Functional and Radiographic Outcomes After Shoulder Surgery
Functional and Radiographic Outcomes After Shoulder Surgery
The objective of this study is twofold: First, to determine whether higher levels of
 pre-operative psychological distress predict worse outcomes after arthroscopic rotator cuff
 repair; second, to obtain functional outcomes (VAS pain, VAS satisfaction, VAS function,
 Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) Score), physically
 examine and perform a radiographic analysis of patients at a minimum of 6 months after
 reverse total shoulder arthroplasty, total shoulder arthroplasty, arthroscopic
 scapulothoracic bursectomy, acromioclavicular joint reconstruction and arthroscopic rotator
 cuff repair.
Clinical outcome studies have been performed in the evaluation of a variety of shoulder
 pathologies after surgical treatment. Among these disease processes include glenohumeral
 osteoarthritis, rotator cuff arthropathy, acromioclavicular separations and scapulothoracic
 bursitis. A variety of outcomes studies have been performed on these pathologies although few
 have utilized several functional outcome measures. Also with respect to each of these
 diagnoses, several specific areas of research regarding outcomes assessment have not been
 investigated.

 Glenohumeral osteoarthritis is one of the most common shoulder pathologies treated by
 orthopedic surgeons. For endstage osteoarthritis, an anatomic total shoulder arthroplasty
 provides excellent pain relief and functional improvement. In order to perform the
 replacement, the rotator cuff tendon in the front of the shoulder (subscapularis) needs to be
 taken down and then repaired at the completion of the case. There are three basic methods of
 takedown and repair: tenotomy, peel-off and lesser tuberosity osteotomy. The osteotomy has
 been compared clinically to tenotomy and found to provide a lower rate of subscapularis
 tears, higher outcome scores and universal healing evaluated using ultrasound and the PENN
 shoulder score.1 Gerber et al has also evaluated long-term outcomes of total shoulder
 arthroplasty with lesser osteotomy using the Constant score as a measure of outcomes.2
 Unfortunately, many outcome studies evaluating total shoulder arthroplasty utilize the Simple
 Shoulder Test and the American Shoulder and Elbow Surgeons (ASES) Score which have not been
 evaluated. Also, osteotomy was performed only utilizing a "fleck" of bone instead of the
 entire lesser tuberosity. No studies to date have evaluated TSA with an osteotomy of the
 entire lesser tuberosity.

 Reverse total shoulder arthroplasty has shown be a predictable operation for the treatment of
 rotator cuff arthropathy with clinical improvements in both pain and function at long term.
 3,4 Dislocation has been reported between 0% to 9% after reverse total shoulder arthroplasty
 and has been defined as one of the top three most common complications associated with
 reverse TSA.3-10 There is considerable debate regarding whether the subscapularis tendon
 needs repair after reverse TSA. Edwards et al reported a statistically significant reduction
 in dislocation rates from 9% to 0% with addition of subscapularis repair.10 These results had
 significant bias with regards to randomization of patients. Similarly, all patients in the
 non-repair group were at the initial portion of his learning curve. Consequently, the risk
 for instability is likely lower than reported in his series.

 Acromioclavicular joint separations represent one of the most common shoulder injuries
 accounting for approximately 9% of shoulder girdle injuries.11 Acromioclavicular injuries
 have been classified with increasing severity from I to VI based upon disruption of the
 various ligamentous and muscular supports including the acromioclavicular ligaments,
 coracoclavicular ligaments and deltotrapezial fascia.12 Recommended initial treatment for
 grade I to III injuries has been nonoperative with reasonable clinical results while initial
 surgical stabilization has been recommended for higher grade injuries.12-15

 A variety of surgical stabilization techniques for acromioclavicular joint separations have
 been reported including the transfer of the coracoacromial ligament from the acromion to the
 end of the resected distal clavicle originally described by Weaver and Dunn in 1972.16 A
 modification of the Weaver-Dunn acromioclavicular reconstruction was subsequently described
 which included coracoclavicular stabilization with nonabsorbable suture.17 Despite this
 modification, residual subluxation or dislocation of the acromioclavicular joint has been
 identified in up to 29% of patients.17 Consequently, alternative constructs have been
 described including an anatomic reconstruction utilizing a tendon graft which has been shown
 to have superior biomechanical strength compared to a Weaver-Dunn reconstruction.18

 As part of the surgical transition from the modified Weaver-Dunn reconstruction as described
 by Weinstein et al. to a reconstruction using a tendon graft, augmentation of the
 coracoclavicular suture fixation with either allograft or autograft tendon as well as
 performing the coracoacromial ligament transfer has been described.17,19 This differs from
 the anatomic reconstruction described by Mazzocca et al., as it includes both the transferred
 coracoacromial ligament and the hamstring graft for stabilization instead of just the
 graft.11 Coracoclavicular ligament reconstruction with a tendon graft has been reported as a
 treatment option for failed Weaver-Dunn reconstructions.20,21 Possible benefits of the
 combined reconstruction include improved construct strength and a vascularized ligament.
 Drawbacks include increased surgical dissection, increased operating room time and disruption
 of the coracoacromial arch. With the advances in arthroscopic techniques, acromioclavicular
 reconstructions utilizing a tendon graft are now being performed arthroscopically which has
 been described without the addition of coracoacromial ligament transfer.22 Reconstructions
 without coracoacromial ligament transfers may increase the ease of performing a
 reconstruction through smaller incisions with arthroscopic assistance. No study has evaluated
 the clinical effects of adding a coracoacromial ligament transfer to an acromioclavicular
 joint reconstruction utilizing a coracoclavicular tendon graft.

 Scapulothoracic bursitis or "snapping scapula syndrome" is an under-recognized shoulder
 disorder where the bursal sac between the scapula and chest wall becomes irritated and
 inflamed. The etiology is overuse causing reactive bursa formation between the scapula and
 thorax. If conservative measures fail as initial attempts at management, surgical excision of
 the inflamed bursa with resection of the superior medial angle of the scapula can be
 performed. The procedure can be performed either arthroscopically or open. A two-portal or
 three-portal technique can be utilized if performed arthroscopically. Very limited data
 exists regarding outcomes of two-portal or three-portal techniques with no use of validated
 patient-based outcome scores.23,24

 Rotator cuff tearing is the most common shoulder pathology treated by orthopedic surgeons.
 Healing rates after rotator cuff repair have varied in the literature from less than 5% to
 100% dependent on tear size, age, repair construct and muscle quality.25,26 A variety of
 methods have been used to repair the tendon. A recent biomechanical study has shown that
 repair with triple-loaded suture anchors have improved initial biomechanical properties
 compared to other constructs.27 No clinical data exists on healing after repair with triple
 loaded anchors or how healing effects function.
Inclusion Criteria:

 -  Patients whose primary presenting complaint of shoulder pain and who then undergo
 arthroscopic rotator cuff repair performed by the principal investigator for full
 thickness rotator cuff tear will be eligible for inclusion. All patients who have
 undergone reverse total shoulder arthroplasty, total shoulder arthroplasty utilizing a
 lesser tuberosity osteotomy, acromioclavicular joint reconstruction, arthroscopic
 scapulothoracic bursectomy or arthroscopic rotator cuff repair by the PI (RZT) will
 also be eligible for inclusion in the study. These will include patients both at the
 University of Utah as well as the Veteran's Administration Hospital in Salt Lake City.
 All patients presenting complain of shoulder pain will be given the DRAM survey
 preoperative and then evaluated a minimum of 6 months postoperative.

 Exclusion Criteria:

 -  All patients who have undergone total shoulder arthroplasty not utilizing a lesser
 tuberosity osteotomy or who have prior failed rotator cuff repair in the affected
 shoulder will be excluded.

 -  All patients who have undergone an open repair of the supraspinatus or infraspinatus
 rotator cuff tendons will not be eligible.