The robustness of glenohumeral centering measurements in dependence of shoulder rotation and their predictive value in shoulders with rotator cuff tears.

OBJECTIVE: De-centering of the shoulder joint on radiographs is used as indicator for severity of rotator cuff tears and as predictor for clinical outcome after surgery. The objective of the study was to assess the effect of malrotation on glenohumeral centering on radiographs and to identify the most reliable parameter for its quantification. SUBJECTS AND METHODS: In this retrospective study (2014-2018), 249 shoulders were included: 92 with imaging-confirmed supra- and infraspinatus tears (rupture; 65.2 ± 9.9 years) and 157 without tears (control; 41.1 ± 13.0 years). On radiographs in neutral position and external rotation, we assessed three radiographic parameters to quantify glenohumeral centering: acromiohumeral distance (ACHD), craniocaudal distance of the humeral head and glenoid center (Deutsch), and scapulohumeral arch congruity (Moloney). Non-parametric statistics was performed. RESULTS: In both positions, only the distance parameters ACHD (< 0.5 mm) and Deutsch (< 1 mm) were comparable in the two study groups rupture and control. Comparing the parameters between the study groups revealed only ACHD to be significantly different with a reduction of more than 2 mm in the rupture group. Among the parameters, ACHD ≤ 6 mm was the only cut-off discriminating rupture (12-21% of the shoulders with ACHD ≤ 6 mm) and control (none of the shoulders with ACHD ≤ 6 mm). Ninety percent of shoulders with ACHD ≤ 6 mm presented with a massive rotator cuff tear (defined as ≥ 67% of the greater tuberosity exposed). CONCLUSION: Glenohumeral centering assessed by ACHD and Deutsch is not affected by rotation in shoulders with and without rotator cuff tear. An ACHD ≤ 6 mm has a positive predictive value of 90% for a massive rotator cuff tear.

Tibial tunnel enlargement is affected by the tunnel diameter-screw ratio in tibial hybrid fixation for hamstring ACL reconstruction.

INTRODUCTION: There is no evidence on screw diameter with regards to tunnel size in anterior cruciate ligament reconstruction (ACLR) using hybrid fixation devices. The hypothesis was that an undersized tunnel coverage by the tibial screw leads to subsequent tunnel enlargement in ACLR in hybrid fixation technique. METHODS: In a retrospective case series, radiographs and clinical scores of 103 patients who underwent primary hamstring tendon ACLR with a hybrid fixation technique at the tibial site (interference screw and suspensory fixation) were obtained. Tunnel diameters in the frontal and sagittal planes were measured on radiographs 6 weeks and 12 months postoperatively. Tunnel enlargement of more than 10% between the two periods was defined as tunnel widening. Tunnel coverage ratio was calculated as the tunnel diameter covered by the screw in percentage. RESULTS: Overall, tunnel widening 12 months postoperatively was 23.1 ± 17.1% and 24.2 ± 18.2% in the frontal and sagittal plane, respectively. Linear regression analysis revealed the tunnel coverage ratio to be a negative predicting risk factor for tunnel widening (p = 0.001). The ROC curve analysis provided an ideal cut-off for tunnel enlargement of > 10% at a tunnel coverage ratio of 70% (sensitivity 60%, specificity 81%, AUC 75%, p < 0.001). Patients (n = 53/103) with a tunnel coverage ratio of < 70% showed significantly higher tibial tunnel enlargement of 15% in the frontal and sagittal planes. The binary logistic regression showed a significant OR of 6.9 (p = 0.02) for tunnel widening > 10% in the frontal plane if the tunnel coverage ratio was < 70% (sagittal plane: OR 14.7, p = 0.001). Clinical scores did not correlate to tunnel widening. CONCLUSION: Tibial tunnel widening was affected by the tunnel diameter coverage ratio. To minimize the likelihood of disadvantageous tunnel expansion-which is of importance in case of revision surgery-an interference screw should not undercut the tunnel diameter by more than 1 mm.

Long-term results after posterior open glenoid wedge osteotomy for posterior shoulder instability associated with excessive glenoid retroversion.

BACKGROUND: Treatment of posterior shoulder instability (PSI) associated with excessive glenoid retroversion is a rare, challenging problem in shoulder surgery. One proposed technique is posterior open wedge glenoid osteotomy to correct excessive glenoid retroversion as described by Scott. However, this operation is rarely performed, and limited long-term outcomes using this approach are available. The goal of this study was to analyze the long-term outcomes of posterior open wedge glenoid osteotomy for PSI associated with excessive glenoid retroversion. METHODS: Six consecutive patients (7 shoulders) with a mean age of 24 years (range 19-34) were treated with posterior open wedge glenoid osteotomy for PSI associated with a glenoid retroversion greater than 15° and followed up clinically and radiographically at a mean age of 15 years (range 10-19). RESULTS: Recurrent, symptomatic PSI was observed in 6 of 7 shoulders (86%). One necessitated revision with a posterior (iliac crest) bone block procedure and was rated as a failure and excluded from functional analysis. One patient rated his result as excellent, 3 as good, 1 as fair, and 1 as unsatisfactory. Mean relative Constant Score (CS%) was unchanged from preoperation to final follow-up (CS% = 72%) and pain did not significantly decrease (Constant Score = 7-10 points; P = .969). The mean Subjective Shoulder Value (SSV) improved postoperatively, but with 6 patients the improvement did not reach statistical significance (SSV = 42%-67%, P = .053) and the total Western Ontario Shoulder Instability Index averaged 30% at the final follow-up. Mean glenoid retroversion of all 7 shoulders was corrected from 20° (range 16°-26°) to 3° (range -3° to +8°) (P = .018). In the 5 shoulders with preoperative static posterior subluxation of the humeral head, the humeral head was not recentered. All 7 shoulders showed progression of glenoid arthritic changes. CONCLUSIONS: Posterior open wedge glenoid osteotomy for PSI associated with excessive glenoid retroversion neither reliably restored shoulder stability nor recentered the joint or prevent progression of osteoarthritis. Alternative treatments for PSI associated with excessive glenoid retroversion have to be developed and evaluated.

Posterior Open-wedge Osteotomy and Glenoid Concavity Reconstruction Using an Implant-free, J-shaped Iliac Crest Bone Graft in Atraumatic Posterior Instability with Pathologic Glenoid Retroversion and Dysplasia: A Preliminary Report.

BACKGROUND: Atraumatic posterior shoulder instability in patients with pathologic glenoid retroversion and dysplasia is an unsolved problem in shoulder surgery. QUESTIONS/PURPOSES: In a preliminary study of a small group of patients with atraumatic posterior shoulder instability associated with glenoid retroversion ≥ 15° and glenoid dysplasia who underwent posterior open-wedge osteotomy and glenoid concavity reconstruction using an implant-free, J-shaped iliac crest bone graft, we asked: (1) What proportion of the patients had persistent apprehension? (2) What were the improvements in patient-reported shoulder scores? (3) What were the radiographic findings at short-term follow-up? METHODS: Between 2016 and 2018, we treated seven patients for atraumatic posterior shoulder instability. We performed this intervention when posterior shoulder instability symptoms were unresponsive to physiotherapy for at least 6 months and when it was associated with glenoid retroversion ≥ 15° and dysplasia of the posteroinferior glenoid. All seven patients had a follow-up examination at a minimum of 2 years. The median (range) age at surgery was 27 years (16 to 45) and the median follow-up was 2.3 years (2 to 3). Apprehension was assessed by a positive posterior apprehension and/or posterior jerk test. Patient-reported shoulder scores were obtained and included the subjective shoulder value, obtained by chart review (and scored with 100% representing a normal shoulder; minimum clinically important difference [MCID] 12%), and the Constant pain scale score (with 15 points representing no pain; MCID 1.5 points). Radiographic measurements included glenohumeral arthropathy and posterior humeral head subluxation, bone graft union, correction of glenoid retroversion and glenoid concavity depth, as well as augmentation of glenoid surface area. All endpoints were assessed by individuals not involved in patient care. RESULTS: In four of seven patients, posterior apprehension was positive, but none reported resubluxation. The preoperative subjective shoulder value (median [range] 40% [30% to 80%]) and Constant pain scale score (median 7 points [3 to 13]) were improved at latest follow-up (median subjective shoulder value 90% [70% to 100%]; p = 0.02; median Constant pain scale score 15 points [10 to 15]; p = 0.03). Posterior glenoid cartilage erosion was present in four patients (all four had Walch Type B1 glenoids) preoperatively and showed no progression until the final follow-up examination. The median (range) humeral head subluxation index decreased from 69% (54% to 85%) preoperatively to 55% (46% to 67%) postoperatively (p = 0.02), and in two of four patients with preoperative humeral head subluxation (> 65% subluxation), it was reversed to a centered humeral head. CT images showed union in all implant-free, J-shaped iliac crest bone grafts. The median preoperative retroversion was corrected from 16° (15° to 25°) to 0° postoperatively (-5° to 6°; p = 0.02), the median glenoid concavity depth was reconstructed from 0.3 mm (-0.7 to 1.6) preoperatively to 1.2 mm (1.1 to 3.1) postoperatively (p = 0.02), and the median preoperative glenoid surface area was increased by 20% (p = 0.02). No intraoperative or postoperative complications were recorded, and no reoperation was performed or is planned. CONCLUSION: In this small, retrospective series of patients treated by experienced shoulder surgeons, a posterior J-bone graft procedure was able to reconstruct posterior glenoid morphology, correct glenoid retroversion, and improve posterior shoulder instability associated with pathologic glenoid retroversion and dysplasia, although four of seven patients had persistent posterior apprehension. Although no patients in this small series experienced complications, the size and complexity of this procedure make it likely that as more patients have it, some will develop complications; future studies will need to characterize the frequency and severity of those complications, and we recommend that this procedure be done only by experienced shoulder surgeons. The early results in these seven patients justify further study of this procedure for the proposed indication, but longer term follow-up is necessary to continue to assess whether it is advantageous to combine the reconstruction of posterior glenoid concavity with correction of pathological glenoid retroversion and increasing glenoid surface compared with traditional surgical techniques such as the posterior opening wedge osteotomy or simple posterior bone block procedures. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Mid-term results of arthroscopically assisted latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears.

BACKGROUND: With progress in arthroscopic surgery, latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears (RCTs) has become a reliable all-arthroscopic or arthroscopically assisted procedure. The mid-term results of arthroscopically assisted latissimus dorsi transfer (aLDT) are scarce in the literature. The purpose of this study was to report our clinical and radiographic mid-term results of aLDT for irreparable posterosuperior RCTs. METHODS: Thirty-one consecutive patients with a mean age of 55.5 years (range, 38-73 years) at the time of aLDT were evaluated after a mean of 3.5 years (range, 2-5 years). All patients had irreparable, full-thickness tears of at least the complete supraspinatus, with or without infraspinatus tendons, and 12 patients (39%) had undergone previous rotator cuff repair (RCR). A concomitant upper-third subscapularis repair was needed at the time of aLDT in 7 patients (23%). Mid-term results were assessed clinically and radiographically (including magnetic resonance imaging). RESULTS: At final follow-up, 4 patients with failure (13%) had undergone revision to reverse total shoulder arthroplasty (RTSA) essentially for untreatable pain. Patients with revision to RTSA had significantly higher preoperative pain levels (Constant pain score, 6 points vs. 11 points; P = .032) and lower Constant activity scores (2 points vs. 5 points, P = .017) than the remaining 27 patients. Patients with failed previous RCRs had significantly inferior results compared with patients without previous repair (mean Subjective Shoulder Value, 67% vs. 88%; P = .035). For the 27 patients without revision, the mean relative Constant score improved from 63% to 76% (P = .032), the Constant pain score, from 10.5 to 12.7 points (P = .012), and the Subjective Shoulder Value, from 43% to 77% (P < .001). Significant progression of glenohumeral arthropathy by 2 or more grades according to the Hamada classification was observed in 13 of the 27 patients (48%), but there was no significant difference in clinical outcomes between the patients with arthropathy (n = 13) and those without it (n = 14, P = .923). CONCLUSIONS: The mid-term results of aLDT for irreparable posterosuperior RCTs were associated with significant improvements in objective and subjective outcome measures. The failure rate leading to conversion to RTSA was relatively high in this cohort. The failures were associated with unusually intense pain in low-demand individuals and/or revision of failed RCR. Long-term results of aLDT are needed to evaluate the effect of this procedure on the progression of osteoarthritis.

Cortical Thickness Index and Canal Calcar Ratio: A Comparison of Proximal Femoral Fractures and Non-Fractured Femora in Octogenarians to Centenarians.

Background: The cortical thickness index (CTI) is a measure of bone quality and it correlates with the risk of proximal femoral fractures. The purpose of this study was to investigate the CTI in femoral neck, trochanteric fractures and non-fractured femora in geriatric patients and to determine whether there is a correlation between the CTI and the presence of a fracture. Methods: One hundred and fifty patients (fifty femoral neck- (FNFx), fifty trochanteric fractures (TFx) and fifty non-fractured (NFx)) with a mean age of 91 (range 80-104) years were included. Hip radiographs (antero-posterior (ap), lateral) were evaluated retrospectively. Measurements on the proximal femoral inner and outer cortices, including CTI and Dorr's canal calcar ratio (CCR), were assessed for inter-observer reliability (ICC), differences of each fracture and correlation of parameters. Results: The mean ap CTI on the affected side was 0.43, 0.45 and 0.55 for FNFx, TFx and NFx, respectively. There was a significant difference of the ap CTI and CCR comparing the injured and healthy side for both fracture cohorts (p < 0.001). Patients with FNFx or TFx had significantly lower CTI on both sides compared to the NFx group (p < 0.05). There was no difference for CTI (p = 0.527) or CCR (p = 0.291) when comparing both sides in the NFx group. The mean inter-observer reliability was good to excellent (ICC 0.88). Conclusions: In proximal femoral fractures, the CTI and CCR are reduced compared with those in non-fractured femora. Both parameters are reliable and show a good correlation in geriatric patients. Therefore, especially for geriatric patients, the CTI and CCR may help to predict fracture risk and consult patients in daily practice.

Transition from nerve stimulator to sonographically guided axillary brachial plexus anesthesia in hand surgery: block quality and patient satisfaction during the transition period.

OBJECTIVES: Sonographic guidance for peripheral nerve anesthesia has proven increasingly successful in clinical practice; however, fears that a change to sonographically guided regional anesthesia may impair the block quality and operating room work flow persist in certain units. In this retrospective cohort study, block quality and patient satisfaction during the transition period from nerve stimulator to sonographic guidance for axillary brachial plexus anesthesia in a tertiary referral center were investigated. METHODS: Anesthesia records of all patients who had elective surgery of the wrist or hand during the transition time (September 1, 2006-August 25, 2007) were reviewed for block success, placement time, anesthesiologist training level, local anesthetic volume, and requirement of additional analgesics. Postoperative records were reviewed, and patient satisfaction was assessed by telephone interviews in matched subgroups. RESULTS: Of 415 blocks, 341 were sonographically guided, and 74 were nerve stimulator guided. Sonographically guided blocks were mostly performed by novices, whereas nerve stimulator-guided blocks were performed by advanced users (72.3% versus 14%; P < .001). Block performance times and success rates were similar in both groups. In sonographically guided blocks, significantly less local anesthetics were applied compared to nerve stimulator-guided blocks (mean ± SD, 36.1 ± 7.1 versus 43.9 ± 6.1 mL; P< .001), and less opioids were required (fentanyl, 66.1 ± 30 versus 90 ± 62 µg; P< .001). Interviewed patients reported significantly less procedure-related discomfort, pain, and prolonged procedure time when block placement was sonographically guided (2% versus 20%; P = .002). CONCLUSIONS: Transition from nerve stimulator to sonographic guidance for axillary brachial plexus blocks did not change block performance times or success rates. Patient satisfaction was improved even during the early institutional transition period.

Typical Complications After Cartilage Repair of the Ankle Using Autologous Matrix-Induced Chondrogenesis (AMIC).

Background: Autologous matrix-induced chondrogenesis (AMIC) for the treatment of osteochondral lesions of the talus (OLT) results in favorable clinical outcomes, yet high reoperation rates. The aim of this study was to report and analyze typical complications and their risk factors after AMIC for OLT. Methods: A total of 127 consecutive patients with 130 AMIC procedures for OLT were retrospectively assessed. All AMIC procedures were performed in an open fashion with 106 (81.5%) cases requiring a malleolar osteotomy (OT) to access the OLT. Seventy-one patients (54.6%) underwent subsequent surgery. These cases were evaluated at a mean follow-up of 3.1 years (±2.5) for complications reviewing postoperative imaging and intraoperative findings during revision surgery. Six patients (8.5%) were lost to follow-up. Regression model analysis was conducted to identify factors that were associated with AMIC-related complications. Results: Among the 65 (50%) patients who required revision surgery, 18 patients (28%) demonstrated AMIC-related complications with deep fissuring (83%) and thinning (17%) of the AMIC graft. Conversely, 47 patients (72%) underwent subsequent surgery due to AMIC-unrelated reasons including isolated removal of symptomatic hardware (n = 17) and surgery addressing concomitant pathologies with (n = 25) and without hardware removal (n = 5). Previous prior cartilage repair surgery was significantly associated with AMIC graft-associated complications in patients undergoing revision surgery (P = .0023). Among age, body mass index, defect size, smoking, and bone grafting, smoking was the only factor showing statistical significance with an odds ratio of 3.7 (95% CI 1.24, 10.9; P = .019) to undergo revision surgery due to graft-related complications, when adjusted for previous cartilage repair surgery. Conclusion: The majority of revision surgeries after AMIC for OLT are unrelated to the performed AMIC graft but frequently address symptomatic hardware and concomitant pathologies. Both smoking and previous cartilage repair surgery seem to significantly increase the risk of undergoing revision surgery due to AMIC-related complications. Level of evidence: Level IV, case series.

Restoration of Native Leg Length After Opening-Wedge High Tibial Osteotomy: An Intraindividual Analysis.

BACKGROUND: Opening-wedge high tibial osteotomy (OWHTO) has been shown to significantly increase leg length, especially in patients with large varus deformity. Thus, the current literature recommends closing-wedge high tibial osteotomy to correct malalignment in these patients to prevent postoperative leg length discrepancy. However, potential preoperative leg length discrepancy has not been considered yet. HYPOTHESIS: It was hypothesized that patients have a decreased preoperative length of the involved leg compared with the contralateral side and that OWHTO would subsequently restore native leg length. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Included were 67 patients who underwent OWHTO for unilateral medial compartment knee osteoarthritis and who received full leg length assessment pre- and postoperatively. Patients with varus or valgus deformity (>3°) of the contralateral side were excluded. A musculoskeletal radiologist assessed imaging for the mechanical axis, full leg length, and tibial length of the involved and contralateral lower extremity. Statistical analysis determined the pre- and postoperative leg length discrepancy and the influence of the mechanical axis. RESULTS: Most patients (62.7%) had a decreased length of the involved leg, with a mean preoperative mechanical axis of 5.0° ± 2.9°. Length discrepancy averaged -2.2 ± 5.8 mm, indicating a shortened involved extremity (P = .003). OWHTO significantly increased the mean lengths of the tibia and lower limb by 3.6 ± 2.9 and 4.4 ± 4.7 mm (P < .001), leading to a postoperative tibial and full leg length discrepancy of 2.8 ± 4.3 mm and 2.2 ± 7.3 mm (P < .001 and P = .017, respectively). Preoperative leg length discrepancy was significantly correlated with the preoperative mechanical axis of the involved limb (r = 0.292; P = .016), and the amount of correction was significantly associated with leg lengthening after OWHTO (r = 0.319; P = .009). Patients with a varus deformity of ≥6.5° (n = 14) had a preoperative length discrepancy of -4.5 ± 1.6 mm (P < .001) that was reduced to 1.8 ± 3.5 mm (P = .08). CONCLUSION: Patients undergoing OWHTO have a preoperative leg length discrepancy that is directly associated with the varus deformity of the involved extremity. As OWHTO significantly increases leg length, restoration of native leg length can be achieved particularly in patients with large varus deformity.

Correlation of Postoperative Imaging With MRI and Clinical Outcome After Cartilage Repair of the Ankle: A Systematic Review and Meta-analysis.

Background: Magnetic resonance imaging (MRI) is commonly used for evaluation of ankle cartilage repair, yet its association with clinical outcome is controversial. This study analyzes the correlation between MRI and clinical outcome after cartilage repair of the talus including bone marrow stimulation, cell-based techniques, as well as restoration with allo- or autografting. Methods: A systematic search was performed in MEDLINE, Embase, and Cochrane Collaboration. Articles were screened for correlation of MRI and clinical outcome. Guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were used. Chi-square test and regression analysis were performed to identify variables that determine correlation between clinical and radiologic outcome. Results: Of 2687 articles, a total of 43 studies (total 1212 cases) were included with a mean Coleman score of 57 (range, 33-70). Overall, 93% were case series, and 5% were retrospective and 2% prospective cohort studies. Associations between clinical outcome and ≥1 imaging variable were found in 21 studies (49%). Of 24 studies (56%) using the composite magnetic resonance observation of cartilage repair tissue (MOCART) score, 7 (29%) reported a correlation of the composite score with clinical outcome. Defect fill was associated with clinical outcome in 5 studies (12%), and 5 studies (50%) reported a correlation of T2 mapping and clinical outcome. Advanced age, shorter follow-up, and larger study size were associated with established correlation between clinical and radiographic outcome (P = .021, P = .028, and P = .033). Conclusion: Interpreting MRI in prediction of clinical outcome in ankle cartilage repair remains challenging; however, it seems to hold some value in reflecting clinical outcome in patients with advanced age and/or at a shorter follow-up. Yet, further research is warranted to optimize postoperative MRI protocols and assessments allowing for a more comprehensive repair tissue evaluation, which eventually reflect clinical outcome in patients after cartilage repair of the ankle.Level of Evidence: Level III, systematic review and meta-analysis.

Primary Open Latarjet Procedure Results in Functional Differences but No Structural Changes in Subscapularis Muscle Quality vs the Healthy Contralateral Shoulder at Long-term Follow-up.

BACKGROUND: There are concerns that the Latarjet procedure results in loss of glenohumeral rotation and strength and in subscapularis dysfunction. The long-term effects of this procedure on subscapularis quality, glenohumeral rotation, and strength are unknown. PURPOSE/HYPOTHESIS: To analyze the long-term effect of the primary open Latarjet procedure using a muscle-splitting approach on internal and external rotation and strength, as well as subscapularis muscle quality as compared with the healthy contralateral side. We hypothesized that the primary open Latarjet procedure is associated with a reduction of long-term shoulder strength and function and decreased subscapularis quality. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 42 patients who underwent a primary open Latarjet procedure for recurrent anterior shoulder instability at a mean age of 26 years (range, 18-36) were reviewed after a mean follow-up of 8.4 years (range, 5-12). The subscapularis muscle volume and fat fraction of both shoulders were assessed. Bilateral active internal rotation (IR) and external rotation (ER), as well as IR and ER strength, were assessed by isokinetic testing (concentric, eccentric, and fatigability). RESULTS: Active IR (0.6-point difference, P < .001) and ER (4° difference, P = .010) were significantly greater in healthy contralateral shoulders. The IR strength of the operated shoulder was significantly less than that of the healthy shoulder in concentric and eccentric testing (range of deficit, 4%-6%; P < .05). Also, the ER strength of the operated shoulder was significantly less than that of the healthy shoulder in concentric testing (11% deficit, P < .05). Subscapularis muscle volume was significantly greater in the operated shoulder (4% difference, P = .022), and there was no significant difference in fat fraction (P = .114). CONCLUSIONS: The primary open Latarjet procedure was associated with significantly decreased active IR and ER and strength when compared with the healthy contralateral shoulder. The clinical influence of these findings is yet to be defined. There was no increased subscapularis muscle fatty degeneration but a minimal hypertrophy on the operated side at long-term follow-up.

Association of Subchondral Changes With Age and Clinical Outcome in Patients With Osteochondral Fractures in the Knee: MRI Analysis at 1 to 10 Years Postoperatively.

Background: Predictive factors influencing outcomes after surgical fixation of osteochondral fractures (OCFs) in the knee, particularly time between injury and surgery, have not been determined. Purpose: To report imaging and clinical outcomes after OCF fixation and to assess the association between clinical scores and patient characteristics, lesion morphology, and appearance on magnetic resonance imaging (MRI) scans. Study Design: Case series; Level of evidence, 4. Methods: We assessed the clinical and imaging outcomes of 19 patients after screw fixation for OCFs in the knee at a minimum follow-up of 1 year. Patient characteristics, lesion morphology, and time from trauma to surgery were reviewed for each patient. At final follow-up, patients completed a 100-point visual analog scale (VAS) for pain, Tegner activity scale, Knee injury and Osteoarthritis Outcome Score (KOOS), and patient satisfaction survey. Postoperative MRI scans were assessed using the MOCART (magnetic resonance observation of cartilage repair tissue), Osteochondral Allograft MRI Scoring System, and bone marrow edema (BME) size. Results: The mean patient age at surgery was 21.3 ± 11.4 years, and the median time from trauma to surgery was 10 days (range, 0-143 days). The refixed OCF fragment failed in 1 (5.3%) patient on the lateral condyle at 15 months postoperatively. The mean follow-up for the remaining 18 patients was 4.7 ± 3.2 years, and postoperative outcomes were as follows: VAS pain score, 9.5 ± 17.9; Tegner score, 4.8 ± 2.3; KOOS-Pain, 85.9 ± 17.6, KOOS-Symptoms, 76.4 ± 16.1; KOOS-Activities of Daily Living, 90.3 ± 19.0; KOOS-Sport, 74.4 ± 25.4; and KOOS-Quality of Life, 55.9 ± 24.7. Overall, 84.2% were satisfied or very satisfied with outcomes. Patient age was significantly associated with KOOS subscale scores and subchondral imaging parameters including BME and presence of subchondral cysts, which in turn were the only imaging variables linked to clinical outcomes (P < .05). Time from injury to surgery was not correlated with clinical or imaging outcomes. Conclusion: Fixation of OCFs yielded acceptable clinical and imaging outcomes at a mean 5-year follow-up with seemingly little influence of delayed surgical treatment. Postoperative subchondral changes were significantly associated with clinical outcomes and were linked to patient age at surgery.

Long-Term Results and Failure Analysis of the Open Latarjet Procedure and Arthroscopic Bankart Repair in Adolescents.

BACKGROUND: The purpose of this study was to analyze the long-term results of arthroscopic Bankart repair compared with an open Latarjet procedure in adolescents who are at high risk for recurrent anterior shoulder instability. We hypothesized that the long-term stability rate of an open Latarjet procedure would be superior to that of arthroscopic Bankart repair. METHODS: Forty eligible patients (41 shoulders) with a mean age of 16.4 years (range, 13 to 18 years) underwent arthroscopic Bankart repair, and 37 patients (40 shoulders) with a mean age of 16.7 years (range, 14 to 18 years) underwent an open Latarjet procedure. Of these, 34 patients (35 shoulders) in the Bankart group and 30 patients (31 shoulders) in the Latarjet group with long-term follow-up were compared; the overall follow-up rate was 82%. Clinical and radiographic results were obtained after a mean follow-up of 12.2 years (range, 8 to 18 years). RESULTS: Treatment failure occurred in 20 shoulders (57%) in the Bankart repair group and in 2 shoulders (6%) in the open Latarjet procedure group (p < 0.001), representing a significantly higher revision rate for instability in the Bankart group (13) compared with the Latarjet group (1) (p < 0.001). In patients without recurrent shoulder instability (15 in the Bankart group and 29 in the Latarjet group), there was a significant improvement in the Constant score (p = 0.006 in the Bankart group and p < 0.001 in the Latarjet group) and Subjective Shoulder Value (p = 0.009 in the Bankart group and p < 0.001 in the Latarjet group), without any significant difference between the 2 groups. Younger age was the only variable significantly correlated with failure following a Bankart repair (p = 0.01). CONCLUSIONS: Adolescents are at a high risk for treatment failure after Bankart repair, and, therefore, the Latarjet procedure should be strongly considered as a primary procedure for recurrent anterior shoulder instability in this population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Validation of a Novel Patient Specific CT-Morphometric Technique for Quantifying Bone Graft Resorption Following the Latarjet Procedure.

Bone graft resorption following the Latarjet procedure has received considerable concern. Current methods quantifying bone graft resorption rely on two-dimensional (2D) CT-scans or three-dimensional (3D) techniques, which do not represent the whole graft volume/resorption (i.e., 2D assessment) or expose patients to additional radiation (i.e., 3D assessment) as this technique relies on early postoperative CT-scans. The aim of the present study was to develop and validate a patient-specific, CT-morphometric technique combining image registration with 3D CT-reconstruction to quantify bone graft resorption following the Latarjet procedure for recurrent anterior shoulder instability. Pre-operative and final follow-up CT-scans were segmented to digitally reconstruct 3D scapula geometries. A virtual Latarjet procedure was then conducted to model the timepoint-0 graft volume, which was compared with the final follow-up graft volume. Graft resorption at final follow-up was highly correlated to the 2D gold standard-technique by Zhu (Kendall tau coefficient = 0.73; p < 0.001). The new technique was also found to have excellent inter- and intra-rater reliability (ICC values, 0.931 and 0.991; both p < 0.001). The main finding of this study is that the technique presented is a valid and reliable method that provides the advantage of 3D-assessment of graft resorption at long-term follow-up without the need of an early postoperative CT-scan.

Transmural supraspinatus tendon tear caused by suture anchor tip 19-month postacromioclavicular joint stabilisation.

Rotator cuff injuries present rarely in paediatric patients due to the tendon strength at this age. There are reports of ruptures caused by either irritation of the lateral clavicle or acromioclavicular (AC) joint in fractures or after usage of hook plates. In this case report, we present a patient with an acute complete supraspinatus rupture caused by a suture anchor tip from a previously performed AC joint stabilisation. After the diagnosis of a new complete supraspinatus, the causative prominent suture anchor was removed, and the tendon subsequently repaired. This case highlights the close anatomic relation of the AC joint and the rotator cuff, which is imperative to adequately address in injuries to this anatomical location.

Autologous Matrix-Induced Chondrogenesis (AMIC) for Isolated Retropatellar Cartilage Lesions: Outcome after a Follow-Up of Minimum 2 Years.

PURPOSE: To evaluate autologous matrix-induced chondrogenesis (AMIC) for isolated focal retropatellar cartilage lesions and the influence of patellofemoral (PF) anatomy on clinical outcomes at a minimum of 2-year follow-up. METHODS: Twenty-nine consecutive patients (31 knees) who underwent retropatellar AMIC with a mean age of 27.9 ± 11.0 years were evaluated at a follow-up averaging 4.1 ± 1.9 years (range, 2-8 years). Patient factors, lesion morphology, and patient-reported outcome measures, including Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner, Kujula score, and visual analogue scale (VAS) score were collected. PF anatomy was assessed on pre- and postoperative imaging, and subsequently correlated to outcome scores and failure to determine risk factors for poor outcome. RESULTS: At final follow-up, the AMIC graft failed in 4 cases (12.9%) at a mean follow-up of 21 ± 14.1 months. Patients with failed grafts had a significantly smaller patellar and Laurins's PF angle than patients whose graft did not fail (P = 0.008 and P = 0.004, respectively). Concomitant corrective surgery for patellar instability was performed in 29 knees (93.5%). Grafts that did not fail presented with an average Kujala score of 71.3 ± 16.9, KOOS Pain of 76.2 ± 16.6 and Tegner scores of 4.2 ± 1.8. The patellar angle was significantly associated with the patient's satisfaction level (r = 0.615; P < 0.001). CONCLUSION: AMIC for retropatellar cartilage lesions in combination with concomitant corrective surgery for patellar instability results in low failure rate with satisfactory clinical outcome and patient satisfaction of almost 80% at mid-term follow-up. As most failures occurred in patients without concurrent tibial tubercle osteotomy and both a smaller patellar and Laurins's PF angle were associated with less favorable outcome, this study supports the growing evidence for the need of unloading retropatellar cartilage repair, when indicated. LEVEL OF EVIDENCE: Case series; level of evidence, 4.

Salvage Iliac Crest Bone Grafting for a Failed Latarjet Procedure: Analysis of Failed and Successful Procedures.

BACKGROUND: The Latarjet is a successful procedure but can be associated with significant complications, including failure. Iliac crest bone grafting (ICBG) is one of the salvage options for such failure. PURPOSE: To analyze factors associated with failure or success to restore shoulder stability with ICBG after Latarjet failure. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty consecutive patients with recurrence of instability after a Latarjet procedure underwent revision using ICBG. Sixteen patients (80%) with a mean age of 35.0 years (range, 25-55) could be personally reexamined clinically and radiographically (including computed tomography scan) after a mean follow-up of 4.5 years (range, 2-8). Twelve patients had redislocation and 4 had recurrent subluxation after the Latarjet. RESULTS: Salvage ICBG failed in 7 patients because of recurrent dislocations, with 5 necessitating reoperations: 2 arthrodeses, 1 reverse total shoulder arthroplasty, 1 repeat ICBG, and 1 Hill-Sachs allograft reconstruction and Bankart repair. Factors associated with ICBG failure were multidirectional instability (n = 2), subscapularis insufficiency (n = 1), uncontrolled seizures (n = 1), static inferior glenohumeral subluxation (n = 1), total graft resorption (n = 1), and voluntary dislocation attributed to schizoaffective disorder (n = 1). The initial Latarjet graft was malpositioned (too medial) in 3 of these patients. In patients without recurrent instability (n = 9), reasons for Latarjet failure were graft related: 6 graft avulsions, 2 graft resorptions, and 1 medial graft malpositioning. The mean absolute Constant score (62 to 87 points, P = .012) and relative Constant score (66% to 91%, P = .012), pain (10 to 15 points, P < .001), and Subjective Shoulder Value (31% to 85%, P = .011) in the group with a successful procedure were significantly improved over the preoperative state, and the total Western Ontario Shoulder Instability Index averaged 64% at final follow-up. Except in 1 case of major resorption, mild graft resorption or none was observed in successful procedures. Axial and sagittal graft positioning was good in all 9 patients. CONCLUSIONS: Salvage ICBG for failed Latarjet procedures failed in 7 of 16 patients. It was successful in patients with clearly graft-related factors of the initial Latarjet procedure. However, patients with unclear instability symptoms, subscapularis insufficiency, inferior subluxation, uncontrolled seizures, or psychological disorders were poor candidates for salvage ICBG, underlining the importance of careful patient selection for the initial Latarjet procedure and for salvage ICBG.

Perforated flexible catheters improve joint fluid aspiration in shoulder cadavers.

A fluoroscopically controlled anterior approach in supine position is often used for arthrocentesis of the shoulder, but can lead to a high rate of dry aspirations. The aim of this study was to compare the aspiration performance of rigid needles and flexible catheters used with this approach. We hypothesized that a flexible catheter can significantly improve the amount of the obtained fluid. The glenohumeral joint of ten human cadaveric shoulder specimens were sequentially filled with 5, 10, 20 and 30 mL of contrast agent. For each volume the maximum aspirated amount of contrast agent with 4 different aspiration devices (20 gauge needle, 16 gauge needle, 16 gauge flexible catheter and 16 gauge perforated flexible catheter) were compared. All aspirations were done in supine cadaver position from anterior under fluoroscopic control. The aspirated amount of fluid was significantly higher using the 16 gauge perforated flexible catheter (p = 0.002-0.028) compared with all other devices when 5, 10 and 20 mL of contrast agent were in the joint. This perforated flexible catheter aspirated 80-96% of the available fluid while the standard 20 gauge needle aspirated 40-60%. Using a 16 gauge perforated flexible catheter in a supine anterior arthrocentesis technique results in aspiration of most of the fluid in human cadaveric shoulder specimens, while standard needles aspirate only about 50% of it. This can be clinically relevant when there is very little synovial fluid available and might reduce the number of insufficient aspirations.

Nonoperative Treatment of Anterior Glenoid Rim Fractures After First-Time Traumatic Anterior Shoulder Dislocation: A Study with 9-Year Follow-up.

Primary traumatic anterior shoulder dislocations can be associated with displaced anterior glenoid rim fractures. Nonoperative treatment of such fractures has been shown to have excellent results in a small cohort of patients; as such, we have been treating these fractures nonoperatively, regardless of fragment size and degree of displacement, provided that post-reduction computed tomography scans revealed an anteroposteriorly centered humeral head. The aim of this study was to analyze the medium- to long-term results of nonoperative treatment of displaced anterior glenoid rim fractures, assessing in particular the residual instability and development of osteoarthritis. METHODS: In a 2-center study, 30 patients with a mean age of 48 years (range, 29 to 67 years) were evaluated clinically with use of the Subjective Shoulder Value, Constant score, American Shoulder and Elbow Surgeons score, and Western Ontario Shoulder Instability index, as well as radiographically with use of radiographs and computed tomography scans at a mean follow-up of 9 years (range, 5 to 14 years). RESULTS: Fracture-healing was documented in all patients. Seven patients (23%) had post-fracture onset of osteoarthritis (5 with Samilson grade I and 2 with Samilson grade IV). Of these, 1 patient had recurrent instability that was successfully treated with hemiarthroplasty 9 years after the index injury (relative Constant score, 101%), and was excluded from further analysis. No other patient had a recurrent redislocation, subluxation, or positive apprehension. The other 6 patients with new-onset radiographic osteoarthritis were pain-free (mean Constant score pain scale, 15 points) with good shoulder function (relative Constant score, 84% to 108%). A total of 26 patients (90%) rated their functional outcome as good or very good, and 3 patients (10%) rated it as fair. The mean relative Constant score was 97% (range, 61% to 108%), the mean American Shoulder and Elbow Surgeons score was 92 points (range, 56 to 100 points), and the mean Western Ontario Shoulder Instability index score was 126 points (range, 0 to 660 points). All patients returned to full-time work. CONCLUSIONS: Nonoperative treatment of anterior glenoid rim fractures following primary traumatic anterior shoulder dislocation results in excellent clinical outcomes with a very low rate of residual instability and, thus, treatment failure. Asymptomatic radiographic osteoarthritis occurred in roughly 1 of 4 patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.