Mast Cells Mediate Acute Inflammatory Responses After Glenoid Labral Tears and Can Be Inhibited With Cromolyn in a Rat Model.

BACKGROUND: Injuries to the glenoid labrum have been recognized as a source of joint pain and discomfort, which may be associated with the inflammatory responses that lead to the deterioration of labral tissue. However, it is unclear whether the torn labrum prompts mast cell (MC) activation, resulting in synovial inflammatory responses that lead to labral tissue degeneration. PURPOSE: To determine the potential influence of activated MC on synovial inflammatory responses and subsequent labral tissue degeneration and shoulder function deterioration in a rat model by monitoring MC behavior and sequential inflammatory responses within the synovial tissue and labral tissue after injury, suture repair, and MC stabilizer administration. STUDY DESIGN: Controlled laboratory study. METHODS: Anteroinferior glenoid labral tears were generated in the right shoulder of rats (n = 20) and repaired using a tunneled suture technique. Synovial tissue inflammatory responses were modulated in some rats with intraperitoneal administration of an MC stabilizer-cromolyn (n = 10). At weeks 1 and 3, MC activation, synovial inflammatory responses, and labral degeneration were histologically evaluated. Simultaneously, gait analysis was performed before and after surgical repair to assess the worsening of the shoulder function after the injury and treatment. RESULTS: Resident MC degranulation after labral injury (50.48% ± 8.23% activated at week 1) contributed to the initiation of synovial tissue inflammatory cell recruitment, inflammatory product release, matrix metalloproteinase-13, and subsequent labral tissue extracellular matrix degeneration. The administration of cromolyn, an MC stabilizer, was found to significantly diminish injury-mediated inflammatory responses (inflammatory cell infiltration and subsequent proinflammatory product secretion) and improve shoulder functional recovery. CONCLUSION: MC activation is responsible for labral tear-associated synovial inflammation and labral degeneration. The administration of cromolyn can significantly diminish the cascade of inflammatory reactions after labral injury. CLINICAL RELEVANCE: Our findings support the concept that MC stabilizers may be used as a complementary therapeutic option in the treatment and repair of labral tears.

Predictors of Clinical Outcomes and Quality of Life After Sternoclavicular Joint Reconstruction With Hamstring Tendon Autograft.

BACKGROUND: Anterior instability of the sternoclavicular joint (SCJ) is a rare but potentially devastating pathological condition, particularly when it occurs in young or active patients. SCJ reconstruction using hamstring tendon autograft is a commonly used treatment option, yet to date results are limited to small case series. Studies on baseline, preoperative factors and their association with postoperative outcome are limited. PURPOSE: To assess the midterm clinical outcomes and survivorship after SCJ reconstruction using hamstring tendon autograft in patients experiencing anterior SCJ instability and to determine whether baseline patient or causative factors are associated with postoperative outcomes or patient satisfaction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent SCJ reconstruction with a hamstring tendon autograft for anterior SCJ instability between October 2005 and October 2020 were included in this retrospective single-center study. At a minimum of 2 years postoperatively, clinical outcomes were collected, including the following patient-reported outcomes (PROs): the 12-Item Short Form Survey (SF-12) score; American Shoulder and Elbow Surgeons (ASES) score; Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score; Single Assessment Numeric Evaluation (SANE) score; and visual analog scale (VAS) pain score. Subjective postoperative satisfaction with the procedure was quantified on a scale from 0 (very unsatisfied) to 10 (very satisfied). The predictive role of patient factors, including age, sex, and injury in dominant arm, on postoperative PROs and satisfaction at short-term follow-up was evaluated using multiple linear regression. RESULTS: A total of 49 patients (mean age, 29.6 ± 16.2 years; range 13.8-67.1 years; 27 females) were included in the final analysis. At a mean follow-up of 3.9 ± 2.1 years, all PROs had significantly improved, including the mean SF-12 Physical Component Summary score (40.4 ± 6.8 to 52.6 ± 6.9; P < .001), ASES score (54.9 ± 20.4 to 91.0 ± 11.3; P < .001), QuickDASH score (41.2 ± 18.5 to 10.2 ± 9.1; P < .001); SANE score (50.2 ± 21.1 to 88.3 ± 8.8; P < .001), VAS pain score (4.4 ± 2.6 to 0.8 ± 1.4; P < .001), and VAS pain score at its worst (7.4 ± 2.5 to 3.3 ± 2.6; P < .001). The median postoperative satisfaction score was 9 (range, 1-10). Revision-free survivorship was 95.9%. Male patients had a significantly lower VAS pain score at its worst compared with female patients (2.6 ± 2.6 vs 4.1 ± 2.4; P = .045); higher age was significantly correlated with a worse QuickDASH score (correlation coefficient, 0.314; P = .036). Overhead athletes had a significantly lower propensity to return to sport compared with nonoverhead athletes (P = .043), with only 45% of the overhead athletes returning to a level similar to their preinjury level, whereas 81% of the nonoverhead athletes were able to do so. CONCLUSION: The significant improvements in clinical and sport-specific outcomes and high patient satisfaction after SCJ reconstruction with a hamstring tendon autograft demonstrate the success of this procedure in treating anterior SCJ instability. Male sex and younger patient age are associated with superior outcomes, while overhead athletes have to be counseled about difficulties of returning to preinjury level of sport postoperatively.

Outcomes of primary arthroscopic shoulder stabilization in active patients over 40-results at a mean follow-up of 7 years.

Background: The purpose of this study is to report clinical outcomes, return to activity, redislocation rate, and rate of conversion to arthroplasty for active patients over age 40 undergoing primary arthroscopic shoulder stabilization. Methods: Patients over 40 years of age who underwent arthroscopic capsulolabral repair for shoulder instability between December 2005 and January 2018 with a minimum of 2-year postoperative follow-up were enrolled in this retrospective, monocentric study. Clinical outcome scores including the 12-Item Short-Form Survey, American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder, and Hand, Single-Assessment Numeric Evaluation, and visual analog scale pain were collected. Additionally, it was determined which patients reached the minimal clinically important difference and the patient-acceptable symptom state for the ASES score. Bivariate analysis was utilized to determine if there was any association between baseline demographic and clinical factors with the outcome scores. Results: Of a total of 814 patients assessed for eligibility, an aggregate of 40 patients were included and 33 patients (8 females) were available for follow-up. The average age was 49.4 ± 7.6 years. At an average follow-up of 7.0 ± 3.6 years, all the outcome scores significantly improved compared to baseline. These included ASES (69.9 ± 19 to 95.8 ± 7.6, P < .001); the Quick Disabilities of the Arm, Shoulder, and Hand score (29.7 ± 17.7 to 3.9 ± 5.4, P < .002); Single Assessment Numeric Evaluation score (53.5 ± 29.3 to 91.6 ± 14.3, P < .003); the 12-Item Short-Form Survey (45.6 ± 8.8 to 55.2 ± 5.7, P < .001); and the visual analog scale (2.1 ± 2.1 to 0.3 ± 1, P < .002). The minimal clinically important difference was reached by 72.7% of the patients and 81.8% reached the patient-acceptable symptom state threshold for the ASES score. Postoperative shoulder stability improved substantially and significantly. Median postoperative satisfaction was 10/10 (range 1-10). Ninety-five-point-six percent of the patients returned to sport, with 91.0% of the patients able to return to preinjury level. One patient (3%) underwent revision surgery for osteoarthritis, in the form of comprehensive arthroscopic management procedure. The presence of cartilage defects cartilage defects Outerbridge grade >2 (P = .020) and posterior labral lesions (P = .03) at index surgery were significantly associated with inferior outcomes in the ASES score. Conclusion: Active patients aged 40 years and older undergoing arthroscopic shoulder stabilization experienced favorable functional outcomes at a mean follow-up of 7 years, with low rates of revision surgery or of progression to clinically relevant osteoarthritis. However, the presence of high-grade cartilage lesions and the presence of a posterior labral tear were associated with inferior clinical outcomes.

The impact of mental health conditions on clinical and functional outcomes after shoulder arthroplasty: a systematic review.

Background: Shoulder arthroplasty (SA) has been shown to improve quality of life, though outcomes may vary between individuals. Multiple factors may affect outcomes, including preoperative mental health conditions (MHCs). The goal of this systematic review was to evaluate the clinical and functional outcomes after SA in patients with MHC compared to patients without MHC. Methods: This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines outlined by Cochrane Collaboration. A search of PubMed, the Medline Library, and EMBASE was conducted from inception until September 2023 to obtain studies reporting outcomes after total shoulder arthroplasty and reverse total shoulder arthroplasty in patients with and without MHC. Study characteristics and information on clinical and functional outcomes were collected. All included studies were case-control studies. The methodological quality of the included primary studies was appraised using the methodological index for nonrandomized studies scoring. Results: Eleven articles published between 2016 and 2023 met inclusion criteria. In total, 49,187 patients, 49,289 shoulders, and five different MHC were included. 8134 patients in the cohort had a diagnosed MHC. The mean patient age was 67.8 years (range, 63.5-71.6 years), and 52.6% of the patients were female. The mean follow-up time was 35.5 months (range, 16.2-58.3 months). Reverse total shoulder arthroplasty was the most common type of procedure (25,543 shoulders, 51.8%). Depression and anxiety were the most reported psychiatric diagnoses (7990 patients, 98.2%). Patients with versus without MHC reported mean improvements of 38 and 42 in American Shoulder and Elbow Surgeons shoulder score and mean Visual Analog Scale pain improvements of 4.7 and 4.9, respectively. Mean complication rates of 31.4% and 14.2% were observed in patients with versus without MHC, respectively. The most prevalent surgical complication in patients with MHC was infection (1.8%), followed by prosthetic complication (1.7%), and adhesive capsulitis (1.6%). Conclusions: Patients with MHC may have lower preoperative range of motion, worse postoperative shoulder function, and higher postoperative pain levels than patients without MHC. Patients with MHC demonstrated improvements in range of motion and functional outcomes after SA but had higher reported complication and revision rates when compared to patients without MHC. Depression and anxiety were the leading conditions correlated with lower outcomes in patients with MHC after SA. Preoperative physical therapy, mental health counseling, and expectation setting may help these patients reach the maximal achievable benefit from SA.

Correlation between the Long Head of the Biceps Microscopic Degeneration and Extent of Apoptotic Process.

Objectives: The purpose of this study was to determine the correlation between microscopic degeneration in the long head of the biceps tendon (LHBT) and the apoptotic process. Methods: This study included 26 consecutive patients who had undergone arthroscopic biceps tenodesis or tenotomy for symptomatic LHBT with or without concomitant rotator cuff tears (RCTs). Histological examination of the specimens under a light microscope was conducted after staining with hematoxylin, eosin, and the Alcian blue. Histopathological changes were assessed using the original Bonar score and the modified Bonar score and then correlated with the expression of the subsequent apoptosis markers: activated caspase-3 (casp3), tumor protein p53 (p53), and B-cell lymphoma 2 (BCL-2). Results: The mean original Bonar score was 8.65 (range 5-11), while the modified Bonar score was 7.61. There was no correlation between the original Bonar score and the age of the patients, but a positive correlation was found between the modified Bonar score and the age of the patients (p = 0.0022). There was no correlation between the age of patients and the expression indexes of BCL-2 and casp3. However, the expression of the p53 index showed a positive correlation with patient aging (p = 0.0441). Furthermore, there was no correlation observed between the expression of apoptotic indexes and both the original and modified Bonar scale. Conclusions: In LHB tendinopathy, the expression of apoptosis does not seem to directly correlate with the extent of degeneration, particularly in the late stages of tendinopathy. However, the transformations observed in collagen and ground substance were significantly associated with age, as well as tendinous tissue degeneration quantified according to modified Bonar score. The age of patients was also linked with the expression of the p53 index, as an increased apoptosis in the studied population.

The impact of neurologic disorders on clinical and functional outcomes after shoulder arthroplasty: a systematic review.

BACKGROUND: Patients with pre-existing neurologic disorders present a unique set of challenges for shoulder arthroplasty (SA) surgeons due to the presence of concomitant contractures, muscle weakness, and spasticity, which may affect outcomes and complication rates after SA. The goal of this systematic review was to evaluate the clinical and functional outcomes after SA in patients pre-existing with neurologic disorders, focusing on complication and reoperation rates. METHODS: This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines outlined by Cochrane Collaboration. A search of PubMed, the Medline Library, and EMBASE from inception until September 2023 was conducted to obtain studies reporting on outcomes after SA in patients with neurologic disorders. Study demographics and information on outcomes including patient-reported outcomes and complication rates were collected. The methodological quality of included primary studies was appraised using the Methodological Index for Nonrandomized Studies scoring system. RESULTS: Twenty articles published between 1997 and 2023 met inclusion criteria. In total, 13,126 patients with neurologic conditions with 7 different neurologic disorders (Parkinson's disease, epilepsy and seizures, cerebral palsy, poliomyelitis, Charcot neuropathy, cerebrovascular disease, and multiple sclerosis) were included. The mean patient age was 64.3 years (range, 33.0-75.8 years), 51.4% of patients were male, and the mean postoperative follow-up time was 5.1 years (range, 1.4-9.9 years). Parkinson's disease was the most reported neurologic disorder (9 studies, 8033 patients), followed by epilepsy (4 studies, 3783 patients), and multiple sclerosis (1 study, 1077 patients). While these patients did experience improvements in outcomes following SA, high complication and revision rates were noted. CONCLUSIONS: Patients with neurologic disorders demonstrate improvements in pain and function after SA but have higher reported complication and revision rates when compared with patients without neurologic conditions. This systematic review offers valuable data for both the surgeon and patient regarding anticipated clinical results and possible complications from SA in patients with neurologic disorders that may aid in shared decision-making when considering SA.

Arthroscopic rotator cuff repair in active patients younger than 45 Years: a prospective analysis with a mean 5-year follow-up.

Background: To report clinical and activity-specific outcomes after arthroscopic rotator cuff repair (ARCR) for full-thickness supraspinatus tears in active individuals aged less than or equal to 45 years. The pre hoc hypothesis was that patients in this age group would demonstrate significant improvements in clinical outcomes following ARCR along with a significant improvement of athletic abilities. Methods: Patients were included in this study if they were (1) active individuals aged between 18 and 45 years at the time of surgery, (2) had a full-thickness rotator cuff tear of the supraspinatus tendon with or without anterior or posterior extension, and (3) underwent ARCR. Preoperative and postoperative patient-reported outcomes scores including the American Shoulder and Elbow Surgeons (ASES) score; Disabilities of Arm, Shoulder and Hand; Single Assessment Numeric Evaluation; and Short Form-12 Physical Component Summary were prospectively collected and postoperative patient satisfaction (scale of 1-10) was recorded at a minimum of 2 years postoperatively. Attainment of the minimal clinically important difference and patient acceptable symptom state for the ASES was calculated. Athletic activity-specific outcomes and return to activity were investigated prospectively via a custom-made comprehensive questionnaire. Results: Between November 2005 and June 2020, of 1149 RCRs performed by the senior author, 54 patients (mean age 40.9 years, 13 female; follow-up 69.7 ± 35.2 months in a range of 24.6-179.6 months) were included into the outcomes analysis. Of those, 4 patients (7.4%) had progressed to revision RCR. At a follow-up of 5.8 years, outcome scores had significantly improved compared to preoperative baselines (ASES 55.6 ± 13.8 to 90.1 + 15.8; P < .001; Disabilities of Arm, Shoulder and Hand 38.9 ± 18.4 to 11.9 ± 17.1; P < .001, Single Assessment Numeric Evaluation 60.7 ± 22.7 to 79.3 ± 27.6; P = .001, Short Form-12 Physical Component Summary 41.6 ± 8.3 to 51.9 ± 9.0; P ≤ .001). Ninety three point six percent of the patients reached the minimal clinically important difference and 72.6% reached the patient acceptable symptom state. Median satisfaction was 9.5/10. Eighty six percent of the patients returned to sports, while 67% of the patients returned to a similar level compared to preoperatively. All sport-specific metrics such as shoulder strength and endurance (P < .001), intensity (P < .001), and impairments from pain affecting speed (P = .002), endurance (P = .002), and competition (P < .001) significantly improved postoperatively. Conclusion: ARCR of full-thickness rotator cuff tear in active individuals aged 45 years or less results in a clinically relevant improvement of outcomes, function, and quality of life at a minimum of 2 years and mean 5.8-year follow-up with a low rate of revision. While 86% of patients were able to return to activity and sport-specific outcome metrics significantly and substantially improved compared to preoperatively, a return to preinjury levels was not reliably achieved in all patients, with particular limitations observed in overhead active individuals. The data support the hypothesis that patients in this age group demonstrate significant improvements in clinical outcomes following ARCR along with significant improvements in athletic abilities.

Minimum 5-Year Clinical and Return-to-Sport Outcomes After Primary Arthroscopic Scapulothoracic Bursectomy and Partial Scapulectomy for Snapping Scapula Syndrome.

BACKGROUND: Snapping scapula syndrome (SSS) is a rare condition that is oftentimes debilitating. For patients whose symptoms are resistant to nonoperative treatment, arthroscopic surgery may offer relief. Because of the rarity of SSS, reports of clinical outcomes after arthroscopic SSS surgery are primarily limited to small case series and short-term follow-up studies. PURPOSE: To report minimum 5-year clinical and sport-specific outcomes after arthroscopic bursectomy and partial scapulectomy for SSS and to identify demographic and clinical factors at baseline associated with clinical outcomes at minimum 5-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent arthroscopic bursectomy and partial scapulectomy for SSS between October 2005 and February 2016 with a minimum of 5 years of postoperative follow-up were enrolled in this single-center study. Clinical outcome scores, including the 12-Item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) score for pain, were collected at a minimum 5-year follow-up. Additionally, it was determined which patients reached the minimal clinically important difference. Bivariate analysis was used to determine whether baseline demographic and clinical factors had any association with the outcome scores. RESULTS: Of 81 patients eligible for inclusion in the study, follow-up was obtained for 66 patients (age 33.6 ± 13.3 years; 31 female). At a mean follow-up of 8.9 ± 2.5 years (range, 5.0-15.4 years), all of the outcome scores significantly improved compared with baseline. These included the ASES (from 56.7 ± 14.5 at baseline to 87.2 ± 13.9 at follow-up; P < .001), QuickDASH (from 38.7 ± 17.6 to 13.1 ± 14.6; P < .001), SANE (from 52.4 ± 21.2 to 82.7 ± 19.9; P < .001), SF-12 Physical Component Summary (from 39.7 ± 8.3 to 50.3 ± 8.2; P < .001), SF-12 Mental Component Summary (from 48.2 ± 11.7 to 52.0 ± 9.0; P = 0.014) and VAS pain (from 5.2 ± 2.1 to 1.4 ± 2.0; P < .001). The minimal clinically important difference in the ASES score was reached by 77.6% of the patients. Median postoperative satisfaction was 8 out of 10. It was found that 90.5% of the patients returned to sport, with 73.8% of the patients able to return to their preinjury level. At the time of final follow-up, 8 (12.1%) patients had undergone revision surgery for recurrent SSS symptoms. Older age at surgery (P = .044), lower preoperative SF-12 Mental Component Summary score (P = .008), lower preoperative ASES score (P = .019), and increased preoperative VAS pain score (P = .016) were significantly associated with not achieving a Patient Acceptable Symptom State on the ASES score. CONCLUSION: Patients undergoing arthroscopic bursectomy and partial scapulectomy for SSS experienced clinically significant improvements in functional scores, pain, and quality of life, which were sustained at a minimum of 5 years and a mean follow-up of 8.9 years postoperatively. Higher patient age, inferior mental health status, increased shoulder pain, and lower ASES scores at baseline were significantly associated with worse postoperative outcomes.

Preoperative patient factors that predict achieving the minimal clinically important difference following arthroscopic treatment of snapping scapula syndrome.

BACKGROUND: The aim of this study was to define the minimal clinically important difference (MCID) values for patient-reported outcomes (PROs) after arthroscopic treatment of snapping scapula syndrome (SSS) using a distribution-based method, and to identify demographic, clinical, and intraoperative factors significantly associated with the achievement of MCID. It was hypothesized that subjective satisfaction scores after the procedure would be strongly associated with the achievement of MCID thresholds for the PROs and that pain, preoperative response to injection, and a scapulectomy in addition to bursal resection would be predictive of clinically relevant improvement. METHODS: Patients who underwent arthroscopic treatment of SSS between October 2005 and September 2020 with a minimum of 2-year short-term postoperative follow-up were enrolled in this retrospective single-center study. The MCID was calculated using a distribution-based approach for the following PROs: 12-Item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) pain "today" and "at worst." The association between achievement of the MCID and postoperative subjective satisfaction was investigated, and factors associated with achievement of MCID were determined using bivariate analysis. RESULTS: Of a total of 190 patients assessed for eligibility, 77 patients (38.1 ± 14.3 years; 36 females) were included. Within the study population, statistically significant improvements in postoperative SF-12 physical component summary (PCS) (P < .001) and mental component summary (MCS) (P < 0.034), ASES (P < .001), QuickDASH (P < .001), SANE (P < .001), and VAS pain (P < .001) scores were observed at the minimum 2-year follow-up. The calculated MCID threshold values based on the study population were 5.0 for SF-12 PCS, 5.8 for SF-12 MCS, 11.3 for ASES, -10.5 for QuickDASH, 14.7 for SANE, 1.5 for VAS pain, and 1.7 for VAS pain at worst. Reaching the MCID was strongly associated with postoperative satisfaction (rated on a scale of 1-10). Across the PROs, younger age, favorable preoperative response to injection, partial scapuloplasty or scapulectomy, no prior surgery, and pain and function at baseline were significantly associated with attaining MCID. CONCLUSIONS: Patients who underwent arthroscopic treatment for SSS experienced clinically significant improvements in functional scores, pain, and quality of life. This study demonstrated predictive roles for certain patient-specific factors and diagnostic variables for achieving MCID in PROs, which may help surgeons preoperatively assess the probability of success and manage patient expectations.

Mid-term outcomes of microfracture for the treatment of focal, full-thickness cartilage defects isolated to the humeral head.

BACKGROUND: While microfracture has been shown to be an effective treatment for chondral lesions in the knee, evidence to support its use for chondral defects in the shoulder is limited to short-term outcomes studies. The purpose of this study is to determine if microfracture provides pain relief and improved shoulder function in patients with isolated focal chondral defects of the humeral head at a minimum 5-year follow-up. METHODS: Patients who underwent microfracture procedure for isolated focal chondral defects of the humeral head with a minimum follow-up of 5 years between 02/2006 and 08/2016 were included. At minimum 5-year follow-up, pre- and postoperative patient-reported outcome (PRO) measures were collected, including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Short Form-12 (SF-12) Physical Component Summary (PCS), Visual Analog Scale (VAS) for pain, and patient satisfaction level (1 = unsatisfied, 10 = very satisfied). Demographic, injury, and surgical data were retrospectively reviewed. Surgical failure was defined as revision surgery for humeral chondral defects or conversion to arthroplasty. Kaplan-Meier analysis was performed to determine survivorship at 5 years. RESULTS: A total of 17 patients met inclusion/exclusion criteria. There were 15 men and 2 women with an average age of 51 years (range 36-69) and an average follow-up of 9.4 years (range 5.0-15.8). The median ASES score improved from 62 (range: 22-88) preoperatively to 90 (range: 50-100) postoperatively (P = .011). Median satisfaction was 8 out of 10 (range: 2-10). There was no correlation between patient age or defect size and PROs. Postoperatively, patients reported significant improvements in recreational and sporting activity as well as the ability to sleep on the affected shoulder (P ≤ .05). Three patients failed and required revision surgery. The Kaplan-Meier analysis determined an overall survivorship rate of 80% at 5 years. CONCLUSION: The presented study illustrates significant improvements for PROs, improved ability to perform recreational and sporting activities, and a survival rate of 80% at a mean of 9.4 years after microfracture for focal chondral humeral head defects.

The Association of Tobacco Smoking and Level of Apoptosis in the Long Head of the Biceps Chronic Tendinopathy-An Immunohistochemical Study.

BACKGROUND: The substances present in cigarette smoke have a negative impact on cellular integrity and metabolism, can reduce blood flow to tissues, and can disrupt collagen synthesis. Ultimately this can lead to cell death, which clinically may result in impaired tendon healing and the onset of chronic tendinopathy. Within the shoulder, the exact association between the extent of apoptosis in the long head of the biceps (LHB) tendon and harmful factors like cigarette smoke remains unclear. OBJECTIVES: The purpose of this study was to investigate the connection between smoking, the degree of apoptosis in LHB tendinopathy, and the long-term outcomes of surgical treatment. DESIGN: Observational, retrospective study. METHODS: This study included 22 consecutive patients who had undergone arthroscopic biceps tenodesis or tenotomy for symptomatic LHB tendinopathy with or without concomitant rotator cuff tears (RCT). The intra-articular LHB tendon remnants were histologically examined by measuring the level of expression of apoptotic cell markers such as BCL2, cleaved caspase 3, and p53. Pre- and postoperative clinical outcomes were analyzed by collecting patient report outcome measures such as the American Shoulder and Elbow Surgeons (ASES) score and the Visual Analogue Scale (VAS) for pain. RESULTS: The smokers group had a mean pack-year history of 13.12 (SD = 9.94), mean number of cigarettes per day of 14.77 (SD = 4.64), and a mean smoking duration of 16.38 (SD = 10.1) years. Among the smoking indexes, the number of cigarettes per day showed a positive correlation with Snyder classification (p = 0.0459, rho = 0.3682). Non-smokers and smokers did not show a statistically significant difference in the expression indexes of BCL2, cleaved caspase 3, or p53 (p = 0.4216, p = 0.5449, p = 0.5613, respectively). However, the cleaved caspase 3 expression index showed a negative correlation with the severity of rotator cuff lesions in the total population (p = 0.0193, rho = -0.4651). CONCLUSIONS: While apoptotic processes in the LHB tendon were observed, no significant association was found between tobacco smoking, the extent of apoptosis, and clinical outcomes. However, the expression of the apoptotic marker cleaved caspase 3 correlated with the severity of rotator cuff pathology. Furthermore, active smoker status was associated with worse clinical outcomes in terms of pain following LHB tenodesis or tenotomy.

Editorial Commentary: Bridging Graft Techniques Improve Short-Term Outcomes for Irreparable Rotator Cuff Tear Repair.

There is a growing need for nonarthroplasty treatment options for irreparable rotator cuff tears. Options include superior capsular reconstruction (SCR), tendon transfers, subacromial balloon spacer, bridge grafting, biological tuberoplasty, and partial rotator cuff repair with or without augmentation. In our experience, repair with marginal convergence techniques is superior to SCR; if there is enough tissue, repair is the preferred strategy. In an effort to improve outcomes after repair, there has been increased interest in the use of interposition or bridging graft (BG) techniques, in which an allograft or autograft is secured on the humerus laterally and to the remnant tendon medially. Interposition or bridging grafts can be used to supplement partial repair in an effort to replace the patient's own missing tissues, and restore the biomechanical force couple of the rotator cuff and create a humeral head-depressing spacer effect in the subacromial space. These techniques show promising results compared to superior capsular reconstruction. Various graft options for BG are available, including human dermal allograft, fascia lata autograft, and tenotomized biceps autograft. Multiple animal studies have demonstrated that interposition grafts can improve the biomechanical properties of the repair construct, and histological studies in animal models have shown evidence of tissue in-growth into the BG, which could lead to increased repair strength over time. Finally, recent studies suggest that a bridging graft may improve short-term outcomes compared to partial repair alone. It remains to be seen whether this difference is clinically meaningful and durable.

Patient-reported outcomes of arthroscopic repair for partial or full-thickness upper third subscapularis tendon tears with open sub-pectoral biceps tenodesis: minimum 10-year outcomes.

BACKGROUND: Although short-term results are promising, there are limited data for long-term results of arthroscopic subscapularis (SSC) repair. The purpose of this study is to report minimum 10-year outcomes of primary arthroscopic repair of isolated partial or full-thickness tears of the upper third of the SSC tendon. METHODS: Patients who underwent arthroscopic repair of isolated upper third SSC tears, Lafosse type I (>50% of tendon thickness) or type II were included. Surgeries were performed by a single surgeon between November 2005 and August 2011. Patient-reported outcome measures were prospectively collected and retrospectively reviewed at minimum follow-up of 10 years. Patient-reported outcomes utilized included the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (SANE), Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), the Short Form 12 physical component summary, return to activity, and patient satisfaction. A subanalysis of patient age and outcomes was performed. Retears, revision surgeries, and surgical complications were recorded. RESULTS: In total, 29 patients with isolated upper third SSC repairs were identified. After application of exclusion criteria, 14 patients were included in the final analysis. Follow-up could be obtained from 11 patients. The mean age at surgery was 52.7 years (range: 36-72) and the mean follow-up was 12 years (range 10-15 years). The American Shoulder and Elbow Surgeons score improved from 52.9 ± 21.8 preoperatively to 92.2 ± 13.7 postoperatively (P < .001). Regarding the SANE and QuickDASH scores, only postoperative data were available. Mean postoperative SANE, QuickDASH, and Short Form 12 physical component summary scores were 90.27 ± 10.5, 14.6 ± 15.5, and 49.2 ± 6.6, respectively. Median patient satisfaction was 10 (range 6-10). Patients reported improvements in sleep, activities of daily living, and sports. There was no correlation between patient age and clinical outcome (P > .05). No patients underwent revision surgery for a SSC retear. CONCLUSION: Arthroscopic repair of upper third SSC tendon tears leads to improved clinical scores and high patient satisfaction at minimum 10-year follow-up. The procedure is durable, with no failures in the presented cohort.

Outcomes of total shoulder arthroplasty in patients with prior anterior shoulder instability: minimum 5-year follow-up.

BACKGROUND: Patients with a history of anterior shoulder instability (ASI) commonly progress to glenohumeral arthritis or even dislocation arthropathy and often require total shoulder arthroplasty (TSA). The purposes of this study were to (1) report patient-reported outcomes (PROs) after TSA in patients with a history of ASI, (2) compare TSA outcomes of patients whose ASI was managed operatively vs. nonoperatively, and (3) report PROs of TSA in patients who previously underwent arthroscopic vs. open ASI management. METHODS: Patients were included if they had a history of ASI and had undergone TSA ≥5 years earlier, performed by a single surgeon, between October 2005 and January 2017. The exclusion criteria included prior rotator cuff repair, hemiarthroplasty, or glenohumeral joint infection before the index TSA procedure. Patients were separated into 2 groups: those whose ASI was previously operatively managed and those whose ASI was treated nonoperatively. This was a retrospective review of prospective collected data. Data collected was demographic, surgical and subjective. The PROs used were the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score. Failure was defined as revision TSA surgery, conversion to reverse TSA, or prosthetic joint infection. Kaplan-Meier survivorship analysis was performed. RESULTS: This study included 36 patients (27 men and 9 women) with a mean age of 56.4 years (range, 18.8-72.2 years). Patients in the operative ASI group were younger than those in the nonoperative ASI group (50.6 years vs. 64.0 years, P < .001). Operative ASI patients underwent 10 open and 11 arthroscopic anterior stabilization surgical procedures prior to TSA (mean, 2 procedures; range, 1-4 procedures). TSA failure occurred in 6 of 21 patients with operative ASI (28.6%), whereas no failures occurred in the nonoperative ASI group (P = .03). Follow-up was obtained in 28 of 30 eligible patients (93%) at an average of 7.45 years (range, 5.0-13.6 years). In the collective cohort, the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score significantly improved, with no differences in the postoperative PROs between the 2 groups. We found no significant differences when comparing PROs between prior open and prior arthroscopic ASI procedures or when comparing the number of prior ASI procedures. Kaplan-Meier analysis demonstrated a 79% 5-year survivorship rate in patients with prior ASI surgery and a 100% survivorship rate in nonoperatively managed ASI patients (P = .030). CONCLUSION: At mid-term follow-up, patients with a history of ASI undergoing TSA can expect continued improvement in function compared with preoperative values. However, TSA survivorship is decreased in patients with a history of ASI surgery compared with those without prior surgery.

Does glenoid version and its correction affect outcomes in anatomic shoulder arthroplasty? A systematic review.

BACKGROUND: Correction of glenoid retroversion is commonly performed in anatomic total shoulder arthroplasty (TSA) to increase component contact area and decrease eccentric loading of the glenoid component. Despite demonstrated biomechanical advantages, limited information exists on the clinical benefit of correcting glenoid retroversion. The purpose of this systematic review is to critically evaluate the existing literature on the effect of preoperative and postoperative glenoid retroversion on clinical functional and radiologic outcomes in patients who underwent anatomic TSA. METHODS: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using PubMed, Embase, and Cochrane Library evaluating the impact of glenoid retroversion on clinical and radiologic outcomes of TSA. English-language studies of level I through IV evidence were included. Blinded reviewers conducted multiple screens and methodological quality was appraised using the Modified Coleman Methodology Score. RESULTS: Sixteen studies, including 3 level III and 13 level IV studies (1211 shoulders), satisfied all inclusion criteria. To address glenoid retroversion, 9 studies used corrective reaming techniques, and 4 studies used posteriorly augmented glenoids. Two studies used noncorrective reaming techniques. Mean preoperative retroversion ranged from 12.7° to 24° across studies. Eleven studies analyzed the effect of glenoid retroversion on clinical outcomes, including patient-reported outcome scores (PROs), range of motion (ROM), or clinical failure or revision rates. Most studies (8 of 11) did not report any significant association of pre- or postoperative glenoid retroversion on any clinical outcome. Of the 3 studies that reported significant effects, 1 study reported a negative association between preoperative glenoid retroversion and PROs, 1 study reported inferior postoperative abduction in patients with postoperative glenoid retroversion greater than 15°, and 1 study found an increased clinical failure rate in patients with higher postoperative retroversion. Ten studies reported radiographic results (medial calcar resorption, Central Peg Lucency [CPL] grade, Lazarus lucency grade) at follow-up. Only 1 study reported a significant effect of pre- and postoperative retroversion greater than 15° on CPL grade. CONCLUSION: There is currently insufficient evidence that pre- or postoperative glenoid version influences postoperative outcomes independent of other morphologic factors such as joint line medialization. Given that noncorrective reaming demonstrated favorable postoperative outcomes, and postoperative glenoid version was not significantly and consistently found to impact outcomes, there is inconclusive evidence that correcting glenoid retroversion is routinely required.

Biomechanical Evaluation of the 2 Different Levels of Coracoid Graft Positions in the Latarjet Procedure for Anterior Shoulder Instability.

Background: In the Latarjet procedure, the ideal placement of the coracoid graft in the medial-lateral position is flush with the anterior glenoid rim. However, the ideal position of the graft in the superior-inferior position (sagittal plane) for restoring glenohumeral joint stability is still controversial. Purpose: To compare coracoid graft clockface positions between the traditional 3 to 5 o'clock and a more inferior (for the right shoulder) 4 to 6 o'clock with regard to glenohumeral joint stability in the Latarjet procedure. Study Design: Controlled laboratory study. Methods: A total of 10 fresh-frozen cadaveric shoulders were tested in a dynamic, custom-built robotic shoulder model. Each shoulder was loaded with a 50-N compressive load while an 80-N force was applied in the anteroinferior axes at 90° of abduction and 60° of shoulder external rotation. Four conditions were tested: (1) intact, (2) 6-mm glenoid bone loss (GBL), (3) Latarjet procedure fixed at 3- to 5-o'clock position, and (4) Latarjet procedure fixed at 4- to 6-o'clock position. The stability ratio (SR) and degree of lateral humeral displacement (LHD) were recorded. A 1-factor random-intercepts linear mixed-effects model and Tukey method were used for statistical analysis. Results: Compared with the intact state (1.77 ± 0.11), the SR was significantly lower after creating a 6-mm GBL (1.14 ± 0.61, P = .009), with no significant difference in SR after Latarjet 3 to 5 o'clock (1.51 ± 0.70, P = .51) or 4 to 6 o'clock (1.55 ± 0.68, P = .52). Compared with the intact state (6.48 ± 2.24 mm), LHD decreased significantly after GBL (3.16 ± 1.56 mm, P < .001) and Latarjet 4 to 6 o'clock (5.48 ± 3.39 mm, P < .001). Displacement decreased significantly after Latarjet 3 to 5 o'clock (4.78 ± 2.50 mm, P = .04) compared with the intact state but not after Latarjet 4 to 6 o'clock (P = .71). Conclusion: The Latarjet procedure in both coracoid graft positions (3-5 and 4-6 o'clock) restored the SR to the values measured in the intact state. A more inferior graft position (fixed at 4-6 o'clock) may improve shoulder biomechanics, but additional work is needed to establish clinical relevance. Clinical Relevance: An inferior coracoid graft fixation, the 4- to 6-o'clock position, may benefit in restoring normal shoulder biomechanics after the Latarjet procedure.

Primary Latarjet procedure versus Latarjet in the setting of previously failed Bankart repair: a systematic review.

OBJECTIVES: The purpose of this study is to systematically review the comparative studies in the literature to compare the outcomes of the Latarjet procedure in the setting of a previously failed Bankart repair versus those undergoing the Latarjet procedure as a primary surgery for anterior shoulder instability. METHODS: A systematic search in Pubmed, EMBASE, and The Cochrane Library databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Cohort studies comparing outcomes in the Latarjet procedure as a primary surgery versus the Latarjet procedure in the setting of a previously failed Bankart repair were included. RESULTS: Ten studies with 1913 patients were included. There was a significantly lower rate of recurrent instability in those with a Latarjet procedure as a primary surgery (4.8% vs 12.1%, p â€‹= â€‹0.007). There was also a significantly lower rate of complications with the Latarjet procedure as a primary surgery (6.2% vs 10.2%, p â€‹= â€‹0.03). Furthermore, there was a significant difference in the rate of revision surgery in favour of the Latarjet procedure as a primary surgery (4.8% vs 10.9%, p â€‹= â€‹0.02). However, there were similar rates of redislocations (2.8% vs 3.4%, p â€‹= â€‹0.82) and return to play (67.7% vs 78.5%, p â€‹= â€‹0.30) between the two cohorts. CONCLUSION: This study found that the Latarjet procedure as a revision procedure for a previously failed Bankart repair resulted in higher rates of complications, recurrent instability, and revisions than the Latarjet procedure performed as a primary procedure. LEVEL OF EVIDENCE: Level III, Systematic Review & Meta-Analysis of Level III studies.

Sternoclavicular Joint Reconstruction With Gracilis Tendon Autograft.

Clinical instability of the sternoclavicular (SC) joint is a challenging problem. Recurrent subluxation and pain can lead to significant functional limitations. Although many patients respond positively to conservative treatment, chronic dislocations often require operative intervention. The complex anatomy of the diarthrodial SC joint and the existence of concomitant SC joint degenerative changes compounded with close-by neurovascular structures present a surgical challenge. The purpose of this Technical Note is to describe a technique for the open management of symptomatic sternoclavicular joint instability using a figure-of-8 reconstruction with a gracilis autograft. The present authors believe this technique provides a technically safe and reproducible method for reconstructing the SC joint without compromising biomechanical strength.

Arthroscopic Labral Repair and Pancapsular Shift With Knotless All-Suture Anchors in the Setting of Multidirectional Instability of the Shoulder.

In the management of multidirectional type of shoulder instability (MDI), arthroscopic surgical stabilization is a preferred treatment option after failed conservative therapy regimens because of the ability to easily access all aspects of the capsule with one surgical procedure. As arthroscopic techniques have evolved, factors critical to postoperative success have been elucidated. Currently, optimal arthroscopic treatment of MDI involves circumferentially restoring labral integrity, a tailored, patient-specific surgical reduction of capsular volume, and adequately managing potential lesions of the biceps anchor. The purpose of this article and accompanying video is to present our technique for arthroscopic circumferential labral repair and pancapsular shift using knotless all-suture anchors in the setting of MDI with a concurrent type II SLAP lesion.

Correlation of Acromial Morphology With Risk and Direction of Shoulder Instability: An MRI Study.

BACKGROUND: The influence of bony morphology on the development of posterior shoulder instability is not well known. PURPOSE: To determine if acromial morphology, as measured on magnetic resonance imaging (MRI), is associated with posterior or anterior shoulder instability. DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: MRI measurements of posterior acromial coverage (PAC), posterior acromial height (PAH), posterior acromial tilt (PAT), and anterior acromial coverage (AAC) were completed for 3 separate matched groups who underwent surgical intervention: posterior instability, anterior instability, and a comparison group of patients who underwent arthroscopic surgery for snapping scapula. Inclusion criteria were patients with recurrent instability <40 years of age without multidirectional instability, glenoid bone loss >13.5%, or glenoid retroversion >10%. RESULTS: Overall, 37 patients were included in each group. PAC was significantly less in the posterior instability group than in the anterior instability and comparison groups (68.3° vs 88.7° vs 81.7°; P < .001). PAH was significantly greater in the posterior group than in the anterior instability group (11.0 mm vs -0.1 mm; P < .001) and comparison group (0.7 mm; P < .001). There was no difference between the posterior and anterior groups in terms of PAT or AAC (P = .45 and P = .05, respectively). PAT was significantly smaller in the posterior instability group than the comparison group (55.2° vs 62.2°; P = .026). The anterior and comparison groups were not significantly different in PAH or PAT (P = .874 and P = .067, respectively) but were significantly different in AAC (P = .026). CONCLUSION: A higher and flatter posterior acromion, as measured on preoperative MRI, appears to be associated with patients who require arthroscopic capsulolabral repair due to posterior shoulder instability. This information may help clinicians to both diagnose and predict the need for operative intervention for patients with posterior labral tears.