Use of intraoperative platelet-rich plasma during rotator cuff repair is correlated with increased patient-level charges across multiple categories.

BACKGROUND: As the efficacy of platelet-rich plasma (PRP) as an adjunct in rotator cuff repair (RCR) is debated, the decision to use PRP may be more heavily affected by its cost. We sought to quantify whether augmenting arthroscopic RCR with PRP injections at the time of surgery is correlated with increased patient-level charges. METHODS: All outpatient records reported in Texas from 2010 to 2018 were obtained from the publicly available Texas Healthcare Information Collection database through the Texas Department of State Health Services. All records including a Current Procedural Terminology code for arthroscopic RCR were included. Of the 139,587 records identified within this group, 1662 also contained a Current Procedural Terminology code for intraoperative PRP injection. Patient-level charge data were compared between those who received and those who did not receive concomitant PRP injection during the same outpatient surgical encounter. Subgroup analyses were performed across surgical facilities and insurance types. Mann-Whitney U tests were used to compare charges between PRP and non-PRP cases. Linear regression was used to predict the change in billed charges according to standard charge categories. P values less than .05 were considered statistically significant. RESULTS: The total charges for arthroscopic RCR over the 8-year period were $4.66 billion, coming to $33,371 ± $22,118 per case. Cases that included PRP injection were found to have significantly greater overall charges than cases that did not ($54,452 ± $33,637 vs. $33,117 ± $21,818; P < .001). Linear regression indicated that concomitant PRP injections predicted an increase in combined total charges by $22,027 (95% confidence interval, $20,425-$23,628; P < .001). CONCLUSIONS: PRP utilization at the time of rotator cuff surgery is correlated with increased patient-level charges overall, which occur across all charge subcategories and persist across surgical facility, surgeon volume, and insurance type. Detailed cost analysis is recommended to explore this charge correlation, and future cost-benefit analyses of PRP use in RCR should explore costs beyond that solely associated with PRP preparation, as these may have previously been overlooked.

Reliability and accuracy of telemedicine-based shoulder examinations.

BACKGROUND: Telemedicine has become a critical component in the evaluation and management of patients with shoulder pathology. However, the interobserver reliability of findings on virtual physical examination relative to in-person evaluation is unclear. The purpose of this study was to determine the reliability of prerecorded video telemedicine for the evaluation of shoulder pathology compared with traditional in-person physical examination. METHODS: New patients with unilateral shoulder pain presenting to a single-surgeon shoulder clinic were recruited between July and November 2020. In 1 visit, patients were evaluated with standardized in-person and video-guided telemedicine physical examinations in randomized order. Patients were evaluated for range of motion (ROM) and symptoms including pain, weakness, and apprehension. The telemedicine examination was recorded and consisted of a video guide displaying self-directed shoulder examination maneuvers that patients performed during remote coaching by an independent non-physician observer. The in-person physical examination was performed by the treating physician. The telemedicine videos were evaluated by two independent observers for interobserver reliability. The treating physician subsequently evaluated the telemedicine videos after a minimum two-month washout period for intraobserver reliability and intra-platform reliability. Interobserver and intraobserver reliability analyses were conducted using Kuder-Richardson formula 20 (KR-20). Specificity and likelihood ratios were calculated with P < .05 representing statistical significance. RESULTS: A total of 32 patients (17 male and 15 female patients; average age, 50.2 ± 16.2 years) were included in the analysis. Overall Kuder-Richardson formula 20 (KR-20) reliability across 40 physical examination maneuvers was 0.391 ± 0.332 (76.4% ± 15.4% agreement) between the in-person and telemedicine examinations. Telemedicine maneuvers examining ROM limitations had the highest degree of reliability, sensitivity, specificity, and likelihood of also producing a positive finding on the in-person examination (0.700 ± 0.114, 66.5%, 81.0%, and 6.06, respectively). Telemedicine maneuvers identifying apprehension associated with glenohumeral instability were found to have the lowest reliability, sensitivity, and likelihood of producing a positive finding on the in-person examination (0.170 ± 0.440, 23.5%, and 0.518, respectively). All patients were satisfied with their telemedicine experience. CONCLUSION: The overall reliability of a non-physician-directed video-guided telemedicine examination ranged from unacceptable to good. Shoulder ROM limitations identified during the telemedicine examinations were found to be the most reliable, whereas evaluations of instability were found to be the least reliable. Although initial telemedicine evaluation by a non-physician may be appropriate for ROM evaluation, in-person physician evaluation is recommended to confirm suspected diagnoses, especially if clinical concern for shoulder instability exists. Alternative methods of telemedicine delivery should be explored to improve the reliability of self-directed physical examination maneuvers.

Is outpatient shoulder arthroplasty safe in patients aged ≥65 years? A comparison of readmissions and complications in inpatient and outpatient settings.

BACKGROUND: Recent studies indicate that outpatient total shoulder arthroplasty (TSA) is cost-effective and may have a low complication rate similar to inpatient TSA. However, existing studies have included younger patient cohorts who typically possess fewer medical comorbidities. Patients aged ≥65 years are commonly enrolled in Medicare, which has traditionally designated TSA as an inpatient-only procedure. The purpose of this study was to compare surgical complication rates and 90-day readmission rates between inpatient and outpatient TSA performed in adults aged ≥65 years. METHODS: Medical records for all patients aged ≥65 years who underwent primary anatomic or reverse TSA by a single surgeon from July 2015 to May 2020 were reviewed. Patients were preselected for outpatient or inpatient surgery based on lack of significant cardiopulmonary comorbidities and patient preference. Demographics, body mass index (BMI), and American Society of Anesthesiologists (ASA) scores were collected in addition to emergency department (ED) visits and readmissions within 90 days of the index surgery. Relationships among frequency and types of complications and surgical setting (inpatients vs. outpatient) were assessed. Complication rates and demographic variables between inpatient and outpatient procedures were compared. Logistic regressions were performed to account for interacting predictor variables on the odds of having complications. RESULTS: A total of 145 shoulders (138 patients; 95 male, 43 female) were included in the analysis, of which 98 received inpatient TSA and 47 received outpatient TSA. Average age was 75.5 ± 7.2 for inpatient TSA and 70.5 ± 4.5 for outpatient TSA (P < .001). Patient age (P < .001), ASA score ≥3 (P < .001), and reverse TSA (P = .002) were significantly positively correlated with receiving inpatient surgery. There were 16 complications (16.3%) in the inpatient group and 9 complications (19.1%) in the outpatient group (P = .648). There were no significant differences in the frequency of postoperative complications, return to the ED, or reoperations between inpatient and outpatient procedures (P > .05). Each 1-year increase in age increased the predicted odds of having a surgical complication by 14% (odds ratio = 1.14; P = .021), irrespective of surgical setting. Those who underwent inpatient TSA had a significantly higher frequency of 90-day readmission (inpatient=16, outpatient=1; P = .034). CONCLUSIONS: Postoperative complications and ED returns were not significantly different between inpatient and outpatient TSA. Each 1-year increase in age increased the odds of postoperative surgical complications by 14%, regardless of surgical setting. Outpatient TSA was found to be safe for appropriately selected patients aged ≥65 years, and re-evaluation of TSA as an inpatient-only procedure should be considered.

Fibrin Clots Maintain the Viability and Proliferative Capacity of Human Mesenchymal Stem Cells: An In Vitro Study.

BACKGROUND: Augmentation of soft-tissue repairs with an autologous fibrin clot has been used clinically for nearly four decades; however, fibrin clots tend to produce an abundance of scar tissue, which is known to inhibit soft-tissue regeneration. Mesenchymal stem cells (MSCs) embedded in fibrin clots before repair could reduce scar tissue deposition and facilitate soft-tissue regeneration. To our knowledge, no published studies have directly evaluated the viability or bioactivity of MSCs in fresh human fibrin clots over time. The purpose of this study was to evaluate the viability and bioactivity of human MSCs inside human fibrin clots over time in nutritive and non-nutritive culture media. QUESTIONS/PURPOSES: We hypothesized that human MSCs would (1) be captured inside fibrin clots and retain their proliferative capacity, (2) remain viable for at least 7 days in the fibrin clots, (3) maintain their proliferative capacity for at least 7 days in the fibrin clots without evidence of active apoptosis, and (4) display similar viability and proliferative capacity when cultured in a non-nutritive medium over the same time periods. METHODS: Twelve patients (mean age 33.7 years; range 4-72 years) who underwent elective knee surgery were approached between February 2016 and October 2017; all patients agreed to participate and were enrolled. MSCs isolated from human skeletal muscle and banked after prior studies were used for this analysis. On the day of surgery and after expansion of the MSC population, 3-mL aliquots of phosphate-buffered saline containing approximately 600,000 labeled with anti-green fluorescent protein (GFP) antibodies were transported to the operating room, mixed in 30 mL of venous blood from each enrolled patient, and stirred at 95 rpm for 10 minutes to create MSC-embedded fibrin clots. The fibrin clots were transported to the laboratory with their residual blood for analysis. Eleven samples were analyzed after exclusion of one sample because of a processing error. MSC capture was qualitatively demonstrated by enzymatically digesting half of each clot specimen, thus releasing GFP-positive MSCs into culture. The released MSCs were allowed to culture for 7 days. Manual counting of GFP-positive MSCs was performed at 2, 3, 4, and 7 days using an inverted microscope at 100 x magnification to document the change in the number of GFP-positive MSCs over time. The intact remaining half of each clot specimen was immediately placed in proliferation media and allowed to culture for 7 days. On Days 1, 2, 3, 4, and 7, a small portion of the clot was excised, flash-frozen, cryosectioned (8-µm thickness), and immunostained with antibodies specific to GFP, Ki67 (indicative of active proliferation), and cleaved caspase-3 ([CC3]; indicative of active apoptosis). Using an inverted microscope, we obtained MSC cell counts manually at time zero and after 1, 2, 3, 4, and 7 days of culture. Intact fresh clot specimens were immediately divided in half; one half was placed in nutritive (proliferation media) and the other was placed in non-nutritive (saline) media for 1, 2, 3, 4, and 7 days. At each timepoint, specimens were processed in an identical manner as described above, and a portion of each clot specimen was excised, immediately flash-frozen with liquid nitrogen, cryosectioned (8-µm thickness), and visualized at 200 x using an inverted microscope. The numbers of stain-positive MSCs per field of view, per culture condition, per timepoint, and per antibody stain type were counted manually for a quantitative analysis. Raw data were statistically compared using t-tests, and time-based correlations were assessed using Pearson's correlation coefficients. Two-tailed p values of less than 0.05 (assuming unequal variance) were considered statistically significant. RESULTS: Green fluorescence, indicative of viable GFP-positive MSCs, was absent in all residual blood samples after 48 hours of culturing; GFP-positive MSCs were visualized after enzymatic digestion of clot matrices. The number of GFP-positive MSCs per field of view increased between the 2-day and 7-day timepoints (mean 5.4 ± 1.5; 95% confidence interval, 4.7-6.1 versus mean 17.0 ± 13.6; 95% CI, 10.4-23.5, respectively; p = 0.029). Viable GFP-positive MSCs were present in each clot cryosection at each timepoint up to 7 days of culturing (mean 6.2 ± 4.3; 95% CI, 5.8-6.6). There were no differences in MSC counts between any of the timepoints. There was no visible evidence of GFP +/CC3 + double-positive MSCs. Combining all timepoints, there were 0.34 ± 0.70 (95% CI, 0.25-0.43) GFP+/Ki67+ double-positive MSCs per field of view. The mitotic indices at time zero and Day 7 were 7.5% ± 13.4% (95% CI, 3.0%-12.0%) and 7.2% ± 14.3% (95% CI, 3.3%-12,1%), respectively (p = 0.923). There was no visible evidence of GFP +/CC3 + double-positive MSCs (active apoptosis) at any timepoint. For active proliferation in saline-cultured fibrin clots, we found averages of 0.1 ± 0.3 (95% CI, 0.0-0.2) and 0.4 ± 0.9 (95% CI, 0.0-0.8) GFP/Ki67 double-positive MSCs at time zero and Day 7, respectively (p = 0.499). The mitotic indices in saline culture at time zero and Day 7 were 2.9% ± 8.4% (95% CI, 0.0%-5.8%) and 9.1% ± 20.7% (95% CI, 1.2%-17.0%; p = 0.144). There was no visible evidence of GFP +/CC3 + double-positive MSCs (active apoptosis) at any timepoint in either culturing condition. CONCLUSION: These preliminary in vitro results show that human MSCs mixed in unclotted fresh human venous blood were nearly completely captured in fibrin clots and that seeded MSCs were capable of maintaining their viability, proliferation capacity, and osteogenic differentiation capacity in the fibrin clot for up to 7 days, independent of external sources of nutrition. CLINICAL RELEVANCE: Fresh human fibrin clots have been used clinically for more than 30 years to improve soft-tissue healing, albeit with scar tissue. Our results demonstrate that allogenic human MSCs, which reduce soft-tissue scarring, can be captured and remain active inside human fibrin clots, even in the absence a nutritive culture medium.

Editorial Commentary: Will Suture Tape Augmentation Prove to Be the Answer to Anterior Cruciate Ligament Graft Remodeling, Ultimate Strength, and Safe Return to Play?

Anterior cruciate ligament graft augmentation may protect the graft during the early phases of graft remodeling. A concern is stress-shielding, and recent time-zero biomechanical models are promising in this regard. To get the best answer, it will require in vivo healing studies conducted in animals, and eventually human studies using non-invasive imaging techniques, and ultimately clinical outcome studies including evaluation of return to play in athletes. For now, until additional research studies are available, this type of augmentation is best reserved as an option in carefully selected patients with a small graft size at the time of harvest.

Editorial Commentary: Déjà Vu: Double-Bundle Anterior Cruciate Ligament Reconstruction Revisited.

Regardless of the technique utilized, tunnel expansion following anterior cruciate ligament reconstruction remains a mystery and a clinical challenge. No procedure seems to be immune to this, even anatomic double-bundle reconstruction. This technique was introduced more than 20 years ago and showed great promise while also contributing significantly to our current knowledge of anterior cruciate ligament anatomy and biomechanics. However, we must remember that new techniques do carry with them new side effects that we must document and acknowledge if we hope to improve our surgical outcomes.

Quantification of patient-level costs in outpatient total shoulder arthroplasty.

BACKGROUND: Patient-level costs of inpatient and outpatient total shoulder arthroplasty (TSA) irrespective of payer status are seldom reported. The purpose of this study was to compare patient-level costs of primary elective TSA between inpatient and outpatient surgery centers. METHODS: By use of the Texas Health Care Information Collection database, inpatient and outpatient TSAs performed between 2010 and 2015 were identified according to billing codes. Patient-level costs (total charges and itemized charges) were analyzed according to type of surgery center (inpatient vs outpatient) and inpatient volume (high volume vs low volume). Statistical comparisons were performed using 1-way analysis of variance and 2-sample independent t tests. Mixed-model analysis of variance was used to compare the rate of cost change between inpatient and outpatient TSAs from 2010-2015. P < .05 represented statistical significance. RESULTS: A total of 21,331 inpatient TSAs and 1542 outpatient TSAs were performed from 2010-2015 in the state of Texas. Inpatient TSA costs were significantly higher than outpatient TSA costs ($76,109 [standard deviation (SD), $48,981] vs $22,907 [SD, $13,599]; P < .001). After exclusion of inpatient-specific charges, inpatient TSA remained 41.1% more expensive than outpatient TSA ($32,330 [SD, $24,221] vs $22,907 [SD, $13,599]; P < .0001). High-volume inpatient TSA was less expensive than low-volume inpatient TSA; however, high-volume inpatient TSA remained 33.4% more costly than outpatient TSA even after exclusion of inpatient-specific charges ($30,579 [SD, $23,233] vs $22,907 [SD, $13,599]; P < .0001). CONCLUSIONS: In the state of Texas, the patient-level costs of primary elective inpatient TSA were significantly higher than those of the equivalent outpatient procedure. This difference persisted after exclusion of low-volume inpatient TSA centers and inpatient-specific ancillary charges.

Predictors of outcomes after arthroscopic transosseous equivalent rotator cuff repair in 155 cases: a propensity score weighted analysis of knotted and knotless self-reinforcing repair techniques at a minimum of 2 years.

PURPOSE: To evaluate the outcomes of two commonly used transosseous-equivalent (TOE) arthroscopic rotator cuff repair (RCR) techniques for full-thickness supraspinatus tendon tears (FTST) using a robust multi-predictor model. METHODS: 155 shoulders in 151 patients (109 men, 42 women; mean age 59 ± 10 years) who underwent arthroscopic RCR of FTST, using either a knotted suture bridging (KSB) or a knotless tape bridging (KTB) TOE technique were included. ASES and SF-12 PCS scores assessed at a minimum of 2 years postoperatively were modeled using propensity score weighting in a multiple linear regression model. Patients able to return to the study center underwent a follow-up MRI for evaluation of rotator cuff integrity. RESULTS: The outcome data were available for 137 shoulders (88%; n = 35/41 KSB; n = 102/114 KTB). Seven patients (5.1%) that underwent revision rotator cuff surgery were considered failures. The median postoperative ASES score of the remaining 130 shoulders was 98 at a mean follow-up of 2.9 years (range 2.0-5.4 years). A higher preoperative baseline outcome score and a longer follow-up had a positive effect, whereas a previous RCR and workers' compensation claims (WCC) had a negative effect on final ASES or SF 12 PCS scores. The repair technique, age, gender and the number of anchors used for the RCR had no significant influence. Fifty-two patients returned for a follow-up MRI at a mean of 4.4 years postoperatively. Patients with a KSB RCR were significantly more likely to have an MRI-diagnosed full-thickness rotator cuff re-tear (p < 0.05). CONCLUSIONS: Excellent outcomes can be achieved at a minimum of 2 years following arthroscopic KSB or KTB TOE RCR of FTST. The preoperative baseline outcome score, a prior RCR, WCC and the length of follow-up significantly influenced the outcome scores. The repair technique did not affect the final functional outcomes, but patients with KTB TOE RCR were less likely to have a full-thickness rotator cuff re-tear. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Correction to: Predictors of outcomes after arthroscopic transosseous equivalent rotator cuff repair in 155 cases: a propensity score weighted analysis of knotted and knotless self-reinforcing repair techniques at a minimum of 2 years.

The author claims that his name is wrongly listed on PubMed. It seems, that first and last name have been mixed up. Correct first name is: J. Christoph (on PubMed: J.).

Outcomes After Open Revision Repair of Massive Rotator Cuff Tears With Biologic Patch Augmentation.

PURPOSE: To assess minimum 2-year clinical outcomes after open revision biologic patch augmentation in patients with massive rotator cuff retears who had deficient rotator cuff tendons with healthy rotator cuff muscles. METHODS: Patients with massive posterosuperior rotator cuff retears who underwent open revision rotator cuff repair with patch augmentation were identified from a surgical registry. Outcomes data collected included American Shoulder and Elbow Surgeons; Quick Disabilities of the Arm, Shoulder and Hand; Single Assessment Numeric Evaluation; and Short Form-12 Physical Component Summary scores along with postoperative patient satisfaction, and activity modification. RESULTS: There were 10 men and 2 women (13 shoulders, 1 bilateral) with a mean age of 57 years (range, 26 to 68 years). All patients had at least one prior arthroscopic rotator cuff repair. After patch augmentation, there were no complications, no adverse reactions to the patch, and no patients required further surgery. One patient (7.7%) with 4 prior cuff repairs had a documented posterosuperior retear on magnetic resonance imaging 2 months after repair. Minimum 2-year outcome scores were available for 12 of 13 (92.3%) shoulders after a mean follow-up period of 2.5 years (range, 2.0 to 4.0 years). The ASES score improved by 21.5 points. Although the pain component of the ASES score and the total ASES score did not improve significantly, the function component of the ASES score improved significantly when compared with their preoperative baselines (P < .05). Median patient satisfaction at final follow-up was 9/10 (range, 2 to 10). CONCLUSIONS: Biologic patch augmentation with human acellular dermal allograft was a safe and effective treatment method for patients with massive rotator cuff retears with deficient posterosuperior rotator cuff tendons in the presence of healthy rotator cuff muscles. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Clinical Results After Conservative Management for Grade III Acromioclavicular Joint Injuries: Does Eventual Surgery Affect Overall Outcomes?

PURPOSE: To compare the clinical outcomes in patients with grade III acromioclavicular (AC) joint injuries in whom nonoperative therapy was successfully completed and those who had nonoperative therapy failure and who proceeded to undergo surgical reconstruction. METHODS: Forty-nine patients were initially treated nonoperatively for grade III AC joint injuries with physical therapy. Patients completed questionnaires at initial presentation and after a follow-up period of 2 years. Outcome measures included the Short Form 12 Physical Component Score; American Shoulder and Elbow Surgeons score; Quick Disabilities of the Arm, Shoulder and Hand score; and Single Assessment Numeric Evaluation score. Failure of nonoperative treatment occurred when a patient underwent AC reconstruction before final follow-up. RESULTS: Forty-one patients with a mean age of 39 years (range, 18 to 79 years) were included. In this cohort, 29 of 41 patients (71%) successfully completed nonoperative therapy whereas 12 of 41 (30%) had nonoperative therapy failure at a median of 42 days (range, 6 days to 17.0 months). Of the 41 patients, 39 (95.3%) were contacted to determine treatment success. Of the 12 patients who had nonoperative therapy failure, 11 (92%) had sought treatment more than 30 days after the injury. Subjective follow-up data were available for 10 of 12 patients (83.3%) who had nonoperative therapy failure and for 23 of 29 patients (79.3%) who were successfully treated nonoperatively. The mean length of follow-up was 3.3 years (range, 1.8 to 5.9 years). Although there were no statistically significant differences in outcome scores between groups, those who sought treatment more than 30 days after their injury showed decreased postoperative Single Assessment Numeric Evaluation scores (P = .002) and Short Form 12 Physical Component Scores (P = .037). CONCLUSIONS: According to our results, (1) a trial of nonoperative treatment is warranted because successful outcomes can be expected even in patients who eventually opt for surgery and (2) patients who presented more than 30 days after their injury were less likely to complete nonoperative treatment successfully. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Clinical outcomes after autograft reconstruction for sternoclavicular joint instability.

BACKGROUND: Instability of the sternoclavicular (SC) joint is a rare condition. However, in some cases, SC joint instability may lead to persistent pain and impairment of shoulder function that requires surgical management. This study evaluated clinical outcomes after SC joint reconstruction with hamstring tendon autograft in patients with SC joint instability. METHODS: From December 2010 to January 2014, 21 reconstructions of the SC joint with hamstring tendon autograft were performed. Outcomes data were prospectively collected and retrospectively reviewed. Data analyzed included American Shoulder and Elbow Surgeons score, Quick Disability of the Arm, Shoulder and Hand, physical component of the Short Form 12, and Single Assessment Numeric Evaluation scores. Pain with activities of daily living, work, and sleep were separately analyzed along with painless use of arm for activities. Patients were also questioned regarding postoperative satisfaction. RESULTS: Nine women and 10 men (2 bilaterals), with a mean age of 30 years (range, 15-56 years), were monitored for a mean of 2 years (range, 12-36 months) postoperatively. Mean American Shoulder and Elbow Surgeons, Quick Disability of the Arm, Shoulder and Hand, and Single Assessment Numeric Evaluation scores significantly improved (P < .001). Pain scores also improved over preoperative baselines, including pain with activities of daily living, work, and sleep (P < .001). Median satisfaction at final follow-up was 8.5 (range, 7-10). There were no intraoperative or postoperative complications and no cases of recurrent instability. CONCLUSION: Free hamstring tendon autograft reconstruction for SC joint instability resulted in significantly improved clinical outcomes with high patient satisfaction and no intraoperative or postoperative complications.

Resorbable collagen scaffolds for the treatment of meniscus defects: a systematic review.

PURPOSE: The purpose of this study was to evaluate the clinical and structural outcomes after resorbable collagen meniscus scaffold implantation through a systematic review of the published literature. METHODS: A systematic search of both the PubMed and Embase databases was undertaken to identify all studies that reported clinical and/or structural outcomes after resorbable collagen meniscus scaffold implantation for the treatment of defects involving either the medial or lateral meniscus. Extracted data included study characteristics; surgical methods and rehabilitation protocols; objective outcomes; and preoperative and postoperative subjective outcome scores including Lysholm, Tegner, International Knee Documentation Committee, and visual analog scale scores. RESULTS: Thirteen studies were included in this review. There were 10 Level IV studies, 2 Level II studies, and 1 Level I study with follow-up intervals ranging from 3 months to 12.5 years. With a few exceptions, the study designs used in each study generally followed those which had been previously performed. Substantial differences in rehabilitation protocols and concomitant procedures were noted that may have had an effect on overall clinical outcomes. Objective findings were mostly consistent and typically showed minimal degenerative changes on postoperative radiographs, decreased signal intensity of the scaffold over time on magnetic resonance imaging, the presence of meniscus-like tissue at second-look arthroscopy, and good integration of new tissue as evidenced by histologic analysis of biopsy specimens. Most studies reported satisfactory clinical outcomes, and most patients showed substantial improvements in comparison with mean preoperative baseline values. CONCLUSIONS: On the basis of this systematic review, implantation of resorbable collagen scaffolds for the treatment of meniscus defects provides satisfactory clinical and structural outcomes in most cases. There is evidence that collagen meniscus scaffold implantation provides superior clinical outcomes when compared with partial meniscectomy alone. LEVEL OF EVIDENCE: Level IV, systematic review of Level I, II, and IV studies.

Two-Year Outcomes After Primary Anatomic Coracoclavicular Ligament Reconstruction.

PURPOSE: The purpose of this study was to report the clinical and structural outcomes after anatomic coracoclavicular ligament reconstruction (ACCR) with free tendon allografts in patients with grade III and grade V acromioclavicular (AC) joint dislocations. METHODS: Thirty-one shoulders underwent primary ACCR with tendon allografts for Rockwood grade III and grade V AC joint dislocations. Preoperative data included patient demographic characteristics, injury characteristics, and surgical history, along with American Shoulder and Elbow Surgeons (ASES) scores, Short Form 12 Physical Component Summary (SF-12 PCS) scores, and various pain scales. Outcome measures were also collected a minimum of 2 years postoperatively with the addition of Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; Single Assessment Numeric Evaluation (SANE) scores; and patient satisfaction. In addition, preoperative and postoperative coracoclavicular distances were analyzed using standard anteroposterior radiographs. RESULTS: ACCR was performed in 31 patients (31 shoulders) with a mean age of 43.9 years (range, 21 to 71 years). In 7 patients (22.6%) a complication occurred that required a subsequent surgical procedure including graft rupture/attenuation (2), clavicle fractures (2), distal clavicle hypertrophy (2), and adhesive capsulitis (1). Of the remaining 24 patients, 20 (83.3%) had subjective outcome data available after a minimum 2-year follow-up period (mean, 3.5 years; range, 2.0 to 6.2 years). The mean postoperative ASES and SF-12 PCS scores significantly improved when compared with the preoperative baseline values (58.9 v 93.8 for ASES scores [P < .001] and 45.3 v 54.4 for SF-12 PCS scores [P = .007]). At final follow-up, the SANE and QuickDASH scores were 89.1 and 5.6, respectively, with a median patient satisfaction rating of 9 of 10. CONCLUSIONS: Patients who did not require revision surgery showed excellent postoperative outcome scores: The mean ASES score was 93.8, the mean SANE score was 89.1, and the mean QuickDASH score was 5.6, with a median patient satisfaction rating of 9 of 10. Further study regarding ACCR techniques should focus on decreasing the risks of complications and maintaining reduction of the AC joint. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Clinical and structural outcomes after arthroscopic repair of full-thickness rotator cuff tears with and without platelet-rich product supplementation: a meta-analysis and meta-regression.

PURPOSE: The purpose of this study was to perform a systematic review, meta-analysis, and meta-regression of all Level I and Level II studies comparing the clinical or structural outcomes, or both, after rotator cuff repair with and without platelet-rich product (PRP) supplementation. METHODS: A literature search of the PubMed and EMBASE databases was performed to identify all Level I or II studies comparing the clinical or structural outcomes, or both, after arthroscopic repair of full-thickness rotator cuff tears with (PRP+ group) and without (PRP- group) PRP supplementation. Data included outcome scores (American Shoulder and Elbow Surgeons [ASES], University of California Los Angeles [UCLA], Constant, Simple Shoulder Test [SST] and visual analog scale [VAS] scores) and retears diagnosed with imaging studies. Meta-analyses compared preoperative, postoperative, and gain in outcome scores and relative risk ratios for retears. Meta-regression compared the effect of PRP treatment on outcome scores and retear rates according to 6 covariates. Minimum effect sizes that were detectable with 80% power were also calculated for each study. RESULTS: Eleven studies were included in this review and a maximum of 8 studies were used for meta-analyses according to data availability. There were no statistically significant differences between the PRP+ and PRP- groups for overall outcome scores or retear rates (P > .05). Overall gain in the Constant score was decreased when liquid PRP was injected over the tendon surface compared with PRP application at the tendon-bone interface (-6.88 points v +0.78 points, respectively; P = .046); however, this difference did not reach the previously reported minimum clinically important difference (MCID) for Constant scores. When the initial tear size was greater than 3 cm in anterior-posterior length, the PRP+ group exhibited decreased retear rates after double-row repairs when compared with the PRP- group (25.9% v 57.1%, respectively; P = .046). Sensitivity power analyses revealed that most included studies were only powered to detect large differences in outcome scores between groups. CONCLUSIONS: There were no statistically significant differences in overall gain in outcome scores or retear rates between treatment groups. Gain in Constant scores was significantly increased when PRPs were applied at the tendon-bone interface when compared with application over the top of the repaired tendon. Retear rates were significantly decreased when PRPs were used for the treatment of tears greater than 3 cm in anterior-posterior length using a double-row technique. Most of the included studies were only powered to detect large differences in outcome scores between treatment groups. In addition, an increased risk for selection, performance, and attrition biases was found. LEVEL OF EVIDENCE: Level II, meta-analysis of Level I and Level II studies.

Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes.

Rotator cuff tear size has an important effect on clinical outcomes after repair. Management options for massive rotator cuff tears are numerous, and selection of the most appropriate treatment method for individual patients can be a challenge. An understanding of the pathomechanics, treatment, and clinical outcomes in patients with massive rotator cuff tears can serve as a guide for clinical decision-making. The purpose of this article was to review treatment options and clinical outcomes for the management of massive rotator cuff tears.

Posterosuperior rotator cuff tears: classification, pattern recognition, and treatment.

The posterosuperior rotator cuff, composed of the supraspinatus and infraspinatus tendons, is the most common site for full-thickness rotator cuff tears and represents a significant source of shoulder disability worldwide. Recognition of and classification of full-thickness tear patterns are essential in order to optimize surgical treatment and to improve prognosis. Until recently, tear patterns have been described using one- or two-dimensional classification systems. Three-dimensional pattern recognition is critical to achieving the most successful outcome possible. For more complex patterns, a combination of side-to-side stitching, margin convergence, and interval slide techniques may be needed to achieve a tension-free tendon-bone repair. Biomechanical and anatomic evidence supports the use of linked double-row repairs for most full-thickness tears. Although double-row repairs seem to result in improved structural outcomes, clinical evidence has not shown differences in outcomes scores between single-row and double-row repairs. Single-row repair may be performed in partial-thickness, small full-thickness, or very massive, immobile tears, whereas double-row repair may be performed in most other cases.

The role of arthroscopy in the management of glenohumeral osteoarthritis: a Markov decision model.

PURPOSE: The purposes of this study were (1) to construct a theoretical Markov decision model to compare the total remaining quality-adjusted life-years following either arthroscopic management (AM) or total shoulder arthroplasty (TSA) for the treatment of glenohumeral osteoarthritis and (2) to determine the possible effects of age on the preferred treatment strategy. METHODS: A Markov decision model was constructed to compare AM and TSA in patients with glenohumeral osteoarthritis. The rates of surgical complications, revision surgery, and death were derived from the literature and analyzed. The principal outcome measure was the mean total remaining quality-adjusted life-years after each treatment strategy. Sensitivity analyses were performed for age at the initial procedure, utilities, and transition probabilities. RESULTS: This theoretical decision model showed that AM was the preferred strategy for patients younger than 47 years, TSA was the preferred strategy for patients older than 66 years, and both treatment strategies were reasonable for patients aged between 47 and 66 years. The model was highly sensitive to age at the index surgery, utilities of wellness states, survivorship, and the probability of failure after either AM or TSA. CONCLUSIONS: According to this theoretical decision model, AM was the preferred treatment strategy for patients younger than 47 years, primary TSA was the preferred treatment strategy for patients older than 66 years, and both treatment options were reasonable for patients aged between 47 and 66 years. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

Clinical and structural outcomes after arthroscopic single-row versus double-row rotator cuff repair: a systematic review and meta-analysis of level I randomized clinical trials.

BACKGROUND: The purpose of this study was to perform a systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row with double-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates. METHODS: A literature search was undertaken to identify all level I randomized controlled trials comparing structural or clinical outcomes after single-row versus double-row rotator cuff repair. Clinical outcomes measures included in the meta-analysis were the American Shoulder and Elbow Surgeons, University of California-Los Angeles, and Constant scores; structural outcomes included imaging-confirmed re-tears. Meta-analyses compared raw mean differences in outcomes measures and relative risk ratios for imaging-diagnosed re-tears after single-row or double-row repairs by a random-effects model. RESULTS: The literature search identified a total of 7 studies that were included in the meta-analysis. There were no significant differences in preoperative to postoperative change in American Shoulder and Elbow Surgeons, University of California-Los Angeles, or Constant scores between the single-row and double-row groups (P = .440, .116, and .156, respectively). The overall re-tear rate was 25.9% (68/263) in the single-row group and 14.2% (37/261) in the double-row group. There was a statistically significant increased risk of sustaining an imaging-proven re-tear of any type in the single-row group (relative risk, 1.76 [95% confidence interval, 1.25-2.48]; P = .001), with partial-thickness re-tears accounting for the majority of this difference (relative risk, 1.99 [95% confidence interval, 1.40-3.82]; P = .039). CONCLUSION: Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs, especially with regard to partial-thickness re-tears. However, there were no detectable differences in improvement in outcomes scores between single-row and double-row repairs.

Treatment of Lateral Epicondylitis: Is Surgery Still an Option?

Background: The prevailing trend for the treatment of lateral epicondylitis (LE) is nonsurgical. Although many providers consider LE surgery controversial, others consider surgical intervention in patients with recalcitrant symptoms. The purpose of this study is to analyze epidemiological changes in LE surgery over a 9-year period prior to the coronavirus pandemic in 2019. Methods: A cross-sectional analysis of the Texas health care database from 2010 to 2018 was performed. We analyzed all procedures performed for LE during the set time period using Current Procedure Terminology (CPT) codes. Statistical analyses included procedures performed, patient demographics, zone of residence, and insurance designation. Results: There were a total of 12802 records of LE with 1 or more associated surgical procedures. Lateral epicondylar debridement (with/without tendon repair) was the most common procedure recorded, followed by arthroscopic procedures and tendon lengthening. Overall incidence remained low and did not significantly change during the studied period; however, surgical case volumes were significantly higher in metropolitan areas and increased at a faster rate when compared with those of more rural regions. Commercial insurance was the most prevailing form of payment. The incidence was significantly higher in the age group between 45 and 64 years old and most commonly performed in Caucasian females. Conclusions: The benefit of surgery for the treatment of LE has yet to be completely elucidated; however, surgical intervention continues to be offered. Although the incidence of surgery for the treatment of LE remained low over the study period, the volume of cases in metropolitan areas increased at a fast rate between 2010 and 2018. The results of this study found that surgery is still a treatment option in some patients despite the controversy. Level of Evidence: Economic/Decision Analysis, Level IV.