Prospective 1-Year Outcomes Are Maintained at Short-Term Final Follow-Up After Superior Capsular Reconstruction Augmentation of Complete Rotator Cuff Repair.

PURPOSE: To evaluate the outcomes of arthroscopic superior capsular reconstruction (SCR) augmentation of complete, massive rotator cuff repair (RCR). METHODS: A retrospective study of dermal allograft SCR-augmented RCRs performed by a single surgeon from June 2016 through December 2017 was performed with the following inclusion criteria: massive rotator cuff tear amenable to complete repair but with poor-quality native rotator cuff tissue. Radiographic follow-up was performed at 1 year, and clinical follow-up was performed at both 1 year and a minimum 2 years after surgery. Clinical follow-up included the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, Subjective Shoulder Value score, active forward elevation, and external rotation. Radiographs and magnetic resonance imaging (MRI) scans were assessed for muscle quality using the Goutallier classification, and graft and cuff integrity was assessed according to the Sugaya classification. RESULTS: The inclusion criteria were met by 24 patients at 1 year and by 18 (75%) at a minimum of 2 years postoperatively. Patient-reported outcomes were improved compared with preoperative data and were maintained at minimum 2-year follow-up, with median American Shoulder and Elbow Surgeons scores of 42.5 (interquartile range [IQR], 30.8-58.7) versus 93.9 (IQR, 82.4-100) (P < .001); median Subjective Shoulder Value scores of 30 (IQR, 20-50) versus 90 (IQR, 86.2-97.2) (P < .001); and median visual analog scale pain scores of 5.5 (IQR, 1-9) versus 0 (IQR, 0-0.8) (P = .001). Evaluation of graft and tendon healing on postoperative MRI revealed poor interobserver agreement and showed 10 completely healed grafts (42%), 9 partially healed grafts (38%), and 5 completely disrupted grafts (21%), with 42% of supraspinatus tendons and 54% of infraspinatus tendons healed. CONCLUSIONS: SCR with dermal allograft augmentation of complete RCR with poor-quality tissue shows very good clinical outcomes at minimum 2-year follow-up. Poor interobserver agreement regarding postoperative graft and rotator cuff integrity by MRI was found. The healing rate for the SCR grafts was 79%. The rates of healing of the native supraspinatus and infraspinatus tendons were 42% and 54%, respectively. LEVEL OF EVIDENCE: Level IV, retrospective case series.

The Basis of Innovation: Depth, Breadth, and Tenacity.

The transition from open shoulder surgery to arthroscopic shoulder surgery represents a classic paradigm shift. In order for that paradigm shift to have occurred, the early pioneers in this discipline had to assume several burdens of their new craft: the burden of "arthroscopic identification"; the burden of developing the language of arthroscopy; the burden of disseminating arthroscopic knowledge; the burden of developing safe arthroscopic instruments and implants; and the burden of proving biomechanical and structural equivalency between arthroscopic and open constructs. Embracing these obligations, they were able to produce the paradigm shift to arthroscopic shoulder surgery through a spirited mix of depth, breadth, and tenacity, defying long odds and conventional wisdom while creating a major breakthrough in shoulder surgery.

Superior Capsular Reconstruction for the Operatively Irreparable Rotator Cuff Tear: Clinical Outcomes Are Maintained 2 Years After Surgery.

PURPOSE: To evaluate the results of arthroscopic superior capsular reconstruction (SCR) after 2-year minimum follow-up and to compare the results with those seen in a previously studied group of patients at 1 year postoperatively. METHODS: The retrospective study period was October 2014 through September 2016. Inclusion criteria were arthroscopic dermal allograft SCR performed for operatively irreparable posterosuperior rotator cuff tear with intact or repairable subscapularis tendon, failure of nonoperative treatment, and clinical follow-up at 1 and minimum 2 years postoperatively. Patients lost to follow-up or undergoing revision of the SCR were excluded from the analysis. The primary outcome measure was American Shoulder and Elbow Surgeons (ASES) score (mean, [95% confidence interval], P value). Secondary outcomes included visual analog pain rating (0-10), subjective shoulder value, and active forward elevation and external rotation (degrees). Radiographic analysis included acromiohumeral interval (millimeters) and graft integrity 1-year postoperation. Complications and reoperations were reviewed from the medical record. RESULTS: Forty-one patients met inclusion criteria at mean 34 months postoperatively, and 8 were excluded. ASES score improved from 52 (46-57) preoperative to 90 (87-92; P < .0001) and 89 (86-92; P < .0001) at 1-year postoperation and at final follow-up without diminishing in the interim (P = .9). All secondary clinical outcomes improved from preoperative to final follow-up. Subjective shoulder value diminished 5% between 1 year and final follow-up (P = .03), whereas active external rotation improved 11° during this time (P = .02). In total, 85% of grafts were fully healed, with acromiohumeral interval improved from 7 (6-8) mm to 8 mm (7-9; P = .04). There were 2 (5%) revisions and 6 (14%) failures to reach the minimally clinically important improvement in ASES score: a 19% rate of unsatisfactory outcomes. There was an additional 1 reoperation (2%) and 1 (2%) medical complication. CONCLUSIONS: Arthroscopic joint preservation surgery for massive, operatively irreparable posterosuperior rotator cuff tears with dermal allograft SCR and associated procedures results in improved clinical outcomes that are durable between 1 and minimum 2-year follow-up. LEVEL OF EVIDENCE: IV retrospective case series.

Shoulder arthroscopy: a bridge from the past to the future.

This article constitutes the text of the Codman Lecture, delivered by the author to the attendees of the International Congress of Shoulder and Elbow Surgeons on September 19, 2019, in Buenos Aires, Argentina.

Superior Capsular Reconstruction Reverses Profound Pseudoparalysis in Patients With Irreparable Rotator Cuff Tears and Minimal or No Glenohumeral Arthritis.

PURPOSE: The purpose of the study was to investigate the rate and magnitude of return of active forward elevation (aFE) of the arm for patients with severe preoperative elevation dysfunction (less than 45° of aFE and termed profound pseudoparalysis) and massive, irreparable (or partially reparable) rotator cuff tears without arthritis treated with arthroscopic superior capsular reconstruction (SCR). METHODS: The period for this retrospective study was October 2014 to October 2016. Inclusion criteria included patients treated arthroscopically for an incompletely reparable massive rotator cuff tear (2 tendons fully torn or tear dimension > 5 cm), preoperative aFE of less than 45° (profound pseudoparalysis) with full passive elevation, an intact or reparable subscapularis tendon, radiographic classification Hamada 0-3, and 12-month clinical follow-up. The primary outcome measure was aFE (degrees) at 1 year postoperative. Secondary outcomes included visual analog scale pain rating (0-10), American Shoulder and Elbow Surgeons score, subjective shoulder value, and active external rotation. Graft integrity and Goutallier grade of supraspinatus and infraspinatus at 1 year postoperative were evaluated by magnetic resonance imaging. RESULTS: Ten patients met the inclusion criteria. Nine of 10 patients (90%) regained active overhead use of the arm after SCR with preoperative aFE (mean ± standard error of the mean [95% confidence interval (CI)]) 27° ± 2° [95% CI, 24°-30°] improving to postoperative aFE 159° ± 15° [95% CI, 130°-187°; P < .0001]. All secondary outcome measures were also improved at 1 year postoperative (visual analog scale, 4.6 ± 0.8 to 0.5 ± 0.2; P = .001; American Shoulder and Elbow Surgeons, 52 ± 6 to 89 ± 3; P = .0002; subjective shoulder value, 36 ± 3 to 91 ± 1; P < .0001; active external rotation, 24° ± 7° to 43° ± 8°; P = .002), and 7 of 10 SCR grafts were fully healed by MRI. No complications or reoperations occurred. CONCLUSIONS: Profound pseudoparalysis of the shoulder (active elevation less than 45°) in massive, irreparable rotator cuff tears without arthritis was reversed in 90% of patients after arthroscopic SCR. Reverse shoulder replacement has been proposed to be the only reliable surgical option in this patient group, but SCR appears to be a valid joint-preserving option for improving function with a low rate of complications. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic Rotator Cuff Repair: How to Avoid Retear.

A healed rotator cuff repair results in a superior outcome for the patient compared with a non-healed repair. The surgeon can maximize the chance of a healed repair by knowing the end-point of each key step in the repair process and adhering to a few core principles. First, the rotator cuff tear pattern (e.g. crescent, L-tear, reverse L-tear, U-tear) must be recognized, starting with careful assessment of preoperative MRI but concluding with the arthroscopic assessment of tear edge mobility. Second, a low-tension, anatomic, and mechanically robust repair construct (e.g. linked, double row; load-sharing rip stop; margin convergence to bone) must be determined based on the tear pattern. Increasingly, surgeons are recognizing the importance of the superior capsule of the shoulder, which can appear as a separate pathoanatomic structure in a delaminated rotator cuff tear and require independent suturing in the repair construct. Third, the biological healing capacity of the repair site must be optimized by using meticulous preparation of the greater tuberosity bone, including removal of soft tissue remnants, light burring, and creation of bone vents. Finally, avoid aggressive early rehabilitation after arthroscopic rotator cuff repair respecting that tendon to bone healing is unlikely to occur before 12 weeks postoperatively. Sling immobilization and judicious use of early passive motion should be used for the first 6 weeks, with passive shoulder range of motion performed during weeks 6-12 postoperatively. Rotator cuff strengthening, and active overhead use of the arm should be delayed until at least 12 weeks after surgery to minimize the risk of retear.

Arthroscopic Rotator Cuff Repair in 2019: Linked, Double Row Repair for Achieving Higher Healing Rates and Optimal Clinical Outcomes.

The primary aim of rotator cuff repair surgery is to restore the musculotendinous units by creating a complete, tension-free repair construct that optimizes conditions for tendon-to-bone healing. There are many factors outside the control of the surgeon that are capable of affecting the healing process; however, there are also a number of important technical considerations that the surgeon can control, including familiarity with methods to deal with immobile tissues and techniques to perform novel repair constructs. It is clear that linked double row repairs are more likely to heal, and healed rotator cuff repairs best restore shoulder strength, improve patients' satisfaction, and maximize functional outcomes.

Hill-Sachs Lesion Classification by the Glenoid Track Paradigm in Shoulder Instability: Poor Agreement Between 3-Dimensional Computed Tomographic and Arthroscopic Methods.

PURPOSE: The purpose of this study was to determine the amount of agreement between preoperative 3-dimensional computed tomographic (3D-CT) and intraoperative arthroscopic classification of Hill-Sachs lesions (HSLs) according to the glenoid track (GT) paradigm. METHODS: Records for patients treated surgically for anterior shoulder instability from a single surgeon's practice from August 2013 until March 2016 were retrospectively reviewed. Inclusion criteria were presence of an HSL, < 25% glenoid bone loss, bilateral 3D-CT, and arthroscopically recorded bone loss measurements. Records for patients with chronic dislocations or prior operations were excluded. Calculations by 3D-CT and arthroscopy were performed as follows: Hill-Sachs interval (HSI) was the distance from rotator cuff insertion to medial edge of the HSL; GT was 83% of the normal glenoid width minus any glenoid defect; on-track was HSI less than GT; off-track was HSI greater than GT. RESULTS: Sixteen shoulders with HSL status determined as on- or off-track demonstrated agreement between the 2 methods in 10 of 16 cases (63%, Cohen's κ = 0.16). All 6 cases with disagreement were calculated as on-track by 3D-CT and off-track by arthroscopic measurement. The GT was larger as determined by 3D-CT measurement (22 ± 1 mm [21-24]) compared with arthroscopy (18 ± 1 mm [17-20], P = .002). CONCLUSIONS: Preoperative 3D-CT showed slight agreement compared with intraoperative arthroscopic measurements in classifying HSL as on-track versus off-track in the GT paradigm; larger GT size by 3D-CT versus arthroscopy accounted for all discrepancies. Determination of off-track status based on preoperative 3D-CT versus determination with the arthroscopic method would result in fewer HSLs treated with remplissage if the GT treatment paradigm were followed. Surgeons using the GT paradigm to determine treatment of HSL by remplissage should recognize the potential for discordance between arthroscopic and radiographic measurements.

The Histology of a Healed Superior Capsular Reconstruction Dermal Allograft: A Case Report.

Acellular human dermal allograft commonly is used in the surgical treatment of complex rotator cuff tears, but little information is known about the biological fate of these grafts in human subjects. In this case report, the authors describe a patient who presented with a radiographically healed acellular human dermal allograft superior capsular reconstruction but had humeral head avascular necrosis. The healed superior capsular reconstruction, including graft-bone interfaces, was explanted after 7 months and sent for histologic analysis. A successful biological reconstruction of the superior capsule was found. The graft demonstrated gross and microscopic incorporation with the host, including a tendon-like structure, aligned collagen fibers, fibroblast-like cells, and no clear graft-host distinction. Cellular infiltration ranged from 5% to 14% (central graft) to 65% to 92% (sutured attachment points). Neovascularization and active graft remodeling were confirmed histologically. LEVEL OF EVIDENCE: V, case report.

Does an Increased Critical Shoulder Angle Affect Re-tear Rates and Clinical Outcomes Following Primary Rotator Cuff Repair? A Systematic Review.

PURPOSE: To determine if an increased critical shoulder angle (CSA) predisposes patients to higher re-tear rates and worse clinical outcomes after rotator cuff (RC) repair. METHODS: A comprehensive search of the PubMed, MEDLINE, and EMBASE databases was performed in October 2018 for English-language studies pertaining to RC repair and an increased CSA in accordance with Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. Studies of all levels of evidence were included provided that any outcomes, including pain, patient-reported outcomes, and re-tear rates, were reported. RESULTS: Of a group of 1126 studies that satisfied the initial search criteria, 6 studies were included in the final analysis, comprising data from 473 patients. Three comparative studies were assessed for an association between increased CSA and RC re-tear rates. Among these 3 studies that compared RC re-tear rate in patients with larger and smaller CSAs, 22 of 97 patients (23%) with a larger CSA had a RC re-tear in comparison to 10 of 99 patients (10%) with a smaller CSA. All 3 studies demonstrated higher RC re-tear rates in patients with larger CSAs (risk ratio, 2.39-9.66, I2 = 7%.) The mean CSA in those patients who did not have RC re-tears ranged from 34.3° to 37°, and the mean CSA in those patients who had RC re-tears ranged from 37° to 40°. CONCLUSION: RC re-tear rates were higher in patients with larger CSAs among comparative, nonrandomized studies. However, the heterogeneity of the relevant literature limits the strength of his observation. Based on the current literature, it remains unclear as to whether lateral acromioplasty affects clinical outcomes as a function of a reduced postoperative CSA. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Editorial Commentary: Superior Capsule Reconstruction With Dermal Allograft: Achieving the Goal of Joint Preservation.

Active patients with massive irreparable rotator cuff tears and no glenohumeral arthritis have long posed a dilemma for shoulder surgeons. Such high-demand patients do not do well with partial cuff repair, as their results tend to deteriorate over time. They are also not good candidates for reverse total shoulder arthroplasty due to high rates of complications and high revision rates. The early good results of superior capsular reconstruction for these challenging patients are very encouraging, and they highlight the potential for superior capsular reconstruction to be a reliable joint-preserving option with low morbidity.

Preoperative Radiographic Risk Factors for Incomplete Arthroscopic Supraspinatus Tendon Repair in Massive Rotator Cuff Tears.

PURPOSE: To determine if preoperative imaging findings of massive rotator cuff (RC) tears were associated with (1) incomplete arthroscopic repair and (2) the use of advanced mobilization techniques (interval slides) and/or the use of a load-sharing rip stop repair construct. METHODS: Eighty-six consecutive patients who underwent arthroscopic repair for massive RC tears performed by a single surgeon between July 2013 and July 2015 were retrospectively evaluated. Previously proposed radiographic risk factors for irreparability (acromiohumeral distances, tangent sign, and the Goutallier stage of fatty infiltration for the supraspinatus) were analyzed. Associations between preoperative imaging characteristics and intraoperative results of RC surgery were determined using binary logistic regressions and Fisher's exact tests. The interobserver reliability of imaging characteristics was determined using intraclass correlation coefficients (ICCs). RESULTS: Seventy-six massive RC tears were fully reparable (88%). In the case of 10 RC tears (12%), a complete repair was not obtained. Inability to obtain a complete repair of the supraspinatus was associated with a positive tangent sign (30% irreparable) versus a negative tangent sign (6.3% irreparable, odds ratio [OR] = 6.3, P = .0102) and with Goutallier grade 3-4 fatty infiltration of the supraspinatus (42.9% irreparable) versus grade 0-2 fatty infiltration (5.7% irreparable, OR = 11.8, P = .001). Advanced arthroscopic techniques (interval slides or load-sharing rip stop) for dealing with poor-quality or retracted tendon were used in 62% of cases; however, no associations were found between preoperative imaging characteristics and these techniques. Interobserver reliability was moderate (ICC = 0.75-0.90) for the tangent sign (ICC = 0.78) and high-grade (Goutallier 3-4) fatty infiltration of the supraspinatus (ICC = 0.74). CONCLUSIONS: A positive tangent sign and/or high-grade fatty infiltration (Goutallier 3-4) of the supraspinatus were risk factors for incomplete RC repair. However, these were not completely predictive of reparability because the majority of massive RC tears with these imaging characteristics were still fully reparable. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Preliminary Results of Arthroscopic Superior Capsule Reconstruction with Dermal Allograft.

PURPOSE: The purpose of this study was to evaluate the short-term outcomes of arthroscopic superior capsule reconstruction (SCR) with dermal allograft for the treatment of irreparable massive rotator cuff tears (MRCTs). METHODS: A multicenter study was performed on patients undergoing arthroscopic SCR for irreparable MRCTs. The minimum follow-up was 1 year. Range of motion and functional outcome according to visual analog scale (VAS) pain, American Shoulder and Elbow Surgeons (ASES) score, and subjective shoulder value (SSV) score were assessed preoperatively and at final follow-up. Radiographs were used to evaluate the acromiohumeral interval (AHI). RESULTS: Fifty-nine patients with a mean age of 62.0 years had a minimum follow-up of 1 year. Twenty-five patients (42.4%) had a prior rotator cuff repair. Forward flexion improved from 130° preoperative to 158° postoperative, and external rotation improved from 36° to 45°, respectively (P < .001). Compared with preoperative values, the VAS decreased from 5.8 to 1.7, the ASES score improved from 43.6 to 77.5, and the SSV score improved from 35.0 to 76.3 (P < .001). The AHI was 6.6 mm at baseline and improved to 7.6 mm at 2 weeks postoperatively but decreased to 6.7 mm at final follow-up. Based on postoperative magnetic resonance imaging, 45% (9 of 20) of the grafts demonstrated complete healing. Forty-six (74.6%) cases were considered a success. Eleven patients (18.6%) underwent a revision procedure including 7 reverse shoulder arthroplasties. CONCLUSIONS: Arthroscopic SCR using dermal allograft provides a successful outcome in approximately 70% of cases in an initial experience. The preliminary results are encouraging in this difficult to manage patient population, but precise indications are important and graft healing is low in our initial experience. LEVEL OF EVIDENCE: Level IV, case series.

Superior Capsule Reconstruction.

In patients who have a massive rotator cuff tear without glenohumeral arthritis in whom surgery is indicated, surgeons should always attempt a complete repair. Interval slides and linked high-strength repair constructs can be used; however, despite advanced mobilization and repair techniques, some rotator cuff tears are not fully repairable. Promising early outcomes have been reported in select patients with a massive rotator cuff tear who undergo superior capsule reconstruction with the use of acellular dermal allograft.

Editorial Commentary: Off-Track Hill-Sachs Lesions in Adolescents With Multiple Anterior Dislocations: The Case for Stabilizing Adolescent First-Time Dislocators.

Recurrent anterior dislocations in adolescents reveal a high rate of off-track Hill-Sachs lesions, much higher than in adults. This new information makes a strong case in favor of arthroscopic Bankart repair for adolescents with a first-time anterior dislocation of the shoulder.

Level of the Subscapularis Split During Arthroscopic Latarjet.

PURPOSE: To determine the location of the subscapularis split during arthroscopic Latarjet created by an inside-out technique passing a switching stick from the posterior portal across the glenohumeral joint. METHODS: An inside-out technique was used to arthroscopically create a subscapularis split in 20 fresh-frozen human cadaveric shoulders. The distance between the exit point of the switching stick and the upper border of the subscapularis and the anterior circumflex vessels was measured arthroscopically and after open dissection. RESULTS: Twelve splits were in the upper third of the subscapularis, 3 were at the junction of the upper third and the middle third, and 5 were in the middle third. None were at the junction between the middle and lower third as desired. CONCLUSIONS: Using the inside-out method during arthroscopic Latarjet may produce a high subscapularis split if it is performed from with a switching stick that is inserted through the posterior approach, and passed across the glenohumeral joint at the level of the inferior glenoid. CLINICAL RELEVANCE: This study analyzed the relative risk of high subscapularis split during the arthroscopic Latarjet procedure.

Arthroscopic Joint Preservation in Severe Glenohumeral Arthritis Using Interpositional Human Dermal Allograft.

PURPOSE: To investigate the outcomes of arthroscopic glenoid resurfacing (AGR) for severe glenohumeral arthritis at short- to medium-term follow-up. METHODS: We performed a multicenter retrospective review of consecutive patients undergoing AGR (2005-2013) with a minimum of 2 years' follow-up or until revision. Patients lost to follow-up and those included in a prior study were excluded. The indications for AGR were severe primary shoulder osteoarthritis without significant bone loss in younger, higher-demand patients. Outcome measures included revision, pain and American Shoulder and Elbow Surgeons (ASES) scores, and range of motion. Exact logistic regression was used to assess preoperative risk factors for revision. RESULTS: Forty-three shoulders with an average of 60 months' clinical follow-up underwent AGR. The rate of revision to prosthetic arthroplasty was 23% (95% confidence interval [CI], 12%-39%) after a mean of 45 months. The visual analog scale pain score (0-10) improved from a median of 7 to 2 (median difference [Δ], 4 [95% CI, 3-6]; P < .0001), representing pain relief similar to total shoulder arthroplasty in young patients. Improvements in the median ASES score (from 47 to 76; Δ, 28 [95% CI, 17-40]; P < .0001), active forward elevation (from 110° to 140°; Δ, 20° [95% CI, 10°-35°]; P < .0001), and active external rotation (from 0° to 20°; Δ, 10° [95% CI, 5°-20°]; P < .0001) were noted. The mean age of revised shoulders (60 years [95% CI, 54-66 years]) was higher than that of surviving shoulders (53 years [95% CI, 50-57 years], P = .005). The preoperative ASES score of revised shoulders (34 [95% CI, 27-42]) was lower than that of surviving shoulders (47 [95% CI, 43-51], P = .006). No complications were noted. CONCLUSIONS: AGR with dermal allograft is a safe option for joint preservation in selected patients, provides pain relief, and has an acceptable rate of revision to prosthetic arthroplasty at short-term to midterm follow-up. Increased age and lower preoperative ASES score were risk factors for failure of AGR. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Cost-Effectiveness of Arthroscopic Rotator Cuff Repair Versus Reverse Total Shoulder Arthroplasty for the Treatment of Massive Rotator Cuff Tears in Patients With Pseudoparalysis and Nonarthritic Shoulders.

PURPOSE: To determine the most cost-effective treatment strategy for patients with massive rotator cuff tears and pseudoparalysis of the shoulder without osteoarthritis of the glenohumeral joint (PP without OA). Specifically, we aimed to compare arthroscopic rotator cuff repair (ARCR) versus reverse total shoulder arthroplasty (RTSA) and investigate the effect of patient age on this decision. METHODS: A Markov decision model was used to compare 3 treatment strategies for addressing PP without OA: (1) ARCR with option to arthroscopically revise once, (2) ARCR with immediate conversion to RTSA on potential failure, and (3) primary RTSA. Hypothetical patients were cycled through the model according to transition probabilities, meanwhile accruing financial costs, utility for time in health states, and disutilities for surgical procedures. Utilities were derived from the Short Form-6D scale and expressed as quality-adjusted life-years. Model parameters were derived from the literature and from expert opinion, and thorough sensitivity analyses were conducted. TreeAge Pro 2015 software was used to construct and assess the Markov model. RESULTS: For the base-case scenario (60-year-old patient), ARCR with conversion to RTSA on potential failure was the most cost-effective strategy when we assumed equal utility for the ARCR and RTSA health states. Primary RTSA became cost-effective when the utility of RTSA exceeded that of ARCR by 0.04 quality-adjusted life-years per year. Age at decision did not substantially change this result. CONCLUSIONS: Primary ARCR with conversion to RTSA on potential failure was found to be the most cost-effective strategy for PP without OA. This result was independent of age. Primary ARCR with revision ARCR on potential failure was a less cost-effective strategy. LEVEL OF EVIDENCE: Level IV, economic and decision analysis.

The anterior borders of the clavicle and the acromion are not always aligned in the intact acromioclavicular joint: a cadaveric study.

BACKGROUND: The aim of this study was to find reliable anatomic landmarks of the normal acromioclavicular joint (ACJ) that could enable the precise evaluation of the horizontal displacement of the clavicle after dislocation. The hypothesis was that the anterior borders of the acromion and the clavicle are always aligned in intact ACJs. MATERIALS AND METHODS: In 30 cadaveric specimens, the anterior and posterior borders of the ACJ's articular facets and the most prominent anterior and posterior bony landmarks of the acromion and the clavicle were identified. The anterior and posterior overhang of the acromion and the clavicle was measured in relation to the borders of the articular facets. Therefore, the possible anterior and posterior alignment of the ACJ was evaluated. RESULTS: Anteriorly, only 18 ACJs (60%) were aligned whereas 7 (24%) had major overhang of the acromion and 3 (10%) had major overhang of the clavicle. Similarly, 18 cases (60%) were posteriorly aligned, whereas 6 (20%) had major clavicular overhang and 4 (14%) had major overhang of the acromion. In 78% of these cases, the ACJ was aligned as well anteriorly as posteriorly (P < .001). Finally, the larger the width of the acromion (P = .032) or the clavicle (P = .049), the better the posterior joint alignment. CONCLUSION: Our hypothesis was not verified. The acromion and clavicle are not perfectly aligned in a significant number of specimens with intact ACJs (40% of cases). The most reliable landmarks remain their articular facets.

A 70° Arthroscope Significantly Improves Visualization of the Bicipital Groove in the Lateral Decubitus Position.

PURPOSE: The purpose of this study was to quantify the length of the bicipital groove viewable with a 70° arthroscope and to compare this distance visualized with use of a 30° arthroscope in both cadavers and living subjects. METHODS: Diagnostic glenohumeral arthroscopy in the lateral decubitus position was performed on 10 fresh-frozen cadaveric shoulders from a posterior portal. Using 70° and 30° arthroscopes, the distalmost viewable portion of the bicipital groove was percutaneously marked. Dissection of each specimen was then performed, and the distances between the articular margins of the humeral head to each marked portion of bicipital groove were recorded. Subsequently, a similar technique was used to measure the visible length of the bicipital groove in a series of 11 patients at the time of diagnostic glenohumeral arthroscopy performed in the lateral decubitus position using 70° and 30° arthroscopes. Descriptive statistics were used for continuous data. Means were compared with a Mann-Whitney test. Statistical significance was set at P ≤ .05. RESULTS: The cadaveric analysis revealed a significant increase in the amount of bicipital groove visualized with the 70° arthroscope versus that visualized with the 30° arthroscope (18.0 ± 6.9 mm v 11 ± 4.7 mm, P = .01). In similar fashion, the results of the in vivo analysis showed that the 70° arthroscope allowed for significantly more visualization of the bicipital groove than the 30° arthroscope (26.3 ± 6.2 mm v 14 ± 4.7 mm, P = .025). CONCLUSIONS: The use of a 70° arthroscope significantly increases the length of bicipital groove visualized during glenohumeral arthroscopy in the lateral decubitus position compared with that of the 30° arthroscope in both cadavers and living subjects. CLINICAL RELEVANCE: Routine use of a 70° arthroscope significantly improves visualization of the bicipital groove and all relevant intra-articular structures compared with that of a 30° arthroscope during diagnostic glenohumeral arthroscopy performed in the lateral decubitus position.