Indications for Augmenting Arthroscopic Bankart Procedure with Remplissage in Patients with Non-engaging Hill-Sachs Lesions Must Be Individualized Based on Surgeon and Patient.

Arthroscopic remplissage has been suggested as a means to decrease recurrent instability in arthroscopic Bankart repair surgery involving patients with significant Hill-Sachs lesions. Remplissage fills the H-S lesion to prevent glenohumeral "engagement" and recurrent instability. Remplissage is not generally indicated in patients with smaller, non-engaging Hill-Sachs lesions. However, a recent review suggests that by expanding the indications to non-engaging H-S lesions, recurrence of shoulder instability may be lower in patients having arthroscopic Bankart repair. Further, the review suggests that patients having Bankart plus remplissage did not lose shoulder external rotation range-of-motion. A concern, in addition to follow-up that likely results in underestimation of recurrence, is that anatomically, remplissage should decrease external rotation, and manual measurement of ER could reflect compensatory scapulothoracic motion. This is a particular problem for throwing athletes.

Iatrogenic Excessive Clavicle Resection as a Complication of Arthroscopic Distal Clavicle Excision.

Arthroscopic distal clavicle excision (DCE) is a reliable procedure to treat acromioclavicular joint arthritis. Typically, only 1 to 2 cm of distal clavicle should be removed. Resection of too much bone can lead to instability of the joint or lack of support to the shoulder. We describe 2 patients who had excessive clavicular bone removed arthroscopically, leading to irreparable clavicular pain and dysfunction. The 2 female patients, ages 56 and 60 years, presented to our clinic with continued pain after DCE. Both had pain intractable with nonoperative treatment and loss of range of motion of the shoulder. Radiographs revealed a distal clavicle defect of 7.5 cm in 1 patient. The second patient had a 2-cm distal clavicular defect with an adjacent 2-cm clavicle bone fragment between the defect and residual clavicle shaft. Both underwent surgery with subtotal claviculectomy for pain control. During surgery, 1 patient had a subclavian vein requiring vascular repair. After 1 year of follow-up, both patients had reduced but residual pain and restricted range of motion. Only 1 patient could rejoin her preinjury occupation. Neither patient could continue with preinjury recreational sports. Excessive removal of the distal clavicle during DCE can result in continued pain and disability of the shoulder. Methods to visualize the anatomy of the distal clavicle and its articulation to the acromion should be considered when performing this operation arthroscopically. Reoperation to remove subtotal clavicle has good clinical outcomes but may lead to serious complications due to the proximity to major neurovascular structures. [Orthopedics. 2024;47(1):e57-e60.].

Editorial Commentary: Extreme Medial Repair of Massive Rotator Cuff Tears With Atrophy Warrants Caution: Robbing Peter to Pay Paul.

Medialization of the rotator cuff insertion as a technique to manage massive rotator cuff tears has been described for decades. However, "extreme medialization" as a means to manage massive rotator cuff tears with significant atrophy warrants caution. Nonanatomic reconstruction almost always carries a price. Biomechanical studies show extreme medialization results in significant and obligate restriction of motion, and it is difficult to imagine how extreme medialization would allow normal clinical motion without substantial scapulothoracic compensation. Similarly, obligatory loss of strength could be expected. Based on the current evidence, I will not indicate this technique for my own patients at the present time.

Anatomic glenohumeral arthroplasty: State of the art.

Anatomical total shoulder arthroplasty in its modern form where it reproduces the normal shoulder has been utilized clinically for more than half a century. As the technology and the designs have changed to recreate the humeral and glenoid sides of the joint, the sophistication of design has resulted in the growing number of cases annually worldwide. This increase is due in part to the increasing number of indications that the prosthesis can treat with successful results. On the humeral side, there have been design changes to better reflect the proximal humeral anatomy, and humeral stems are increasingly placed safely without cement. Platform systems which allow conversion of a failed arthroplasty to a reverse configuration without stem extraction is another design change. Similarly, there has been increasing utilization of short stem and stemless humeral components. Extensive experience with shorter stem and stemless devices, however, has yet to demonstrate the purported advantages of these devices, as recent studies have demonstrated equivalent blood loss, fracture rates, operative times, and outcome scores. Easier revision with these shorter stems remains to be definitively established, with only one study comparing the ease of revision between stem types. On the glenoid side, hybrid cementless glenoids, inlay glenoids, cementless all-polyethylene glenoids, and augmented glenoids have all been investigated; however, the indications for these devices remain unclear. Lastly, innovative surgical approaches to implanting shoulder arthroplasty and the use of patient specific guides and computerized planning, while interesting concepts, still await validation before they are utilized on a widespread basis. While reverse shoulder arthroplasty has been increasingly used to reconstruct the arthritic shoulder, anatomic glenohumeral replacement maintains a significant role in the armamentarium of the shoulder surgeon.

Editorial Commentary: Return to Play in Overhead Athletes After Biceps Tenodesis for SLAP Lesions Is Inconsistent.

The optimal surgical management for the superior labrum anterior to posterior (SLAP) lesion in the overhead athlete remains elusive. Return to play (RTP) or return to sport (RTS) with both SLAP repair and biceps tenodesis in this subgroup has been inconsistent, complicated by incomplete description of what RTP actually involves. While the recent literature regarding biceps tenodesis for SLAP lesions is encouraging, longer-term follow-up and a clear definition of criteria that define what "RTP" looks like will be critical prior to universally embracing biceps tenodesis as a definitive SLAP management option for overhead athletes.

Editorial Commentary: To Properly Apply Delphi Consensus Conclusions, Strengths and Weaknesses of the Process Require Consideration: Unified Expert Opinion or Toxic Fumes Resulting in a Strange Trance?

The Delphi Consensus Process is a tool to allow diverse expert opinion to be consolidated to better understand complex problems. The process has recently been applied to orthopaedic treatment options. While a piece of the puzzle, the strengths and weaknesses of this process must be understood to allow the orthopaedist to apply the conclusions of the Delphi Consensus process effectively. It is important to recognize that expert opinion has been upended time and time again by carefully collected clinical-outcome data. It is unclear whether the visions of the Oracle are due to wisdom or toxic fumes resulting in a strange trance.

Editorial Commentary: Mechanics Versus Biology: Both Are Relevant Principles in Understanding Superior Capsular Reconstruction.

The topic of superior capsular reconstruction remains controversial. Whereas identifying the best time-zero graft configuration for this procedure remains important, the success or failure of the procedure will be dependent on the biology, not just the bench performance. Any conforming object placed in the subacromial space at time zero could center the humeral head and decrease superior translation compared with a massive rotator cuff tear but may not restore translation to normal. It does appear that a thicker graft is better in this regard, but how much thicker is better is unclear. Most of all, whether the mechanical benefits of a thicker graft will be offset by a thicker and potentially less biologically compatible construct is also unclear. In most orthopaedic settings, autografts remain consistently superior to allografts. The contrast in results may be better explained by biology, and the excellent superior capsular reconstruction results reported with autograft have not been replicated universally with dermal allograft.

Editorial Commentary: The Top Cited Rotator Cuff Repair Articles: It's All About Popular.

The Thomson Institute for Scientific Information Web of Science database was used to rank the top 50 articles regarding rotator cuff repair by number of citations received. Although the number of citations is a useful benchmark, it must be taken as only one of many indices of the value of an article to the study of orthopaedics. The most cited articles are out of date, reflecting that a longer time in publication allows more time for citation, and most have low levels of evidence (Level IV, retrospective case series absent a control group).

FDA public workshop: Orthopaedic sensing, measuring, and advanced reporting technology (SMART) devices.

Traditional orthopaedic devices do not communicate with physicians or patients post-operatively. After implantation, follow-up of traditional orthopaedic devices is generally limited to episodic monitoring. However, the orthopaedic community may be shifting towards incorporation of smart technology. Smart technology in orthopaedics is a term that encompasses a wide range of potential applications. Smart orthopaedic implants offer the possibility of gathering data and exchanging it with an external reader. They incorporate technology that enables automated sensing, measuring, processing, and reporting of patient or device parameters at or near the implant. While including advanced technology in orthopaedic devices has the potential to benefit patients, physicians, and the scientific community, it may also increase the patient risks associated with the implants. Understanding the benefit-risk profile of new smart orthopaedic devices is critical to ensuring their safety and effectiveness. The 2018 FDA public workshop on orthopaedic sensing, measuring, and advanced reporting technology (SMART) devices was held on April 30, 2018, at the FDA White Oak Campus in Silver Spring, MD with the goal of fostering a collaborative dialogue amongst the orthopaedic community. Workshop attendees discussed four key areas related to smart orthopaedic devices: engineering and technology considerations, clinical and patient perspectives, cybersecurity, and regulatory considerations. The workshop presentations and associated discussions highlighted the need for the orthopaedic community to collectively craft a responsible path for incorporating smart technology in musculoskeletal disease care.

Editorial Commentary: Stem Cells in Rotator Cuff Surgery: In Search of the Holy Grail.

The use of stem cells in orthopaedics remains a controversial topic, stem cells remain experimental, and significant concerns exist. Studies evaluating diagnoses that may spontaneously resolve could be of low value absent a control group. Only same-day harvest of minimally manipulated stem cells is approved for use in the United States, and these minimally manipulated products may contain insufficient cells to affect outcomes. Extensively cultured cells do not qualify for use in the United States outside of an approved Investigational New Drug Application. Moreover, in other arenas, significant, serious adverse events have been reported after the use of manipulated stem cells. Both the US Food and Drug Administration and American Academy of Orthopaedic Surgeons have recognized the potential for abuse regarding this evolving technology. Published results using stems cells to treat rotator cuff disease are inconsistent, and the optimum source and preparation of the stem cells remains unknown.

Editorial Commentary: "Reversomania" Versus "SCRomania?" Another Piece of the Puzzle in the Superior Capsular Reconstruction Controversy.

The topic of superior capsular reconstruction for the massive rotator cuff tear remains a challenging subject. Multiple issues remain regarding the optimum execution of this operation, including graft type, thickness, and fixation technique. While a valuable addition to understanding the successful performance of this procedure, significant questions remain.

Editorial Commentary: More Is Better? The 6-O'clock Anchor in Instability Surgery.

Placing an anchor at the 6-o'clock position on the glenoid when performing an arthroscopic Bankart repair has been suggested by multiple authors as a potential key step in improving the outcomes of arthroscopic repair. Placement of a 6-o'clock anchor increases the peak resistance force to displacement over a traditional 3-anchor repair. Determining what technique issues are relevant remains problematic, and the ultimate preferred technique remains elusive.

Editorial Commentary: The Effect of Scapula Tilt and Best-Fit Circle Placement When Measuring Glenoid Bone Loss in Shoulder Instability Patients-More Information Complicates an Already Difficult Problem.

Scapular tilt affects bone loss measurement used for glenohumeral instability. The larger question of how to manage bone loss in glenohumeral instability remains unanswered.

Editorial Commentary: "Just When I Thought I'd Seen Everything That Could Go Wrong?" (Often Overheard in the Surgeon's Lounge): Osteonecrosis of the Humeral Head After Arthroscopic Rotator Cuff Surgery.

Osteonecrosis occurs postoperatively after rotator cuff repair, but is there a cause-and-effect relation?

Editorial Commentary: The Debate Over Double-Row Continues: Shoulder Arthroscopic Capsulolabral and Bankart Repair for Shoulder Instability.

In an in vitro cadaver study, the mechanical properties of capsulolabral repair were significantly improved with the authors' double-row technique over single-row repair. Whether this time zero improvement in mechanical properties will translate into improved clinical outcomes remains to be seen, and there are concerns, including risks of increased costs and complications, with the clinical application of the technique.

Platelet-rich fibrin matrix in the management of arthroscopic repair of the rotator cuff: a prospective, randomized, double-blinded study.

BACKGROUND: Arthroscopic rotator cuff repair has a high rate of patient satisfaction. However, multiple studies have shown significant rates of anatomic failure. Biological augmentation would seem to be a reasonable technique to improve clinical outcomes and healing rates. PURPOSE: To represent a prospective, double-blinded, randomized study to assess the use of platelet-rich fibrin matrix (PRFM) in rotator cuff surgery. STUDY DESIGN: Randomized controlled trial; level of evidence, 1. METHODS: Prestudy power analysis demonstrated that a sample size of 30 patients in each group (PRFM vs control) would allow recognition of a 20% difference in perioperative pain scores. Sixty consecutive patients were randomized to either receive a commercially available PRFM product or not. Preoperative and postoperative range of motion (ROM), University of California-Los Angeles (UCLA), and simple shoulder test (SST) scores were recorded. Surgery was performed using an arthroscopic single-row technique. Visual analog scale (VAS) pain scores were obtained upon arrival to the recovery room and 1 hour postoperatively, and narcotic consumption was recorded and converted to standard narcotic equivalents. The SST and ROM measurements were taken at 3, 6, 9, and 12 weeks postoperatively, and final (1 year) American shoulder and elbow surgeons (ASES) shoulder and UCLA shoulder scores were assessed. RESULTS: There were no complications. Randomization created comparable groups except that the PRFM group was younger than the control group (mean ± SD, 59.67 ± 8.16 y vs 64.50 ± 8.59 y, respectively; P < .05). Mean surgery time was longer for the PRFM group than for the control group (83.28 ± 17.13 min vs 73.28 ± 17.18 min, respectively; P < .02). There was no significant difference in VAS scores or narcotic use between groups and no statistically significant differences in recovery of motion, SST, or ASES scores. Mean ASES scores were 82.48 ± 8.77 (PRFM group) and 82.52 ± 12.45 (controls) (F(1,56) = 0.00, P > .98). Mean UCLA shoulder scores were 27.94 ± 4.98 for the PRFM group versus 29.59 ± 1.68 for the controls (P < .046). Structural results correlated with age and size of the tear and did not differ between the groups. CONCLUSION: Platelet-rich fibrin matrix was not shown to significantly improve perioperative morbidity, clinical outcomes, or structural integrity. While longer term follow-up or different platelet-rich plasma formulations may show differences, early follow-up does not show significant improvement in perioperative morbidity, structural integrity, or clinical outcome.

Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates.

BACKGROUND: Tears of the superior labrum (superior labrum anterior and posterior [SLAP] lesions) of the shoulder are uncommon injuries; however, the incidence of surgical correction seems to be increasing. PURPOSE: To report the findings of a review of a proprietary descriptive database that catalogs cases for the purpose of board certification on the demographics of SLAP lesion repair. It is the authors' impression that the percentage of cases of SLAP lesion repairs reported by young orthopaedic surgeons is high and that complications associated with this are not insignificant. STUDY DESIGN: Cohort study; level of evidence, 3. METHODS: We searched the American Board of Orthopedic Surgery (ABOS) part II database to evaluate changes in treatment over time and to identify available outcomes and associated complications of arthroscopic repair of SLAP lesions. The database was searched for all SLAP lesions (ICD-9 code 840.7) and SLAP repairs (CPT code 29807) for the years 2003 through 2008. Utilization was analyzed by geographic region and was also obtained based on applicant subspecialty declaration. RESULTS: There were 4975 SLAP repairs, representing 9.4% of all applicants' shoulder cases. Mean follow-up was 8.9 weeks because of the time-limited case collection period. There were 78.4% who were men, and 21.6% of patients were women. The percentage of shoulder cases that were SLAP repairs increased over the study period from 9.4% to 10.1% by 2008 (P = .0163). Mean age of male patients was 36.4 ± 13.0 years, with a maximum of 85 years. Mean age of female patients was 40.9 ± 14.0 years, with a maximum of 88 years. Pain was reported as absent in only 26.3% of patients at follow-up and function as normal in only 13.1%. There were 40.1% of applicants who self-reported their patients to have an excellent result. The self-reported complication rate was 4.4%. Declared sports medicine specialists had a higher percentage of SLAP repairs than did general orthopaedic surgeons: 12.4% versus 9.2%. CONCLUSION: The percentage of shoulder cases that are SLAP repairs reported by the candidates is 3 times the published incidence supported by the current literature. The large number of repairs in middle-aged and elderly patients is concerning. Focusing on educating young orthopaedic surgeons to appropriately recognize and treat symptomatic SLAP lesions may bring the rate of SLAP repairs down.