Arthroscopic Bankart Repair With Remplissage in Anterior Shoulder Instability Results in Fewer Redislocations Than Bankart Repair Alone at Medium-term Follow-up of a Randomized Controlled Trial.

BACKGROUND: A multicenter, double-blinded randomized controlled trial comparing isolated Bankart repair (NO REMP) to Bankart repair with remplissage (REMP) reported benefits of remplissage in reducing recurrent instability at 2 years postoperative. The ongoing benefits beyond this time point are yet to be explored. PURPOSE: To (1) compare medium-term (3 to 9 years) outcomes of these previously randomized patients undergoing isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) to manage recurrent anterior glenohumeral instability; (2) examine the failure rate, overall recurrent instability, and reoperation rate. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Recruitment and randomization for the original randomized trial occurred between 2011 and 2017. Patients ≥14 years diagnosed with recurrent traumatic anterior shoulder instability with an engaging Hill-Sachs defect of any size were included. Those with a glenoid defect >15% were excluded. In 2020, participants were contacted by telephone and asked standardized questions regarding ensuing instances of subluxation, dislocation, or reoperation on their study shoulder. "Failure" was defined as a redislocation, and "overall recurrent instability" was described as a redislocation or ≥2 subluxations. Descriptive statistics, relative risk, and Kaplan-Meier survival curve analyses were performed. RESULTS: A total of 108 participants were randomized, of whom 50 in the NO REMP group and 52 in the REMP group were included in the analyses in the original study. The mean number of months from surgery to the final follow-up was 49.3 and 53.8 months for the NO REMP and REMP groups, respectively. Failure rates were 22% (11/50) in the NO REMP group versus 8% (4/52) in the REMP group. Rates of overall recurrent instability were 30% (15/50) in the NO REMP group versus 10% (5/52) in the REMP group. Survival curves were significantly different, favoring REMP in both scenarios. CONCLUSION: For the treatment of traumatic recurrent anterior shoulder instability with a Hill-Sachs lesion and subcritical glenoid bone loss (<15%), a significantly lower rate of overall postoperative recurrent instability was observed with arthroscopic Bankart repair and remplissage than with isolated Bankart repair at a medium-term follow-up (mean of 4 years). Patients who did not receive a remplissage experienced a failure (redislocated) earlier and had a higher rate of revision/reoperation than those who received a concomitant remplissage. REGISTRATION: NCT01324531 (ClinicalTrials.gov identifier).

Position statement: management of proximal humerus fractures.

We sought to compare outcomes and reoperation rates for the surgical treatment of proximal humerus fractures (excluding head-splitting fractures, fracture-dislocations, and isolated greater-tuberosity fractures) in men and women older than 60 years. We searched MEDLINE, Embase, and Cochrane through to Feb. 1, 2022, and included all English-language randomized trials comparing operative versus nonoperative treatment; open reduction and internal fixation (ORIF) with locking plate versus intramedullary nail; arthroplasty versus ORIF; and reverse shoulder arthroplasty versus hemiarthroplasty. Outcomes of interest were functional outcomes (e.g., Constant score), pain outcomes (visual analogue scale scores), and reoperation rates for the interventions of interest when available. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This guideline will benefit patients considering surgical intervention for fractures of the proximal humerus by improving counselling on surgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.Nous avons cherché à comparer les résultats et les taux de réintervention à la suite d'un traitement chirurgical pour une fracture de l'humérus proximal (excluant les fractures de la tête humérale, les fractures-luxations et les fractures isolées de la grande tubérosité) chez les hommes et les femmes âgés de plus de 60 ans. Nous avons effectué des recherches dans les bases de données MEDLINE, Embase, et Cochrane jusqu'au 1er février 2022 et avons inclus tous les essais randomisés publiés en anglais comparant différents duos d'interventions : traitements chirurgicaux ou non chirurgicaux; réductions ouvertes avec fixation interne (ROFI) réalisées à l'aide d'une plaque verrouillée ou enclouages centromédullaires; arthroplasties ou ROFI; et arthroplasties inversées de l'épaule ou hémiarthroplasties. Les paramètres d'intérêt étaient la capacité fonctionnelle (p. ex., score de Constant), la douleur (p. ex., échelle analogique visuelle) et le taux de réintervention pour les interventions d'intérêt, selon les données disponibles. Nous avons évalué la qualité des données probantes et la solidité des recommandations à l'aide de l'approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Cette ligne directrice profitera aux patients qui envisagent une intervention chirurgicale après une fracture de l'humérus proximal en améliorant les consultations sur les options de traitement chirurgical et les résultats escomptés. Elle aidera aussi les chirurgiens en améliorant leurs connaissances sur différentes approches chirurgicales. Les données présentées pourraient servir à mettre au point des cadres et des outils pour une prise de décision partagée.

Bone channeling in arthroscopic rotator cuff repair: a systematic review and meta-analysis of level I studies.

BACKGROUND: There is ongoing controversy regarding the effect of bone channeling in arthroscopic rotator cuff repair. Since the most recent systematic reviews in 2019, several large high-level trials have been completed. This study assessed all available level I randomized controlled trials (RCTs) that compared arthroscopic rotator cuff repair with and without bone marrow channeling. METHODS: A systematic search of the Ovid MEDLINE, Embase, and Cochrane Library databases was conducted through mid January 2023. Two reviewers performed screening of studies meeting the eligibility criteria: English-language RCTs in patients aged ≥18 years comparing arthroscopic rotator cuff repair of full-thickness tears with and without bone marrow channeling (channeling group and control group, respectively). Functional scores, pain, healing rates, and reoperations were reviewed using pooled analysis where appropriate. The methodologic quality of included studies was assessed using the Cochrane risk-of-bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: A total of 6 randomized studies (N = 593) met the inclusion criteria. Pooled analysis of all 6 studies showed no significant mean difference in function (1.32; 95% confidence interval [CI], -0.63 to 3.26), as measured by the Constant-Murley score. Retear rates were also not statistically different between groups (risk ratio, 0.99; 95% CI, 0.57 to 1.71), with pooled retear rates of 19.6% (48 of 245) with channeling and 19.8% (51 of 257) without. The other outcomes of interest were only available for analysis in a subset of studies. There were no standardized mean differences in pain (0.09; 95% CI, -0.18 to 0.36), and there were similar reoperation rates (risk ratio, 1.19; 95% CI, 0.43 to 3.34) in the channeling and control groups. For the included studies, the overall quality of evidence by outcome was judged to be moderate (function, pain, and reoperations) or low (retear rates), mainly owing to risk of bias (all outcomes) and inconsistency (retear rates). CONCLUSION: The results of this study refute the findings of prior systematic reviews that showed that channeling reduces the retear rate when combined with arthroscopic rotator cuff repair. This meta-analysis of level I evidence, including recent larger RCTs, demonstrates that bone marrow stimulation in the setting of primary arthroscopic rotator cuff repair has no significant effect on functional outcomes, healing, pain, or reoperation rates.

Indications and outcomes of glenoid osteotomy for posterior shoulder instability: a systematic review.

Background: There is limited evidence examining glenoid osteotomy as a treatment for posterior shoulder instability. Methods: A search of Medline, Embase, PubMed and Cochrane Central Register of Controlled Trials was conducted from the date of origin to 28th November 2019. Nine out of 3,408 retrieved studies met the inclusion criteria and quality was assessed using the Methodological Index for Non-randomized Studies tool. Results: In 356 shoulders, the main indication for osteotomy was excessive glenoid retroversion (greater than or equal to approximately -10°). The mean preoperative glenoid version was -15° (range, -35° to -5°). Post-operatively, the mean glenoid version was -6° (range, -28° to 13°) and an average correction of 10° (range, -1° to 30°) was observed. Range of motion increased significantly in most studies and all standardized outcome scores (Rowe, Constant-Murley, Oxford instability, Japan Shoulder Society Shoulder Instability Scoring and mean shoulder value) improved significantly with high rates of patient satisfaction (85%). A high complication rate (34%, n = 120) was reported post-surgery, with frequent cases of persistent instability (20%, n = 68) and fractures (e.g., glenoid neck and acromion) (4%, n = 12). However, the revision rate was low (0.6%, n = 2). Conclusion: Glenoid osteotomy is an appropriate treatment for posterior shoulder instability secondary to excessive glenoid retroversion. However, the high rate of persistent instability should be considered when making treatment decisions.Level of Evidence: Systematic review; Level 4.

Position statement: management of rotator cuff tears in adults.

We sought to compare success and re-tear rates of surgically treated full-thickness tears of the rotator cuff in men and women older than 18 years of age to develop a guideline intended for orthopedic surgeons and other health care providers who assess, counsel and care for these patients. We searched Medline, Embase and Cochrane databases through to Apr. 20, 2021, and included all English-language randomized trials comparing single-row versus double-row fixation via arthroscopic approaches; latissimus dorsi transfer (LDT) versus partial rotator cuff repair, lower trapezius transfer (LTT), and superior capsular reconstruction (SCR); and early versus late arthroscopic rotator cuff repair for traumatic tears. We also considered observational studies comparing LDT with LTT and partial repair and studies comparing early versus late treatment of traumatic rotator cuff tears. Outcomes of interest were functional outcomes, pain outcomes, and re-tear rates associated with these interventions. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. This guideline will benefit patients seeking surgical intervention of full thickness rotator cuff tears by improving counselling on surgical treatment options and outcomes. It will also benefit surgical providers by expanding their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.

Transcutaneous electrical nerve stimulation (TENS) and extracorporeal shockwave therapy (ESWT) in lateral epicondylitis: a systematic review and meta-analysis.

Background: Consensus has not yet been reached regarding the optimal nonoperative treatment of lateral epicondylitis. Physiotherapy is often utilized, yet the specific modalities used can vary significantly, making this treatment arm quite broad. The role and efficacy of passive physiotherapy by way of transcutaneous electrical nerve stimulation (TENS) and extracorporeal shockwave therapy (ESWT) are not well understood. The purpose of this systematic review and meta-analysis was to compare transcutaneous electrical nerve stimulation (TENS) and extracorporeal shockwave therapy (ESWT) with no active treatment. Methods: MEDLINE, Embase, and Cochrane were searched through till September 20, 2021. All English-language randomized trials comparing passive electrophysiotherapy treatments compared with no active treatment/placebo of patients >18 years of age with lateral epicondylitis with minimum 6-month follow-up were included. Results: In the pooled analysis of 2 trials, ESWT provided no benefit compared to no active treatment for pain (-7.063, 95% confidence interval [CI]: -19.16 to 3.89) or function (standardized mean difference [SMD]: 0.03, 95% CI: -0.31 to 0.38, I 2  = 0%). TENS showed no improvement in function compared with control with a mean difference in PRTEE scores of 2.93 points (95% CI -8.30 to 2.43) at 12 months, nor were differences seen in pain scores at 12 months (P = .139). Discussion: The available evidence does not support the use of passive electrophysiotherapy modalities, TENS or ESWT in the treatment of lateral epicondylitis.

Intraoperative Channeling in Arthroscopic Rotator Cuff Repair: A Multicenter Randomized Controlled Trial.

BACKGROUND: Despite recent advances in arthroscopic rotator cuff repair, the retear rate remains high. New methods to optimize healing rates must be sought. Bone channeling may create a quicker and more vigorous healing response by attracting autologous mesenchymal stem cells, cytokines, and growth factors to the repair site. HYPOTHESIS: Arthroscopic rotator cuff repair with bone channeling would result in a higher healing rate compared with arthroscopic rotator cuff repair without adjuvant channeling. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Our primary objective was to compare healing rates in patients undergoing arthroscopic rotator cuff repair for degenerative tears, with and without bone channeling. Secondary objectives included comparisons of the Western Ontario Rotator Cuff Index (WORC) score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Constant strength subscore, and visual analog scale (VAS) for pain score between groups. Patients undergoing arthroscopic rotator cuff repair were recruited at 3 sites and were randomized to receive either bone channeling augmentation or standard repair. Healing was determined via ultrasound at 24 months postoperatively. WORC, ASES, and Constant scores were compared between groups at baseline and at 3, 6, 12, and 24 months postoperatively. RESULTS: A total of 168 patients were enrolled between 2013 and 2018. Intention-to-treat analysis revealed no statistical differences in healing rates between the 2 interventions at 24 months postoperatively. Statistically significant improvements occurred in both groups from preoperatively to all time points for the WORC, the ASES score, the Constant score or Constant strength subscore, and the VAS for pain (P < .0001). No differences were observed between the bone channeling and control groups in WORC, ASES, Constant, and VAS pain scores at any time point. CONCLUSION: This trial did not demonstrate the superiority of intraoperative bone channeling in rotator cuff repair over standard rotator cuff repair at 24 months postoperatively. Healing rates, patient-reported function, and quality-of-life outcomes were similar between groups. REGISTRATION: NCT01877772 (ClinicalTrials.gov identifier).

Management of Proximal Humeral Fractures in Adults: A Systematic Review and Meta-Analysis.

OBJECTIVES: Differences in function, pain, and reoperation rates were compared between the following treatment options: (1) operative vs. nonoperative treatment and (2) various surgical treatments including open reduction internal fixation, intramedullary nail, hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA). DATA SOURCES: MEDLINE, Embase, and Cochrane were searched through February 1, 2022. All English-language randomized trials comparing operative and nonoperative treatment of proximal humeral fractures with a control group in patients 18 years or older were included. DATA EXTRACTION: Demographic data, functional and pain scores and re-operation rates were extracted. Study quality was determined with the Cochran risk of bias tool and the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE). Heterogeneity was determined with the I-squared statistic. DATA SYNTHESIS: Meta-analysis of included studies using mean difference and odds ratios where appropriate. CONCLUSIONS: Surgical treatment with either locked plates or HA results in similar functional scores and pain outcomes as nonoperative treatment, although plates were associated with higher reoperation rates in 3-part and 4-part fractures. In 3-part and 4-part fractures, RSA results in higher function and pain scores compared with HA. Further high-quality trials should focus on RSA, and further study is required to better define the role of open reduction internal fixation in the younger patient population. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Ultrasound-determined healing rates with subscapularis tenotomy versus peel after anatomic shoulder arthroplasty.

BACKGROUND: Several techniques have been described for mobilizing the subscapularis tendon in anatomic total shoulder arthroplasty (TSA). The purpose of this study was to compare subscapularis tendon healing rates, as determined by ultrasound, in patients following anatomic TSA with either a subscapularis tenotomy or subscapularis peel. METHODS: This study was a secondary analysis of patients from a previous randomized controlled trial in which patients underwent anatomic TSA and were randomized to either a tenotomy or peel approach. The primary outcome was postoperative tendon healing rates determined on ultrasound at >12 months after surgery. Secondary outcomes included postoperative tendon thickness measured on ultrasound; elbow position (neutral alignment in the belly-press position vs. posterior); internal rotation function measured with the third and fourth questions of the American Shoulder and Elbow Surgeons questionnaire; and Western Ontario Osteoarthritis of the Shoulder index. Radiographs were analyzed in patients with torn tendons. RESULTS: One hundred patients were randomized to a tenotomy (n = 47) or peel (n = 53) approach. Postoperative ultrasound results were available in 88 patients. Tendon healing rates were 95% for tenotomy vs. 75% for peel (P = .011). The mean postoperative tendon thickness was 4 mm (standard deviation, 1.0 mm) and 4 mm (standard deviation, 1 mm) in the tenotomy and peel groups, respectively (P = .37). Internal rotation function was not associated with healing status (P = .77 and P = .22 for questions 3 and 4, respectively, of the American Shoulder and Elbow Surgeons questionnaire), nor was elbow position (P = .2) in the belly-press position. DISCUSSION: We observed that subscapularis tenotomy had a higher healing rate than peel as determined by ultrasound in TSA patients. There was no statistically significant difference in postoperative tendon thickness in intact tendons as measured on ultrasound when comparing subscapularis mobilization techniques, nor was there any association between healing status and internal rotation function or elbow position.

Arthroscopic Rotator Cuff Repair with and without Acromioplasty in the Treatment of Full-Thickness Rotator Cuff Tears: Long-Term Outcomes of a Multicenter, Randomized Controlled Trial.

BACKGROUND: The aim of this study was to reevaluate patients from a previous randomized controlled trial at a long-term follow-up to determine the long-term efficacy of subacromial decompression in patients with full-thickness rotator cuff tears. METHODS: This is a secondary study based on a previous, multicenter, randomized controlled trial with patients allocated to arthroscopic rotator cuff repair with or without acromioplasty. The original study was conducted between 2003 and 2011, and the secondary study was conducted between 2015 and 2021. Patients were invited by a blinded assessor to return to complete the Western Ontario Rotator Cuff (WORC) index and a questionnaire about reoperation and to undergo a clinical assessment. If participants were unable to return, they were asked to complete the questionnaires by mail. A chart review on all participants in the original study was conducted. RESULTS: Eighty-six patients were randomized in the original trial, with 31 of 45 from the group without acromioplasty and 25 of 41 from the acromioplasty group returning for long-term follow-up. The mean duration (and standard deviation) of follow-up was 11.2 ± 2.4 years for the group without acromioplasty and 11.5 ± 2.6 years for the acromioplasty group. There was no significant difference in WORC scores between the groups with and without acromioplasty at the time of the long-term follow-up (p = 0.30). Seven (16%) of the 45 patients in the group without acromioplasty underwent reoperation. One (2%) of the initial 41 patients allocated to acromioplasty underwent reoperation. All patients who underwent a reoperation had a Type-2 or 3 acromion. CONCLUSIONS: Patients who underwent rotator cuff repair with or without acromioplasty experienced improvement of outcomes from their preoperative level at a long-term follow-up (mean, 11 years), and there were no differences in patient-reported outcomes, specifically WORC scores, between these groups. However, a significantly higher reoperation rate was observed in patients who had rotator cuff repair without acromioplasty, specifically in those with a Type-2 or 3 acromion. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Position statement: nonoperative management of lateral epicondylitis in adults.

We sought to compare methods of nonsurgical treatment of lateral epicondylitis in men and women older than 18 years to develop a guideline intended for orthopedic surgeons and other health care providers who assess, counsel and care for these patients. We searched Medline, Embase and Cochrane through to Mar. 9, 2021, and included all English-language studies comparing nonsurgical approaches. We compared physiotherapy versus no active treatment, corticosteroids versus placebo, platelet-rich plasma (PRP) versus placebo, and autologous blood injection versus placebo. Outcomes of interest were pain outcomes (visual analogue scale scores) and functional outcomes. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. This guideline will benefit patients seeking nonsurgical intervention for lateral epicondylitis by improving counselling on nonsurgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various nonsurgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.

InSpace Implant Compared with Partial Repair for the Treatment of Full-Thickness Massive Rotator Cuff Tears: A Multicenter, Single-Blinded, Randomized Controlled Trial.

BACKGROUND: The purpose of this study was to prospectively evaluate the efficacy and safety of a subacromial balloon spacer (InSpace implant; Stryker) compared with arthroscopic partial repair in patients with irreparable, posterosuperior massive rotator cuff tears. METHODS: Patients ≥40 years of age with symptomatic, irreparable, posterosuperior, massive rotator cuff tears and an intact subscapularis who underwent failed nonoperative management were included in this randomized controlled trial comparing the InSpace implant with partial repair. Clinical outcome data were collected at baseline through a 24-month follow-up. The primary outcome was improvement in the American Shoulder and Elbow Surgeons (ASES) scores. The secondary outcomes included change from baseline in the Western Ontario Rotator Cuff (WORC) score, the visual analog scale (VAS) pain score, the Constant-Murley shoulder score, the EuroQol-5 Dimensions-5-Level (EQ-5D-5L) score, active range of motion, and operative time. Complications and reoperations for each group were also recorded. RESULTS: Twenty sites randomized 184 patients: 93 in the InSpace group and 91 in the partial repair group. Significant and clinically relevant improvements in the ASES score from baseline were noted in both groups at Month 12 and were maintained at Month 24. Overall, 83% of patients in the InSpace group and 81% of patients in the partial repair group achieved the ASES minimally clinically important difference threshold, and 82% of patients in the InSpace group and 79% of patients in the partial repair group achieved the substantial clinical benefit threshold. Forward elevation was significantly greater in the InSpace group compared with the partial repair group at Day 10 (p = 0.04), Week 6 (p = 0.0001), Month 12 (p = 0.005), and Month 24 (p = 0.003). The operative time was significantly shorter in the InSpace group (p < 0.0001). No device-related surgical complications were noted, and 4 reoperations after InSpace implantation and 3 reoperations after partial repair were required. CONCLUSIONS: The InSpace implant is an appropriate alternative to partial repair in patients with irreparable posterosuperior massive rotator cuff tears and an intact subscapularis. Notable benefits include early functional recovery and pain relief combined with a shorter operative time. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Nonoperative treatment of lateral epicondylitis: a systematic review and meta-analysis.

BACKGROUND: There is an ongoing controversy regarding the nonoperative treatment of lateral epicondylitis. Given that the evidence surrounding the use of various treatment options for lateral epicondylitis has expanded, an overall assessment of nonoperative treatment options is required. The purpose of this systematic review and meta-analysis was to compare physiotherapy (strengthening), corticosteroids (CSIs), platelet-rich plasma (PRP), and autologous blood (AB) with no active treatment or placebo control in patients with lateral epicondylitis. METHODS: MEDLINE, Embase, and Cochrane were searched through till March 8, 2021. Additional studies were identified from reviews. All English-language randomized trials comparing nonoperative treatment of patients >18 years of age with lateral epicondylitis were included. RESULTS: A total of 5 randomized studies compared physiotherapy (strengthening) with no active treatment. There were no significant differences in pain (mean difference: -0.07, 95% confidence interval [CI]: -0.56 to 0.41) or function (standardized mean difference [SMD]: -0.08, 95% CI: -0.46 to 0.30). Seven studies compared CSI with a control. The control group had statistically superior pain (mean difference: 0.70, 95% CI: 0.22 to 1.18) and functional scores (SMD: -0.35, 95% CI: -0.54 to -0.16). Two studies compared PRP with controls, and no differences were found in pain (SD: -0.15, 95% CI: -1.89 to 1.35) or function (SMD: 0.14, 95% CI: -0.45 to 0.73). Three studies compared AB with controls, and no differences were observed in pain (0.49, 95% CI: -2.35 to 3.33) or function (-0.07, 95% CI: -0.64 to 0.50). DISCUSSION: The available evidence does not support the use of nonoperative treatment options including physiotherapy (strengthening), CSI, PRP, or AB in the treatment of lateral epicondylitis.

What outcomes are important in the recovery from acromio-clavicular (AC) joint pathology? A focus group study with patients and surgeons.

INTRODUCTION: Acromio-clavicular (AC) joint pathology is a disabling condition that can restrict quality of life through chronic pain and functional limitation. The objective of this study was to determine symptoms and patient-centred outcomes identified by patients with AC pathology and from experienced shoulder surgeons. METHODS: Qualitative research methods were undertaken with patient and surgeon focus groups. Patients with AC-joint pathology were invited to participate and were stratified into two cohorts: AC instability and AC osteoarthritis (OA). RESULTS: Sixteen patients participated in five patient focus group discussions including 10 patients with AC instability and six patients with AC OA. Four surgeons participated in two focus groups. Although some themes were common to both AC Instability and AC OA, a number of themes were unique to each. A number of themes were identified that do not appear in existing AC joint scores. CONCLUSION: Although many factors affecting the AC joint were common to instability and OA pathology, several factors appear to be unique to each and do not appear in existing AC joint metrics. These symptoms and patient-centered outcomes may be used by clinicians in the assessment of patients with AC pathology and in the development of rehabilitation programs.Implications for rehabilitationA thorough understanding of symptoms and patient-centred outcomes associated with acromio-clavicular arthritis and instability is necessary in order to conduct an accurate clinical assessment and design an effective rehabilitation program that meets the clinical needs of patients.Patients in this study identified several themes relevant to assessment and rehabilitation program development including pain location, type of pain (eg. burning pain), and specific activities that induced pain that do not exist in current existing tools.Our finding that certain themes were only raised in either acromio-clavicular instability or osteoarthritis suggests that there may be differences in important outcomes for patients depending on the underlying cause of the acromio-clavicular joint pathology. By incorporating these themes into clinical assessments, outcomes important to patients may be elicited to monitor response to rehabilitation following injury or surgery.

Treatment of rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: There is ongoing controversy regarding optimal treatment for full-thickness rotator cuff tears. Given that the evidence surrounding the use of various treatment options has expanded, an overall assessment is required. OBJECTIVES: The following were compared to determine which resulted in improved patient-reported function, pain, and reoperation rates for each: (1) double-row (DR) fixation and single-row (SR) fixation in arthroscopic cuff repair; (2) latissimus dorsi transfer (LDT) with lower trapezius transfer (LTT), partial rotator cuff repair, and superior capsular reconstruction (SCR); and (3) early and late surgical intervention. METHODS: Medline, Embase, and Cochrane were searched through to April 20, 2021. Additional studies were identified from reviews. The following were included: (1) All English-language randomized controlled trials (RCTs) in patients ≥18 years of age comparing SR and DR fixation, (2) observational studies comparing LDT with LTT, partial repair, and SCR, and (3) observational studies comparing early vs. late treatment of full-thickness rotator cuff tears. RESULTS: A total of 15 RCTs (n = 1096 randomized patients) were included in the meta-analysis of SR vs. DR fixation. No significant standardized mean differences in function (0.08, 95% confidence interval [CI] -0.09, 0.24) or pain (-0.01, 95% CI -0.52, 0.49) were observed. There was a difference in retear rates in favor of DR compared with SR fixation (RR 1.56, 95% CI 1.06, 2.29). Four studies were included in the systematic review of LDT compared with a surgical control. LDT and partial repair did not reveal any differences in function (-1.12, 95% CI -4.02, 1.78) on comparison. A single study compared arthroscopically assisted LDT to LTT and observed a nonstatistical difference in the Constant score of 14.7 (95% CI -4.06, 33.46). A single RCT compared LDT with SCR and revealed a trend toward superiority for the Constant score with SCR with a mean difference of -9.6 (95% CI -19.82, 0.62). Comparison of early vs. late treatment revealed a paucity of comparative studies with varying definitions of "early" and "late" treatment, which made meaningful interpretation of the results difficult. CONCLUSION: DR fixation leads to similar improvement in function and pain compared with SR fixation and results in a higher healing rate. LDT transfer yields results similar to those from partial repair, LTT, and SCR in functional outcomes. Further study is required to determine the optimal timing of treatment and to increase confidence in these findings. Future trials of high methodologic quality comparing LDT with LTT and SCR are required.

A Multicenter Randomized Controlled Trial Comparing Single-Row With Double-Row Fixation in Arthroscopic Rotator Cuff Repair: Long-Term Follow-up.

BACKGROUND: The long-term outcomes of single- versus double-row fixation in arthroscopic rotator cuff repair are not currently known. PURPOSE: To compare the treatment effects of the single- versus double-row suture technique in arthroscopic rotator cuff repair of full-thickness tears at 10-year follow-up. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients were evaluated at 10 years postoperatively. The primary outcome measure was the Western Ontario Rotator Cuff Index (WORC). Secondary outcome measures included the American Shoulder and Elbow Surgeons (ASES) score, Constant score, strength, and incidence of revision surgery. Ultrasound was used to evaluate the rotator cuff to determine repair integrity. Statistical analyses consistent with those of the main trial were conducted. RESULTS: Of the original 90 participants, 77 (85%) returned at a mean follow-up of 10 years. At ten year follow-up, the WORC score was higher in the double row group (79.9 [95% CI, 16.2 to 99.1]) compared with the single row group (72.9, [95% CI, 4.3 to 100]), P = .020. From baseline to 2 years, the mean change in WORC scores for the single-row group was -48.5 compared with -40.6 for the double-row group, with a between-group difference of -7.8 (95% CI, -20.4 to 4.7). From 2 to 10 years, the change in WORC scores for the single-row group was 11.5 compared with -0.2 for the double-row group, with a between-group difference of 11.7 (95% CI, -0.7 to 24.3). From baseline to 10 years, the mean between-group difference was 3.9 (95% CI, -7.8 to 15.6). Similarly, a decrease in ASES scores was observed between 2 and 10 years for the single-row group (9.2 [95% CI, 0.9 to 17.5]; P = .029), with a nonsignificant decrease in ASES scores for the double-row group (6.2 [95% CI, -3.2 to 15.6]; P = .195) as well as a decrease in Constant scores for both the single- (9.5 [95% CI, 1.4 to 17.5]; P = .020) and double-row (14.4 [95% CI, 5.6 to 23.3]; P = .001) groups. Overall, 3 participants developed a full-thickness tear after 2 years: 2 from the double-row group and 1 from the single-row group. One participant from each study group underwent revision surgery after the 2-year time point. CONCLUSION: A statistically significant (but likely not clinically important) difference in WORC scores was seen at 10-year follow-up in favor of double-row fixation. Between baseline and 10-year follow-up, a decrease in most outcome scores was observed in both the single- and the double-row groups. REGISTRATION: NCT00508183 (ClinicalTrials.gov identifier).

Effect of age, gender, and body mass index on incidence and satisfaction of a Popeye deformity following biceps tenotomy or tenodesis: secondary analysis of a randomized clinical trial.

BACKGROUND: The purpose of this study was to determine the incidence of Popeye deformity following biceps tenotomy vs. tenodesis and evaluate risk factors and subjective and objective outcomes. METHODS: Data for this study were collected as part of a randomized clinical trial in which patients aged ≥18 years undergoing arthroscopic shoulder surgery for a long head of the biceps tendon lesion were allocated to undergo tenotomy or tenodesis. The primary outcome measure for this secondary analysis was rate of Popeye deformity at 24 months postoperation as determined by an evaluator blinded to group allocation. Those with a deformity indicated their satisfaction with the appearance of their arm on a 10-cm visual analog scale, rated their pain and cramping, and completed the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form and the Western Ontario Rotator Cuff index. Isometric elbow flexion and supination strength were also measured. Cohen kappa was calculated to measure inter-rater reliability between patient and evaluator on the presence of a deformity. Logistic regression was performed to identify predictors of presence or absence of a Popeye deformity. RESULTS: One hundred fourteen patients were randomly assigned to 2 groups, of which 42 to the tenodesis group and 45 to the tenotomy group completed a 24-month follow-up. Based on clinical observation, the odds of a Popeye in the tenotomy group were 4.3 times greater than in the tenodesis group (P = .018) with incidence of 33% (15/45) and 9.5% (4/42), respectively. Surgical technique was the only significant predictor of perceived deformity, with male gender trending toward significance (odds ratio 7.33, 95% confidence interval 0.867-61.906, P = .067). Mean (standard deviation) satisfaction score of those with a deformity regarding appearance of their arm was 7.3 (2.6). Increasing satisfaction was correlated with increasing age (r = 0.640, P = .025), but there was no association with gender (r = -0.155, P = .527) or body mass index (r = -0.221, P = .057). Differences in subjective outcomes were dependent on whether the Popeye was clinician- or self-assessed. CONCLUSION: The odds of developing a perceived Popeye deformity was 4.3 higher after tenotomy compared to tenodesis based on clinician observation. Male gender was trending toward being predictive of having a deformity. Pain and cramping were increased in those with a self-reported Popeye. Younger patients were significantly less satisfied with a deformity despite no difference in functional outcomes at 24 months. Thus, biceps tenodesis may be favored in younger male patients to minimize the risk of Popeye and the risk of dissatisfaction in the appearance of their arm following surgery.