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Functional and Ultrasonography Imaging Outcomes of Arthroscopic Simultaneous Rotator Cuff and Bankart Repair after Shoulder Dislocation
ABSTRACTS
patients were excluded. Patients were surveyed preoperatively and postoperatively at intervals of 2, 6, 12, 18 and 24 weeks. Patient outcomes were scored using the Pittsburgh Sleep Quality index (PSQI), Simple Shoulder Test (SST), Visual Analog Score (VAS) and single assessment numeric evaluation score (SANE). Demographic and surgical factors were also collected for analysis. Analyses were performed using R 2.15.3 (R Foundation for Statistical Computing, Vienna Austria) Results: Ninety-two percent of patients reported preoperative PSQI scores indicative of sleep disturbance (score >6 out of 21), with an average preoperative PSQI of 11.7(stdev + 4.61). A statistically significant improvement in PSQI was achieved at 3 months (mean score 8.4, p 0.0003, 81% follow-up) and continued to improve through 6 months. A PSQI score < 5, considered normal sleep, was achieved by 32% (16/50) at 3 months, 54% (22/41) at 4.5 months and 63% (32/51) at 6 months. Multivariable linear regression of all surgical and demographic factors vs. PSQI was performed. The addition of subacromial decompression (SAD) to RCR statistically improved PSQI score at 3 months (n¼28, 9.4 vs. 7.13, p 0.0049). Furthermore, preoperative narcotic use was correlated with worse PSQI score at 3 months (n¼10, 11.0 vs 7.7, p 0.067). Conclusion: : 92% of patients undergoing arthroscopic RCR have sleep disturbance. Sleep quality was statistically improved by 3 months postoperatively and continued through 6 months. At 6 months 63% of patients no longer had sleep disturbance. Patients not taking preoperative narcotics as well as patient’s receiving SAD along with their RCR had better improvements in sleep. Is Transosseous-Equivalent Rotator Cuff Repair “Self-Reinforcing” Compared to Single-Row Repair? SS-31A Friday, May 2, 10:00 AM MAXWELL PARK, M.D., PRESENTING AUTHOR ROBERT GUNZENHAUSER, B.A. MICHAEL BENEFIEL, B.A. MICHELLE MCGARRY, M.S. CHONG PARK, PH.D. THAY LEE, PH.D. Introduction: Transosseous-equivalent (TOE) rotator cuff repair has been theorized to be “self-reinforcing” with increasing tendon load. The purpose of this study was to biomechanically verify and characterize the effect of increasing tendon load on frictional resistance over a repaired footprint with both single row (SR) and TOE repair techniques. Methods: In ten fresh-frozen human shoulders, TOE and SR supraspinatus tendon repairs were performed. For all repairs, a Tekscan pressure sensor was secured on the greater tuberosity at the tendon-footprint interface. The supraspinatus tendon was loaded with 0, 20, 40, 60, and 80 N. The shoulders were tested at 0 and 30 abduction with 0 of humeral rotation. The area of interest was defined at 160 mm2. For comparisons, paired t-tests and multivariate regression analyses were employed.
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Results: The SR repair had significant (p<0.05) increases in footprint contact force (N) between each and all tendon loading conditions (1.36 0.54 N, 2.94 0.81 N, 4.57 1.27 N, 6.00 1.64 N, 7.59 2.05 N for tendon loads of 0, 20, 40, 60, and 80 N, respectively). The TOE repair demonstrated the same relationships for footprint contact force with increasing tendon load (p<0.05) (5.93 1.21 N, 10.60 1.65 N, 14.07 2.15 N, 16.60 2.62 N, 18.41 3.06 N, for each progressive tendon load, respectively). This relationship was also seen for contact area and pressure for both repairs. Comparing between repairs, TOE repair had more footprint contact force, area, pressure, and peak pressure at each load, for both 0 and 30 degrees of abduction (p<0.05). Abduction did not significantly affect contact variables. With increasing load, the TOE repair had a significantly higher progression (slope) of footprint force and pressure compared to the SR repair. Conclusion: Self-reinforcing capacity in rotator cuff repair has been biomechanically verified and characterized. While the SR repair demonstrated increasing footprint force and pressure with progressive tendon loading, this effect was significantly greater with the TOE repair. Tendon-bridging sutures spanning the footprint can provide a compression vector and increasing frictional resistance over the footprint with tendon loading; this may protect structural integrity and improve healing biology. In contrast, without footprint bridging sutures, SR repair cannot provide a self-protective effect. Footprint contact force increases with increasing tendon load. The contact force progression (slope of the measurements) was significantly higher with the TOE repair, demonstrating a “self-reinforcing” effect with tendon loading. (Vertical axis, footprint contact force; N, Newtons; Horizontal axis, supraspinatus tendon load [N]). Functional and Ultrasonography Imaging Outcomes of Arthroscopic Simultaneous Rotator Cuff and Bankart Repair after Shoulder Dislocation SS-31B Friday, May 2, 10:05 AM EDWARD SHIELDS, M.D., PRESENTING AUTHOR MARK MIRABELLI, M.D. SIMON AMSDELL, M.D. ROBERT THORSNESS, M.D. JOHN GOLDBLATT, M.D. MICHAEL MALONEY, M.D. ILYA VOLOSHIN, M.D. Introduction: Currently there is limited information in the literature describing outcomes after repair of both rotator cuff (RC) and Bankart lesion in patients after acute shoulder dislocation. We hypothesized that in this specific population the functional outcomes after simultaneous arthroscopic RC and Bankart repair will be similar to the contralateral (normal) shoulder regardless of the integrity of the rotator cuff repair. Methods: Patients who underwent arthroscopic simultaneous RC repair and Bankart repair with minimum of 2 years follow-up were identified through billing records by CPT codes from 2007 to present. Clinic notes were
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ABSTRACTS
reviewed and patients who presented after shoulder dislocation were isolated. Demographic and functional outcome data was obtained including American Shoulder and Elbow Society (ASES), Constant-Murley, and Short Form (SF) 36 scores. The affected shoulder also underwent ultrasound (US) imaging to assess the integrity of the RC. Student T and Mann-Whitney U tests were used for comparisons based on normality and variance. Data presented as mean standard deviation (SD). Results: Thirteen consecutive patients that underwent simultaneous arthroscopic RC and Bankart repair after shoulder dislocation were identified. Average age was 58.811.2 at the time of the procedure. Surgeries were performed at an average of 1.81.0 months from injury. Pre-operatively, there were 5 isolated full thickness tears of the supraspinatus, 3 patients with combined full thickness infraspinatus and supraspinatus tears, 2 patients with isolated full thickness subscapularis tears, 1 patient with full tears of the supraspinatus, infraspinatus, and subscapularis, and 2 patients with near full thickness tears of the supraspinatus. Average follow up after the repair was 37.4613.7 months. American Shoulder and Elbow Society scores did not differ between the affected (89.712.6) and unaffected shoulders (94.976.65; P>0.05). Constant scores between affected (80.518.9) and unaffected shoulders (86.777.87) were also similar (P>0.05). Abduction strength of the affected shoulder (15.396.35 pounds) was indistinguishable from the unaffected shoulder (15.355.2 pounds; P>0.05). Short-form 36 physical component summary (48.41) was slightly below US population average, while the mental component summary (58.9) was above average. Normative values for SF-36 subgroups of physical function (50.35) and bodily pain (51.4) were near population norms. Ultrasonography of previously affected shoulders at the time of follow up demonstrated persistent or recurrent tears in 1 patient with complete supraspinatus and subscapualaris tears, and 3 patients with isolated complete supraspinatus tears. One patient had a new isolated complete subscapularis tear with previously repaired supraspinatus tear healed. Patients with confirmed full thickness rotator cuff tears at the time of follow up in the affected shoulder had similar ASES scores (90.911.8 versus 97.64.3), Constant scores (77.820.3 versus 84.787.23), and abduction strength (11.545.32 versus 12.584.48 pounds) compared to their unaffected shoulder (P>0.05). Conclusion: Following simultaneous arthroscopic repair of the RC and a Bankart lesion, the affected extremity has similar functional status and strength compared to the non-injured side at 3 years after surgery. The persistent or recurrent rotator cuff tear rate of 31% did not appear to significantly impact functional outcomes in this patient population.
Validation of A Computer-Assisted Dynamic Simulation For Treatment of Femoroacetabular Impingement (FAI) SS-32 Friday, May 2, 1:30 PM ASHEESH BEDI, M.D., PRESENTING AUTHOR
OLUSANJO ADEOYE, M.D., M.B.A. JAMES ROSS, M.D. CHRIS LARSON, M.D. J. W. THOMAS BYRD, M.D. BRYAN KELLY, M.D. Introduction: An incomplete resection with residual deformity is a common cause for failure after arthroscopic hip preservation surgery for femoroacetabular impingement (FAI). The purpose of this study was (i) to compare the morphology of a virtual osteoplasty as templated by CT-based, 3D dynamic simulation modeling to the morphology after actual operative treatment of symptomatic FAI by a high volume surgeon, and (ii) to compare the morphology of a virtual osteoplasty to the actual operative treatment executed by less experienced surgeons in patients presenting for revision FAI surgery. Methods: Sixty-one (26 males, 35 females) patients with symptomatic FAI underwent preoperative and postoperative high-resolution computed tomography scans of the affected hips(s). A computer-assisted, 3D dynamic simulation modeling of the involved hip(s) using the preoperative CT scan was performed. A virtual osteoplasty to establish normal head-neck offset, head sphericity, and to eliminate focal retroversion / overcoverage of the acetabular rim was performed. 3D modeling of the involved hip using a postoperative CT scan was then performed. Alpha angles and location of cam deformity was characterized on all radial sequences, and 3D acetabular coverage of the femoral head was defined. Virtual range of motion was also determined and compared for the preoperative, virtual postoperative and actual postoperative simulations. Forty-nine (22 males, 27 females) patients who underwent hip arthroscopy for symptomatic FAI presented for evaluation and underwent preoperative high-resolution computed tomography of the affected hip. The residual deformity was characterized and compared to the range of motion of morphology after a CT-based virtual correction as described above. Results: The preoperative mean alpha angle was 6911 and 56.810.4 degrees in males and females, respectively. Preoperatively, in males, mean hip flexion was 117.411.7, internal rotation was 29.112.2 and FADIR (flexion of 90, adduction of 15, internal rotation) was 20.912.4. In females, mean hip flexion was 123.29.9, internal rotation was 38.911.9 and FADIR was 30.112.9. Both the virtual and actual osteoplasty in the defined regions of impingement resulted in significant improvements in the alpha angles, acetabular impingement areas, hip flexion, internal rotation and FADIR in both males and females (P <0.05). Furthermore, the morphology of the virtual osteoplasty and actual postoperative hip demonstrated minimal differences in maximum alpha angle and acetabular coverage (<3 degree difference and <1% coverage difference respectively) In the revision surgery cohort,the pre-revision mean alpha angle was 6815 degrees, and mean hip flexion, internal rotation, and FADIR was 11514, 2815, and 2014 degrees respectively. In contrast, the virtual correction identified considerable residual deformity with
patients were excluded. Patients were surveyed preoperatively and postoperatively at intervals of 2, 6, 12, 18 and 24 weeks. Patient outcomes were scored using the Pittsburgh Sleep Quality index (PSQI), Simple Shoulder Test (SST), Visual Analog Score (VAS) and single assessment numeric evaluation score (SANE). Demographic and surgical factors were also collected for analysis. Analyses were performed using R 2.15.3 (R Foundation for Statistical Computing, Vienna Austria) Results: Ninety-two percent of patients reported preoperative PSQI scores indicative of sleep disturbance (score >6 out of 21), with an average preoperative PSQI of 11.7(stdev + 4.61). A statistically significant improvement in PSQI was achieved at 3 months (mean score 8.4, p 0.0003, 81% follow-up) and continued to improve through 6 months. A PSQI score < 5, considered normal sleep, was achieved by 32% (16/50) at 3 months, 54% (22/41) at 4.5 months and 63% (32/51) at 6 months. Multivariable linear regression of all surgical and demographic factors vs. PSQI was performed. The addition of subacromial decompression (SAD) to RCR statistically improved PSQI score at 3 months (n¼28, 9.4 vs. 7.13, p 0.0049). Furthermore, preoperative narcotic use was correlated with worse PSQI score at 3 months (n¼10, 11.0 vs 7.7, p 0.067). Conclusion: : 92% of patients undergoing arthroscopic RCR have sleep disturbance. Sleep quality was statistically improved by 3 months postoperatively and continued through 6 months. At 6 months 63% of patients no longer had sleep disturbance. Patients not taking preoperative narcotics as well as patient’s receiving SAD along with their RCR had better improvements in sleep. Is Transosseous-Equivalent Rotator Cuff Repair “Self-Reinforcing” Compared to Single-Row Repair? SS-31A Friday, May 2, 10:00 AM MAXWELL PARK, M.D., PRESENTING AUTHOR ROBERT GUNZENHAUSER, B.A. MICHAEL BENEFIEL, B.A. MICHELLE MCGARRY, M.S. CHONG PARK, PH.D. THAY LEE, PH.D. Introduction: Transosseous-equivalent (TOE) rotator cuff repair has been theorized to be “self-reinforcing” with increasing tendon load. The purpose of this study was to biomechanically verify and characterize the effect of increasing tendon load on frictional resistance over a repaired footprint with both single row (SR) and TOE repair techniques. Methods: In ten fresh-frozen human shoulders, TOE and SR supraspinatus tendon repairs were performed. For all repairs, a Tekscan pressure sensor was secured on the greater tuberosity at the tendon-footprint interface. The supraspinatus tendon was loaded with 0, 20, 40, 60, and 80 N. The shoulders were tested at 0 and 30 abduction with 0 of humeral rotation. The area of interest was defined at 160 mm2. For comparisons, paired t-tests and multivariate regression analyses were employed.
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Results: The SR repair had significant (p<0.05) increases in footprint contact force (N) between each and all tendon loading conditions (1.36 0.54 N, 2.94 0.81 N, 4.57 1.27 N, 6.00 1.64 N, 7.59 2.05 N for tendon loads of 0, 20, 40, 60, and 80 N, respectively). The TOE repair demonstrated the same relationships for footprint contact force with increasing tendon load (p<0.05) (5.93 1.21 N, 10.60 1.65 N, 14.07 2.15 N, 16.60 2.62 N, 18.41 3.06 N, for each progressive tendon load, respectively). This relationship was also seen for contact area and pressure for both repairs. Comparing between repairs, TOE repair had more footprint contact force, area, pressure, and peak pressure at each load, for both 0 and 30 degrees of abduction (p<0.05). Abduction did not significantly affect contact variables. With increasing load, the TOE repair had a significantly higher progression (slope) of footprint force and pressure compared to the SR repair. Conclusion: Self-reinforcing capacity in rotator cuff repair has been biomechanically verified and characterized. While the SR repair demonstrated increasing footprint force and pressure with progressive tendon loading, this effect was significantly greater with the TOE repair. Tendon-bridging sutures spanning the footprint can provide a compression vector and increasing frictional resistance over the footprint with tendon loading; this may protect structural integrity and improve healing biology. In contrast, without footprint bridging sutures, SR repair cannot provide a self-protective effect. Footprint contact force increases with increasing tendon load. The contact force progression (slope of the measurements) was significantly higher with the TOE repair, demonstrating a “self-reinforcing” effect with tendon loading. (Vertical axis, footprint contact force; N, Newtons; Horizontal axis, supraspinatus tendon load [N]). Functional and Ultrasonography Imaging Outcomes of Arthroscopic Simultaneous Rotator Cuff and Bankart Repair after Shoulder Dislocation SS-31B Friday, May 2, 10:05 AM EDWARD SHIELDS, M.D., PRESENTING AUTHOR MARK MIRABELLI, M.D. SIMON AMSDELL, M.D. ROBERT THORSNESS, M.D. JOHN GOLDBLATT, M.D. MICHAEL MALONEY, M.D. ILYA VOLOSHIN, M.D. Introduction: Currently there is limited information in the literature describing outcomes after repair of both rotator cuff (RC) and Bankart lesion in patients after acute shoulder dislocation. We hypothesized that in this specific population the functional outcomes after simultaneous arthroscopic RC and Bankart repair will be similar to the contralateral (normal) shoulder regardless of the integrity of the rotator cuff repair. Methods: Patients who underwent arthroscopic simultaneous RC repair and Bankart repair with minimum of 2 years follow-up were identified through billing records by CPT codes from 2007 to present. Clinic notes were
e18
ABSTRACTS
reviewed and patients who presented after shoulder dislocation were isolated. Demographic and functional outcome data was obtained including American Shoulder and Elbow Society (ASES), Constant-Murley, and Short Form (SF) 36 scores. The affected shoulder also underwent ultrasound (US) imaging to assess the integrity of the RC. Student T and Mann-Whitney U tests were used for comparisons based on normality and variance. Data presented as mean standard deviation (SD). Results: Thirteen consecutive patients that underwent simultaneous arthroscopic RC and Bankart repair after shoulder dislocation were identified. Average age was 58.811.2 at the time of the procedure. Surgeries were performed at an average of 1.81.0 months from injury. Pre-operatively, there were 5 isolated full thickness tears of the supraspinatus, 3 patients with combined full thickness infraspinatus and supraspinatus tears, 2 patients with isolated full thickness subscapularis tears, 1 patient with full tears of the supraspinatus, infraspinatus, and subscapularis, and 2 patients with near full thickness tears of the supraspinatus. Average follow up after the repair was 37.4613.7 months. American Shoulder and Elbow Society scores did not differ between the affected (89.712.6) and unaffected shoulders (94.976.65; P>0.05). Constant scores between affected (80.518.9) and unaffected shoulders (86.777.87) were also similar (P>0.05). Abduction strength of the affected shoulder (15.396.35 pounds) was indistinguishable from the unaffected shoulder (15.355.2 pounds; P>0.05). Short-form 36 physical component summary (48.41) was slightly below US population average, while the mental component summary (58.9) was above average. Normative values for SF-36 subgroups of physical function (50.35) and bodily pain (51.4) were near population norms. Ultrasonography of previously affected shoulders at the time of follow up demonstrated persistent or recurrent tears in 1 patient with complete supraspinatus and subscapualaris tears, and 3 patients with isolated complete supraspinatus tears. One patient had a new isolated complete subscapularis tear with previously repaired supraspinatus tear healed. Patients with confirmed full thickness rotator cuff tears at the time of follow up in the affected shoulder had similar ASES scores (90.911.8 versus 97.64.3), Constant scores (77.820.3 versus 84.787.23), and abduction strength (11.545.32 versus 12.584.48 pounds) compared to their unaffected shoulder (P>0.05). Conclusion: Following simultaneous arthroscopic repair of the RC and a Bankart lesion, the affected extremity has similar functional status and strength compared to the non-injured side at 3 years after surgery. The persistent or recurrent rotator cuff tear rate of 31% did not appear to significantly impact functional outcomes in this patient population.
Validation of A Computer-Assisted Dynamic Simulation For Treatment of Femoroacetabular Impingement (FAI) SS-32 Friday, May 2, 1:30 PM ASHEESH BEDI, M.D., PRESENTING AUTHOR
OLUSANJO ADEOYE, M.D., M.B.A. JAMES ROSS, M.D. CHRIS LARSON, M.D. J. W. THOMAS BYRD, M.D. BRYAN KELLY, M.D. Introduction: An incomplete resection with residual deformity is a common cause for failure after arthroscopic hip preservation surgery for femoroacetabular impingement (FAI). The purpose of this study was (i) to compare the morphology of a virtual osteoplasty as templated by CT-based, 3D dynamic simulation modeling to the morphology after actual operative treatment of symptomatic FAI by a high volume surgeon, and (ii) to compare the morphology of a virtual osteoplasty to the actual operative treatment executed by less experienced surgeons in patients presenting for revision FAI surgery. Methods: Sixty-one (26 males, 35 females) patients with symptomatic FAI underwent preoperative and postoperative high-resolution computed tomography scans of the affected hips(s). A computer-assisted, 3D dynamic simulation modeling of the involved hip(s) using the preoperative CT scan was performed. A virtual osteoplasty to establish normal head-neck offset, head sphericity, and to eliminate focal retroversion / overcoverage of the acetabular rim was performed. 3D modeling of the involved hip using a postoperative CT scan was then performed. Alpha angles and location of cam deformity was characterized on all radial sequences, and 3D acetabular coverage of the femoral head was defined. Virtual range of motion was also determined and compared for the preoperative, virtual postoperative and actual postoperative simulations. Forty-nine (22 males, 27 females) patients who underwent hip arthroscopy for symptomatic FAI presented for evaluation and underwent preoperative high-resolution computed tomography of the affected hip. The residual deformity was characterized and compared to the range of motion of morphology after a CT-based virtual correction as described above. Results: The preoperative mean alpha angle was 6911 and 56.810.4 degrees in males and females, respectively. Preoperatively, in males, mean hip flexion was 117.411.7, internal rotation was 29.112.2 and FADIR (flexion of 90, adduction of 15, internal rotation) was 20.912.4. In females, mean hip flexion was 123.29.9, internal rotation was 38.911.9 and FADIR was 30.112.9. Both the virtual and actual osteoplasty in the defined regions of impingement resulted in significant improvements in the alpha angles, acetabular impingement areas, hip flexion, internal rotation and FADIR in both males and females (P <0.05). Furthermore, the morphology of the virtual osteoplasty and actual postoperative hip demonstrated minimal differences in maximum alpha angle and acetabular coverage (<3 degree difference and <1% coverage difference respectively) In the revision surgery cohort,the pre-revision mean alpha angle was 6815 degrees, and mean hip flexion, internal rotation, and FADIR was 11514, 2815, and 2014 degrees respectively. In contrast, the virtual correction identified considerable residual deformity with