2008 American Shoulder and Elbow Surgeons Open Meeting

2008 AMERICAN SHOULDER AND ELBOW SURGEONS OPEN MEETING

1 TREATMENT OF TRAUMATIC POSTERIOR 6; and malunion, 1. Visual analog pain score, Simple Shoulder STERNOCLAVICULAR DISLOCATION Test (SST), and American Shoulder and Elbow Surgeons (ASES) Michael A. Wirth, MD, David Groh, MD, Charles A. Rockwood scores were obtained. Revision surgery included conversion to Jr., MD, University of Texas Health Science Center, San Antonio, TX hemiarthroplasty, 6; revision ORIF, 2; and conversion to reverse Background: Traumatic posterior sternoclavicular joint injuries shoulder arthroplasty, 2. Results: Average pain values decreased are rare. However, complications associated with this entity are from 8.2 to 3.1. Average range of motion improved from 45.5 common and include brachial plexus compression, pneumothorax, to 100.1 forward elevation, 10 to 30.3 external rotation, and vascular compromise, esophageal rupture, and death. Although from L2 to T10 in internal rotation. Average SST scores improved many of these complications are observed at the time of injury, from 4.2 to 8.1, and ASES scores improved from 48.3 to 75.4. In- late appearing complications have also been noted with unreduced traoperative findings included locking screw pullout, articular sur- retrosternal injuries and highlight the importance of decompressing face penetration, glenoid screw penetration, glenohumeral the hilar structures by closed or open reduction techniques. arthrosis, and plate displacement. There was no evidence of infec- Methods: Between 1976 and 2005, 34 patients with a traumatic tion in any case. Conclusions: Despite successful outcomes with posterior sternoclavicular joint injury were treated at our institution. PHLP, complications do arise. Careful preoperative planning and Eight of these were displaced physeal fractures of the medial clav- technical application are important to good outcomes. Recognition icle and were excluded. Of the remaining 26 patients, 1 died and of failed reduction and fixation remains critical. Patient selection 4 were lost to follow-up, leaving 21 posterior sternoclavicular dislo- and bone quality may play a role in failure. Revision surgery re- cations for long-term follow-up (average, 5 years). Signs and symp- mains difficult with variable results. toms included dysphagia, ipsilateral extremity cyanosis and swelling, paresthesia, dyspnea, and shortness of breath. Associ- ated injuries included pulmonary and cardiac contusion, pneumothorax, subclavian artery and vein injury, and associated fractures. All patients underwent initial closed reduction, which was successful in 8 patients. The remaining 13 patients were 3 THE IMPORTANCE OF CENTERING OF THE HUMERAL treated with open reduction and sternoclavicular joint reconstruc- HEAD IN ACUTE FRACTURE ARTHROPLASTY RELATED TO THE tion. Results: Patients were evaluated with respect to pain, function, HEALING OF THE GREATER TUBEROSITY range of motion, strength, and patient satisfaction, according to Peter Habermeyer, MD, Sven Roessing, MD, Petra Magosch, MD, a modification of the University of California at Los Angeles Rating Sven Lichtenberg, MD, ATOS Clinic, Heidelberg, Germany Scale. Overall, 18 of the 21 patients were graded as good or ex- Aim: The aim of the study was to evaluate the centering of the cellent. Patients treated with either closed or open reduction com- prosthetic humeral head into the glenoid in dependence on the heal- pared favorably in terms of improvement in ratings for pain, ing of the greater tuberosity and to clarify its influence on the func- strength, motion, and the ability to perform work and sports. Con- tional outcome of shoulder arthroplasty for acute fractures. clusion: Our experience suggests that successful closed reduction Methods: Thirty patients of a prospective multicentric study, having compares favorably with open reduction. Moreover, once the joint received a primary humeral head replacement due to a 4-part frac- has been reduced closed, it is usually stable. In the present series, ture at a mean age of 72 years, were followed up after exactly 1 early recognition of injury, followed by closed reduction and figure- year by an independent observer with a clinical and standardized of-eight immobilization, was highly successful and obviated the radiographic examination in 3 planes and the gender- and age-re- risks of operation. Patients in whom closed reduction failed ob- lated Constant Score documenting the functional outcome. Results: tained good results with operative treatment aimed at reconstruc- The postoperative radiograph control revealed a centered pros- tion of the costoclavicular ligaments. thetic humeral head in 52%, an inferior position of the prosthetic humeral head in 23%, and the humeral head was positioned too high in 26%. After 1 year, only 36% of the patients showed a centered prosthetic humeral head, 61% showed an upward migration, and the prosthetic head was positioned too low in 4%. One year postoperatively, the mean relative Constant Score was 65% (range, 10%- 2 COMPLICATIONS OF PROXIMAL HUMERAL LOCKED 99%). An anatomic healing of the greater tuberosity was observed PLATING in 47% of the cases. Resorption of the greater tuberosity was partial Anand M. Murthi, MD, Bryan Butler, MD, University of Maryland in 29% and complete in 20%. In 6% of the cases, a slight malposi- School of Medicine, Baltimore, MD tion of the greater tuberosity was observed. In patients with a cen- Introduction: Despite the global increase in proximal humerus tered prosthetic head, a mean head-tuberosity distance (HTD) of locked plating (PHLP) systems, significant complications with their 9 mm was observed, and patients with an upward migrated pros- use have been experienced. Methods: Between 2003 and 2005, thetic head had a mean HTD of 13 mm. Patients with a centered 10 patients (10 shoulders) treated with open reduction internal fix- prosthetic humeral head received a significantly (P ¼ .002) higher ation (ORIF) using a PHLP presented to our service with complica- Constant Score (85%) than patients presenting with an upward mi- tions related to the PHLP. There were 6 women and 4 men with grated prosthetic head (Constant Score, 54%). Patients with an an- an average age of 52.4 years. The average follow-up was 26 atomic healing of the greater tuberosity achieved a Constant Score months (range, 24-36 months). Preoperative and postoperative of 75%, whereas patients with a partially or totally resorption of the pain scores and range of motion were evaluated. All 10 patients greater tuberosity achieved a Constant Score of 58%. Conclusion: had an initial diagnosis of displaced 2- or 3-part proximal humeral The centering of the prosthetic humeral head into the glenoid is fractures. Diagnosis at presentation included PHLP hardware fail- strongly related to the postoperative functional result. We observed ure, 8; avascular necrosis, 8; posttraumatic arthritis, 2; nonunion, a progression of upward migration of the prosthetic head. In

e1 e2 ASES Abstracts J Shoulder Elbow Surg

contrast to the literature, we found a slight correlation between the ing on the effects of nanofiber organization on the response of cells centering of the prosthetic humeral head and the radiologic healing derived from human rotator cuff tendon. Specifically, cell attach- of the greater tuberosity. The centering of the prosthetic humeral ment, alignment, and matrix elaboration on both aligned and un- head and the Constant Score depends on the HTD. aligned poly(lactide-co-glycolide; PLGA) nanofiber scaffolds will be evaluated, and the effect of in vitro cell culture on matrix mechanical properties will be measured. It is hypothesized that cell attachment, alignment, and matrix elaboration will be regulated by fiber 4 NANOFIBER-BASED SCAFFOLD FOR ROTATOR CUFF organization. Methods: Scaffold fabrication: Aligned and un- REPAIR AND AUGMENTATION aligned nanofiber scaffolds composed of PLGA 85:15 (Lakeshore) Helen H. Lu, PhD, Kristen L. Moffat, MS, Jeffrey P. Spalazzi, MS, were produced by the electrospinning process.8 Briefly, a 35 vol% Stephen B. Doty, PhD, William N. Levine, MD, Columbia University, solution of PLGA in DMF (Sigma) and ethanol was electrospun at New York, NY 1.0 mL/h and 8-10 kV. A rotating collecting target was used to Introduction: Rotator cuff repair is one of the most commonly perform aligned fiber mesh. Cells and cell culture on nanofiber mesh: formed shoulder procedures in the United States,1 and the treatment Human rotator cuff fibroblasts were derived from explant cultures es- of rotator cuff tears and chronic degeneration represents significant tablished after rotator cuff surgery. Cultures were grown in DMEM clinical challenges. Augmentation of rotator cuff repair or substitu- +10% serum, 1% NEAA, 1% antibiotics. Scaffolds were sterilized tion with biologic or synthetic grafts has not resulted in substantial by ultraviolet irradiation for 30 minutes. Cells were seeded (3 improvement over traditional repair techniques.2 Consequently, al- 104 cells/cm2) on the aligned or unaligned scaffolds for 1, 7, and ternative grafts for improving rotator cuff repair are needed.2-4 14 days. Acellular scaffolds and monolayer culture served as con- The ideal graft for rotator cuff repair and augmentation must be trol groups. End point analyses: Structural properties of the as-fabri- biodegradable and biomimetic with physiologic mechanical prop- cated scaffolds were measured (Table I). Viability and cell erties. Nanofiber scaffolds are advantageous for tissue engineer- morphology were examined using confocal microscopy (n ¼ 3) ing,5-7 because fiber diameter mimics that of native collagen. and scanning electron microscopy (SEM, n ¼ 3). Cell and fiber Moreover, mechanical properties can be controlled by selectively in- alignment were analyzed using custom software for circular statisti- troducing structural anisotropy in scaffold design to emulate the cal analysis.9,10 Results are expressed as mean angle, mean vector nanostructure organization of soft tissues. This study evaluates the length, and angular deviation. Production of collagen types I and III potential of nanofiber-based scaffolds for rotator cuff repair, focus- was visualized using immunohistochemistry (n ¼ 3). Sample

Table I Structural properties of scaffolds

Fiber diameter (nm) Average pore diameter (mm) Porosity (%) Permeability (m4/N$s)

Aligned 615 6 152 4.2 6 1.2 80.7 6 2.9 (7.87 6 2.47) E-12 Unaligned 568 6 147 4.91 6 0.8 81.7 6 3.9 (5.72 6 0.63) E-12

Figure 1 Cell response on nanofiber scaffolds. Left, Cell distribution at day 14 (original magnification 1000; bar ¼ 50 mm). Middle, Cell viability (green) and distribution at day 14 (original magnification 20; bar ¼ 100 mm). Right, Type 1 collagen deposition at day 7 (original magnification 20; bar ¼ 100 mm). J Shoulder Elbow Surg ASES Abstracts e3

scaffolds for rotator cuff repair. References: (1) AAOS, 2003; (2) Dejardin et al, 2001; (3) Thomopoulos et al, 2002; (4) Funakoshi et al, 2006; (5) Iannotti et al, 2006; (6) Li et al, 2002; (7) Smith, Ma, 2004; (8) Lee et al, 2005; (9) Reneker, Chun, 1996; (10) Costa et al, 2003; (11) Itoi et al, 1995.

5 IN-VITRO AND IN-VIVO TESTING OF A TISSUE ENGINEERED ‘‘OFF-THE-SHELF’’ SCAFFOLD TO ENHANCE ROTATOR CUFF TENDON HEALING Andrew J. Leo, MD, Joshua S. Dines, MD, Pasquale Razzano, MS, David M. Dines, MD, Daniel Grande, PhD, Long Island Jewish Med- ical Center, Bayside, NY Purpose: Improved rates of healing after rotator cuff tears would result in improved clinical outcomes. Previous studies of platelet- derived growth factor-b (PDGF-b) and insulin-like growth factor-1 Figure 2 Cell alignment conforms to scaffold organization at day (IGF-1) have documented their ability to improve tendon healing. 14 This 2-part study examined the effect of poly-L-lactic acid (PLLA) scaffolds preconditioned with IGF-1 and PDGF-b–transduced rat tendon fibroblasts (RTF) on in vitro wild-type RTF proliferation and in vivo rat mechanical properties (n ¼ 5) over in vitro culturing time were mea- tendon repair. Methods: Both the in vitro and the in vivo investiga- sured in tension (Instron, 5 mm/min). Results: Cell attachment and tions used preconditioned bioactive scaffolds. Fibroblasts from rat alignment: Rotator cuff fibroblasts seeded on the aligned scaffolds rotator cuff tendons were transduced with the gene for either adopt an elongated morphology and organize along the long PDGF-b or IGF-1, seeded onto PLLA scaffolds, and incubated for axis of the fibers. In contrast, cells on unaligned scaffold are polyg- 3, 6, or 9 weeks. Control scaffolds were seeded with wild-type onal and are randomly oriented (Figure 1). Circular statistical anal- RTFs, or not seeded at all. After 3 or 7 days in culture, the scaffolds ysis reveals that over time, cell alignment and distribution conform to were pulse labeled with tritiated proline (H3Pro) and tritiated thymi- that of the scaffold (Figure 2). Cell growth and matrix production: dine (H3Thy) to assess collagen and DNA synthesis, respectively. In Cells proliferate on all scaffolds, while producing both types I and the in vivo study, the bioactive scaffold used was the PDGF-b precon- III collagen (Figure 1). Alignment analyses reveal that collagen ditioned scaffold, incubated for 9 weeks, and then lyophilized and deposition also conforms to fiber organization. Mechanical proper- frozen at –80C to create a unique, ‘‘off-the-shelf’’ bioactive scaffold ties: Aligned nanofiber scaffolds consistently measure a significantly that is preladen with growth factor. Twenty-four Sprague-Dawley rats higher elastic modulus and ultimate stress compared with unaligned underwent surgical transection of the tendon and primary repair by scaffolds (Figure 3). Elastic modulus remains relatively constant in 1 of 3 methods: (1) suture alone (control A), (2) suture plus empty culture and is within the range of that reported for human supraspi- PLLA scaffold (control B), or (3) suture plus PDGF-b preconditioned natus tendon.11 Discussion: The findings of this study reveal that scaffold (experimental group). Rats were euthanized at different structural anisotropy of the aligned and isotropy of the unaligned time points, and the repair sites were assessed histologically. scaffold directly guide human rotator cuff fibroblast attachment Results: In the in vitro study, scaffolds preconditioned with growth fac- and matrix deposition. Controlled cell response on the biomimetic tor promoted wild-type RTF proliferation. Scaffolds preconditioned nanofiber scaffold resulted in a more physiologically relevant matrix with IGF-1–transduced cells demonstrated the highest level of colla- for rotator cuff repair. Scaffold elastic modulus was maintained over gen synthesis compared with the other groups. Both IGF-1 and PDGF- time and remained comparable with that of the supraspinatus ten- b experimental groups showed equally stimulated cell proliferation don. Taken collectively, these results demonstrate that the nano- compared with control and wild-type RTFs. In the in vivo study, re- fiber-based scaffold is a promising system for rotator cuff repair. pairs that included the scaffolds preconditioned with growth factor Furthermore, scaffold fiber organization has a profound effect on demonstrated the best overall histologic repair. There was no evi- cellular response and is a critical factor in the design of functional dence of an immune response to the scaffolds. Conclusions: This 2- part study demonstrates the ability of scaffolds preconditioned with growth factors to promote tendon fibroblast function in both in vitro and in vivo model systems. The ability of these scaffolds to improve tendon repair after being lyophilized and stored at –80C provides promise that an ‘‘off-the-shelf’’ patch can be used to clinically enhance the outcome of rotator cuff repairs. Future studies in larger an- imal models will further elucidate this potential.

6 FROG GLUE ENHANCES ROTATOR CUFF REPAIR EX VIVO Neal L. Millar, MD, Tim A. Bradley, MD, Nicola A. Walsh, MD, Richard C. Appleyard, PhD, Michael J. Tyler, DSc, George A. C. Murrell, MD, PhD, West Of Scotland Orthopedic Training Scheme, Glasgow, Scotland; and Orthopedic Research Institute, Sydney, Australia Aims: Rotator cuff tendons are typically reattached to the proximal humerus using either transosseous sutures or suture anchors. Their primary mode of failure is at the tendon bone interface .1 Sur- gical adhesives are used to bond cartilage, tendons, and bone, and Figure 3 Scaffold elastic modulus as a function of cell growth and to close wounds. In an attempt to increase the tendon-bone interface time. we investigated the addition of a novel adhesive secreted from e4 ASES Abstracts J Shoulder Elbow Surg

a species of Australian frog (Notaden bennetti)2 to different methods rine did not have a consistent or significant effect on chondrocyte vi- of rotator cuff repair. Methods: Forty-two fresh frozen sheep infraspi- ability. Discussion: The results of this study demonstrate that the natus tendons were repaired using 3 different techniques: transoss- commonly used local anaesthetics bupivacaine, lidocaine, and ropi- eous sutures, 2 Mitek RC Quickanchors with 1 suture per anchor, vacaine have a negative effect on chondrocyte viability in cultured and 2 Opus Magnum anchors with 1 suture per anchor, all using bovine articular cartilage discs. Using a well-characterized model, a mattress stitch configuration. In each group, 7 shoulders were re- this study demonstrated that the effect of exposure to bupivacaine, paired with the addition of a small amount of frog glue to the infra- lidocaine, and ropivacaine was in both a dose- and duration-depen- spinatus ‘‘footprint,’’ and 7 were used as control, with no adhesive. dent fashion. Furthermore, addition of epinephrine did not consis- Mechanical testing was performed using a mechanical tensile test- tently or significantly effect chondrocyte viability, suggesting that it ing machine. Results: The strongest construct in the control groups is the active drug itself that is likely cytotoxic. Because adult chondro- was the Mitek suture anchors (mean, 86 6 5 N), followed by the cytes have little or no capacity to regenerate, these results suggest Opus suture anchor (69 6 6 N) and transosseous repair (50 6 6 that high-dose, long-term intraarticular use of local anesthetics N). This proved significant (P <.05) between both metallic anchors should be with caution. and the transosseous repair. The addition of frog glue resulted in a significant increase in load to failure and total energy required until failure in all repair techniques (P < .01). There was a 2-fold increase in load to failure of both the Opus Magnum (143 6 8N) 8 THE EVOLUTION OF DISLOCATION ARTHROPATHY IN and Mitek RC Fastin (165 N 6 20 N) anchors, whereas the transoss- FIRST TIME ANTERIOR SHOULDER DISLOCATION IN THE eous repair (86 6 8 N) had a 1.7-fold increase in its load to failure. YOUNG. 223 SHOULDERS PROSPECTIVELY FOLLOWED FOR Conclusions: These data suggest that (1) suture anchor fixation is 25 YEARS. a stronger construct requiring a larger amount of total force to fail Lennart Hovelius, MD, Bjorn Sandstrom, MD, Modolv Saeboe, MD, than transosseous repair using a 1-suture repair technique, and (2) Bengt-Goran Augustini, MD, Lars Krantz, MD, Hans Fredin, MD, Bo the addition of an adhesive to the tendon-bone interface significantly Tillander, MD, Ulf Skoglund, MD, Ulf Sennerby, MD, Division of Sur- enhances both ultimate load and total energy required to failure in gery and Perioperative Science, Department of Orthopedics, Umea all repair types. The unique properties of this frog glue (strong, flex- University Hospital, Sweden; Orthopedic and Radiological Depart- ible, sets in water, and biocompatibility) may ultimately lead to the ments, Ga¨vle; Orthopedic Departments, O¨ rebro, Eksjo¨, Malmo¨, production of a useful adjunct for rotator cuff repair in humans. Ref- Kalmar, Karlstad, and Falun, Sweden. erences: 1. Cummins, et al. Arthroscopy 2005;21:1236-41; 2. Introduction: During the years 1978-1979, 255 patients, aged Graham, et al. Biomacromolecules 2005;6:3300-3312. 12 to 40 years, with a first time anterior shoulder dislocation (257 shoulders) were included in a prospective Swedish multicenter study. Methods: The 25-year follow-up started in 2003 and finished in February 2005. Of the 227 patients (229 shoulders) 7 LOCAL ANESTHETICS INDUCE CHONDROCYTE DEATH IN who were alive, the follow-up and radiology were performed in BOVINE ARTICULAR CARTILAGE DISCS IN A DOSE AND 223 (97.4%) shoulders. Results: Radiologic examination showed DURATION DEPENDENT MANNER that 99 of 223 (44 %) shoulders were normal, 65 (29%) had Ian Lo, MD, May Chung, BSc, Sherri Liang, BSc, Paul Sciore, PhD, mild dislocation arthropathy, 21 (9%) had moderate arthropathy, Richard Boorman, MD, Kenneth Muldrew, PhD, Gail and 38 (17%) had severe arthropathy (Samilson-Prieto). Of the Thornton, PhD, Jerome Rattner, PhD, University of Calgary, Canada 95 shoulders without a recurrence, 17 (17.9%) had moderate/se- Introduction: After arthroscopic surgery, it has been common vere arthropathy. In 66 shoulders that recurred once or more with- practice to inject various local anesthetics into the joint for pain re- out surgery, 26 (39.4%) had moderate/severe arthropathy, and lief. In addition, infusion of local anesthetics using indwelling cathe- 16 of 62 (25.8%) surgically stabilized shoulders had moderate/ ters for 24 to 48 hours has become common for outpatient severe arthropathy. Seven of 221 patients (7 shoulders) were con- arthroscopic surgery. Recently, some authors have reported cata- sidered as alcoholics at 25 years, and all 7 had severe arthropa- strophic acute chondrolysis after arthroscopic surgery. Although thy (P < .001). Other factors that significantly correlated with some cases have been associated with thermal capsulorraphy, other increased arthropathy (moderate/severe) were age older than authors have implicated intraarticular catheter use to acute chon- 25 years when the primary dislocation occurred (P ¼ .01) and drolysis. However, the effect of local anesthetics on articular carti- a high-energetic sports activity causing the primary dislocation lage is unclear. This study evaluated the effect of the local (P ¼ .009). Shoulders that had not recurred had less arthropathy anesthetics bupivacaine, lidocaine, and ropivacaine on chondro- (moderate/severe) than shoulders classified as recurrent (P ¼ cyte viability on bovine articular cartilage discs. Methods: Bovine ar- .047) or stabilized by time (P ¼.007). Sixty-two shoulders with sur- ticular cartilage was obtained from the condylar surfaces of the gical treatment had less arthropathy than shoulders that become radial-carpal joint. Full-thickness cartilage discs were isolated from stable over time (P ¼ .047). Mild arthropathy at 10 years (osteo- the joint surface using a 4-mm punch. After washing, discs were in- phytes < 3 mm) was more often associated with moderate or se- cubated in various concentrations of 0.25% bupivacaine, 1% lido- vere arthropathy at 25 years than radiologically normal caine, and 0.5% ropivacaine 6 epinephrine for 1, 3, 12, and 24 shoulders at 10 years (P < .001). Incongruent joints at 10 years hours. After incubation, discs were cut into 70-mm sections, and more often had moderate/severe arthropathy after 25 years than cell viability was determined using SYTO 13 green fluorescent nu- joints classified as congruent at 10 years (P ¼ .001). Conclusions: cleic acid stain and ethidium bromide. Results: Results demonstrated The degree of initial trauma, age, and remaining instability are im- that 0.25% bupivacaine, 1% lidocaine, and 0.5% ropivacaine had portant factors with respect to the evolution of dislocation arthrop- a negative effect on chondrocyte viability in bovine articular carti- athy; however, shoulders without a recurrence are also involved lage discs. This effect was both dose- and duration-dependent. For with this process. example, when cultured for 12 hours in increasing concentrations (2.5%, 5%, 10%, 25%, 50%, 100%) of 0.25% bupivacaine, chondrocyte viability decreased from 90%, 87%, 83%, 76%, 23%, and 5%, respectively. Similar results were obtained from 1% lidocaine 9 ARTHROSCOPIC ROTATOR INTERVAL CLOSURE: EFFECT and 0.5% ropivacaine. In addition, when cultured in a 50% solution ON STABILITY AND RANGE OF MOTION IN AN ANTERIOR of 0.25% bupivacaine for increasing time periods (1, 3, 5, 8, and AND POSTERIOR STABILIZATION MODEL 24 hours), chondrocyte viability decreased from 88%, 70%, 63%, Matthew T. Provencher, MD, Timothy S. Mologne, MD, Michio 53%, 30%, and 3%, respectively. Similar results were obtained Hongo, MD, PhD, Kristi Zhao, MS, Anthony A. Romeo, MD, for 1% lidocaine and 0.5% ropivacaine. The addition of epineph- Kai N. An, PhD, Naval Medical Center, San Diego, CA J Shoulder Elbow Surg ASES Abstracts e5

Introduction: Although the use of rotator interval (RI) closure is fre- injured athletes (category II or III) completed the questionnaire. quently touted as a useful supplement to shoulder instability repairs, These athletes then underwent an intervention: rest, therapy, or sur- the addition of a RI closure after arthroscopic instability repair has gery, or both. A follow-up questionnaire was administered at a min- not been fully investigated. The purposes of this study are to investi- imum of 3 months and data analyzed. Results: The initial 13-item gate if a RI closure improves glenohumeral stability in an anterior questionnaire correlated very well with the DASH and DASH and posterior instability shoulder model. Methods: Fourteen fresh- sports/performing arts module (convergent validity, –0.89 and – frozen cadaveric shoulder specimens were dissected free of soft tis- 00.80 respectively). Retest reliability was excellent (Pearson r ¼ sues, leaving the rotator cuff intact with simulated cuff loading. All 0.94; root mean square error, 10.1 points), significantly better specimens were mounted in a custom testing apparatus using infra- than that of the DASH sports module (r ¼ 0.77; P <.01), and better red sensors to document glenohumeral translation and rotation. The than the DASH (r ¼ 0.86). Three items were removed due to lack of specimens were then tested for stability in the following order: in- reliability or correlation with final score, resulting in a final 10-item tact/vented state after posterior stretch, after arthroscopic posterior questionnaire with an interitem reliability of 0.94 (Cronbach a). A (7 specimens) or anterior (7 specimens) instability repair with suture total of 282 competitive overhead athletes finished the revised ques- anchors, and then after RI closure. Each of the 3 testing conditions tionnaire. Median scores by category were 98.80 (I), 69.12 (II), measured (1) external and internal rotation at neutral, (2) external and 43.18 (III), respectively. All cross-category comparisons and internal rotation at 90 abduction, (3) posterior translation at showed significant differences (P <.001). Those athletes with a his- neutral rotation, (4) posterior translation at 90 abduction with inter- tory of injury, current injury, or an inactive status scored significantly nal rotation, and (5) sulcus testing in neutral. Results: Posterior stabil- lower than their counterparts (P <.001 for all comparisons). Of the ity was improved after anchor capsulolabral repair (6.8 mm to cohort of 55 injured athletes tested for responsiveness, 24 (44%) 3.9 mm; P < .01), but there was no improvement after RI closure completed a follow-up questionnaire after undergoing an interven- (3.9 to 3.6 mm; P ¼ .6). However, anterior stability was improved tion. Eleven (46%) changed category (from II or III to I) and improved after capsulolabral repair (9.5 mm to 4.3 mm; P ¼.01) and also im- their score an average of 25.98 points compared with an average proved further by RI closure (4.3 to 2 mm; P ¼.001). The mean loss change of –1.18 points for athletes who remained injured (II or III). of external rotation (ER) was significantly increased by the addition The mean score of athletes who returned to play was 87.94 (I), of the RI closure in both neutral and abducted positions as a position which was different from those who remained injured: 62.83 (II) of shoulder function, with a mean ER loss of 28 in neutral (P <.01). and 39.88 (III). Conclusions: Our new patient-reported instrument The addition of a RI closure slightly did not change sulcus stability in is valid, reliable, and responsive. These encouraging results support neutral position (P ¼.4). There were no significant differences in loss the use of our new questionnaire for the functional assessment of of internal rotation in either neutral or 90 abduction, and the re- overhead athletes in future studies. This questionnaire may be mainder of range of motion studied yielded no difference between more sensitive to subtle changes in performance of overhead ath- the intact/vented state. Conclusions: The addition of an arthroscopic letes than traditional shoulder and elbow scoring instruments. RI closure after posterior instability repair did not improve posterior stability. Anterior stability was improved after RI closure. Arthro- scopic RI closure significantly decreased ER at both neutral and abducted arm positions. We demonstrated no biomechanical benefit of RI closure for posterior instability; however, anterior stability 11 HYPERTROPHY OF THE ANTERIOR CORACOACROMIAL was improved. There is a predictable loss of ER after arthroscopic LIGAMENT IN THE YOUNG OVERHEAD ATHLETE AS A CAUSE RI closure. OF SHOULDER PAIN Gregory P. Nicholson, MD, Stacy L. Twigg, PA-C, John Paul Rue, MD, Rush University Medical Center, Chicago, IL Background: Shoulder pain in the young overhead athlete is more commonly thought to be due to instability or superior labrum 10 THE DEVELOPMENT AND VALIDATION OF anteroposterior (SLAP) pathology. We encountered a series of A FUNCTIONAL ASSESSMENT TOOL FOR THE UPPER young overhead athletes with shoulder pain not due to instability EXTREMITY IN THE OVERHEAD ATHLETE or SLAP pathology but to hypertrophy of the anterior coracoacro- Benjamin G. Domb, MD, Frank Alberta, MD, Scott Bissell, MD, Ka- mial ligament (CAL) with bursitis. All had pain at the anterolateral ren Mohr, PT, Lewis A. Yocum, MD, Neal S. ElAttrache, MD, corner of the acromion. We report the clinical characteristics, pa- Frank W. Jobe, MD, Kerlan-Jobe Orthopedic Clinic, Los Angeles, thology, and results of treatment of this previously unreported asso- CA ciation. Materials: Twenty-nine young (average age 18, range 15- Objectives: There are no validated upper extremity instruments 27), predominantly female (19 [66%]; 10 male) overhand athletes designed specifically to evaluate the performance and function of presented with shoulder pain unresponsive to conservative treat- overhead athletes. Current shoulder and elbow scoring systems ment. Of these, 76% had pain at the anterolateral acromial corner, may not be sensitive to subtle changes in performance in this high- 71% had pain with an overhand arc of motion from abduction/ex- demand population. Our purpose was to develop and validate ternal rotation to abduction/internal rotation position, and 53% had a new patient reported questionnaire for overhead athletes. SLAP-type physical examination findings. There were no instability Methods: Potential questionnaire items were developed through in- symptoms. In females there were 6 in volleyball, 6 swimmers, 4 put from team trainers, team physicians, and physical therapists. Pi- throwers, and 3 with overhand activity. All males were in baseball lot data were collected from 21 intercollegiate baseball and softball (5 pitchers, 5 position players). All had failed conservative treat- players who completed an initial 13-item questionnaire as well as ment, and could not perform their sport. Their average preoperative the Disabilities Arm, Shoulder and Hand (DASH) instrument and scores were American Shoulder and Elbow Surgeon (ASES), 60; the DASH sports/performing arts module. Subjects also rated Simple Shoulder Test (SST), 7.5; and visual analogue scale (VAS) each item for importance. This same group was retested 4 weeks pain score, 4.3. All underwent examination under anesthesia and later to examine reliability. Correlation with the DASH and DASH arthroscopy. There was no evidence of instability or SLAP pathology. sports/performing arts module and test-retest reliability were ana- Twenty-one (72%) of these stable shoulders had a small vertical pos- lyzed. The questionnaire was revised to a final 10-item instrument. terior labral tear near the ‘‘equator.’’ All had varying degrees of sub- For validation of the score, 282 healthy competitive overhead ath- acromial bursitis, but the primary pathology was a thickened letes completed the revised questionnaire as well as the DASH anterior band of the CAL. It inserted on the acromion, but extended and DASH sports/performing arts module, and were self-catego- laterally out under the deltoid muscle. This formed an ‘‘awning’’ at rized as playing pain-free (I), playing with pain (II), or not playing the anterolateral acromial corner that created subacromial space due to pain (III). To test responsiveness, an additional group of 55 compromise. The hypertrophic CAL anterior edge and lateral e6 ASES Abstracts J Shoulder Elbow Surg

extension was excised in all. Five also required osseous acromio- salata outcome scores when comparing these groups. Statistical plasty. The posterior labral tear only required de´bridement. Results: analysis revealed no significant differences in outcomes due to fac- At an average follow-up of 2.2 years (range, 1-5 years), all had re- tors including gender, sidedness, arm dominance, number of an- turned to the former level of overhead activity. Rapid rehabilitation chors used, use of metal or bioabsorbable anchors, or was possible and the average time to return to overhead sport activ- performance of concomitant procedures such as bursectomy, acro- ity without restriction was 5 months (range, 3-8 months). Average mioplasty, or rotator cuff de´bridement. Overall, 74% patients in- postoperative scores were ASES, 98; SST, 11.7; and VAS, 0.3 (P volved in athletics were able to return to their preinjury level of < .05). There were no complications, reoperations, and no occult competition. There were 5 complications, including 4 patients instability revealed over time. Conclusion: A preoperative diagnosis with refractory postoperative stiffness, 1 of whom required operative of SLAP lesion was most common in this series. This is the first de- intervention to regain motion, and 1 traumatic reinjury requiring re- scription of this clinical entity: high-level, young (<25 years), repet- peat repair. Conclusion: With advances in arthroscopic techniques itive overhand athletes with shoulder pain to have a stable shoulder, and instrumentation, arthroscopic treatment of superior labral le- a posterior labral tear, and a hypertrophic CAL. There was a pre- sions has evolved. On the basis of our findings, favorable outcomes dominance of women in this series. We feel this is a variant of im- can be anticipated in most patients after arthroscopic SLAP repair; pingement, most likely due to the repetitive overhand activity. This however, only 3 of 4 patients may be capable of returning fully to was not secondary to occult instability or posterior capsule tightness. their previous level of athletic ability. All athletes were able to return to their previous level of sport. Ar- throscopy was successful in identifying and treating the pathology. Not all overhead athletes’ shoulder problems should be attributed to occult instability or SLAP pathology. An index of suspicion should 13 PROSPECTIVE ANALYSIS OF ARTHROSCOPIC ROTATOR be used in young overhand athletes with shoulder pain for this clin- CUFF REPAIR: PROGNOSTIC FACTORS AFFECTING CLINICAL ical entity. AND ULTRASOUND OUTCOME John D. MacGillivray, MD, Ronald S. Adler, MD, PhD, Shane J. Nho, MD, MS, Edward V. Craig, MD, Frank A. Cordasco, MD, MS, Answorth A. Allen, MD, Russell F. Warren, MD, David W. 12 PROSPECTIVE OUTCOMES AFTER ARTHROSCOPIC Altchek, MD, Hospital for Special Surgery, New York, NY REPAIR OF TYPE II SLAP LESIONS Introduction: Rotator cuff tears are frequently seen in combination Stephen F. Brockmeier, MD, James E. Voos, MD, Riley J. Williams with associated soft tissue pathology about the shoulder. The Rotator III, MD, David W. Altchek, MD, Stephen J. O’Brien, MD, Frank A. Cuff Registry was established to prospectively evaluate the effective- Cordasco, MD, MS, Answorth A. Allen, MD, Hospital for Special ness of arthroscopic rotator cuff repairs (ARCRs) during a 5-year pe- Surgery, New York, NY riod with respect to anatomic healing as documented by ultrasound Introduction: There is currently no prospective study document- and clinical outcomes. The purpose of the present study is to deter- ing patient outcomes after arthroscopic superior labrum anteropos- mine which rotator cuff characteristics and associated pathology terior (SLAP) repair using modern techniques. The objective of this may influence anatomic healing and clinical outcomes. Methods: study was to prospectively evaluate patients with type II SLAP tears From August 2003, patients with symptomatic rotator cuff tears treated with arthroscopic suture anchor fixation at minimum 2-year who failed conservative treatment were prospectively enrolled in follow-up. Methods: Forty-seven patients (39 men, 8 women; the study. Patients who had undergone prior shoulder surgery were mean age, 36.1 years) treated for symptomatic type II SLAP tears excluded from the study. Before surgery, all patients completed Amer- were evaluated before surgery and at after 2 years of follow-up us- ican Shoulder and Elbow Surgeons (ASES) Shoulder Assessment and ing the American Shoulder and Elbow Surgeons (ASES) score, L’In- physical examination. Intraoperative data were collected at the time salata outcomes instruments, and physical examination. Before of surgery to characterize the rotator cuff tear and associated pathol- injury, 34 patients participated in athletics, including 28 overhead ogy. The surgical technique and any concomitant procedures were athletes. Patients with rotator cuff tears requiring repair or concom- also recorded. After surgery, the patients were asked to follow-up itant shoulder instability were excluded. A distinct traumatic injury on an annual basis and complete the ASES Shoulder Assessment. was reported by 25 patients, with the remaining 22 patients noting At each follow-up time point, a single, blinded musculoskeletal radi- an insidious onset of symptoms, often associated with athletics. ologist interpreted all ultrasound studies to evaluate for the quality of Results: At an average of 2.7 years of follow-up, the mean ASES the repaired rotator cuff tendons. Subgroup analysis was performed and L’Insalata scores were 92.6 and 90.2, respectively, compared to compare rotator cuff characteristics such as number of tendons, with baseline scores of 61.6 and 61.9 (P <.0001). Patient-reported acromioclavicular joint pathology, biceps pathology, and suture an- satisfaction averaged 8.3 of 10; outcomes were good to excellent in chor row configuration. Results: The study enrolled 193 patients; of 41 (87%). Average patient-reported satisfaction was significantly these, 136 completed 1-year follow-up, and 117 patients completed higher in patients with a discrete traumatic etiology (9.01 vs 2-year follow-up. Their average age was 58.6 6 9.8 years, with 113 7.48); however, there was no significant difference in ASES or L’In- (58.5%) men and 80 (41.5%) women. All patients underwent ARCR

Table I Effect of tendon involvement and suture anchor row conﬁguration.

ASES score Intact by ultrasound, % Group Patients, No. Pre-op 1 year 2 years 1 year 2 years

ST N ¼ 104 48.0 6 24.2 86.9 6 17.7 93.2 6 13.7 75.60 87.90 MT N ¼ 59 58.2 6 22.3a 79.2 6 20.2a 87.7 6 15.8 44.7a 47.2a ST, SR N ¼ 55 44.0 6 24.0 86.5 6 19.7 93.1 6 17.8 71.40 86.20 ST, DR N ¼ 36 52.3 6 23.6 89.4 6 15.5 94.6 6 9.5 85.20 87.50 MT, SR N ¼ 22 57.6 6 21.5 78.2 6 21.7 87.4 6 15.1 33.30 45.50 MT, DR N ¼ 36 55.3 6 23.5 78.5 6 20.7 86.7 6 17.4 42.30 45.00

ASES, American Shoulder and Elbow Surgeon;ST,single tendon; MT, multiple tendons; SR, single row; DR, double row. aDenotes statistically signiﬁcant difference between groups (P < .05). J Shoulder Elbow Surg ASES Abstracts e7

Table II Effect of rotator cuff repair and concomitant procedures

ASES score Intact by ultrasound, % Group Patients, No. Pre-op 1 year 2 year 1 year 2 year

No DCE 89 52.7 6 24.4 86.2 6 18.3 94.6 6 8.4 73.90 86.50 DCE 15 43.2 6 25.4 70.5 6 24.4a 85.5 6 19.7 27.3a 33.3a No biceps tenotomy 96 47.3 6 24.5 85.3 6 18.8 94.0 6 8.9 81.70 85.50 Biceps tenotomy 15 47.7 6 30.1 76.4 6 22.0 81.9 6 23.6 7.7%* 11.1a

ASES, American Shoulder and Elbow Surgeon; DCE, distal clavicle excision. aDenotes statistically significant difference between groups (P < .05). with suture anchor fixation. The single-tendon ARCRs had greater Table I Group characteristics ASES scores at 1 year and a greater percentage of intact repairs at 1 and 2 years than the multiple-tendons ARCRs (P < .05). There FTD size were no significant differences between single-row and double- No FTD row suture anchor configurations in ASES score and ultrasound (Ta- Characteristic change Increase Decrease healed ble I). Patients undergoing ARCR with distal clavicle excision or biceps tenotomy had significantly worse clinical outcomes and lower percentage of intact repairs (P <.05; Table II). Conclusion: Single-ten- Patients, No. 78 16 9 9 6 a 6 a 6 6 don rotator cuff repairs have excellent clinical outcomes and 87.9% Age, mean 57.3 9.7 62.9 8.0 63.6 9.7 56.8 8.9 6 intact repairs, and multiple-tendon rotator cuff repairs have reason- SD y 6 ab 6 a 6 b 6 able clinical outcomes but only 47.2% intact repairs at 2 years. Size, mean 2.71 1.1 4.13 1.8 4.8 1.6 3.0 1.8 6 ARCRs with concomitant distal clavicle excision or biceps tenotomy SD cm occurred in the setting of larger rotator cuff tears, and therefore, there Tendon involvement was poor evidence of ultrasound healing compared with isolated ab a b ARCRs. There are no statistically significant differences between sin- Single, % 78.2 25 33.3 66.7 gle-row and double-row suture anchor configuration. The findings of Multiple, % 21.8 75 66.7 33.3 the present study suggest that the best outcomes occur in isolated, sin- Row configuration gle tendon ARCRs, and therefore, support early ARCR to optimize an- Single, % 49.2 64.3 22.2 57.1 atomic healing and clinical outcomes. Double, % 50.8 35.7 77.8 42.9 FTD, full-thickness defect. aDenotes statistically significant difference between ‘‘No change’’ 14 ARTHROSCOPIC ROTATOR CUFF REPAIR: PROSPECTIVE and ‘‘Increase FTD size’’ groups. EVALUATION WITH SEQUENTIAL ULTRASONAGRAPHY bDenotes statistically significant difference between ‘‘No change’’ Daniel P. Tomlinson, MD, Ronald S. Adler, MD, PhD, Shane J. and ‘‘Decrease FTD size’’ groups. Nho, MD, MS, Frank A. Cordasco, MD, MS, Edward V. Craig, MD, Russell F. Warren, MD, John D. MacGillivray, MD, David W. Altchek, MD, Hospital for Special Surgery, New York, NY with a full thickness defect at 1 year (Table I). Discussion: In the pres- Background: Numerous studies of arthroscopic rotator cuff re- ent study, serial ultrasounds were used to follow the postoperative pair (ARCR) have reported excellent clinical results in the short healing of tendons after ARCR. Overall, 83 of the 113 patients term. More recent studies have used postoperative ultrasound to de- (73%) undergoing ARCR had healed at the latest follow-up with ul- termine the effectiveness of ARCR, and the results for single-tendon trasound evaluation. Of these, 74 rotator cuff repairs that were de- tears have been encouraging. The purpose of the present study is termined to be healed by an initial ultrasound remained healed in to determine the postoperative status of rotator cuff tendon healing successive ultrasounds. The other 9 cases were read as having de- after ARCR at multiple time points based on ultrasound evaluation. fects at 3 months or 1 year, but eventually healed at 2 years. Rotator Methods: The Rotator Cuff Registry was established after Investiga- cuff defects appear to change in size over the course of time. Rotator tional Review Board approval to determine the effectiveness of cuff tears of less than 3 cm and in patients younger than 60 years old ARCR with clinical outcomes and ultrasound at 3 months, 1 year, appear to remain healed or heal over time. and 2 years postoperatively. A single blinded musculoskeletal radiologist interpreted all the ultrasounds and assessed the degree of tendon healing along with the location and size of the defect, if present. Because the focus of this study was to access tendon integrity 15 VASCULARITY OF THE ROTATOR CUFF AFTER over time, inclusion criteria were patients who had more than 1 post- ARTHROSCOPIC REPAIR: CHARACTERIZATION USING operative ultrasound study. Patients with only a single postoperative CONTRAST-ENHANCED ULTRASOUND ultrasound study were excluded. Results: Between August 2003 and Seth C. Gamradt, MD, Ronald S. Adler, MD, PhD, Alex August 2005, 193 patients enrolled in the Rotator Cuff Registry, and Maderazo, MD, Russell F. Warren, MD, David W. Altchek, MD, Ste- 113 patients met the inclusion criteria. There were 74 patients (65%) phen Fealy, MD, Hospital for Special Surgery, New York, NY who had a healed rotator cuff documented by ultrasound at more Background: Persistent defects are common after rotator cuff re- than 1 time point: 13 at 3 months and 1 year; 5 at 3 months and pair; this suggests that the biology of tendon–bone healing in rotator 2 years; 34 at 1 and 2 years; and 22 at 3 months, 1 year, and 2 cuff repair is suboptimal. Using contrast-enhanced ultrasound, we years. Of the 35 patients who had a change in their ultrasound result have previously documented an age-related decrease in rotator at 2 different time points, 9 decreased in defect size and 16 in- cuff vascularity in the asymptomatic volunteer. To date, there has creased in defect size over time. Nine patients with ARCR had a de- been limited in-vivo assessment of vascularity of the shoulder after ro- fect at either 3 months or 1 year that was healed at 2 years. One tator cuff repair. It has been assumed that a robust vascular response patient with ARCR who initially healed at 3 months went on to retear, at the tendon–bone interface during rotator cuff repairs is an integral e8 ASES Abstracts J Shoulder Elbow Surg

part to the healing process. However, in a previous study using efforts to improve the rate of healing after rotator cuff repair should Power Doppler sonography after miniopen rotator cuff repair, there take into account not only surgical technique, but also the compro- appeared to be paradoxically diminished blood flow at the site of mised biology of the rotator cuff tissue. the cancellous trough. This study characterized vascularity of rotator cuff tendon–bone interface using contrast enhanced ultrasound, which has improved sensitivity compared with Power Doppler and evaluated the vascularity of the repaired rotator cuff after exercise 16 ORTHOPEDIC VERSUS RADIOLOGY READING OF to determine if recruitment of blood flow the area of repair during ac- SHOULDER MRI SCANS: A PROSPECTIVE STUDY tivity can occur. Methods: After obtaining Institutional Review Board Stephen C. Weber, MD, Jeffrey I. Kauffman, MD, Carol Parise, PhD, approval, 10 patients (mean age, 58.5 years) were enrolled in the Sacramento Knee and Sports Medicine, Sacraments, CA study. Patients underwent arthroscopic single-row rotator cuff repair Background: Shoulder magnetic resonance imaging (MRI) stud- with suture anchors (average 2 anchors doubly loaded with No. 2 ies have traditionally been read by radiologists. These readings nonabsorbable suture) of supraspinatus tears that averaged 2 have often been at odds with the interpretation of the orthopedist, 1.25 cm in size. The patients then underwent lipid microsphere (Def- who has access to the patients’ history, physical examination, radio- inity, 10 mL/kg, Bristol-Myers Squibb) contrast-enhanced shoulder graphs, and other ancillary studies. Expertise based on training ultrasound examinations 3 months after rotator cuff repair. Images should be similar, because the hours spent in residency reviewing were obtained at baseline, after contrast administration at rest, musculoskeletal imaging are similar for both radiologists and ortho- and after contrast administration after exercise to optimally visualize pedists. Methods: Presented here is a comparison of readings pro- the blood flow to the shoulder. Qualitative and quantitative analysis vided by orthopedists vs radiologists of 100 consecutive shoulder was performed by evaluating 3 regions of interest (supraspinatus MRI scans with validation with video-documented pathology at ar- tendon, tendon footprint/suture anchor site, and peribursal area) throscopy. All studies were interpreted blinded to the subsequent sur- with ultrasound imaging quantification and analysis software gical findings; the surgeon could not be blinded as to the (QLAB, Philips, Andover, MA). This permitted analysis of each re- interpretations of the radiologist and orthopedist at surgery. Results: gion-of-interest and normalization of data for interpretation of the Of the MRI scans read by the radiologists, 36% were thought to mean intensity per pixel. Two 2-minute acquisitions were obtained show labral pathology vs only 2% by the orthopedist. Partial cuff after each contrast bolus from which baseline and peak enhance- tears were interpreted in 32% of studies by the radiologist vs 23% ment were estimated for each region of interest. Results: Eight re- of the orthopedists. Complete tears of the rotator cuff showed rea- pairs were completely intact 3 months after repair; 2 had sonable agreement between radiologists and orthopedists, al- a persistent defect. Table I summarizes the vascularity data in the though the orthopedists definitively identified 98% of complete 3 regions of interest in intact repairs. A robust vascular response tears vs 89% of radiologists. The radiologists missed all full subsca- was seen at the anchor site in the greater tuberosity 3 months after pularis tears; 4 of 5 patients identified with tears of the subscapularis rotator cuff repair (Table I). Comparatively little blood flow was ob- by the radiologist were correctly interpreted by the orthopedist as served in the rotator cuff tendon. Exercise recruited blood flow to all normal. Calcific tendonitis apparent on plain radiographs was 3 regions of interest. In the 2 cases with a persistent rotator cuff de- missed 80% of the time on MRI by the radiologist. Sensitivities, spec- fect, blood flow was not robust at the anchor site (average 14 dB ificities, and k values for all diagnostic categories were significantly peak and 0.37 dB/s rate of rise). Conclusion: This study is the first better for orthopedists than radiologists, except for glenohumeral ar- to quantify in vivo vascularity of the rotator cuff after arthroscopic re- thritis. Radiologists showed a significant increase in false-positive pair. Three conclusions can be drawn from these data. First, the ro- and nondefinitive interpretations compared with orthopedists. The tator cuff is relatively avascular after repair at 3 months. Also, the reasons are multifactorial, but may have to do in part with the advan- supraspinatus tendon in a rotator cuff that has torn and been re- tages present to orthopedists by virtue of the increased clinical and paired is much less vascular than age-matched patients without a ro- radiographic information available to them at the time of interpreta- tator cuff tear from our previous study. Second, a robust vascular tion. Conclusion: Treatment based solely on the radiology interpreta- response occurs at the suture anchor site in the greater tuberosity. tion of MRI scans should be avoided, and the increased cost This suggests that the blood supply for healing of the tendon-bone in- associated with concurrent radiology interpretation of MRI scans terface after rotator cuff repair comes from the bony side. An intact may be questioned. repair may be necessary to foster angiogenesis at the repair site. Third, exercise recruits blood flow to both the greater tuberosity and rotator cuff. Although the study is limited in that the repairs were evaluated at only 1 time point, these data suggest that the re- 17 INCREASED INCIDENCE OF FALSE POSITIVE ROTATOR paired rotator cuff tendon is relatively avascular and that the blood CUFF PATHOLOGY IN MRI’S OF PATIENTS WITH ADHESIVE supply to the tendon bone interface comes from the bone. Future CAPSULITIS Stephen L. Brown, MD, Bryan J. Loeffler, MD, Donald F. D’Alessandro, MD, James E. Fleischli, MD, Patrick M. Connor, MD, OrthoCarolina, Center for Shoulder and Elbow Table I Mean vascular scores of intact rotator cuff repairs 3 months Surgery, Center for Sports Medicine, Charlotte, NC after rotator cuff repair of three regions of interesta Introduction: The clinical presentation of adhesive capsulitis may mimic that of rotator cuff disease and can therefore present the clini- Vascular score Anchor Rotator cian with a diagnostic dilemma. Diagnosis is made through careful (mean) Peribursal site cuff history taking and physical examination. Magnetic resonance imaging (MRI), however, is often used as a diagnostic adjunct to provide Before exercise further objective insight into the shoulder condition. We hypothesize Peak, dB 27 31.4 13.8 that MRIs provide an increased incidence of false-positive rotator Rate of rise, dB/s 2.88 4.31 1.11 cuff findings in patients with adhesive capsulitis. The purpose of After exercise this study is to correlate preoperative MRI interpretations with oper- Peak, dB 31 34.8 15.6 ative findings in patients with adhesive capsulitis. Methods: Using Rate of rise, dB/s 4.36 4.74 1.63 an Investigational Review Board-approved protocol, we identified 70 consecutive patients who underwent arthroscopic glenohumeral aThe peak contrast enhancement, measured in decibels (dB) corre- capsular release between September 2001 and April 2007. Charts lates with vascular volume, and the rate of enhancement rise were retrospectively reviewed, and every effort was made to include (dB/s) correlates directly with perfusion. in this study only those patients with adhesive capsulitis as their J Shoulder Elbow Surg ASES Abstracts e9

primary diagnosis. Patients were included in the study if (1) there shoulders with an asymptomatic rotator cuff tear is not known. The was a preoperative diagnosis of primary adhesive capsulitis, (2) purpose of this study was to determine the prevalence of rotator an MRI was obtained before referral for surgical intervention and cuff tears in individuals with bilateral asymptomatic shoulders and an official musculoskeletal radiologist interpretation was available, to evaluate their isometric shoulder strength. Methods: We per- and (3) arthroscopic glenohumeral capsular release was performed formed ultrasound scan on bilateral shoulders of 237 volunteers after failure of conservative treatment. Patients were excluded from (144 men, 93 women; average age, 60 years; range, 40-83 years) the study when there was (1) a history of a significant traumatic in- with no current or previous shoulder symptoms or abnormalities in jury to the shoulder resulting in the potential of a primary injury order to identify rotator cuff tears. Subjects were divided into 4 with secondary stiffness, (2) a preoperative or postoperative diagno- age groups (40 to 49, 50 to 59, 60 to 69, and >70 years). Isometric sis that was etiologic in the patient’s stiffness (ie, osteoarthritis, avas- strength of external rotation at side and of scapular plane abduction cular necrosis, etc), (3) a history of open or arthroscopic surgery, on both shoulders was measured with an Isobex dynamometer. and (4) if no preoperative MRI interpretation was available. Of Results: We identified rotator cuff tears in 41 subjects (17%). The the 70 patients, 34 met the necessary criteria for inclusion, and their prevalence of rotator cuff tears in each age group was 0%, 10%, records were reviewed to obtain baseline demographic data, his- 20%, and 43%, respectively. The prevalence of cuff tears was tory, MRI interpretations, operative findings, and surgical proce- 31% in the subjects aged 60 or older and 43% the subjects aged dures performed. The attending surgeon performed all surgeries 70 or older. Full-thickness tears were bilateral in 4 (2%), unilateral and clearly documented the intraoperative findings in the operative in 17 (7%), and in 5 (2%) were unilateral with a concurrent par- report as well as with intraoperative photographs. All patients who tial-thickness in the other shoulder. Partial-thickness tears were unilat- underwent surgery had close inspection of their rotator cuff from eral in 13 (6%) and bilateral in 2 (1%). Abduction strength of the both the articular and bursal perspectives. Results: The study cohort shoulders with a large full-thickness tear was significantly lower consisted of 17 men and 17 women. Average age was 53.8 years than that of the contralateral shoulders with intact cuff, a partial-thick- (range, 36-70 years). Average duration of symptoms was 12.3 ness tear, or a small full-thickness tear. Abduction strength of the months (range, 3-30 months). The dominant arm was involved in shoulders with a full-thickness tear was significantly lower than 20 patients. Fourteen patients recalled a specific episode of minor that of the age- and gender-matched controls. However, there was trauma that was felt to subjectively initiate the painful process, and no statistical difference in the mean strength between the population 20 reported an insidious onset of symptoms. Seven patients were di- with intact rotator cuff and population with intact or torn rotator cuff. abetic (3 type I, 4 type II), and 2 patients were being treated for hy- Conclusions: Asymptomatic rotator cuff tears were common in the el- pothyroidism. Average preoperative scapular elevation was 115, derly population, and prevalence increased with age. The abduc- external rotation was 35, and internal rotation was to the ipsilateral tion strength of the shoulders with a large full-thickness tear was greater trochanter. Twenty-nine of 34 patients (85.2%) in the study significantly decreased despite a lack of symptoms. Abduction group had preoperative MRI evidence of high grade tendinosis, par- strength measurement was best in detecting large full-thickness tears tial-thickness (PT) or full-thickness (FT) rotator cuff tear (RCT), as inter- in asymptomatic shoulders. preted by a musculoskeletal radiologist, and 21 (61.7%) had evidence of either a PT- or FT-RCT. The radiologist interpretation pre- dicted a FT-RCT in 7 of 34 (20.6%). In only 5 patients (14.7%) was the MRI reading for the rotator cuff pathology normal. At the time of surgery, 5 patients (14.7%) were found to have objective rotator cuff 19 IMPINGEMENT SYNDROME: TEMPORAL OUTCOMES pathology. Three (8.8%) were treated with de´bridement for articular OF NON-OPERATIVE TREATMENT sided tears of the supraspinatus involving less than 3 mm of the me- Craig A. Cummins, MD, Lisa M. Sasso, MD, Daniel Nicholson, MD, dial footprint. Two patients (5.8%) were found to have significant PT- Northwestern University Medical Center, Chicago, IL RCTs, which were treated with arthroscopic repair. No patient had Background: Impingement syndrome is a painful shoulder condi- a FT-RCT at the time of surgery; in fact, only 1 of the 7 MRIs that tion in which the soft tissues under the acromion are pinched be- were interpreted preoperatively as a FT-RCT was found to have tween neighboring structures as the arm is raised horizontally. The any objective evidence of rotator cuff pathology at the time of sur- purpose of this study was to evaluate the temporal outcomes of pa- gery. Conclusion: The diagnosis of adhesive capsulitis is made clin- tients treated for the diagnosis of impingement syndrome. Methods: ically. Relying on the interpretation of MRIs in this setting without We performed a prospective study to evaluate the temporal and final clinical correlation may provide misleading information regarding outcomes 2 years after initiation of treatment for impingement syn- the potential of concomitant rotator cuff pathology. Of our patients drome in 100 consecutive patients. The inclusion criteria for the who underwent arthroscopic capsular release for recalcitrant adhe- study were a diagnosis of impingement syndrome, age of 35 to sive capsulitis, 62% (21 of 34) had preoperative MRI evidence of PT- 65 years, and a positive response to a subacromial lidocaine injec- and FT-RCTs. Only 15% (5 of 34) had objective evidence of rotator tion (>50% decrease in pain). All patients were started on a stan- cuff pathology noted at the time of surgery. We believe it is of utmost dardized nonoperative treatment protocol that consisted of importance to be aware of this potential imaging pitfall when partici- a subacromial steroid injection (methylprednisolone), followed by pating in the care of patients with stiff shoulders so that an accurate a 4-week course of physical therapy. Demographic data, medical diagnosis may be established, thereby avoiding unnecessary or po- and surgical history, and specific information regarding their shoul- tentially aggravating surgical intervention. More research is needed der injury was collected at the initial patient encounter. All patients to further define this correlation and to elucidate the potential filled out the validated shoulder assessment by the American Shoul- cause(s) for this phenomenon. der and Elbow Society (ASES) and visual analogue pain score at their initial visit and at follow-up appointments at 6 weeks, 3 and 6 months, and 1 and 2 years. Results: Of the 100 patients followed up in the study, 80 had a satisfactory result and did not require surgery. The nonoperative cohort was followed up average of 22.7 18 SHOULDER STRENGTH OF INDIVIDUALS WITH months. The average patient outcome score increased from 58 to ASYMPTOMATIC ROTATOR CUFF TEAR 95, and the average pain score decreased from 4.6 to 0.6. Twenty Hyun-Min Kim, MD, Ari Zelig, BA, Anthony S. Wei, MD, Sharlene A. patients did not have a significant improvement and went on to op- Teefey, MD, Jay D. Keener, MD, Leesa M. Galatz, MD, Ken erative intervention. The average time to surgical intervention was Yamaguchi, MD, Washington University, St. Louis, MO 32.5 weeks. Overall, there was a statistically significant improve- Introduction: Asymptomatic rotator cuff tears are common in the ment in patient outcomes (ASES) and pain scores (VAS) between elderly population. Although the shoulder function is perceived as the initiation of treatment and the 1-year follow-up assessment (P < normal by the individuals themselves, the objective strength of these .001); no improvement was identified past 1 year. In addition, e10 ASES Abstracts J Shoulder Elbow Surg

improvement was demonstrated between each time point for the pularis tears were the subjects of this study. The mean follow-up was VAS pain score and the ASES score, with the exception of no im- 46.8 months (range, 10-80 months), with the end point being failure provement between 6 weeks and 3 months (P ¼ .6813 and P ¼ and revision of the procedure if the follow-up was less than 24 .8966, respectively)., Duration of symptoms, pain score on presen- months. The patients were divided into three groups. Group I con- tation, and the number of comorbid diagnoses were not predictive sisted of 12 patients who had shoulder instability with an isolated ir- of patients requiring surgery (P ¼ .5225, P ¼ .5006, and P ¼ reparable tear of the subscapularis. Group II consisted of 10 patients .4514, respectively). The number of injections, however, was found who had rupture of the subscapularis after shoulder arthroplasty. to correlate with a patient requiring surgery (P ¼ .0002). Patients Group III consisted of 11 patients who had rupture of the subscapu- who demonstrated a poor response to the initial corticosteroid injec- laris as part of a massive irreparable rotator cuff tear. Results were tion, defined as a pain score exceeding 5 at the 6-week follow-up graded according to pain relief, improved function, and resolution assessment, were more likely to require surgery (P < .05). Of the of instability. Results: The preoperative and postoperative mean 20 patients who went on to surgery, 14 had an additional shoulder (range) Constant scores improved from 40.9 (28-50) to 60.8 (28- diagnosis identified at the time of arthroscopy. Conclusions: Most pa- 89; P ¼ .043) in group I, from 32.9 points (17-47) to 41.9 (24- tients treated nonoperatively for impingement syndrome demon- 73; P ¼ .793) in group II, and from 28.7 (20-42) to 52.3 (24-78; strated significant temporal improvement in their symptoms up to 1 P ¼ .015) in group III. Overall, treatment failed in 15 of the 33 pa- year after initiation of treatment. No improvement was identified tients, and they required an additional surgery. There were 2 infec- past 1 year. Patients in whom nonoperative treatment failed often tions. Discussion: PMT has limited value in patients with had an additional shoulder diagnosis identified at the time of arthro- subscapularis insufficiency after arthroplasty, and although it seems scopic surgery. to help with pain in patients with massive rotator cuff tears, it has no value in the restoration of function in this group. Improvement of pain and function can be expected in some patients with isolated subscapularis tears, although results do not seem as promising as prior lit- 20 DOES SLOWER REHABILITATION LEAD TO STIFFNESS erature indicates. FOLLOWING ARTHROSCOPIC ROTATOR CUFF REPAIR? Bradford O. Parsons, MD, Raymond A. Klug, MD, James N. Gladstone, MD, Kenneth J. Accousti, MD, Evan L. Flatow, MD, Mount Sinai Medical Center, New York, NY 22 CLINICAL OUTCOMES OF ARTHROSCOPIC TREATMENT Objectives: Early passive range of motion (PROM) has been ad- OF OCD LESIONS OF THE CAPITELLUM vocated after open rotator cuff repair to prevent stiffness. Because of Jonathan D. Chappell, MD, Neal S. ElAttrache, MD, Kerlan-Jobe concern over retear rates after arthroscopic repair, many authors Orthopaedic Clinic, Los Angeles, CA have advocated slower rehabilitation. We sought to examine the ef- Objectives: Osteochondritis dissecans (OCD) of the capitellum is fect of a conservative postoperative regimen, sling immobilization a rare condition that occurs in adolescent athletes from excessive for 6 weeks, on ROM after arthroscopic cuff repair. Methods: Fifty- valgus loading. Arthroscopic de´bridement and microfracture offers six patients with full-thickness rotator cuff tears were prospectively a minimally invasive technique for treatment of central lesions. Le- followed up for 1 year after arthroscopic repair. Patients with preop- sions involving the lateral column with engagement of the radial erative stiffness were excluded. ROM was assessed preoperatively head require reconstruction with osteochondral autografts. The pur- and at 2, 6, 12, 24, and 52 weeks postoperatively. Preoperative pose of this study is to evaluate these arthroscopic treatment options. and postoperative American Shoulder and Elbow Surgeons Methods: Sixteen athletes with OCD lesions of the capitellum were (ASES) and Constant scores were recorded. Forty-three patients available for follow-up. Eleven patients underwent arthroscopic de´- had an magnetic resonance imaging (MRI) study at 1 year postop- bridement and microfracture, and 5 patients with lateral lesions un- eratively to assess repair integrity. Results: During the first 6 weeks derwent arthroscopic transfer of osteochondral autografts. Clinical postoperatively, 43 patients (77%) had ‘‘good’’ PROM (elevation assessment scores were used to evaluate outcomes with an average >100 and external rotation [ER] >30), while 13 (23%) were 36-month follow-up in the microfracture group and 100-month fol- ‘‘stiff’’ (elevation <100 and/or ER <30). No patients were stiff low-up in the osteochondral autograft group. Results: In the micro- at 1 year. By MRI, 44% of the repairs were intact at 1 year. There fracture group, postoperative flexion contracture decreased from was a trend for better healing in the ‘‘stiff’’ group: 70% of repairs 13.2 to 2.4 (P ¼ .02), flexion/extension arc of motion increased were intact on MRI, compared with 38% in the ‘‘good ROM’’ group from 115 to 136 (P ¼ .01), and pronation/supination arc of mo- (P ¼ .13). There was no difference in ASES, Constant scores, or tion increased from 160 to 179 (P ¼ .01). Follow-up clinical as- ROM at 1 year between groups. Conclusions: Six weeks of sling im- sessment scores resulted in excellent outcomes in all 11 patients, mobilization after arthroscopic rotator cuff repair does not appear to and all patients returned to their previous level of sports participa- result in long-term stiffness. Patients with perioperative stiffness tion. In the osteochondral autograft group, no differences were ob- trended toward better tendon healing. Early PROM is not necessary served in preoperative and postoperative range of motion. Excellent to avoid stiffness after arthroscopic rotator cuff repair and may have clinical rating scores were achieved in 3 patients, good in 1, and a detrimental effect on tendon healing. fair in 1. All 5 patients returned to their previous level of competition. Conclusions: At early follow-up, arthroscopic treatment of OCD lesions of the capitellum with microfracture resulted in improved range of motion, excellent elbow rating scores, and an excellent rate of re- 21 PECTORALIS MAJOR TRANSFER FOR TREATMENT OF turn to competitive sports. At long-term follow-up, arthroscopic treat- IRREPARABLE SUBSCAPULARIS TENDON TEARS: HOW WELL ment of lateral lesions with osteochondral autografts resulted in DOES IT REALLY WORK? good clinical elbow rating scores and excellent return to competitive Laurence D. Higgins, MD, Mehmet Ozbaydar, MD, Bassem sports. Elhassan, MD, David S. Diller, BA, Daniel Massimini, BS, Jon J. P. Warner, MD, Massachusetts General Hospital, Boston, MA Introduction: Pectoralis major transfer (PMT) has been reported as a reasonable alternative in the treatment of irreparable subscapu- 23 CORTICOSTEROID INJECTION FOR LATERAL ELBOW laris tears using a number of methods. The purpose of this study was PAIN: A RANDOMIZED PLACEBO CONTROLLED CLINICAL to evaluate our experience with this procedure in a variety of scenar- TRIAL ios associated with subscapularis tendon failure. Methods: Between Marjolijn Henket, MD, Anneluuk L. C. Lindenhovius, MSc, Jamie 2000 and 2005, 33 patients (19 men and 14 women; average Cowan, BA, Santiago Lozano-Calderon, MD, Chaitanya S. age, 49 years) who had PMT for the treatment of irreparable subsca- Mudgal, MD, Jesse B. Jupiter, MD, David Ring, MD, PhD, J Shoulder Elbow Surg ASES Abstracts e11

Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA Hypothesis: Corticosteroid injection is often used for treatment of lateral epicondylitis despite poor scientific support. We performed a randomized clinical trial comparing dexamethasone injection with injection of lidocaine alone (placebo) for treatment of lateral epicondylitis. Methods: The protocol enrolled 64 patients (27 men, 37 women): 31 dexamethasone and 33 placebo. This abstract is based on preliminary data from 44 patients (20 dexamethasone, 24 placebo) who completed the protocol. At the initial visit we evaluated depression (Center for Epidemiologic Studies Depression), pain catastrophizing (PCS), neuroticism (Eysenck Personality Questionnaire- Revised) and baseline Disabilities of the Arm, Shoulder and Hand (DASH). At 1 and 6 months we recorded pain and satisfaction using visual analogue scales (p-VAS, s-VAS), DASH score, and grip strength. Results: From enrollment to 1 month to 6 months after injection, the mean DASH score improved from 28.3 to 26.6 to 12.5 in the placebo group and from 31.2 to 25.6 to 18.9 in the dexamethasone group. The mean p-VAS score improved from 5.9 to 3.7 to 2.5 in the dexamethasone group and from 4.8 to 4.3 to 1.7 in the placebo group. The mean s-VAS improved from 6.5 to 8.5 in the placebo group and from 4.7 to 6.9 in the dexamethasone group. The improvements within each cohort were statistically significant, but the differences between cohorts were not. A positive correlation between DASH scores and depression (r ¼ 0.64, P < .01) and poor coping/catastrophizing (r ¼ 0.65, P < .01) was found at all visits. Conclusion: Lateral epicondylitis is a benign, self-limiting tendinosis of middle age. Perceived disability from this condition is strongly related to depression and poor coping mechanisms. Dexamethasone injection did not provide significantly better pain relief or perceived improvement in disability than placebo at any time point. Corticoste- roid injection is not an evidenced-based treatment of lateral epicondylitis. Figures 1 and 2 The mean 61 SD angulation of the forearm in the varius orientation for (Fig 1) pronated and (Fig 2) supinated flexion (n ¼ 5). The larger the initial tension, the more the elbow tracked in valgus. 24 LATERAL COLLATERAL LIGAMENT REPAIR OF THE ELBOW USING TRANSOSSEOUS SUTURES RESTORES JOINT to over-tighten the ligament and pull the elbow into valgus. These KINEMATICS AND STABILITY data suggest that acute repair of the LCL using a transosseous suture Gilliam S. Fraser, BSc, Graham J. King, MSc, MD, FRCSC, James A. technique should be performed with a tension of 20N or perhaps Johnson, PhD, Jamie E. Pichora, MSc, Louis F. Ferreira, BESc, less to restore stability. Jamie R. Brownhill, BEng, University of Western Ontario, London, Ontario, Canada Purpose: This in vitro study evaluated the influence of ligament tensioning and the effectiveness of lateral collateral ligament (LCL) 25 CLINICAL OUTCOMES OF THE DANE TJ TECHNIQUE TO repair using transosseous sutures on the initial kinematics and stabil- TREAT ELBOW MCL INSUFFICIENCY ity of the elbow. Methods: Six fresh upper extremities were mounted Joshua S. Dines, MD, Neal S. ElAttrache, MD, John Conway, MD, in a motion simulator with tracking system, which enabled both pas- Wade Smith, PA-C, Christopher A. Ahmad, MD, Kerlan Jobe Ortho- sive and simulated active elbow flexion. The elbow with an intact paedic Clinic, Los Angeles, CA LCL was tested then sectioned from its humeral origin and repaired Introduction: Ulnar collateral ligament (UCL) insufficiency of the with a transosseous suture technique. Locking sutures were placed in elbow is a potentially career-ending injury in professional athletes. the LCL and passed through a humeral bone tunnel entering at the Because of an increased understanding of the relevant anatomy center of curvature of the capitellum, with exit holes in the lateral epi- and improved surgical techniques, modifications to the original pro- condyle. An actuator pulled on the sutures to achieve 20, 40, and cedure have allowed surgeons to better restore normal elbow kine- 60 N of LCL repair tension, and the sutures were then secured. matics with improved strength of the reconstructed ligament. The dependent variable of this study was the motion pathways of Previously, the senior author (NE) published a biomechanical evalu- the ulna relative to the humerus. The data were analyzed using ation of a novel UCL reconstruction technique using interference a 2-way, repeated-measures analysis of variance with relevant screw fixation, which showed that load to failure with this technique post hoc paired t tests. Results: With the arm oriented in the horizon- was 90% that of the native ligament. Further modification of the tech- tal position under varus gravity loading, the repairs tracked in nique involved the combining of Altchek’s docking technique (DA) greater valgus than the intact LCL regardless of the repair tension. proximally with interference screw fixation on the ulna. This has The larger the initial repair tension, the more the elbows tracked been called the DANE TJ method, and in this paper we present in valgus. Initial tension of 60 N was statistically different than the the preliminary results of this new technique. Methods: During a 3- intact LCL with the forearm in pronation (P ¼ .04; Figure 1). Both year period, 22 athletes were treated with surgical reconstruction the 40 and 60 N initial tensions were statistically different than the of the UCL using proximal docking and distal interference screw fix- intact LCL with the forearm in supination (P <.01; Figure 2). Conclu- ation of the ligament (DANE TJ technique). All patients had a history sions: Repair of the LCL using transosseous sutures effectively re- and physical examination consistent with UCL injury and a magnetic stored the initial varus stability of the elbow. The initial tension of resonance imaging (MRI) study demonstrating pathology in the LCL repairs affected the kinematics of the elbow, with a tendency medial UCL. Patients were evaluated at a minimum of 2 years e12 ASES Abstracts J Shoulder Elbow Surg

postoperatively on the basis of their ability to return to previous levels findings during surgery or in the initial postoperative period that pre- of athletics. Outcomes were classified using a modified Conway dispose primary reconstructions to fail. This study, however, should Scale. Results: At the most recent follow-up, 19 of 22 patients had help physicians when counseling baseball players who suffer excellent results, and 2 had a fair result. One patient, who was a re- retears of their MCL. vision case, had a poor result, but the 2 other revision UCL reconstructions had excellent outcomes. In addition, when used in 2 cases of sublime tubercle avulsions, the results were excellent. Post- operative complications occurred in 4 patients: 2 developed ulnar 27 SURVIVORSHIP ANALYSIS OF THE GLENOID neuritis, and 2 required second surgeries for lysis of adhesions. COMPONENT IN TOTAL SHOULDER ARTHROPLASTY Three of these 4 patients went on to have excellent outcomes. Tyler J. Fox, MD, Akin Cil, MD, John W. Sperling, MD, Joaquin San- Conclusion: The DANE TJ technique is based on biomechanical stud- chez-Sotelo, MD, Cathy D. Schleck, BS, Robert H. Cofield, MD, ies that show increased biomechanical strength with interference Mayo Clinic, Rochester, MN screw fixation. Furthermore, it creates a more isometric ulna inser- Introduction: Total shoulder arthroplasty has become an increas- tion with decreased risk of ulna bone bridge fracture. Clinically, ingly common and successful procedure. However, despite improve- the preliminary results reported in this paper compare favorably ments in surgical technique, implant design and materials, and with other published techniques. These early data support the use instrumentation systems, glenoid component loosening and wear of the DANE TJ technique for revision cases and cases of sublime are perceived as major modes of failure of total shoulder arthro- tubercle insufficiency. plasty. Currently, there is limited information about the survivorship of different glenoid component designs. The purpose of this study is to determine the length of survival of several different glenoid component designs implanted at our institution, with the end points of 26 REVISION SURGERY FOR FAILED ELBOW MEDIAL mechanical failure or revision. Methods: Our institutional Mayo COLLATERAL LIGAMENT RECONSTRUCTION Clinic Joint Registry database was searched to identify all patients Joshua S. Dines, MD, Lewis A. Yocum, MD, Neal S. ElAttrache, MD, who received a primary total shoulder arthroplasty at the Mayo Joshua B. Frank, MD, Ralph Gambardella, MD, Frank Jobe, MD, Clinic between January 1, 1984, and December 31, 2004. Patients Kerlan Jobe Clinic, Los Angeles, CA were divided into 6 groups based on the type of glenoid component Introduction: Despite the fact that excellent results may be implanted: cemented all-polyethylene Cofield I component, achieved in up to 90% of primary elbow medial ulnar collateral lig- uncemented metal-backed Cofield I component, cemented all-poly- ament (UCL) reconstructions, retears of the ligament have been re- ethylene Neer II component, cemented metal-backed Neer II compo- ported. In 1 large series, the incidence of retear was 2%. As the nent, cemented all-polyethylene keeled Cofield II component, and number of primary reconstructions continues to increase, one can cemented all-polyethylene pegged Cofield II component. Kaplan- expect a commensurate increase in the number of revision medial Meier analysis was used to determine the comparative survivorship collateral ligament (MCL) reconstructions performed. This is the first of these different glenoid component designs free of revision for me- report to look solely at the results of revision MCL surgery. We hy- chanical failure or loosening of the glenoid component. Where ap- pothesized that, given the difficulty associated with revision proce- propriate, univariate or multivariable analysis, or both, were dures, the complication rate relative to primary reconstructions performed to compare component survival vs gender, age, cement would increase while the percentage of athletes returning to their status, and operative diagnosis. Results: A search of the joint registry previous level of play would decrease. Methods: This was a retro- identified 1542 total shoulder arthroplasties in 1431 patients per- spective review of 15 patients who underwent revision surgery for formed during the indicated time period, and 121 shoulders were retear of a reconstructed elbow MCL. All patients had undergone revised for mechanical failure or loosening of the glenoid compo- previous elbow MCL reconstruction and had new history and phys- nent. The survival rates with 95% confidence intervals (CI) for ical examination findings consistent with UCL injury. There were 12 each of the respective glenoid component designs are displayed professional baseball players and 3 college-level players at the time in the Table I. In addition to revision for glenoid component reasons, of their revision procedure. Patients were evaluated at a minimum of 51 shoulders underwent reoperation for other reasons, with reten- 2 years after revision surgery. Outcomes were classified using the tion of the glenoid component. Within the Cofield I metal-backed Conway Scale. Results: Average time to revision was 36 months. group, primary shoulder arthroplasties performed on men and after The Jobe technique was used in 11 cases; DANE TJ in 3, and pri- trauma resulted in poorer glenoid survival, with hazard ratios of mary repair in 1. Of these, 33% (5 of 15 excellent) returned to their 2.50 (95% CI, 1.48-4.28; P < .001) and 1.95 (95% CI, 1.09- previous level of play for at least 1 season. In addition, there were 4 3.47; P ¼ .02), respectively. Cofield II all-polyethylene glenoids good, 2 fair, and 4 poor results. Six (40%) patients had complica- compared with Neer II all-polyethylene glenoids showed improved tions; 1 of which required a subsequent surgery for lysis of adhe- survival at 5 years, with a hazard ratio of 0.15 (95% CI, 0.03- sions. There was 1 retear of the MCL. Conclusion: The rate of 0.84; P ¼.03. Conclusions: The comparison of survivorship rates be- return to play after revision MCL surgery is much lower than after pri- tween the various glenoid component designs implanted at our insti- mary reconstruction. As was expected, the complication rate of revi- tution demonstrates that the metal-backed uncemented glenoid sion surgery is higher as well. Future studies may help elucidate design had higher revision rates than did cemented counterparts.

Table I Survival rates of component designs

Survival % (95% conﬁdence interval) Component No. Mean age 5 yrs 10 yrs 12 yrs 15 yrs

Neer II all-poly 99 63 96 (92-100) 96 (92-100) 94 (89-100) Neer II metal-backed 254 65 96 (94-99) 94 (91-97) 89 (85-94) Cofield I metal-backed 316 65 86 (82-90) 79 (74-84) 67 (59-76) Cofield I all-poly 18 55 94 (84-100) 94 (84-100) 87 (71-100) Cofield II all-poly keeled 497 67 99 (98-100) 94 (91-98) 89 (79-100) Cofield II all-poly pegged 358 67 99 (98-100) J Shoulder Elbow Surg ASES Abstracts e13

Coﬁeld II all-polyethylene pegged cemented components showed more accurate glenoid component placement relative to traditional statistically improved survival rates at 5 years compared with the ini- techniques. More accurate glenoid implantation may improve pros- tial Neer II all-polyethylene components. Within the Coﬁeld I metal- thetic longevity and decrease the revision rate in the clinical setting. backed group, primary total shoulder arthroplasty performed on Computer-assisted surgery can produce improved accuracy and re- men and for a diagnosis of trauma or posttraumatic arthritis had liability of glenoid implantation in total shoulder arthroplasty. higher revision rates.

29 MANAGEMENT OF GLENOHUMERAL ARTHRITIS IN YOUNG PATIENTS WITH BIOLOGICAL RESURFACING OF THE 28 IMPROVED ACCURACY AND RELIABILITY OF GLENOID COMPUTER-ASSISTED GLENOID IMPLANTATION IN TOTAL Jon J. P. Warner, MD, Mehmet Ozbaydar, MD, Bassem SHOULDER ARTHROPLASTY: A RANDOMIZED CONTROLLED Elhassan, MD, David S. Diller, BA, Daniel Massimini, BS, Massachu- TRIAL setts General Hospital, Boston, MA Duong Nguyen, MD, FRCSC, Louis Ferreira, BSc, Jamie Background: Biologic resurfacing of the glenoid, with or without Brownhill, PhD, Graham King, MSc, MD, FRCSC, Darren resurfacing of the humeral head, has been proposed as a treatment Drosdowech, MD, FRCSC, Kenneth Faber, MD, MHPE, FRCSC, option for younger patients with symptomatic osteoarthritis of the Jim Johnson, PhD, University of Western Ontario, London, Ontario, shoulder. The purpose of this study is to report our experience using Canada this approach in the management of young patients with glenohum- Introduction: Total shoulder arthroplasty has been shown to be eral arthritis. Method: Between 2000 and 2006, 19 patients (14 effective in relieving pain and restoring function in patients with de- men and 5 women) with an average age of 39 years underwent bi- bilitating shoulder arthritis. However, glenoid replacement remains ologic resurfacing of the glenoid. Achilles allograft was used in 17 challenging due to the difficult joint exposure and visualization of patients, anterior capsule in 1 patient, and autogenous fascia lata in anatomic reference landmarks. Improper positioning of the glenoid 1 patient. Six patients underwent only an open de´bridement of the component can lead to early failure. This study evaluated a com- humeral head, 3 patients had resurfacing of the humeral head puter-assisted technique to achieve a more accurate and reliable with a stemless resurfacing implant (SRI), and 10 patients had hemi- placement of the glenoid component. We hypothesized that the arthroplasty. The average follow-up was 46 months (range, 12-102 computer-assisted technique would achieve a more accurate and re- months). Results were graded according to pain relief, subjective liable placement of the glenoid component compared with tradi- shoulder value, and improved function. Critical radiographic review tional methods. Methods: Sixteen paired cadaveric shoulders was also performed. Results: Thirteen patients (68%) required revi- were randomized to traditional or computer-assisted glenoid im- sion surgery at a mean of 15 months (range, 6-36 months) postop- plantation (CAGI). Both techniques were performed by 1 of 2 expe- eratively. The main reasons for revision were persistent pain and rienced shoulder surgeons. All phases of glenoid implantation were decreased range of motion. Radiographic evaluation at the time tracked and recorded by the computer. However, for the traditional of revision surgery showed a complete obliteration of the glenohum- technique, the surgeon was blinded with respect to the computer out- eral space in all patients. One of these patients was revised with an put. Preoperative planning using computed tomography (CT) imag- SRI and a meniscal allograft. The other 12 patients underwent revi- ing (Mimics, Materialise Medical, USA) with 3-dimensional (3D) sion to total shoulder arthroplasty. At the time of revision surgery, the modeling (Rhinoceros 3D, Robert McNeel and Associates, USA) allograft used to resurface the glenoid was found to be absent and and intraoperative tracking (Flock of Birds, Ascension Technologies, replaced by scar tissue in all patients. At an average follow-up of Burlington, VT) with feedback provided to the surgeon was used in 15 months (range, 6-36 months) after revision surgery, the pain the CAGI group. Custom jigs were developed to track instruments level, subjective shoulder value, and Constant scores improved in and to correct for scapular motion. A standardized protocol for all patients (P ¼.003). Six patients did not undergo revision surgery, quantifying the glenoid center, version, inclination, and ultimate gle- and 2 of them had good functional outcomes in terms of pain relief noid component placement and orientation was used. Results: The and improved range of motion. However, the remaining 4 patients mean native glenoid version and inclination were, respectively, – had persistent pain and limited range of motion, and 1 was sched- 5.2 6 5.0 and 3.0 6 5.7 for the CAGI group and –5.9 6 uled for a revision surgery. Conclusion: Management of glenohum- 5.9 , 0.5 6 2.9 for the traditional group (P > .05). There was eral arthritis with biologic resurfacing of the glenoid should be no significant demographic difference between the groups (P > performed with caution. It does not improve surgical outcomes, .05). The quality of the bone and soft tissues were similar in both and the graft does not remain as a structurally competent tissue. groups. The computer-assisted technique was more accurate in This is reflected by the high failure rate and need to perform revision achieving the correct version during all phases of glenoid implanta- surgery in our reported patients. tion (P < .05 paired t test; 80% power). The mean absolute error (from the target value of 0) in glenoid version was greater for the traditional technique (7.4 6 3.8) compared with 1.5 6 1.9 for the computer-assisted method (P < .05). The error was minimal 30 MENISCAL ALLOGRAFT GLENOID RESURFACING IN for the computer-assisted technique during the initial pin insertion CONJUNCTION WITH HEMIARTHROPLASTY: 1- TO 5-YEAR and reaming but increased during glenoid placement and cement- FOLLOW-UP ing. The largest error in version using the traditional method was ob- Michael A. Wirth, MD, University of Texas Health Science Center, served during the drilling of the peg holes (8.3 6 4.6; P < .05). San Antonio, TX The error was also significant during reaming (7.0 6 3.9; P < Introduction: Soft tissue interposition using a meniscal allograft is .05) where visualization was obscured by the reamer heads. There gaining interest as a biologic means of resurfacing the glenoid in was no significant difference in accuracy of the glenoid component young patients with glenohumeral arthritis. Published reports have placement with respect to inclination angles (P >.05) or in accuracy described several advantages of meniscal allografts over other between the 2 surgeons (P > .05). In the traditional group without methods of biologic resurfacing, including the evidence for syno- navigation, all components were implanted in too much retrover- vial-based healing in the knee, improved structural characteristics, sion. This was particularly true in the setting of excessive retroversion and a wedge shape that compensates for glenoid wear while con- of the native glenoid, when even the experienced surgeons had tributing to the concavity-compression mechanism of shoulder stabil- difficulty deciding on the correct orientation of the implanted ity. This study presents the results of 27 patients with 1- to 5-year glenoid component. Conclusions: Preoperative planning using CT follow-up. Methods: Thirty consecutive patients underwent hemiar- imaging with 3D modeling and intraoperative tracking results in throplasty and glenoid resurfacing with a meniscal allograft, and e14 ASES Abstracts J Shoulder Elbow Surg

27 of these were reviewed at an average of 24 months (range, 12- 60 months) after the procedure. The average age was 45 (range, 27-55). The diagnosis was osteoarthritis in 10, posttraumatic degen- erative joint disease in 13, postreconstruction arthropathy in 3, and rheumatoid arthritis in 1. The technique for meniscal fixation was analogous to the method used for aortic or mitral valve replacement in cardiothoracic surgery. Initially, three commissural or segmenting sutures were placed around the perimeter of the glenoid, followed by additional sutures in each of the 3 zones. Results: Visual analog scales (VAS), the shoulder score index (SSI), and the simple shoulder test (SST) were obtained prospectively. The averages for elevation and external rotation, number of ‘‘yes’’ responses on the SST, and VAS scores for pain, function, and quality of life all demonstrated significant improvement. All radiographs demonstrated an improvement in the joint space. Two patients showed a progressive decline in outcome scores at an average of 14 months after the index procedure. At the time of reoperation, both meniscal grafts revealed near complete deterioration and loss of joint space radiographically. Discussion: Meniscal allograft resurfacing of the glenoid in conjunction with humeral head replacement arthroplasty Figure 1 Pain scores postoperatively. appears to be useful in younger patients with glenohumeral arthrosis: 25 of 27 patients demonstrated pain relief and improved function at a mean follow-up of 24 months. corded. In addition, preoperative and 6-week postoperative range of motion measurements and any postoperative complications were noted. Descriptive statistics were run on all of the recorded vari- ables. Four types of statistical analysis were used, including the stan- 31 AUTOLOGOUS PLATELET GEL REDUCES PAIN WITH dard t -test, nonparametric Wilcoxon test, the Fischer exact test, and TOTAL SHOULDER ARTHROPLASTY a repeated measures mixed model; P <.05 was considered signifi- Douglas P. Zavadil, MPS, CCP, LCP, Charles Craig Satterlee, MD, cant. Results: Forty patients were enrolled in the study. One patient Jaime M. Costigan, RN, David W. Holt, MA, CCT, Valerie K. in each group became outliers because they had complications un- Shostrom, MS, North Kansas City Hospital, North Kansas City, MO related to the platelet gel that extended their stay. Thus, the effective Introduction: Platelet-rich plasma application has been reported study population was 19 for each group. There was no significant during total knee replacement, with improved pain control, range of difference between the 2 groups for age, sex, preoperative platelet motion, and lower postoperative bleeding. Anticoagulated autolo- count, hemoglobin, leukocyte counts, or range of motion except for gous blood drawn preoperatively may be processed to yield plate- internal rotation. Although APG treatment appeared to increase the let-rich plasma. Platelet-rich plasma is then activated to an percentage of the patient’s preoperative hemoglobin seen at 24 and autologous platelet gel (APG) with thrombin and calcium chloride. 72 hours (P ¼.09), shorten the time required on the PCA pump (P ¼ This gel can be placed in the wound site of a total shoulder arthro- .13), and shorten their postoperative stay (P ¼ .12), none of those plasty to enhance healing and act as a hemostatic agent. We per- differences reached statistical significance. However in our study, formed a blinded, randomized, and controlled study comparing 2 APG significantly decreased our patients pain (P ¼ .007; Figure 1) groups of patients undergoing total shoulder arthroplasty for osteo- and their pain medicine requirement (P < .05; Figure 2) and in- arthritis, one with and one without the addition of APG. To our creased their internal rotation measurement (P < .05). Conclusion: knowledge, this is the first such study reported for shoulder arthro- The addition of APG during total shoulder arthroplasty has many the- plasty. Methods: After obtaining Institutional Review Board approval oretic advantages regarding hemostasis, wound healing, and infec- and informed consent, 40 eligible patients undergoing total shoul- tions. Indeed, we found it to be clinically and statistically beneficial der arthroplasty were prospectively enrolled in the study between May 2005 and June 2006. The patients were randomly assigned to the control group or the treatment group; and their designation was blinded to the patient and all parties involved in the postoperative care except the surgeon. All patients had a diagnosis of primary osteoarthritis and a preoperative platelet count greater than 100,000/uL. After the induction of anesthesia, the phlebotomy site was prepared, and 52 mL of blood was drawn off by the staff anesthesiologist using a 60-mL syringe containing 8 mL of anticoagulant (Medtronic Anticoagulant Citrate Dextrose Solution A). The blood was processed to produce 9 mL of platelet-rich plasma (PRP) and 20 mL of platelet-poor plasma (PPP). During surgery the plasma was mixed with calcium chloride and thrombin to form APG. Platelet- rich gel was applied to the bone and soft tissues of the surgical site deep to the deltopectoral interval, and the platelet-poor gel was applied to the subcutaneous tissue. All surgeries were performed by the same surgeon utilizing the same prosthesis in a similar manner. All patients received an interscalene block with general anesthesia, followed postoperatively by a fentanyl patient-controlled anesthesia (PCA) pump at standardized settings. Preoperative diagnosis, age, sex, date of surgery and discharge, preoperative platelet counts, platelet and leukocyte counts of the PRP and PPP fractions, hemoglobin levels postoperatively and at 24 and 72 hours postoperatively, pain scores, and postoperative narcotic use were re- Figure 2 Fentanyl requirements postoperatively J Shoulder Elbow Surg ASES Abstracts e15

in reducing postoperative pain and narcotic pain medicine use. We ical and radiologic evaluation. Mean follow-up was 39 months had no known complications related to its use. Although APG ap- (range, 24-95 months). Results: Nine reoperations (21%) and 10 peared to improve hemostasis and length of stay, these findings complications (23%) were encountered, including 4 infections were not statistically significant. Future studies including a larger pa- (leading to 2 resection arthroplasties), 2 instabilities, 1 glenoid frac- tient population might clarify this finding. ture (converted to hemiarthroplasty), and 1 axillary nerve palsy. Thirty-six patients (83%) were satisfied or very satisfied with their result. The adjusted Constant score improved from 29% preoperatively to 75% postoperatively (P < .0001), the Constant score for pain from 4 to 12 points (P < .0001), and active anterior elevation 32 REVERSE SHOULDER ARTHROPLASTY: INDICATIONS from 59 to 114 (P <.0001). Active rotations were limited. A pos- AND RESULTS OF THE FRENCH MULTICENTER STUDY itive postoperative hornblower test negatively influenced Constant Pascal Boileau, MD, Ryan T. Bicknell, MD, MSc, FRCSC, Chris score (42 points compared to 61.5 points, P ¼ .004) and external Chuinard, MD, MPH, University of Nice, Nice France rotation (–6 compared to 15, P ¼ .004). The lowest functional re- Background: The reverse shoulder arthroplasty (RSA) is becom- sults were observed in surgical neck nonunions (with 5 complica- ing increasingly common and the indications expanded. The objec- tions) and isolated greater tuberosity malunions. In type 4 fracture tive of this study is to report the indications and results of RSA in sequelae, patients who had an osteotomy or resection of the GT (n a large multicenter study. Methods: A retrospective, multicenter ¼ 9) had better forward flexion (140 compared to 110, P ¼ study was conducted including all RSA implanted between 1992 .026) and better Constant score (63 points compared to 46 points, and 2002 in five centers in France. Of 457 patients involved in P ¼ .07). Conclusions: RSA can be a surgical option in elderly pa- this study, 243 patients (53%) had cuff pathology: 149 had cuff tients with fracture sequelae, specifically for those with severe mal- tear arthropathy, 48 had massive cuff tears, and 45 had failed union (type 4 fracture sequelae) where hemiarthroplasty gives cuff surgery. Ninety-nine (22%) had revision of a previous arthro- poor results. By contrast, surgical neck nonunions (type 3) and iso- plasty, 60 (13%) had fracture-related problems, 26 (6%) had osteo- lated greater tuberosity malunions are at risk for low functional re- arthritis, and 2% each had rheumatoid arthritis, tumors, or other sults. The surgical technique and the remaining cuff muscles (teres conditions. A total of 389 (85%) shoulders were available for review minor) are important prognostic factors. Functional results are lower with greater than 2 years’ follow-up. The average age at review was and complications/reoperations rates are higher than those re- 75.6 years (range, 22-92 years). The average follow-up was 43.5 ported for RSA in cuff tear arthritis. months (range, 24-142 months). Results: Overall, significant improvement was noted in Constant scores for pain (3.5 to 12.1), activity (5.8 to 15.1), mobility (12.1 to 24.5), and strength (1.3 to 6.1; P <.0001). Active elevation improved, but active internal and external rotation did not. The results were dependent on the indication. Cuff tear arthropathy had the best results, whereas revision procedures had the worst. Young age, preoperative stiffness, teres minor 34 INTRAOPERATIVE AND EARLY POSTOPERATIVE deficiency, tuberosity nonunion, and preoperative complaints of COMPLICATIONS OF REVERSE TOTAL SHOULDER pain rather than loss of function tended to be associated with inferior REPLACEMENT: EXPERIENCE OF ONE SURGEON results. The deltopectoral approach tended toward greater active el- Carl Henry Wierks, MD, Edward McFarland, MD, Richard evation but greater risk of instability. Survivorship to the end points of Skolasky, MA, Johns Hopkins Hospital, Baltimore, MD revision and loosening was better for patients with rotator cuff prob- Background: Reverse total shoulder replacement is a treatment lems than for patients with failed prior hemiarthroplasty. The func- option for patients with symptomatic glenohumeral arthritis and a de- tional results were noted to deteriorate progressively after 6 years ficient rotator cuff. The purposes of this paper were to (1) evaluate in the cuff tear group, after 5 years in the revision hemiarthroplasty one surgeon’s experience with the intraoperative and postoperative group, after 3 years in the osteoarthritis group, and after 1 year in complications of this procedure, (2) determine risk factors for compli- the revision total shoulder arthroplasty group. Conclusions: The over- cations, and (3) compare our results to similar series in the literature. all results of RSA are satisfactory and predictable. Functional results Methods: We retrospectively reviewed a consecutive case series of improved with improved active elevation, but no improvement oc- 20 patients (mean age, 73 years; range, 44-88 years) who under- curred in active internal and external rotation. However, results went reverse total shoulder arthroplasty by one surgeon at our insti- are dependent on the etiology. tution, tabulating intraoperative and postoperative complications. Follow-up averaged 9 months (range, 3-21 months). Descriptive statistics were performed using SAS 9.1 (SAS Institute, Cary, NC). Student t test for continuous measures and c2 test of association for categoric measures was performed. The type I error rate was 33 RESULTS OF REVERSE SHOULDER ARTHROPLASTY IN set at P <.05. Results: Thirty-three complications occurred in 15 pa- PROXIMAL HUMERUS FRACTURE SEQUELAE tients (75%): 11 patients (55%) collectively had 22 intraoperative Lionel Neyton, MD, Pascal Garaud, Pascal Boileau, MD, Ryan complications, and 8 patients (40%) collectively had 11 postopera- Bicknell, MD, FRCSC, Christopher R. Chuinard, MD, University of tive complications. At an average radiographic follow-up of 9 Nice, Nice, France months (range, 3-21 months), 11 patients were found to have scap- Background: The results of nonconstrained arthroplasty in prox- ular notching, and 9 patients had heterotopic ossification. The intra- imal humeral fracture sequelae have been inconsistent. Our purpose operative complication rate for the first 10 patients (first cohort) was was to evaluate the results of reverse shoulder arthroplasty (RSA) in significantly less than that for the second 10 patients (second co- proximal humeral fracture sequelae. Methods: A multicenter retro- hort). Univariate logistic regression analysis revealed that individ- spective series of 45 consecutive patients operated on between uals in the second cohort were approximately 10% as likely to 1995 and 2003 was reviewed. Types of fracture sequelae included have an intraoperative complication as individuals in the first cohort cephalic collapse and necrosis in 8, chronic locked dislocation in 5, (odds ratio, 0.11; 95% confidence interval, 0.01, 0.84). Our intra- surgical neck nonunion in 7, severe malunion in 20, and isolated operative complication rate (55%) was significantly higher than that greater tuberosity malunion in 3). Twenty-six patients had surgical previously published in the literature. Conclusions: Reverse total treatment of the initial fracture, and 17 had nonsurgical treatment; shoulder replacement is a technically demanding procedure with a- 33 Delta and 10 Aequalis reverse prosthesis were implanted. potentially high rate of intraoperative and postoperative com- Mean age at surgery was 72.5 years (range, 57-86). One patient plications, which may be inversely proportional to a surgeon’s died, and 1 patient was lost to follow-up, leaving 43 patients for clin- experience. e16 ASES Abstracts J Shoulder Elbow Surg

35 RESULTS OF DEEP INFECTION AFTER A REVERSE 36 CLINICAL PRESENTATION OF PROPIONIBACTERIUM SHOULDER ARTHROPLASTY ACNES INFECTION FOLLOWING SHOULDER SURGERY Pascal Boileau, MD, Nicolas Jacquot, MD, Christopher Yen Yi-Meng, MD, PhD, Marilee P. Horan, BS, James Bennett, BA, Chuinard, MD, Ryan Bicknell, MD, FRCSC, Medical University of Peter J. Millett, MD, MSc, Steadman Hawkins Research Foundation, Nice, Nice, France Vail, CO Background: The reverse prosthesis is often considered as ‘‘the Purpose: Undiagnosed bacterial infections of the glenohumeral last chance procedure’’ because of few possibilities to reoperate joint can lead to septic arthritis and destruction of joint cartilage. In- or perform a revision in the case of postoperative complications. fections after shoulder surgery are rare. Some postsurgical infections Among those complications, deep infection is probably the most im- are detected immediately, but others are more insidious. Propioni- portant, because it compromises shoulder function and makes it dif- bacterium acnes is a low-virulent anaerobic bacillus that is com- ficult, if not possible, to eradicate the infection. However, the monly disregarded as a contaminant and may require prolonged management of deep infection after a reverse prosthesis is poorly culture to identify. However, P acnes is becoming increasingly impor- reported in the literature. As a result, there is no clear attitude de- tant as a pathogen after shoulder surgery. The purpose of this study fined that surgeons should follow when facing such a complication. was to describe the clinical course for the diagnosis and treatment of Moreover, with the increased number of reverse prosthesis im- P acnes infections in the shoulder. Methods: From November 2005 planted in recent years, associated complications such as infection to February 2007, 11 patients had positive cultures for P acnes. may be seen more frequently. The objective of this study is to report Eight of the patients were male and 3 were female. The average the epidemiology and results of treatment of deep infection after a re- age of the patients was 58 years (range, 24-81 years). Initial clinical verse shoulder arthroplasty. Methods: This is a multicenter retrospec- assessments included physical examination at presentation, pres- tive study involving 457 reverse prosthesis performed between ence of pain, swelling, redness, evaluation of shoulder range of mo- 1992 and 2002. Fifteen patients (3%; mean age, 71 6 9 years), tion, and surgical history. Blood infection markers, joint aspirates, presented with a deep infection. Eight were primary arthroplasties, and multiple tissue biopsies were obtained on each patient. A retro- and 7 were revision procedures. There were 5 associated perioper- spective chart review was conducted and the following information ative fractures and 3 early postoperative complications requiring for each patient was obtained: diagnosis, blood white blood cell surgical treatment. Infection was treated by de´bridement in 4, pros- (WBC) count, erythrocyte sedimentation rate (ESR), blood C-reactive thetic resection in 10, or two-stage revision in 1. Results: The infec- protein (CRP), time for positive culture, antibiotic, and surgical man- tion rate was 2% (8 of 363) for a primary reverse arthroplasty and agement. Results: All 11 patients sought treatment for shoulder pain 7% (7 of 94) for revisions. The infection was diagnosed at a mean of after shoulder arthroscopy or arthroplasty. Four patients underwent 17 months (range, 1-57 months) postoperatively, corresponding to rotator cuff repairs, and 7 had arthroplasty preformed. Two patients 2 acute (<2 months), five subacute (2 to 12 months) and 8 chronic presented with a fever, and 1 had swelling and drainage at the prior infections (>12 months). The most common pathogen was Propioni- surgery incision site. Four patients had recognized surgical infec- bacterium acnes in 6 cases (40%). The mean delay until surgical tions, and all underwent an irrigation and de´bridement with intrao- treatment was 4.9 months (range, 1-57 months), and the mean du- perative cultures and surgical pathology. Six of the 7 arthroplasty ration of antibiotic therapy was 5 months (range, 2-27 months). At patients had implant removal with addition of an antibiotic spacer. a mean follow-up of 34 6 19 months, there were 12 remissions WBC levels at the time of surgery were normal in 10 of 11 patients. (80%) and 3 recurrent infections. The 2 acute infections (1 de´bride- Six of 9 patients had normal CRP levels, and 5 of 8 had normal ESR ment and 1 resection) and the 8 chronic infections (7 resections and levels. All patients had positive cultures of P acnes, which took an av- 1 two-stage revision) were in remission. Among the 5 subacute in- erage of 7 days (range, 5-10 days) to grow in culture. Only 2 of the fections, the 2 resections were in remission, whereas the 3 de´bride- 11 patients had developed acute infections of less than 3 months. Av- ments recurred. Overall, the 10 resections were in remission, with 7 erage time from surgery to diagnosis of with P acnes infection was patients disappointed and 3 satisfied, a mean Constant score of 31 72 months (range, 1-232 months). Patients were treated with 6 6 8 points, and a mean active anterior elevation of 53 6 15. The weeks of intravenous antibiotic therapy. Conclusions: Reports of P 2-stage exchange was in remission but remained disappointed, acnes infections in the literature are rare. The diagnosis of P acnes with a Constant score of 27 points and an active anterior elevation can be difficult because of varied clinical and laboratory tests. In of 90. Conclusions: Infection compromises the functional results of our study, patients that presented with abnormal pain after shoulder the reverse prosthesis whatever the treatment performed. Acute in- surgery were suspected to have infections. Fever, swelling, or drain- fections appear to be satisfactorily treated by de´bridement or resec- age was not usually observed at presentation. CRP and ESR levels tion. Both resection and 2-stage revision can successfully treat were inconsistent, while the WBC levels were normal. If P acnes in- subacute and chronic infection; however, de´bridement alone is inef- fections are suspected, we recommend obtaining multiple synovial fective and not recommended. Surgeons should be aware of the fluid cultures as well as surgical tissue biopsies for prolonged growth high rate of infection when the reverse prosthesis is used in revision on culture media. Cultures should be grown for a minimum of 7 days, arthroplasty. Prevention, by looking for such infection before sur- because shorter incubation times may not be enough time for posi- gery and by performing a 2-stage procedure, is recommended in tive results. Once P acnes is confirmed, surgical de´bridement and the case of any uncertainty. appropriate intravenous antibiotic therapy is necessary.