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Background Interscalene blocks provide analgesia for shoulder surgery but also cause phrenic nerve paralysis. Liposomal bupivacaine is approved for use in interscalene blocks with the potential to provide longer pain control. However, the impact of liposomal bupivacaine on the phrenic nerve has not been evaluated. It was hypothesized that patients who received an interscalene block with both bupivacaine and liposomal bupivacaine would have a decreased diaphragmatic excursion when compared to bupivacaine alone at 24 h. Methods This was a double-blinded study of adult patients who were randomized to receive an interscalene block with either 20 ml 0.5% bupivacaine (bupivacaine group) or 10 ml 0.5% bupivacaine plus 10 ml liposomal bupivacaine (liposomal bupivacaine group). Twenty-six patients were randomized with 22 included in the analysis. Diaphragmatic excursion (via ultrasound) and spirometry were assessed before the block, in the postanesthesia care unit, and at 24 h postblock. The primary outcome was diaphragm excursion with sigh. No adverse events were observed. Results At 24 h, the liposomal bupivacaine group median [25th, 75th], had a greater percent change in diaphragmatic excursion during sigh breath compared to the bupivacaine group, –24% [–30, –9] versus 9% [–8, 26], difference in location, 32 (95% CI, 12 to 52), P = 0.007. Five patients in the liposomal bupivacaine group had a greater than 25% reduction in diaphragmatic excursion at 24 h versus zero in the bupivacaine group. They also had a significantly greater percent reduction in forced expiratory volume in 1 s and forced vital capacity compared with the bupivacaine group at 24 h (median decrease of 22% vs. 2%, P = 0.006, and median decrease of 19% vs. 1%, P = 0.049, respectively). Conclusions The addition of liposomal bupivacaine to bupivacaine in an interscalene block results in statistically significant reductions in diaphragm excursion and pulmonary function testing 24 h after block placement when compared to bupivacaine alone. This reduction, however, falls within the range of normal diaphragmatic function. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background Rotator cuff repair (RCR) is one of the most common elective orthopedic procedures with predictable indications, technique, and outcomes. As a result, this surgery is an ideal choice for studying value. The purpose of this study was to utilize Patient-level value-analysis (PLVA) within the setting of RCR over the one-year episode-of-care. Methods Included patients (n=396) underwent RCR between 2009 and 2016 at a single outpatient orthopedic surgery center. The episode-of-care was defined as one-year following surgery. The Western Ontario Rotator Cuff (WORC) index was collected at both the initial preoperative baseline and the one-year postoperative mark. The total cost-of-care was determined using time-driven activity-based costing (TDABC). Both patient (PLVA) and provider-level value-analysis (pLVA) were performed. Results The average TDABC cost-of-care was derived at $5413.78 ± $727.41 [$5341.92, $5485.64]. At the patient-level, arthroscopic isolated supraspinatus tears yielded the highest value coefficient, 0.82 (ANOVA F-Test, p=0.01). There was a poor correlation between the change in one-year WORC score and the TDABC cost-of-care (r2=0.03). Provider-level value demonstrated significant variation between the 8 evaluated providers (p Conclusion RCR is one of the most common orthopedic procedures, yet the correlations between cost-of-care and patient outcomes is unknown. PLVA quantifies the ratio of functional improvement to the TDABC estimated cost-of-care at the patient-level. This is the first study to apply patient-level value analysis over the first-year episode-of-care. With healthcare transitioning towards value-based delivery, PLVA offers a quantitative tool to measure the value of individual patient care delivery over the entire episode-of-care.

The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability.A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included (1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures.Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥10 years and 48%10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure.The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability.

PURPOSE OF REVIEW: A successful reverse total shoulder arthroplasty requires careful preoperative planning and perioperative management. Preoperative comorbidity risks, perioperative pain management, and postoperative rehabilitation are all critical components of this arthroplasty. The current review examines available literature to guide the perioperative care of the reverse total shoulder arthroplasty patient. RECENT FINDINGS: One of the most important advances for shoulder arthroplasty in recent years has been heightened awareness of various modalities for perioperative pain management. A number of recent studies have focused on the options for regional blockade as a critical tool for postoperative pain relief and the use of either continuous interscalene blocks or single shot blocks are supported. Additional studies are necessary to define the best local anesthetic agent and delivery mechanism to provide appropriate pain relief with a low side effect profile. SUMMARY: Management of the patient throughout the perioperative course is a critical component in achieving better patient outcomes delivering high quality patient care. An orthopedic surgery team focused on perioperative management is better positioned to decrease adverse events and improve patient outcomes after reverse total shoulder arthroplasty.

PURPOSE OF REVIEW: The incidence of shoulder arthroplasty is increasing dramatically for primary arthroplasty but also for revision arthroplasty. Revision to reverse total shoulder arthroplasty is increasingly the salvage operation for failed primary arthroplasty. The purpose of this review is to explore the indications for and results of revision reverse total shoulder arthroplasty. RECENT FINDINGS: Despite relatively high complication and reoperation rates with revision shoulder replacement, revision of failed hemiarthroplasty or total shoulder arthroplasty to reverse total shoulder arthroplasty improves outcomes for many patients. A failed hemiarthroplasty or total shoulder arthroplasty is frequently disabling for the patient and because the surgical revision options are often limited only to reverse total shoulder arthroplasty, the potential improvement is often worth the higher surgical complication or reoperation rate. SUMMARY: Due to the challenges inherent in revision arthroplasty, revision of primary arthroplasty to reverse total shoulder arthroplasty, outcomes are poorer than primary reverse total shoulder arthroplasty. Despite these limitations, patient postoperative pain and function do increase from preoperative levels making conversion of hemiarthroplasty or anatomic total shoulder to reverse total shoulder arthroplasty an important option for a challenging problem.

Shoulder arthroplasty has traditionally been viewed as an inpatient procedure because of the inherent medical comorbidities associated with an aging population and the need for postoperative pain control. Recent studies have shown that in appropriately selected patients, shoulder arthroplasty procedures can be safely done as outpatient procedures and can deliver economic value in today's cost-conscious health care environment. Several factors help ensure a successful surgical outcome, including cooperation from the ambulatory anesthesia service, proper patient selection, and perioperative pain control. Postoperatively, provider availability is vital to complete a seamless patient experience. With appropriate algorithms and care plans in place, outpatient shoulder arthroplasty can be a safe and cost-efficient procedure. The advances pioneered by outpatient shoulder arthroplasty will also serve to benefit inpatient shoulder arthroplasty patients via improved pain control, perioperative education, and potentially decreased length of stay.

Subacromial impingement syndrome (SIS) represents a spectrum of pathology ranging from subacromial bursitis to rotator cuff tendinopathy and full-thickness rotator cuff tears. The relationship between subacromial impingement and rotator cuff disease in the etiology of rotator cuff injury is a matter of debate. Both extrinsic compression and intrinsic degeneration may play a role. Management includes physical therapy, injections, and, for some patients, surgery. There remains a need for high-quality studies of the pathology, etiology, and management of SIS.

Management of the cuff-deficient arthritic shoulder has long been challenging. Early unconstrained shoulder arthroplasty systems were associated with high complication and implant failure rates. The evolution toward the modern reverse shoulder arthroplasty includes many variables of constrained shoulder arthroplasty designs. This review explores the development of reverse shoulder arthroplasty, specifically describing (1) the evolution of reverse shoulder arthroplasty designs, (2) the biomechanical variations in the evolution of this arthroplasty, and (3) the current issues relevant to reverse shoulder arthroplasty today. Using a PubMed search, the literature was explored for articles addressing reverse shoulder arthroplasty, focusing on those papers with historical context. Results of the early designs were apparently poor, although they were not subjected to rigorous clinical research and usually reported only in secondary literature. We identified a trend of glenoid component failure in the early reverse designs. This trend was recognized and reported by authors as the reverse shoulder evolved. Authors reported greater pain relief and better function in reverse shoulder arthroplasty with the fundamental change of Grammont’s design (moving the center of rotation medially and distally). However, current reports suggest lingering concerns and challenges with today’s designs. The history of reverse shoulder arthroplasty involves the designs of many forward-thinking surgeons. Many of these highly constrained systems failed, although more recent designs have demonstrated improved longevity and implant performance. Reverse shoulder arthroplasty requires ongoing study, with challenges and controversies remaining around present-day designs.

The best location for biceps tenodesis is controversial as surgeons have begun to question whether tenodesis location affects the incidence of residual bicipital postoperative pain. An open distal tenodesis technique has been previously proposed to eliminate remaining symptoms at the bicipital groove. We asked the following questions: (1) Does a higher tenodesis in the biceps groove result in postoperative pain? And (2) can the tenodesis location be successfully moved more distally (“suprapectoral tenodesis”) by an arthroscopic technique? We retrospectively reviewed 17 patients undergoing arthroscopic biceps tenodesis and evaluated their tenodesis location, either within the upper half of the groove (five) or in the lower half of the groove or shaft (12). Patient outcomes were assessed with visual analog scale scores for pain, American Shoulder and Elbow Surgeons scores, and Constant-Murley scores. Minimum followup was 12 months (mean, 28 months; range, 12–69 months). Two patients had persistent pain at 12 months; both had a tenodesis in the upper half of the groove. The overall American Shoulder and Elbow Surgeons and Constant-Murley scores were improved at latest followup. Arthroscopic suprapectoral biceps tenodesis represents a new technique for distal tenodesis. Our preliminary observations suggest a more distal tenodesis location may decrease the incidence of persistent postoperative pain at the bicipital groove, although additional research is needed to definitively state whether the proximal location is in fact more painful. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Hypothesis Conservative rehabilitation after arthroscopic rotator cuff repair does not result in long-term stiffness and improves rates of tendon healing. Materials and methods We retrospectively evaluated 43 patients with full-thickness rotator cuff tears who underwent a standardized, conservative protocol of full-time sling immobilization without formal therapy for 6 weeks after arthroscopic repair. At 6 to 8 weeks of follow-up, we categorized patients as "stiff" if they demonstrated forward elevation of less than 100° and external rotation of less than 30° passively; all others were designated "nonstiff." Active range of motion in forward elevation, external rotation, and internal rotation was assessed at 3 months, 6 months, and 1 year. American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores were assessed at 1 year. Follow-up magnetic resonance imaging (MRI) was obtained in all patients to assess tendon healing. Results Ten patients (23%) were considered stiff after rotator cuff surgery. At 1 year, there was no difference in mean forward elevation (166° vs 161°, P = .2), external rotation (62° vs. 58.4°, P = .5), or internal rotation (T7.4 vs T8.2, P = .07) between the stiff and nonstiff groups, respectively. There were no differences in final ASES (83 vs 79, P = .57) and Constant-Murley scores (77 vs. 74, P = .5). Repeat MRI suggested a trend toward a lower retear rate among the stiff patients (70% intact in stiff group vs 36% in nonstiff group, P = .079). Two clinically significant cuff retears occurred in the nonstiff cohort. Discussion Concerns for recalcitrant stiffness have led some to favor early postoperative therapy. We found that early restriction of motion did not lead to long-term stiffness after arthroscopic rotator cuff repair, even in patients who were clinically stiff in the early postoperative period. Conclusions Sling immobilization for 6 weeks after arthroscopic rotator cuff repair does not result in increased long-term stiffness and may improve the rate of tendon healing.

TKA with conventional metal-backed tibial implants subjects the tibial metaphysis to stress shielding, with resultant loss of bone density.We hypothesized tibial bone mineral density in patients with porous tantalum (trabecular metal) tibial baseplates would (1) more closely parallel tibial bone mineral density in the nonoperative control limb and (2) be better maintained than in conventional historical controls.We prospectively followed 41 patients (35 men, six women) 60 years of age or younger undergoing TKA with uncemented trabecular metal tibial components. Patients underwent dual-energy xray absorptiometry scans of both proximal tibiae preoperatively and at 2 months, 1 year, and 2 years postoperatively. We determined bone mineral density in three selected regions of interest (Zone 1, between the pegs; Zone 2, beneath the pegs; Zone 3, directly below entire baseplate). Precision analysis revealed a precision error of 4% or less for each region of interest, indicating adequate power to detect bone mineral density changes of 8% or greater.Bone mineral density percent change was different between the operative and nonoperative knees only in Zone 3 and only at 2 months. There was no change in bone mineral density in any zone in the nonoperative knee at any time. Only in Zone 3 did the bone mineral density decrease at 2 months in the operative knee.Trabecular metal implants appear to maintain tibial bone mineral density in a parallel fashion to the nonoperative limb in this population and better than historical controls.

Arthroplasty performed for complex proximal humerus fractures has traditionally been associated with reliable pain relief but inconsistent patient outcome and satisfaction. Tuberosity displacement or nonunion is most often associated with poorer results. Careful restoration of height and version maximize the opportunity for anatomic tuberosity healing and therefore shoulder function. The use of caution during the rehabilitation phase may also minimize stress of the repair. Attention to these intraoperative and postoperative details may improve tuberosity healing and therefore patient outcome.

Complex fractures of the proximal humerus present a challenge to the orthopedic surgeon. There is little agreement regarding the optimal treatment for these fractures because complications occur with each of the many treatment options available. With hardware failure, osteonecrosis, malunion, and nonunion of concern with primary fixation, many believe arthroplasty to be the treatment of choice for these complex fractures. Certainly, humeral head replacement remains an acceptable option for some fracture patterns. Increasingly, good outcomes are obtained for complex fractures with the use of a variety of fixation techniques, particularly with minimally invasive approaches.

Cases of consecutive new patients seen at orthopedic spine and shoulder clinics were reviewed. Four percent of spine patients had significant shoulder pathology, and 3.6% of shoulder patients had significant spine pathology. Identification of the correct pain generator is a prerequisite for effective treatment in patients with neck and/or shoulder problems. However, distinguishing between the two can be difficult. Relative frequencies of how often one is mistaken for the other have not been well established. Six hundred ninety-four new patients were seen at the orthopedic shoulder clinic (n = 452) or spine clinic (n = 242) at an academic institution during a 2-year period. One hundred seven patients had previous shoulder surgery, and 39 had previous neck surgery. The 548 patients (shoulder clinic, 345; spine clinic, 203) who had no previous surgery were reviewed with respect to workup performed, final diagnosis, subsequent operative procedures, and incidence of referral from the shoulder clinic to the spine clinic and vice versa. Among the patients seen at the shoulder clinic, 325 (94.2%) had shoulder pathology, 6 (1.7%) had neck but no shoulder pathology, 6 (1.7%) had shoulder and neck pathology, and 8 (2.3%) had an unidentifiable cause of pain. Of the 12 patients with neck pathology, none underwent neck surgery. Among the patients seen at the spine clinic, 182 (89.7%) had neck pathology, 5 (2.5%) had shoulder but no neck pathology, 3 (1.5%) had neck and shoulder pathology, and 13 (6.4%) had an unidentifiable cause of pain. Of the 8 patients with shoulder pathology, 1 (12.5%) underwent shoulder surgery. Our analysis suggests that for patients who present to a shoulder surgeon's clinic for shoulder pain, 3.6% will turn out to have neck pathology. For patients who present to a spine surgeon's clinic for neck pain, 4% may turn out to have shoulder pathology. Thus, approximately 1 in 25 patients seen at a surgeon's clinic for a presumed shoulder or neck problem may exhibit neck-shoulder crossover, in which pathology in one may be mistaken for or coexist with the other.

Postoperative periprosthetic fractures of the humerus can be challenging for both the patient and the surgeon given that these fractures are difficult to treat and have high complication rates. The incidence of periprosthetic fractures after anatomic shoulder replacements has been reported to be 0.6%1. A recent series included four patients with a periprosthetic fracture after a reverse-geometry shoulder arthroplasty2, but we do not know of any other report or data on periprosthetic fractures after reverse shoulder arthroplasty. As the numbers of anatomic and reverse total shoulder replacements increase, orthopaedic surgeons will more commonly encounter these difficult fractures. Wright and Cofield proposed a classification system for periprosthetic humeral fractures3, although this system has not been validated and its ability to guide treatment has not been evaluated. In their study, Andersen and colleagues described the operative treatment and surgical outcomes of thirty-six periprosthetic fractures after anatomic (nineteen) or reverse (seventeen) shoulder arthroplasty. Seventeen patients had a well-fixed prosthesis and …

"Impingement syndrome" is a common diagnostic label for patients presenting with shoulder pain. Historically, it was believed to be due to compression of the rotator cuff tendons beneath the acromion. It has become evident that "impingement syndrome" is not likely an isolated condition that can be easily diagnosed with clinical tests or most successfully treated surgically. Rather, it is likely a complex of conditions involving a combination of intrinsic and extrinsic factors. A mechanical impingement phenomenon as an etiologic mechanism of rotator cuff disease may be distinct from the broad diagnostic label of "impingement syndrome". Acknowledging the concepts of mechanical impingement and movement-related impairments may better suit the diagnostic and interventional continuum as they support the existence of potentially modifiable impairments within the conservative treatment paradigm. Therefore, it is advocated that the clinical diagnosis of "impingement syndrome" be eliminated as it is no more informative than the diagnosis of "anterior shoulder pain". While both terms are ambiguous, the latter is less likely to presume an anatomical tissue pathology that may be difficult to isolate either with a clinical examination or with diagnostic imaging and may prevent potentially inappropriate surgical interventions. We further recommend investigation of mechanical impingement and movement patterns as potential mechanisms for the development of shoulder pain, but clearly distinguished from a clinical diagnostic label of "impingement syndrome". For shoulder researchers, we recommend investigations of homogenous patient groups with accurately defined specific pathologies, or with subgrouping or classification based on specific movement deviations. Diagnostic labels based on the movement system may allow more effective subgrouping of patients to guide treatment strategies.

Background: Mini-open reduction and percutaneous fixation of proximal humeral fractures historically results in good outcomes and a low prevalence of osteonecrosis reported with short-term follow-up. The purpose of this study was to determine the midterm results of our multicenter case series of proximal humeral fractures treated with percutaneous fixation. Methods: Between 1999 and 2006, thirty-nine patients were treated with percutaneous reduction and fixation for proximal humeral fractures at three tertiary shoulder referral centers. Twenty-seven of these patients were available for intermediate follow-up at a minimum of three years (mean, eighty-four months; range, thirty-seven to 128 months) after surgery; the follow-up examination included use of subjective outcome measures and radiographic analysis to identify osteonecrosis and posttraumatic osteoarthritis on radiographs. Results: Osteonecrosis was detected in seven (26%) of the total group of twenty-seven patients at a mean of fifty months (range, eleven to 101 months) after the date of percutaneous fixation. Osteonecrosis was observed in five (50%) of the ten patients who had four-part fractures, two (17%) of the twelve patients who had three-part fractures, and none (0%) of the five patients who had two-part fractures. Posttraumatic osteoarthritis, including osteonecrosis, was present on radiographs in ten (37%) of the total group of twenty-seven patients. Posttraumatic osteoarthritis was observed in six (60%) of the ten patients who had four-part fractures, four (33%) of the twelve patients who had three-part fractures, and none (0%) of the five patients who had two-part fractures. Conclusions: Intermediate follow-up of patients with percutaneously treated proximal humeral fractures demonstrates an increased prevalence of osteonecrosis and posttraumatic osteoarthritis over time, with some patients with these complications presenting as late as eight years postoperatively. Development of osteonecrosis did not have a universally negative impact on subjective outcome scores. Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Considerable literature exists regarding the surgical management of rotator cuff tears. Arthroscopic and open rotator cuff repairs have had comparable clinical results in the literature, with distinct advantages and disadvantages to both procedures1,2. Arthroscopy allows for preservation of the deltoid muscle3, improved ability to treat intra-articular lesions3, improved ability to mobilize and release the rotator cuff3, and less immediate postoperative pain4. Open and mini-open repair techniques allow for easier transosseous fixation to better replicate the footprint of the supraspinatus tendon5 and theoretically may provide a better potential for healing5, although transosseous equivalent constructs with use of suture anchors have been described that also show improved pressurized contact area6,7. Open repair and mini-open repair also allow for the placement of a modified Mason-Allen stitch, which, in comparison with the simple stitch, is a stronger method to grasp the tendon8,9. Several studies have examined geographic variation in the number of rotator cuff surgical procedures performed as well as variations in what surgeons deemed to be indications for rotator cuff surgery. For example, Vitale et al. found a large geographic variation in the number of rotator cuff surgical procedures that were performed in Medicare beneficiaries in 199210. This variation may have reflected a lack of clear operative indications and/or an understanding of the risks and benefits of surgery at the time of the study. With respect to surgical indications, Green et al. reported that surgeon preference was the primary deciding factor for performing inpatient rotator cuff surgery11. Dunn et al. also found significant variation in indications for rotator cuff surgery in a survey of selected members of the American Academy of Orthopaedic Surgeons as of the year 200212. Surgeons who had a higher procedure volume favored rotator cuff surgery more than those who had a lower volume12. Mini-open repair was the most frequently used method of repair (46.2%) followed by open (36.6%) and arthroscopic (14.5%)12. Despite many publications addressing rotator cuff repair techniques, indications for rotator cuff surgery, and outcomes in selected groups of patients, little information has been reported recently on trends of use at the national level. The purpose of our study was multifold. First, we sought to determine current trends in resource utilization for rotator cuff repairs, including type and setting of surgical treatment as well as type of anesthesia. The impact of age and sex on resource utilization was also examined. Finally, we also studied other variables (e.g., procedure length) that contribute to health-care costs. The hypotheses of our study were that (1) surgeons are now performing more arthroscopic rotator cuff repairs, (2) more of these repairs are being performed in ambulatory surgery settings, (3) patients who undergo surgery in an inpatient setting are more likely to be older and have more comorbidities, (4) surgical time is longer for arthroscopic repairs, and (5) the use of interscalene block for anesthesia is increasing.

Introduction Injury to the subscapularis tendon can be a cause of significant shoulder dysfunction. Diagnosis can be complex and therefore may be delayed. There is minimal literature on outcomes seen after subscapularis repair but some studies suggest shoulder function after rotator cuff repair is poorer in the setting of subscapularis repair. We present one-year minimum follow-up of a series of both arthroscopic and open subscapularis repairs. Methods We retrospectively reviewed 39 patients with one year follow-up after open or arthroscopic repair of a full-thickness subscapularis tear. Tear size (upper third, upper half, or entire subscapularis tendon) and pattern were recorded and any concomitant procedures documented. Preoperative and postoperative physical exams were completed including range of motion and the presence or absence of an abnormal stomach press. ASES and Constant scores were completed at 1 year by 24 of the total 39 patients. Results An open repair was performed in 17 patients and an arthroscopic repair in 22 patients. Average follow-up was 29 months (range 12-75 months). At most recent postoperative follow-up, the average active range of motion was forward elevation to 140 degrees, external rotation to 53 degrees, and internal rotation to T10. There was no significant difference in postoperative motion between open and arthroscopic repairs. Of those patients with an abnormal stomach press preoperatively, 48% continued to demonstrate an abnormal stomach press at latest follow-up. In those completing subjective outcome scores, the average ASES score was 76 and average Constant score was 73. There was no difference in range of motion, ASES, or Constant scores based on size of tear. Conclusion Outcomes of open and arthroscopic subscapularis repairs were equivalent. In addition, tear size was not predictive of outcome suggesting even complete subscapularis tears may do well after either open or arthroscopic repair. Though a complete repair was performed in all patients, nearly half of patients with an abnormal stomach press preoperatively were unable to perform a normal test postoperatively.

Question: In patients with shoulder impingement syndrome, what is the effectiveness and cost-effectiveness of arthroscopic decompression with acromioplasty and structured exercise compared with structured exercise alone? Design: Randomized (allocation concealed), blinded (outcome assessor) controlled trial with 2-year follow-up. Setting: 2 hospitals in Finland. Patients: 140 patients (18 to 60 years ofage; mean age, 47 y; 63% women) who had suspected shoulder impingement syndrome. Inclusion criteria were a positive Neer test; shoulder pain resistant to rest, anti-inflammatory drugs, subacromial glucocorticosteroid injections, and physiotherapy; and symptoms persisting for 3 months. Exclusion criteria were glenohumeral or acromioclavicular osteoarthritis, signs of glenohumeral instability, previous surgery to the affected shoulder, full-thickness tear of the rotator cuff, cervical radicular syndrome, adhesive capsulitis, or neuropathy of the shoulder area. End-point data were available for 134 patients (96%). Intervention: Patients were allocated to combined surgery plus structured exercise (n = 70) or exercise alone (n = 70). The structured exercise program consisted of an individually tailored home-exercise regimen that aimed to restore painless and normal mobility of the shoulder complex and increase the dynamic stability of the glenohumeral joint and scapula. Training involved the use of stretch bands and light weights. Sessions were held 4 times per week with use of 9 different exercises with 30 to 40 repetitions 3 times. As ability and strength improved, the resistance was increased and the repetitions were decreased. During arthroscopic decompression, the arthroscope was introduced through a standard posterior portal and debridement and decompression were done by shaver or vaporizer. Acromioplasty was performed with a burr drill, starting anteriorly and progressing posterolaterally. 7 to 10 days after surgery, sutures and dressings were removed and patients received the same individually tailored exercise program as provided to the exercise-alone group. Main outcome measures: The primary outcome was self-reported pain on a visual analog scale (VAS) of 0 to 10 (0 = no pain, 10 = maximum imaginable pain; 1.5 was the minimal clinically important difference). Secondary outcomes were disability, pain at night, working ability, shoulder questionnaire score, number of painful days in the previous 3 months, and the proportion of pain-free patients (VAS ≤3). Costs were in 2004 prices (€) and included direct healthcare (operation, hospitalization) and non-healthcare (travel, massage, manipulation) resources. Main results: Analysis was by intention to treat. The study had sufficient power to detect at least a 1.5-unit difference in self-reported pain between combined treatment and exercise. A decrease in self-reported pain exceeding the minimal clinically important difference occurred in both the combined treatment and exercise-alone groups. Between-group differences were not significant (Table). The groups were not different for any of the secondary outcomes. The mean total cost was €2961 in the combined treatment group and €1864 in the exercise group (mean incremental cost €1097). The incremental cost-effectiveness ratio was €5431 per minimal clinically important difference unit With a willingness to pay of €8000 for 1 additional minimal clinically important difference unit, the probability that combined treatment would be acceptable was 56%.