic outcomes for shoulder procedures degeneration and atrophy decreases compliance of the

Table 1 Serious Complications Occurring During Shoulder Surgery in Beach-Chair Position Among 17,471 Cases Adverse Event Type n Comments Frequency % 95% CI of % incidence Emergent intubating during case 7 3 due to soft tissue swelling, 3 lreated 0.04 0.02-0.08 to laryngospasm and one to Hypoxemia Respiratory distress treated without 3 2 due to bronchoaspasm, 1 due to 0.02 <0.001-0.05 intubation laryngospasm Apnea during block performance 1 Due to excessive sedation 0.01 <0.001-0.04 Seizure due to local anesthetic 9 0.05 0.03-0.10 systemic toxicity Persistent phrenic nerve injury 1 0.01 <0.001-0.04 Minor but persistent nerve injury (>6 8 Sensory loss only 0.05 0.02-0.09 months) CNS injury or stroke within 24 hours 1 Focal middle cerebral artery ischemic 0.01 <0.001-0.04 stroke Cognitive dysfunction in context of 3 Gradual return to baseline 0.02 <0.001-0.05 dementia or persistent sedation Persistent headaches or tinnitus 2 0.01 <0.001-0.04 Cardiac arrest 0 0 <0.001-0.02 Myocardial Infarction within 48 hours 1 0.01 <0.001-0.04 Dysrhythmia with hypotension 7 1 atrial ﬁbrillation, 1 brief VT, 0.04 0.02-0.08 1 bigeminy, 4 causeing delay or vasopressor infusion Other drug reaction 1 0.01 <.0001-0.04 Other unexpected admission or visit to ED 10 8 dyspnea or hypoxia, 1 PE, 0.06 0.03-0.11 1 refractory PONV Chronic regional pain syndrome 2 Pain, tingling, numbness c/w CRPS 0.01 <0.001-0.04 Total Adverse Events 56 Of 17471 total beach-chair shoulder 0.32 0.2-0.4 cases

VT: ventricular tachycardia; ED: emergency department; PE: pulmonary embolism; PONV: postoperative nausea and vomiting. J Shoulder Elbow Surg ASES Abstracts e245 Volume 24, Number 8

musculotendinous unit, complicating surgical repair. While repair may prevent degenerative progression, this preoperative change is often irreversible, and effective regenerative ap- proaches have yet to be identified. Mesenchymal stem cells (MSCs) are the leading proposed regenerative agent1.Twoperi- vascular progenitor cell lineages for MSCs have been identified, pericytes and adventitial cells; both have demonstrated the ability to diminish fibrotic changes, regenerate muscle, and recover functional deficits following cardiac and skeletal muscle injury.1,2,3 Degenerative change following murine rotator cuff injury has been studied4,5;however,thetimecourseofrotator cuff muscle atrophy, proposed ideal time points for therapeutic agent administration, and viability of stem cells following injection have yet to be investigated. Prior investigation of adipose derived stem cell therapy utilized adipose stromal fractions; however, these fractions demonstrate significant cell heterogeneity6. Purpose: This study investigates the regenerative potential of two human adipose derived progenitor cell lineages, following murine rotator cuff injury, by identifying the ideal time point for therapeutic intervention, through characterization of progressive post injury muscle degeneration, and assessing the viability of purified adipose derived pericyte and adventitial progenitor cells after injection into mouse supraspinatus muscle. Furthermore, the study utilizes Fluorescence Activated Cell Sorting (FACS) to isolate MSC subsets and culture purified pericyte and adventitial cells for injection therapy. Methods: Three groups of 15 adult wild- type mice (BALB/cAnNCrl) underwent complete transection of Figure 2 Comparison of CD29 and DAPI stained cell populations at 24 hours in control (top), pericyte injected (bottom left), and adven- the supraspinatus tendon (TN), suprascapular nerve denervation + (DN), or both procedures (TN+DN); three groups of three mice un- titial injected (bottom right) tissue. Significantly more CD29 , DAPI derwent sham surgery (control). Five mice per group were eutha- cells are observed following cell injections compared with control. nized at 2, 6, and 10 weeks; at which time the supraspinatus tendon was extracted and weighed. Histologic and immunohisto- chemical (IHC) analysis evaluated fat infiltration (Oil Red O), observed at 6 weeks following massive rotator cuff tear, a viable fibrosis (Trichrome stain), inflammatory infiltrate (CD45, CD68), time point for therapy injection. Initial cell survival statistics demon- and angiogenesis (a-SMA). Two groups of two NOD/SCID mice strate the robustness of these two cell lines following injection into received supraspinatus injection of 3 x105 pericyte or adventitial the supraspinatus, establishing a model for studying the longevity cells. These cell lines were isolated from human adipose tissue of these cell lines and performing histologic and IHC analysis of the via FACS. Injected cell survival was assessed at 24 hours via regenerative effects of these two adipose derived progenitor cell FACS of human specific CD29. Results: Compared with sham, lines. Both pericytes and adventitial cells have demonstrated signif- there is significant muscle weight loss observed in all groups at icant therapeutic effects in muscle repair—displaying tremendous all time points (p < 0.01); maximal muscle weight loss is achieved potential as a viable translational therapy—improving the cellular, at 6 weeks in the DN and TN+DN groups (Figure 1). Progressive structural, and functional deficits that complicate current perioper- increases in fat infiltration, inflammatory infiltrate, angiogenesis, ative management of massive rotator cuff tears. and intermuscular fibrosis are observed at each post-operative time point in all three groups on H&E staining, and confirmed by References IHC analysis. Following FACS analysis (Figure 2), average cell survival percentage was 7.91% for pericytes, and 5.42% for adven- 1. Crisan M, Corselli M, Chen WC, Peault B. Perivascular cells for titial cells. Conclusion: Significant muscle degeneration is regenerative medicine. J Cell Mol Med. 2012 Dec;16(12):2851- 60. doi: 10.1111/j.1582-4934.2012.01617.x. 2. Dellavalle A, Maroli G, Covarello D, Azzoni E, Innocenzi A, Perani L, Antonini S, Sambasivan R, Brunelli S, Tajbakhsh S, Cossu G. Peri- cytes resident in postnatal skeletal muscle differentiate into muscle fi- bres and generate satellite cells. Nat Commun. 2011 Oct 11;2:499. doi: 10.1038/ncomms1508. 3. Chen CW, Okada M, Proto JD, Gao X, Sekiya N, Beckman SA, Corselli M, Crisan M, Saparov A, Tobita K, Peault B, Huard J. Human pericytes for ischemic heart repair. Stem Cells. 2013 Feb;31(2):305- 16. doi: 10.1002/stem.1285. 4. Liu X, Laron D, Natsuhara K, Manzano G, Kim HT, Feeley BT. A mouse model of massive rotator cuff tears. J Bone Joint Surg Am. 2012 Apr 4;94(7):e41. doi: 10.2106/JBJS.K.00620. 5. Kim HM, Galatz LM, Lim C, Havlioglu N, Thomopoulos S. The effect of tear size and nerve injury on rotator cuff muscle fatty degeneration in a rodent animal model. J Shoulder Elbow Surg. 2012 Jul;21(7):847- 58. doi: 10.1016/j.jse.2011.05.004. 6. Rajashekhar G, Traktuev DO, Roell WC, et al. IFATS collection: Ad- ipose stromal cell differentiation is reduced by endothelial cell contact and paracrine communication: role of canonical Wnt signaling. Stem Cells. Oct 2008;26(10):2674-2681. e246 ASES Abstracts J Shoulder Elbow Surg August 2015

28 CLINICAL OUTCOMES AND INTRA-ARTICULAR higher in patients with recurrent dislocation. In group 1, ASES (pre- FINDINGS OF FIRST-TIME SHOULDER DISLOCATIONS AFTER operative 68.9617.0 to postoperative 93.566.9) and Rowe score ARTHROSCOPIC STABILIZATION PROCEDURE: A (62.7613.3 to 90.869.3) were significantly improved. ASES COMPARATIVE STUDY WITH RECURRENT SHOULDER (61.8615.5 to 90.1614.4) and Rowe score (58.6615.1 to DISLOCATIONS 85.4617.2) also improved in group 2. No statistical difference Sang-Jin Shin, MD, Myeong Jae Seo, MD, Nandan N. Rao, MD, was found between two groups in terms of shoulder functional out- Department of Orthopaedic Surgery, Ewha Womans University, comes (p¼0.675 and p¼0.132, respectively). Redislocation Mokdong Hospital, Seoul, South Korea occurred in 1 patient in group 1 and 6 in group 2 (p¼0.427). Pa- Introduction: Optimal treatment for the first-time shoulder disloca- tient’s satisfaction of life after operation were significantly higher tion is still debated despite high rates of recurrent shoulder disloca- in patients who underwent surgery after first-time dislocation tion rate in young patients. This study compared clinical outcomes of (90.065.2 vs. recurrent dislocation 82.767.2, p¼0.01). arthroscopic stabilization procedure between patients with first-time Discussion: Incidence of anterior glenoid erosion and ALPSA lesion traumatic anterior dislocation and patients with recurrent shoulder which are related to redislocation after stabilization procedures dislocation. We also compared the intra-articular findings on were lower and patient’s satisfaction was higher in patients who un- arthroscopy between the two groups of patients younger than 30 derwent arthroscopic stabilization procedure after first-time disloca- years old. Methodology: Thirty-three patients (group 1) (males¼29, tion. ALPSA lesion is known to be related to recurrent dislocation and females¼4, mean age¼26.164.5 years) who underwent arthro- recurrence of instability was almost twice as much than in patients scopic Bankart repair after first-time traumatic anterior shoulder who had only classic Bankart lesion. According to literature, contrib- dislocation and 89 patients (group 2) (males¼83, females¼5, uting factors related to recurrences after arthroscopic Bankart repair mean age¼25.863.2 years) who were treated arthroscopically for recurrent shoulder dislocation patients were glenoid bone loss, for recurrent shoulder dislocation were included. Common inclusion large Hill-Sachs lesion, stretched glenohumeral ligament and num- criteria were age less than 30 years, no general ligamentous laxity ber of suture anchors. Especially more than 25% of the anterior gle- and no previous history of surgery. Inclusion criteria for group 1 noid bone loss showed 75% recurrence rate. In our study, were patients with a radiograph of shoulder dislocation and Bankart postoperative shoulder functional outcomes between patients with lesion in MRA. Patients in group 2 had more than 2 dislocations and first time dislocation and patients with recurrent dislocation showed a positive apprehension test. Preoperative demography, arthro- no statistically significant difference. However, level of satisfaction scopic findings, clinical outcomes using VAS score for pain and pa- regarding quality of life after operation in first time dislocation patient’s satisfaction of life, Rowe and ASES score were compared tients was significantly higher. Patients who have experienced mul- between two groups. Results: The mean duration of follow up was tiple shoulder dislocation before surgery may be apprehensive in 32.663.8 months in group 1 and 34.266.9 months in group 2. abduction and external rotation movement in daily life and higher The patients in group 1 were operated at a mean duration of percentage of them do not participate in active sports due to anxiety 5.564.7 weeks after the index dislocation and those in group 2 of dislocation. This contributed to decline in level of satisfaction in at 49.3638.5 weeks after the index dislocation. Intraoperative life despite satisfactory clinical outcomes. Primary arthroscopic sta- arthroscopy demonstrated no statistical difference between two bilization could be considered as a treatment option in young active groups except anterior glenoid erosion (none in group I and 10 pa- patients with first-time traumatic anterior shoulder dislocation to pre- tients in group 2, p¼0.043), and ALPSA lesion (4 patients in group 1 vent further intra-articular injuries which might contribute to recur- and 26 patients in group 2, p¼ 0.048), which were significantly rences.