No difference in postoperative pain after arthroscopic versus open rotator cuff repair.

BACKGROUND: Rotator cuff repair is a successful treatment in terms of patient satisfaction and pain relief regardless of the repair method. Although arthroscopic repair is commonly thought to be less painful than open or miniopen repair, studies disagree on this point. QUESTIONS/PURPOSES: We wished to compare the results of patient-reported postoperative pain after open versus arthroscopic rotator cuff repair and to identify any predictors of various pain outcomes in these groups. METHODS: One-hundred two patients (52 with open repair, 50 with arthroscopic repair) participated. Preoperatively, patients reported pain levels and self-perceived pain tolerance, and they underwent a test for an objective measurement of pain tolerance. Intraoperative variables included surgery duration and size of the tear. Postoperatively, patients maintained a pain log for 6 weeks, reporting daily pain (VAS) and narcotic consumption. Outcome variables included days to zero pain, the presence of residual pain, weekly pain levels, and cumulative 6-week pain level. Age, sex, tear size, pain tolerance, surgery duration, and self-reported preoperative pain were analyzed as possible predictors of postoperative pain. This study was powered (ß = 0.2 and α = 0.05) to detect a difference of 10% in the VAS and postoperative analgesic use with a requirement of 50 patients in each arm. RESULTS: Days to zero pain (mean, 28.8 days, 95% CI, 24.8-32.8 days versus 27.6 days, 95% CI, 23.3-31.9 days for open versus arthroscopic, respectively; p = 0.69) were not different between the open and arthroscopic repair groups. There were differences of questionable clinical relevance and borderline statistical significance favoring arthroscopic intervention in the second postoperative week (2.3 versus 3.2 of 10 on the VAS; p = 0.045). Otherwise, no differences were seen between the two groups in terms of residual pain, cumulative pain, or medication use. Consistent predictors of postoperative pain affecting multiple outcome measures included severe preoperative pain, smaller tear size, and female sex. CONCLUSIONS: There were no differences of clinically relevant size between arthroscopic and open rotator cuff surgery in this comparative series. Therefore, the choice of arthroscopic rotator cuff repair should not be based on decreased postoperative pain. LEVEL OF EVIDENCE: Level II, therapeutic study. See the Instructions or Authors for a complete description of levels of evidence.

Additional x-ray views increase decision to treat clavicular fractures surgically.

BACKGROUND: The trauma series for clavicular fractures includes anterior-posterior and 20° cephalic tilt radiographs. Management of clavicular fractures either nonoperatively or operatively is dependent on radiographs. We hypothesized that the interobserver and intraobserver reliability of the treatment decision would be improved with a novel 4-view radiographic series over the standard 2-view radiographic trauma series. METHODS: Four-view radiographic analysis was performed and consisted of anterior-posterior, 20° cephalic tilt, 45° cephalic tilt, and 45° caudal tilt. Radiographs were collected for 50 consecutive patients presenting with acute midshaft clavicular fractures. Four blinded orthopedists were asked to judge whether each case should be treated either operatively or nonoperatively based on the standard 2-view series and then the 4-view series a minimum of 1 week later. This procedure was repeated a minimum of 2 months later. The incidence of surgeon treatment modification was analyzed along with interobserver and intraobserver reliability of both series. RESULTS: In 17 cases, at least 1 surgeon changed the treatment decision between 2- and 4-view review. In 13 cases (26%), the treatment was changed from nonoperative to operative. Significantly greater intraobserver reliability was observed for the 4- versus 2-view series (R = 0.76 and R = 0.64, respectively), with no difference in interobserver reliability (intraclass correlation coefficient of 0.88 and 0.87, respectively). CONCLUSIONS: With the use of a novel 4-view radiographic series that includes orthogonal viewing angles, surgeons are more likely to treat clavicular fractures operatively and their intraobserver reliability is improved, suggesting improved visualization of anterior-posterior displacement.

Outcome of open reduction and internal fixation of surgical neck nonunions of the humerus.

OBJECTIVE: The purpose of this study was to evaluate the results of open reduction and internal fixation of nonunions of the surgical neck of the humerus. DESIGN: Retrospective review of patients who underwent operative treatment of a surgical neck of the humerus nonunion. SETTING: Shoulder and elbow service at two university centers. PATIENTS: Thirteen patients with a two-part nonunion of the surgical neck of the humerus who were treated with open reduction and internal fixation with bone graft with a minimum of 12 months' follow-up were included. Patients with avascular necrosis, posttraumatic arthritis, severe humeral head bone loss, or a nonunion of one of the two tuberosities were excluded. INTERVENTION: Open reduction and internal fixation with either a blade plate or a T-plate and autogenous bone graft. MAIN OUTCOME MEASURES: Medical records, operative reports, physical examination, and preoperative and postoperative radiographs were reviewed. Outcome was assessed using Neer's criteria for the evaluation of total shoulder arthroplasty, visual analogue pain scale, range of motion, and ability to perform activities of daily living.RESULTS The results were excellent in 11 patients, satisfactory in 1 patient, and poor in 1 patient. The 11 nonunions in patients with excellent results healed within 6 months. The patient with the poor result initially had a persistent nonunion and required revision, open reduction and internal fixation, and bone grafting. This patient healed and went on to have an excellent result at final follow-up. All fractures were healed at the time of this study. Pain scores decreased from an average of 4.2 preoperatively to 1.2 postoperatively on a 5-point pain scale. Forward elevation in the scapular plane improved from 24 degrees preoperatively to 144 degrees postoperatively. All patients but one were able to attain overhead elevation. All patients were able to perform activities of daily living, such as dressing, bathing, combing hair, and performing perineal care, at final follow-up. Overall satisfaction increased from an average of 1.0 to 9.4 on a 10-point visual analogue scale. CONCLUSIONS: Open reduction and internal fixation with autogenous bone graft results in excellent outcomes even in patients >65 years old and patients with significant medical problems. This treatment method offers predictable fracture healing and has a low complication rate.

Tuberoplasty: creation of an acromiohumeral articulation-a treatment option for massive, irreparable rotator cuff tears.

This article reports the results of treatment for irreparable tears of the rotator cuff with a new procedure that we have termed a tuberoplasty. The tuberoplasty procedure involves removal of exostoses on the humerus followed by reshaping of the greater tuberosity to create a smooth, congruent acromiohumeral articulation. The coracoacromial ligament is preserved, and an acromioplasty is not performed. Twenty patients underwent this procedure with a minimum 27-month follow-up. All patients had significant disabling pain and weakness preoperatively. On the basis of the modified UCLA rating scale, the overall score increased from 9.3 to 27.7, with 12 excellent results, 6 good results, and 1 fair result (95% satisfactory). Pain relief was most dramatic, with 13 patients (68%) completely pain-free. All patients were able to perform activities of daily living, and 9 of 11 who were employed preoperatively returned to work. All patients had residual weakness in external rotation. There were no poor results and no complications.

Shoulder instability: accuracy of MR imaging performed after surgery in depicting recurrent injury--initial findings.

PURPOSE: To analyze a series of postoperative magnetic resonance (MR) images obtained in patients with recurrent signs or symptoms of instability in whom subsequent surgical correlation was performed to determine the accuracy in diagnosing recurrent injury. MATERIALS AND METHODS: The authors identified 24 patients who underwent MR imaging after shoulder instability surgery and had recurrent instability requiring repeat surgery. Twelve nonenhanced MR images and six indirect and six direct MR arthrograms were retrospectively reviewed with consensus to determine the presence or absence of recurrent labral or rotator cuff tear. Operative reports were reviewed to confirm the presence or absence of labral or rotator cuff tear. The mean interval between initial surgery and MR imaging was 10 months. The mean interval until repeat surgery was 2 months. RESULTS: Overall, the accuracy of postoperative MR imaging was 79% in depicting recurrent labral tear and 88% in depicting recurrent rotator cuff tear. Indirect MR arthrography had 100% accuracy for recurrent labral tear detection, whereas direct MR arthrography and nonenhanced MR imaging had accuracies of 67% and 75%, respectively. Direct MR arthrography was more sensitive, 100% versus 71%, but less specific, 60% versus 80%, than nonenhanced MR imaging in depicting recurrent labral tears. Direct MR arthrography had 100% accuracy in depicting rotator cuff tear, whereas both indirect MR arthrography and nonenhanced MR imaging had 83% accuracy. CONCLUSION: MR imaging, indirect MR arthrography in particular, appears to be an accurate means of evaluating the shoulder following instability surgery.