A systematic review of randomized control trials looking at functional improvement of rotator cuff partial thickness tears following platelet-rich-plasma injection: a comparison of glenohumeral joint vs. subacromial bursa vs. intratendinous injection locations.

Background: Prior research has demonstrated that platelet-rich plasma (PRP) has shown promising results in the treatment of knee osteoarthritis, lateral epicondylitis, and rotator cuff disease. However, there is a lack of standardization with PRP regarding its use for partial thickness rotator cuff tears (PTRCTs). The primary objective of this review is to assess the location of PRP injections in the shoulder, and how it corresponds to shoulder functional outcomes in PTRCTs. Methods: Data sources included randomized controlled trials (RCTs) conducted between January 2010 and September 2021 with the terms PRP, partial thickness rotator cuff tears, intra-articular injections, subacromial injections, and intratendinous injections. Major inclusion criteria: partial thickness rotator cuff tears only, functional outcome scores pre-injection and post-injection, minimum 2-month follow-up time, and nonsurgical PRP injections only. Major exclusion criteria: PRP used as an adjunct therapy, full-thickness rotator cuff tears, and surgical intervention before treatment. Results: A total of 8 RCTs were included which utilized PRP injected into the shoulder for PTRCTs. Studies were grouped by the location of the injection with the following breakdown: 1 glenohumeral joint, 4 subacromial bursa, and 3 intratendinous as the site of injection of PRP. Intra-articular PRP showed a 46.2% improvement (P < .05) in the Disabilities of the Arm, Shoulder, and Hand score at 12-month follow-up, however PRP compared to physical therapy had no statistical difference. For subacromial injections, one study showed no statistical difference between hyaluronic acid and PRP vs PRP, but both groups showed improvement compared to normal saline at 3, 6, and 12 months (P < .05). For intratendinous injections, PRP was found to be superior in the Shoulder Pain and Disability Index scores at 66.1% improvement (P < .05) at 3 months and 71.6% at 6 months (P < .05) after two PRP injections when compared to dry needling. Another study showed a statistically significant difference in ASES score when combining LP-PRP injection intratendinous and subacromial bursa when compared to corticosteroid at 3 months. Furthermore, at 6-month follow-up, the PRP group showed significant improvement in the Oxford Shoulder Score compared to a subacromial bursa corticosteroid group 53.8% vs 31.7% (P < .01). Conclusion: Based on our review of current literature, there is inconclusive evidence of the ideal location to inject PRP when partial rotator cuff tear is present. Despite PRP showing improved functional outcomes in patients diagnosed with PTRCT regardless of the injection site, more research is needed to figure out the optimal concentration of PRP, frequency of injection, and who are ideal candidates when utilizing PRP for PTRCTs.

Surgeon Performance as a Predictor for Patient-Reported Outcomes After Arthroscopic Partial Meniscectomy.

Background: Surgeon performance has been investigated as a factor affecting patient outcomes after orthopaedic procedures to improve transparency between patients and providers. Purpose/Hypothesis: The purpose of this study was to identify whether surgeon performance influenced patient-reported outcomes (PROMs) 1 year after arthroscopic partial meniscectomy (APM). It was hypothesized that there would be no significant difference in PROMs between patients who underwent APM from various surgeons. Study Design: Case-control study; Level of evidence, 3. Methods: A prospective cohort of 794 patients who underwent APM between 2018 and 2019 were included in the analysis. A total of 34 surgeons from a large multicenter health care center were included. Three multivariable models were built to determine whether the surgeon-among demographic and meniscal pathology factors-was a significant variable for predicting the Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain subscale, the Patient Acceptable Symptom State (PASS), and a 10-point improvement in the KOOS-Pain at 1 year after APM. Likelihood ratio (LR) tests were used to determine the significance of the surgeon variable in the models. Results: The 794 patients were identified from the multicenter hospital system. The baseline KOOS-Pain score was a significant predictor of outcome in the 1-year KOOS-Pain model (odds ratio [OR], 2.1 [95% CI, 1.77-2.48]; P < .001), the KOOS-Pain 10-point improvement model (OR, 0.57 [95% CI, 0.44-0.73), and the 1-year PASS model (OR, 1.42 [95% CI, 1.15-1.76]; P = .002) among articular cartilage pathology (bipolar medial cartilage) and patient-factor variables, including body mass index, Veterans RAND 12-Item Health Survey-Mental Component Score, and Area Deprivation Index. The individual surgeon significantly impacted outcomes in the 1-year KOOS-Pain mixed model in the LR test (P = .004). Conclusion: Patient factors and characteristics are better predictors for patient outcomes 1 year after APM than surgeon characteristics, specifically baseline KOOS-Pain, although an individual surgeon influenced the 1-Year KOOS-Pain mixed model in the LR test. This finding has key clinical implications; surgeons who wish to improve patient outcomes after APM should focus on improving patient selection rather than improving the surgical technique. Future research is needed to determine whether surgeon variability has an impact on longer-term patient outcomes.

What is the Efficacy of Intra-Articular Platelet-Rich Plasma Injections for Knee Osteoarthritis in Clinical Practice? A "Real-Life" Prospective Cohort.

INTRODUCTION: Platelet-rich plasma (PRP) injections may improve symptoms in patients suffering from knee osteoarthritis. However, there is a lack of data on its effectiveness in a "real-life" cohort. This multi-site institutional registry study aimed to assess patients' longitudinal progress after PRP injection for knee osteoarthritis. MATERIALS AND METHODS: All patients receiving PRP injections for knee osteoarthritis at a large, integrated tertiary academic center (December 18, 2017 to March 1, 2021) were eligible. A prospective data collection instrument was used to collect patient demographics, procedural information, and patient-reported outcome measures. Overall, 97 patients met the inclusion criteria, and 53 were included in the analysis. RESULTS: One in four patients (26%) improved on all three Knee Injury and Osteoarthritis Outcome Score subscales: 17% in two subscales and 20% in one subscale, respectively. Overall, 64% of patients improved in at least one patient-reported outcomes measure. At six months post injection, 49% of patients were satisfied. CONCLUSION: PRP injection provides positive changes in two out of three patients in different magnitudes and characteristics with careful attention to clinically meaningful differences.

An integrated educational and multimodal approach to achieving an opioid-free postoperative course after arthroscopic rotator cuff repair.

BACKGROUND: In the realm of shoulder surgery, arthroscopic rotator cuff repair (RCR) is one of the most painful procedures and is often associated with higher opioid consumption. The purpose of this study was to evaluate effectiveness of preoperative and postoperative patient education and multimodal pain management to achieve an opioid-free postoperative recovery after RCR. METHODS: Sixty patients who underwent RCR were divided in 2 groups. All patientsreceived an interscalene nerve block and multimodal pain management. The opioid intervention group (OIG) in addition received preoperative education on expectations of pain, non opioid pain protocols, and alternate therapiesto minimize pain as well as customized postoperative instructions. Patients were compared on pain levels, opioid consumption, and outcomes scores preoperatively and at 48 hours, 2 weeks, and final follow-up. Patient-reported outcomes and opioid usage were compared and analyzed using student's t-tests and logistic regression. RESULTS: At 48 hours, 15% of OIG patients reported use of rescue opioids after surgery compared with 100% of control group patients. Zero percent of OIG patients reported opioid use at 2 weeks compared to 90% of control group patients (P = .0196). Patients in both groups showed significant improvements in all outcome scores (P ≤ .05). At 6 weeks, functional, Constant, and satisfaction outcome scores were all higher in the OIG (P < .05). At last follow-up, there were no significant differences for all patient-reported outcomes between groups. CONCLUSIONS: Application of patient education tools and innovative multimodal pain management protocols successfully eliminates the need for opioids while maintaining excellent patient satisfaction and outcomes.

Innovative patient education and pain management protocols to achieve opioid-free shoulder arthroplasty.

BACKGROUND: The creation of pain as the fifth vital sign led to skyrocketing opioid prescriptions and a crisis with addiction and abuse among Americans. The purpose of this study was to evaluate the effectiveness of a patient engagement model including education and innovative opioid-free multimodal pain management to achieve an opioid-free recovery after shoulder arthroplasty (SA). METHODS: Fifty patients undergoing SA were divided into 2 groups. In the opioid-free group (OFG), patients received additional preoperative education in combination with an innovative non-opioid multimodal pain management protocol and non-opioid alternatives. Patients were compared regarding pain levels and opioid consumption at 48 hours and at 2 weeks, as well as patient-reported outcome measures, using Student t tests. RESULTS: No significant differences were found in age (average, 69.76 years) (P = .14), American Society of Anesthesiologists grade (average, 2.25) (P = .24), sex, body mass index (average, 29.5) (P = .34), or comorbidity burden. In the OFG, 24% of patients reported use of rescue opioids (<2 pills) within the first 48 hours after surgery with complete cessation by 2 weeks postoperatively. Comparatively, in the control group, 100% of patients reported using opioids in the first 48 hours after surgery and 80% reported still taking opioids at 2 weeks postoperatively. Patients in both groups showed significant improvements in outcome scores (P ≤ .05), with the OFG reporting significantly higher American Shoulder and Elbow Surgeons pain (P = .036) and Constant (P = .005) scores. CONCLUSIONS: Our findings support complete elimination of opioid use by 2 weeks after SA using a patient engagement model with non-opioid-based alternative pain management. The elimination of opioid pain management did not diminish outcomes or patient satisfaction after SA.

How orthopedic surgeons can impact opioid use and dependence in shoulder arthroplasty.

BACKGROUND: Considering that the United States is facing a crisis with opioid misuse and orthopedists are the third largest provider of these prescriptions, it is important to delineate risk factors associated with use and dependence. Our purpose was to identify risk factors for and patient characteristics of increased opioid use and postoperative opioid dependence in total shoulder arthroplasty (TSA) patients. METHODS: This was a retrospective study of 752 TSA patients who underwent surgery in 1 health care system from 2012-2016. Recorded variables included demographics and opioid prescriptions from prescription drug monitoring programs. Preoperative and postoperative opioid dependence was defined as continuous opioid prescriptions for at least 3 months prior to or after surgery. Statistical analyses and odds ratio analyses were performed. RESULTS: Of the 752 patients in total, 241 (32%) became or remained postoperatively dependent whereas 68% (511) were able to wean off of opioids by 3 months. In the preoperatively dependent cohort, only 27% were able to wean off opioids at 1 month and 53%, by 3 months postoperatively. Odds ratio calculations showed that patients with preoperative opioid use had a 3.52 (95% confidence interval, 2.433-5.089) times increased risk of postoperative dependence compared with opioid-naive patients. Of those receiving postoperative opioid refills, 69% were provided these refills by their orthopedic surgeons. DISCUSSION AND CONCLUSIONS: Although the majority of TSA patients weaned off of opioids after surgery, our results demonstrate a 3.5 times higher risk of postoperative dependence in patients who used preoperative opioids. Orthopedists were major contributors to continued postoperative opioid use, and increased efforts to minimize opioid prescriptions before, during, and after TSA may help curtail overuse and dependence. These results highlight the hazard that preoperative opioid use entails for shoulder arthritis patients.

Can patient and fracture factors predict opioid dependence following upper extremity fractures?: a retrospective review.

BACKGROUND: Since the early 1990s, opioids have been used as a mainstay for pain management surrounding fracture injuries. As opioid dependence has become a major public health issue, it is important to understand what factors can leave patients vulnerable. The purpose of this study was to examine what risk factors, patient or injury severity, contribute most to postoperative opioid dependence following surgical treatment of proximal humerus fractures (PHFs). METHODS: A retrospective review of all patients who underwent an open reduction and internal fixation of PHF was performed within a large multisite hospital system. Recorded variables included age, gender, ASA class, BMI, fracture type, time to surgery, pre- and postoperative opioid prescriptions, physical and psychological comorbidities, smoking status, and complications. Pre- and postoperative opioid dependence was defined as prescription opioid use in the 3 months leading up to or following surgery. Odds ratio calculations were performed for each variable, and a multivariate logistic regression was used to compare all predictors. RESULTS: A total of 198 surgically treated PHFs were included in the cohort with an average age of 59.9 years. Thirty-nine cases were determined to be preoperatively opioid dependent while 159 cases were preoperatively opioid naïve. Preoperative opioid dependence was found to be a significant risk factor for postoperative narcotic dependence, carrying a 2.42 times increased risk. (CI 1.07-5.48, p = 0.034). Fracture type was also found to be a risk factor for postoperative dependence, with complex 3- and 4-part fracture patients being 1.93 times more likely to be opioid dependent postoperatively compared to 2 part fractures (CI 1.010-3.764, p = 0.049). All other factors were not found to have any significant influence on postoperative opioid dependence. CONCLUSIONS: Our results demonstrate that the most important risk factors of postoperative opioid dependence following proximal humerus fractures are preoperative dependence and fracture complexity. It is important for orthopedic surgeons to ensure that patients who have more complex fractures or are preoperatively opioid dependent receive adequate education on their increased risk and support to wean off of opioids following surgery. LEVEL OF EVIDENCE: III.

Glenohumeral Anatomic Study. A Comparison of Male and Female Shoulders with Similar Average Age and BMI.

INTRODUCTION: Numerous anatomic studies of the shoulder have quantified the size, shape, and variability of either the humerus or scapula individually. However, few have attempted to quantify the relationship of the humerus to the scapula to better understand the spatial variation of these bones in both male and female shoulders. METHODS: Seventy-four cadaveric shoulder CT scans (37 males and 37 females with statistically equivalent age and BMI) were reconstructed using Mimics ® to create 3D models of the humerus and scapula. After 3D reconstruction, each CT bone model was analyzed in Rapidform® to quantify the morphology of the humerus, scapula, and the spatial relationship between the two to better understand the role of gender on the morphological variability of the glenohumeral joint. RESULTS: Spatial glenohumeral relationships of male shoulders were significantly larger than female shoulders in 13 of 16 measurements; morphology of male humeri were significantly larger than female humeri in 17 of 24 measurements, and scapula and glenoid morphology of male shoulders were significantly larger than female scapula and glenoids in 11 of 22 measurements. DISCUSSION: Numerous significant gender differences in spatial relationships and morphology were identified in this anatomic study of the glenohumeral joint. An improved understanding of these observed binomial distributions has utility for shoulder arthroplasty prosthesis design, computer navigation, and may also be useful to the orthopaedic surgeon during surgical preoperative planning.

The incidence of radiographic aseptic loosening of the humeral component in reverse total shoulder arthroplasty.

BACKGROUND: The reverse total shoulder arthroplasty (RTSA) has been used in the treatment of complex shoulder problems. The incidence of aseptic loosening of the humeral component has not been previously reported. METHODS: This is a multicenter, retrospective, blinded, case-control radiographic review of 292 patients to determine the rate of humeral stem loosening. There were 177 cemented and 115 press-fit humeral components. Radiographs were critiqued for radiolucent lines adjacent to the humeral stem based on the method described by Gruen et al. RESULTS: The overall rate of loosening was 0.74%. No radiographic loosening occurred in the press-fit group (115 stems). In the cemented group (177 stems), 2 shoulders (1.18%) were identified with radiographically loose stems. No loosening occurred in the press-fit group. No statistically significant difference was found in humeral stem loosening when the press-fit group and the cemented group were compared (P = .198). DISCUSSION: Our study indicates the cemented or press-fit RTSA system will result in a low incidence of radiolucent lines and radiographic loosening. Compared with historical survivorship of conventional anatomic total shoulder arthroplasty, RTSA shows a lower rate of radiographic stem loosening at a mean of 38.46 months. CONCLUSIONS: The RTSA has a low incidence of humeral stem loosening at midterm. These results underscore the importance of careful selection of patients to provide the benefits of this surgical technique. Press-fit fixation may provide a lower risk to stem loosening.

Outcome of Large to Massive Rotator Cuff Tears Repaired With and Without Extracellular Matrix Augmentation: A Prospective Comparative Study.

PURPOSE: To compare the results of arthroscopic repair of large to massive rotator cuff tears (RCTs) with or without augmentation using an extracellular matrix (ECM) graft and to present ECM graft augmentation as a valuable surgical alternative used for biomechanical reinforcement in any RCT repair. METHODS: We performed a prospective, blinded, single-center, comparative study of patients who underwent arthroscopic repair of a large to massive RCT with or without augmentation with ECM graft. The primary outcome was assessed by the presence or absence of a retear of the previously repaired rotator cuff, as noted on ultrasound examination. The secondary outcomes were patient satisfaction evaluated preoperatively and postoperatively using the 12-item Short Form Health Survey, the American Shoulder and Elbow Surgeons shoulder outcome score, a visual analog scale score, the Western Ontario Rotator Cuff index, and a shoulder activity level survey. RESULTS: We enrolled 35 patients in the study: 20 in the ECM-augmented rotator cuff repair group and 15 in the control group. The follow-up period ranged from 22 to 26 months, with a mean of 24.9 months. There was a significant difference between the groups in terms of the incidence of retears: 26% (4 retears) in the control group and 10% (2 retears) in the ECM graft group (P = .0483). The mean pain level decreased from 6.9 to 4.1 in the control group and from 6.8 to 0.9 in the ECM graft group (P = .024). The American Shoulder and Elbow Surgeons score improved from 62.1 to 72.6 points in the control group and from 63.8 to 88.9 points (P = .02) in the treatment group. The mean Short Form 12 scores improved in the 2 groups, with a statistically significant difference favoring graft augmentation (P = .031), and correspondingly, the Western Ontario Rotator Cuff index scores improved in both arms, favoring the treatment group (P = .0412). CONCLUSIONS: The use of ECM for augmentation of arthroscopic repairs of large to massive RCTs reduces the incidence of retears, improves patient outcome scores, and is a viable option during complicated cases in which a significant failure rate is anticipated. LEVEL OF EVIDENCE: Level III, prospective, blinded, nonrandomized, comparative study.

Biomechanical analysis of rotator cuff repairs with extracellular matrix graft augmentation.

Despite advances in surgical techniques, 20% to 90% of rotator cuff (RTC) repairs fail. They tend to fail at the suture-tendon junction due to tension at the repair and gap formation prior to healing. This study evaluated the gap formation and ultimate tensile failure loads of a RTC repair with a decellularized human dermal allograft. Augmentation of a RTC repair with an extracellular matrix graft decreased gap formation and increased load to failure in a human RTC repair model.

Arthroscopic repair of rotator cuff tears using extracellular matrix graft.

Despite advances in surgical technology, as well as generally good outcomes, repairs of full-thickness rotator cuff tears show a retear rate of 25% to 57% and may fail to provide full return of function. The repairs tend to fail at the suture-tendon junction, which is due to several factors, including tension at the repair site, quality of the tendon, and defective tissue repair. One strategy to augment repair of large to massive rotator cuff tears is the development of biological scaffold materials, composed of extracellular matrix (ECM). The goal is to strengthen and evenly distribute the mechanical load across the repair site, thus minimizing the rupture risk of the native tendon while providing the biological elements needed for healing. The promising results of ECM-derived materials and their commercial availability have increased their popularity among shoulder surgeons. In contrast to a traditional open or arthroscopically assisted mini-open approach, this completely arthroscopic technique offers the full advantages warranted by the use of a minimally invasive approach. This technical guide describes arthroscopic rotator cuff repair using an ECM graft technique.

Scapular notching in reverse shoulder arthroplasty: validation of a computer impingement model.

PURPOSE: The purpose of this study is to validate a reverse shoulder computer impingement model and quantify the impact of implant position on scapular impingement by comparing it to that of a radiographic analysis of 256 patients who received the same prosthesis and were followed postoperatively for an average of 22.2 months. METHODS: A geometric computer analysis quantified anterior and posterior scapular impingement as the humerus was internally and externally rotated at varying levels of abduction and adduction relative to a fixed scapula at defined glenoid implant positions. These impingement results were compared to radiographic study of 256 patients who were analyzed for notching, glenoid baseplate position, and glenosphere overhang. RESULTS: The computer model predicted no impingement at 0° humeral abduction in the scapular plane for the 38 mm, 42 mm, and 46 mm devices when the glenoid baseplate cage peg is positioned 18.6 mm, 20.4 mm, and 22.7 mm from the inferior glenoid rim (of the reamed glenoid) or when glenosphere overhang of 4.6 mm, 4.7 mm, and 4.5 mm was obtained with each size glenosphere, respectively. When compared to the radiographic analysis, the computer model correctly predicted impingement based upon glenoid base- plate position in 18 of 26 patients with scapular notching and based upon glenosphere overhang in 15 of 26 patients with scapular notching. CONCLUSIONS: Reverse shoulder implant positioning plays an important role in scapular notching. The results of this study demonstrate that the computer impingement model can effectively predict impingement based upon implant positioning in a majority of patients who developed scapular notching clinically. This computer analysis provides guidance to surgeons on implant positions that reduce scapular notching, a well-documented complication of reverse shoulder arthroplasty.

Addressing glenoid erosion in reverse total shoulder arthroplasty.

Severe glenoid wear is technically problematic, has a higher complication rate, and inferior results in the setting of shoulder arthroplasty. This paper introduces four basic strategies for treating glenoid erosion with a reverse shoulder arthroplasty which include; 1. eccentric reaming, 2. bone grafting of glenoid, 3. reaming and bone grafting, and 4. using augmented baseplates. The benefits and shortcomings of each of these techniques are discussed. The reverse shoulder arthroplasty has many advantages over anatomic shoulder arthroplasty when dealing with severe glenoid defects. Augmented baseplates are new and allow the surgeon to treat various different glenoid defects with preservation of glenoid subchondral bone.

Surgical outcome following arthroscopic fixation of acromioclavicular joint disruption with the tightrope device.

The objective of this study was to evaluate the preliminary radiographic and clinical results of grade IV and V acromioclavicular joint disruption repair using the arthroscopic Arthrex acromioclavicular TightRope (Naples, Florida) fixation technique. Numerous procedures have been described for surgical management of acromioclavicular joint disruption. The TightRope device involves an arthroscopic technique that allows nonrigid anatomic fixation of the acromioclavicular joint. A cohort of 10 men and 2 women with a mean age of 43 years (range, 25-61 years) underwent the acromioclavicular joint TightRope procedure between April 2007 and October 2009. Eleven patients had either Rockwood grade IV or V disruptions and 1 sustained a distal third clavicle fracture with acromioclavicular joint disruption. Data was collected from a chart review. Patients were evaluated clinically, radiographically, by the simple shoulder test, and by overall satisfaction. There were 2 failures of reduction and 1 loss of reduction at final radiographic follow-up. The rate of fixation failure was 16.6%. All patients had >110° of total elevation. The majority of patients obtained satisfactory functional results according to the Simple Shoulder Test averaging 11 of 12 questions answered positively (range, 7-12; standard deviation, 1.50) and 11 of 12 patients were satisfied with the procedure. At final phone interview at approximately 2 years postoperatively, 6 patients were lost to follow-up. The remaining patients were all satisfied with the procedure and no patients reported subjective loss of reduction or deterioration of function. Simple Shoulder Test average was maintained with 11 of 12 positively answered questions (range, 7-12; standard deviation, 2.0) This case series revealed a high rate of fixation failure with the TightRope system. Still, most patients were satisfied with the procedure and achieved high functional shoulder results.