Survival and Clinical Outcomes after Unconstrained Total Knee Arthroplasty for Tibial Plateau Fractures-A Retrospective Study with Minimum 4-Year Follow-Up.

This study investigated survival, complications, revisions, and patient-reported outcomes (PROs) for unconstrained total knee arthroplasty (TKA) in posttraumatic osteoarthritis (PTO) caused by intraarticular tibial plateau fractures with minimum four years follow-up. Forty-nine patients (71.4% male; 58.7 years) were included. Kaplan-Meier analysis was performed with failure defined as TKA removal. Patients without failure underwent pre- and postoperative evaluation (range of motion (ROM), Oxford Knee Score (OKS), Knee Society Score (KSS), anatomical femorotibial angle (aFTA), proximal tibial slope (PTS)) and Short Form-12 (SF-12) Physical (PCS) and Mental Component Summary (MCS) assessment at final follow-up. Fifteen (30.6%) patients had a complication, and eight (16.3%) patients underwent prosthesis removal at median 2.5 years. Cumulative survival rate of TKA was 79.6% at 20 years. A total of 32 patients with a mean follow-up of 11.8 years underwent further analyses. ROM (p = 0.028), aFTA (p = 0.044), pPS (p = 0.009), OKS (p < 0.001) and KSS (p < 0.001) improved significantly. SF-12 PCS was 42.3 and MCS was 54.4 at final follow-up. In general, one third of patients suffer a complication, and one in six patients has their prosthesis removed after TKA for PTO due to tibial plateau fractures. In patients who do not fail, TKA significantly improves clinical and radiographic outcomes at long-term follow-up.

The Effect of Buttress Plating on Biomechanical Stability of Coronal Shear Fractures of the Capitellum: A Cadaveric Study.

PURPOSE: The purpose of this study was to compare, using a cadaveric model, the biomechanical properties of headless compression screws (HCSs) and HCSs augmented with a buttress plate (BP) in capitellar fractures. METHODS: Twenty pairs of fresh-frozen humeri (mean age, 46.3 years; range, 33-58 years) were used. The soft tissue was removed, and a Dubberley type IA capitellar fracture was created. One specimen in each pair was randomly assigned to receive either two 2.5-mm HCSs (HCS group) or two 2.5-mm HCSs augmented with an anterior 2.4-mm BP (HCS + BP group). This resulted in a similar distribution of the left and right humeri between the groups. Cyclic loading was performed, and displacement of the capitellum at 50, 100, 250, 500, 1,000, and 2,000 cycles was assessed using a motion capture system. This was followed by load-to-failure testing, wherein the load at a displacement of 1 and 2 mm was recorded. Failure was defined as 2-mm displacement. RESULTS: During cyclic loading, there were no significant differences in the displacement between the HCS and HCS + BP groups at any of the assessed cycles. During load-to-failure testing, no significant strength differences were observed in the load at 1-mm displacement between the HCS (mean: 449.8 N, 95% CI: 283.6-616.0) and HCS + BP groups (mean: 606.2 N, 95% CI: 476.4-736.0). However, a significantly smaller load resulted in a 2-mm displacement of the fragment in the HCS group (mean: 668.8 N, 95% CI: 414.3-923.2) compared with the HCS + BP group (mean: 977.5 N, 95% CI: 794.1-1,161.0). CONCLUSIONS: Anterior, low-profile buttress plating in addition to HCSs results in a significantly higher load to failure compared with HCSs alone in a biomechanical Dubberley type IA capitellar fracture model. CLINICAL RELEVANCE: The addition of an anterior BP may be considered to improve initial stability in select cases such as osteoporotic patients or when the posterolateral column is frail.

Qualitative and Quantitative Anatomy of the Humeral Attachment of the Pectoralis Major Muscle and Structures at Risk: A Cadaveric Study.

Background: Surgical pectoralis major (PM) repair can offer improved functional outcomes over nonoperative treatment. However, there is a lack of literature on consensus of the anatomical site of the humeral attachment. Purpose: To provide qualitative and quantitative anatomic analysis of the PM by focusing on humeral insertion and relevant structures at risk. Study Design: Descriptive laboratory study. Methods: Eight fresh-frozen male cadavers were dissected. The relevant landmarks that were collected and measured included (1) PM footprint length at the humeral insertion (total, sternal head, and clavicular head insertions); (2) PM tendon length from the humeral insertion to the musculotendinous junction; (3) distance from the PM humeral insertion to the lateral (LPN) and medial (MPN) pectoral nerves; and (4) distance from the coracoid process to the musculocutaneous nerve (MCN) in anatomical position. Results: The total PM footprint length was 81.4 mm (95% CI, 71.4-91.3). The sternal and clavicular heads that make up the PM had footprint lengths of 42.1 mm (95% CI, 32.9-51.4) and 56.6 mm (95% CI, 46.5-66.7), respectively. The PM tendon was wider at the clavicular head (74.7 mm; 95% CI, 67.5-81.7) than the sternal head insertions (43.0 mm; 95% CI, 40.1-45.9). The distances from the PM humeral insertion to LPN and MPN were 93.2 mm (95% CI, 83.1-103.3) and 103.8 mm (95% CI, 98.3-109.4), respectively. The coracoid process to MCN distance was 68.5 mm (95% CI, 60.2-76.8). Conclusion: This study successfully quantifies anatomic dimensions of the PM tendon, its sternal and clavicular head insertions, and its location relative to nearby vital structures. Such knowledge can provide surgeons with a better understanding of the PM in relation to nearby neurovascular structures during anatomic PM repair and reconstruction to avoid debilitating complications. Clinical Relevance: Knowledge of the quantitative anatomy of the PM at the humeral footprint along structures at risk may aid surgeons with identifying the injured part of the PM and improve outcomes for anatomic repair and reconstruction.

Neurovascular Anatomic Locations and Surgical Safe Zones When Approaching the Posterior Glenoid and Scapula: A Quantitative and Qualitative Cadaveric Anatomy Study.

Purpose: To characterize the qualitative anatomy of posterior scapula structures encountered with the Judet approach and to perform a quantitative evaluation of these structures' anatomic locations, including their relationships to osseus landmarks to identify safe zones. Methods: Twelve fresh-frozen cadaveric shoulders (mean age, 55.2 years; range 41-64 years; 5 left, 7 right) were dissected. A coordinate measuring machine was used to collect the coordinates of anatomic landmarks, structures at risk during surgical approach to the posterior scapula, and the footprints of muscle attachments on the posterior scapula. These coordinates were analyzed for their relationships with clinically relevant anatomy. Results: The suprascapular nerve was a mean of 20.3 mm (18.9-21.7 mm) medial to the glenoid 9-o'clock position. The posterior circumflex artery and vein were a mean of 100.0 mm (92.2-107.7 mm) lateral to along the lateral border of the scapula from the inferior angle of the scapula and a mean of 41 mm (34.2-47.9 mm) medial along the lateral scapular border from the 6-o'clock position on the glenoid rim. The long head of the triceps covers a mean of 132 mm2, and it was found to be contiguous with the glenoid capsule at the 6-o'clock position. Conclusions: A safe zone exists 19 mm medially from the glenoid 9-o'clock position to the suprascapular nerve and a minimum of 34.2 mm medially along the lateral scapular border from the glenoid 6 o'clock to the posterior circumflex scapular artery. Clinical Relevance: The modified Judet approach is a minimally invasive surgery that reduces surgical trauma but necessitates precise knowledge of scapular neurovascular anatomy. Surgeons should be aware of these intervals to help avoid these structures when working near the posterior shoulder. This study may allow us to define neurovascular safe zones when this approach is used.

SLAP Repair Versus Subpectoral Biceps Tenodesis for Isolated SLAP Type 2 Lesions in Overhead Athletes Younger Than 35 Years: Comparison of Minimum 2-Year Outcomes.

Background: It remains unclear if young overhead athletes with isolated superior labrum anterior-posterior (SLAP) type 2 lesions benefit more from SLAP repair or subpectoral biceps tenodesis. Purpose: To evaluate clinical outcomes and return to sport in overhead athletes with symptomatic SLAP type 2 lesions who underwent either biceps tenodesis or SLAP repair. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was performed in patients who underwent subpectoral biceps tenodesis (n = 14) or SLAP repair (n = 24) for the treatment of isolated type 2 SLAP lesions. All patients were aged <35 years at time of surgery, participated in overhead sports, and were at least 2 years out from surgery. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numerical Evaluation (SANE) score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; and the 12-Item Short Form (SF-12) physical component score. Return to sport and patient satisfaction were documented. Clinical failures requiring revision surgery and complications were reported. Results: Preoperative baseline scores in both the tenodesis and SLAP repair groups were similar. There were no significant differences between the groups on any postoperative outcome measure: For biceps tenodesis versus SLAP repair, the ASES score was 92.7 ± 10.4 versus 89.1 ± 16.7, the SANE score was 86.2 ± 13.7 versus 83.0 ± 24.1, the QuickDASH score was 10.0 ± 12.7 versus 9.0 ± 14.3, and SF-12 was 51.2 ± 7.5 versus 52.8 ± 7.7. No group difference in return-to-sports rate (85% vs 79%; P = .640) was noted. More patients in the tenodesis group (80%) reported modifying their sporting/recreational activity postoperatively because of weakness compared with patients in the SLAP repair group (15%; P = .022). One patient in each group progressed to surgery for persistent postoperative stiffness, and 1 patient in the tenodesis group had a postoperative complication related to the index surgery. Conclusion: Both subpectoral biceps tenodesis and SLAP repair provided excellent clinical results for the treatment of isolated SLAP type 2 lesions, with a high rate of return to overhead sports and a low failure rate, in a young and high-demanding patient cohort. More patients reported modifying their sporting/recreational activity because of weakness after subpectoral tenodesis.

Anatomic safe zones for arthroscopic snapping scapula surgery: quantitative anatomy of the superomedial scapula and associated neurovascular structures and the effects of arm positioning on safety.

BACKGROUND: Neurovascular anatomy has not been previously quantified for the arthroscopic snapping scapula approach with the patient in the most frequent patient position ("chicken-wing" position). The purposes of this study were (1) to determine anatomic relationships of the superomedial scapula and neurovascular structures at risk during arthroscopic surgical treatment of snapping scapula syndrome (SSS), (2) to compare these measurements between the arm in the neutral position and the arm in the chicken-wing position, and (3) to establish safe zones for arthroscopic treatment of SSS. METHODS: Eight fresh-frozen cadaveric hemi-torsos (mean age, 55.8 years; range, 52-66 years) were dissected to ascertain relevant anatomic structure locations including the (1) spinal accessory nerve, (2) dorsal scapular nerve, and (3) suprascapular nerve. A coordinate measuring device was used to collect data on the relationships of anatomic landmarks and at-risk structures during the surgical approach. RESULTS: The dorsal scapular nerve was a mean of 24.4 mm medial to the superomedial scapula in the neutral position and 33.1 mm medial in the chicken-wing position (P < .001); the dorsal scapular nerve was 21.7 mm medial to the medial border of the scapular spine in the neutral position and 35.5 mm medial in the chicken-wing position (P < .001). The mean distance from the superomedial angle to the spinal accessory nerve intersection at the superior scapular border was 16.5 mm in the neutral position and 15.0 mm in the chicken-wing position (P = .031). The average distance from the superomedial angle to the closest point of the spinal accessory nerve was 11.6 mm and 10.4 mm in the neutral position and chicken-wing position, respectively (P = .039). CONCLUSION: Neurologic structures around the scapula vary significantly between the neutral arm position and the chicken-wing position commonly used in the arthroscopic treatment of SSS. The chicken-wing position improves safe distances for the dorsal scapular nerve during medial-portal placement and should be considered as a primary position for arthroscopic management of SSS.

Open Fixation of Displaced Greater Tuberosity Fractures Yields Similar Patient-Reported Outcomes to Acute Arthroscopic Rotator Cuff Repair at 2 Years: A Matched Cohort Analysis.

Purpose: To evaluate and compare patient-reported outcomes (PROs) after isolated greater tuberosity (GT) fracture fixation versus acute rotator cuff repair (RCR) at a minimum of 2 years. Methods: Patients who underwent isolated GT fracture fixation were compared in a 1-to-3 fashion with patients who underwent arthroscopic RCR for an acute rotator cuff tear by a single surgeon from January 2006 and to July 2018. Data were prospectively collected and retrospectively reviewed. PROs were compared pre- and postoperatively as well as between groups (American Shoulder and Elbow Surgeons [ASES], General Health Short Form-12 Physical Component [SF-12 PCS], Single Assessment Numerical Evaluation [SANE], Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH], and satisfaction). Reoperation rates were analyzed. Results: A total of 57 patients (14 with isolated GT fracture fixation, mean age 45.7 years; and 43 who underwent ARCR for acute tears, mean age 56.6 years) were evaluated (P = .050). ASES scores significantly improved from 39.7 to 94.1 (P = .018) in the isolated GT fracture fixation group and from 51.0 to 95.2 (P < .001) in acute RCR group. At final follow-up, mean QuickDASH scores were 8.9 and 7.9 (P = .677) and SANE scores were 91.1 and 87.3 (P = .616) for the GT and acute RCR groups, respectively. The median satisfaction was 10/10 for the GT group and 10/10 for the RCR group. Additional comparison of patients who underwent double-row repair for an acute rotator cuff tear or isolated GT fracture revealed no significant difference in outcomes (P > .404). Conclusion: Minimum 2-year PROs after fixation of isolated GT fractures show relatively high outcome scores whether treated by open reduction and internal fixation or arthroscopic fixation using a double-row bridging technique. The improvements in PROs are similar to those achieved with acute rotator cuff tears that were fixed arthroscopically with RCR. Further analysis of these results suggest that the functional outcomes of tendon-to-bone healing with linked, double-row rotator cuff repairs are similar to those of bone-to-bone healing as seen with GT fractures. Level of Evidence: III, retrospective comparative study.

Arthroscopic Axillary Nerve Neurolysis From the Anteroinferior Glenoid Through the Quadrilateral Space to the Terminal Deltoid Branches.

Axillary nerve compression is a rare cause of posterolateral shoulder pain. Once the diagnosis is confirmed and after failure of conservative measures, open procedures have been the mainstay of treatment for several decades. More recently, arthroscopic techniques have been proposed, which offer several advantages, including improved access to difficult locations, better visualization, and less surgical morbidity. The objective of this Technical Note is to describe an arthroscopic neurolysis of the axillary nerve from the inferior humeral pouch, through the quadrilateral space and into the subdeltoid recess.

Development of a New Emergency Medicine Spinal Immobilization Protocol for Pediatric Trauma Patients and First Applicability Test on Emergency Medicine Personnel.

OBJECTIVES: The purpose of this study was to (i) develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) perform an applicability test on emergency medicine personnel. METHODS: A structured search of the literature published between 1980 and 2019 was performed in MEDLINE using PubMed. Based on this literature search, a new Emergency Medicine Spinal Immobilization Protocol for pediatric trauma patients (E.M.S. IMMO Protocol Pediatric) was developed. Parameters found in the literature, such as trauma mechanism and clinical findings that accounted for a high probability of spinal injury, were included in the protocol. An applicability test was administered to German emergency medicine personnel using a questionnaire with case examples to assess correct decision making according to the protocol. RESULTS: The E.M.S. IMMO Protocol Pediatric was developed based on evidence from published literature. In the applicability test involving 44 emergency medicine providers revealed that 82.9% of participants chose the correct type of immobilization based on the protocol. A total of 97.8% evaluated the E.M.S. IMMO Protocol Pediatric as helpful. CONCLUSIONS: Based on the current literature, the E.M.S. IMMO Protocol Pediatric was developed in accordance with established procedures used in trauma care. The decision regarding immobilization is made on based on the cardiopulmonary status of the patient, and life-threatening injuries are treated with priority. If the patient presents in stable condition, the necessity for full immobilization is assessed based upon the mechanisms of injury, assessment of impairment, and clinical examination.

Outcomes After Arthroscopic Rotator Cuff Repair Using Margin Convergence Versus Superior Capsular Reconstruction: Should Candidates for Margin Convergence Be Treated With Superior Capsular Reconstruction?

BACKGROUND: Both margin convergence rotator cuff repair (MC-RCR) and superior capsular reconstruction (SCR) result in improved clinical outcomes in the treatment of massive rotator cuff tears (RCTs). The question remains whether it is better to perform MC-RCR using native, albeit occasionally deficient, tissues or to perform primary SCR. PURPOSE/HYPOTHESIS: To compare the clinical results of MC-RCR versus SCR for the treatment of massive RCTs. It was hypothesized that SCR would yield better outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included were patients who underwent arthroscopic MC-RCR or SCR for massive RCTs performed by a single surgeon between 2014 and 2019. MC-RCR was performed if it was technically possible to close the defect; otherwise, SCR was performed. Outcomes were assessed at 6 months and then annually using American Shoulder and Elbow Surgeons; Single Assessment Numerical Evaluation; shortened version of Disabilities of the Arm, Shoulder and Hand; 12-Item Short Form Health Survey Physical Component Summary; and patient satisfaction scores. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) were compared between groups. Revision surgeries and complications were reported. RESULTS: Included were 46 patients in the MC-RCR group (mean age, 59 ± 8 years) and 46 patients in the SCR group (mean age, 57 ± 7 years); 29 patients in each group were available at 2-year follow-up. Preoperative outcome scores were not significantly different between groups. Within groups, all outcome scores improved from pre- to postoperatively (P < .05), with no significant differences in postoperative scores or patient satisfaction between groups. No significant between-group differences were noted in the percentage of patients who reached the MCID, SCB, and PASS (MCID, 92.3% vs 84.6%; SCB, 80.8% vs 80.8%; and PASS, 66.7% vs 66.7%). SCR had a significantly lower survivorship rate compared with MC-RCR (84.7% vs 100%) (P = .026). CONCLUSION: Both MC-RCR and SCR provided similar improvement in outcomes; however, SCR resulted in a significantly lower survivorship rate at 2 years postoperatively. If an RCT is technically repairable, we recommend that it be repaired primarily, even if MC techniques are needed to close the defect. SCR remains a good option for massive RCTs that are not technically repairable.

Grade III Acromioclavicular Separations Treated With Suspensory Fixation Techniques: A Systematic Review of Level I Through IV Studies.

PURPOSE: To perform a systematic review comparing clinical outcomes, radiographic outcomes, and complication rates after acute (surgery ≤6 weeks from injury) versus chronic (surgery >6 weeks from injury) acromioclavicular joint reconstructions for grade III injuries using modern suspensory fixation techniques. METHODS: We performed a systematic review of the literature examining acute versus chronic surgical treatment of Rockwood grade III acromioclavicular joint separations using the Cochrane registry, MEDLINE database, and Embase database over the past 10 years according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria included techniques using suspensory fixation, a minimum study size of 3 patients, a minimum follow-up period of 6 months, human studies, and English-language studies. The methodology of each study was evaluated using the Methodological Index for Non-randomized Studies (MINORS) tool for nonrandomized studies and the revised Cochrane risk-of-bias (RoB 2) tool for randomized controlled trials. RESULTS: The systematic review search yielded 20 studies with a total of 253 patients. There were 2 prospective randomized controlled trials, but most of the included studies were retrospective. On comparison of acute surgery (≤6 weeks) and chronic surgery (>6 weeks), individual studies reported a range of Constant scores of 84.4 to 98.2 and 80.8 to 94.1, respectively. The ranges of radiographic coracoclavicular distances reported at final follow-up also favored acute reconstructions, which showed improved reduction (9.2-15.7 mm and 11.7-18.6 mm, respectively). The reported complication rates ranged from 7% to 67% for acute reconstructions and from 0% to 30% for chronic reconstructions. CONCLUSIONS: The ranges in the Constant score may favor acute reconstructions, but because of the heterogeneity in the surgical techniques in the literature, no definitive recommendations can be made regarding optimal timing. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Influence of Radiographic Parameters on Reduction of the Critical Shoulder Angle With Arthroscopic Lateral Acromioplasty-A Mathematical Model.

OBJECTIVES: To develop a mathematical model for the preoperative planning of arthroscopic lateral acromioplasty (ALA) and to evaluate the role of radiographic parameters with regards to the critical shoulder angle (CSA). METHODS: Anteroposterior (AP) radiographs of patients who underwent rotator cuff surgery were screened to identify true AP radiographs. Radiographs were assessed for (1) native CSA, (2) CSA after simulated resection of a spur if present, (3) amount of ALA necessary to achieve a CSA of 34°, (4) CSA after 5-mm ALA, (5) lateral acromion angle, (6) acromion index, and (7) sclerosis of the greater tuberosity. RESULTS: A total of 1191 radiographs were screened. Of the 124 patients included, the native CSA was large (≥35°) in 56 patients (45%). In 30 patients (24%), a subacromial spur was detected and resection reduced the CSA by a median of 2°. Spur resection alone reduced the CSA to ≤34° in 19 patients (15.3%). Mean amount of ALA to achieve a CSA of 34° was 3.9 ± 1.8 mm, and this value strongly correlated with the CSA before ALA (R = 0.88, P < .001). The linear regression model to determine the amount of ALA to achieve a CSA of 34° was as follows: R e q u i r e d A L A i n m m = - 39.120 + 1.165 ∗ C S A n a t i v e The multiple R2 for this model was 0.777. Mean reduction of CSA by 5-mm ALA was 3.8 ± 0.8° and 75% of large CSAs were reduced to a CSA of 30-34°. The acromion index had no significant independent influence on the model (P = .427), whereas lateral acromion angle was an independently significant predictor of required ALA to achieve a CSA of 34° (P = .019). Sclerosis of the greater tuberosity was significantly associated with a CSA of 35° or greater (P = .003). CONCLUSIONS: The amount of ALA needed to reduce a large CSA to 34° correlates with the CSA before ALA and can preoperatively be planned with the use of a simple equation. LEVEL OF EVIDENCE: Level III; cross-sectional design; epidemiology study.

Minimum 10-Year Outcomes of Primary Arthroscopic Transosseous-Equivalent Double-Row Rotator Cuff Repair.

BACKGROUND: Modern rotator cuff repair techniques demonstrate favorable early and midterm outcomes, but long-term results have yet to be reported. PURPOSE: To determine 10-year outcomes and survivorship after arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair. STUDY DESIGN: Case series; Level of evidence 4. METHODS: The primary TOE rotator cuff repair procedure was performed using either a knotted suture bridge or knotless tape bridge technique on a series of patients with 1 to 3 tendon full-thickness rotator cuff tears involving the supraspinatus. Only patients who were 10 years postsurgery were included. Patient-reported outcomes were collected pre- and postoperatively, including American Shoulder and Elbow Surgeons (ASES), 12-Item Short Form Health Survey (SF-12), Single Assessment Numeric Evaluation (SANE), shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and satisfaction. Kaplan-Meier survivorship analysis was performed. Failure was defined as progression to revision surgery. RESULTS: A total of 91 shoulders (56 men, 31 women) were included between October 2005 and December 2009. Mean follow-up was 11.5 years (range, 10.0-14.1 years). Of 91 shoulders, 5 (5.5%) failed and required revision surgery. Patient-reported outcomes for patients who survived were known for 80% (69/86). Outcomes scores at final follow-up were as follows: ASES, 93.1 ± 10.8; SANE, 87.5 ± 14.2; QuickDASH, 11.1 ± 13.5; and SF-12 physical component summary (PCS), 49.2 ± 10.1. There were statistically significant declines in ASES, SANE, and SF-12 PCS from the 5-year to 10-year follow-up, but none of these changes met the minimally clinically important difference threshold. Median satisfaction at final follow-up was 10 (range, 3-10). From this cohort, Kaplan-Meier survivorship demonstrated a 94.4% survival rate at a minimum of 10 years. CONCLUSION: Arthroscopic TOE rotator cuff repair demonstrates high patient satisfaction and low revision rates at a mean follow-up of 11.5 years. This information may be directly utilized in surgical decision making and preoperative patient counseling regarding the longevity of modern double-row rotator cuff repair.

Complex Revision Glenoid Reconstruction with Use of a Distal Tibial Allograft.

BACKGROUND: Coracoid transfer procedures have been increasingly utilized for anterior shoulder instability with associated glenoid bone loss1. Unfortunately, in a young, high-risk patient population, these procedures can fail secondary to traumatic causes but also because of bone graft resorption or malposition or hardware prominence, among other reasons2. In active patients, revision glenoid reconstruction may be indicated. Distal tibial osteoarticular allografts have been utilized to treat recurrent anterior shoulder instability for several years3. Recently, this technique has been applied to cases of failed Latarjet procedures in order to reconstitute the absent glenoid bone stock4, demonstrating excellent clinical outcomes at a minimum follow-up of 3 years2. DESCRIPTION: The procedure is performed in the beach-chair position. First, a diagnostic shoulder arthroscopy is performed to assess the cartilaginous surfaces, to examine the Hill-Sachs lesion and its engagement, and to remove any loose bodies. Next, the prior deltopectoral incision is developed, and the deltopectoral interval is utilized to visualize the subscapularis. The subscapularis is split at the junction of its upper two-thirds and lower one-third. Careful dissection is used to develop the subscapularis split from lateral to medial because the prior coracoid transfer affects the native neurovascular anatomy medially. If substantial coracoid bone remains from the previous transfer, a conjoined tendon tenotomy can be performed to further aid in visualization5. Next, any associated hardware is removed, and the coracoid bone remnant is removed. The glenoid defect is sized, and the osseous glenoid bed is prepared. A fresh-frozen distal tibial allograft is then fashioned, washed of marrow elements, and enhanced with platelet-rich plasma before being fixed to the glenoid with use of 2 cortical screws in a lagged fashion. The capsule and subscapularis split are then closed to complete the repair. ALTERNATIVES: Alternatives to revision glenoid reconstruction with distal tibial allograft include reconstruction with an iliac crest autograft, distal clavicular autograft, revision coracoid transfer, or nonoperative treatment through rehabilitation and activity modification. RATIONALE: In cases of failed coracoid transfer for anterior shoulder instability with associated glenoid bone loss, distal tibial allograft is the superior revision treatment option for several reasons: it allows for an osteoarticular graft, offers flexibility in terms of graft size, and requires no donor-site morbidity. Distal tibial allograft allows active, high-risk patients to have restored and maintained stability with low complication and graft-resorption rates2. EXPECTED OUTCOMES: Glenoid reconstruction with a distal tibial allograft is associated with improved patient-reported outcomes from preoperatively, as well as recurrence rates of <10% and graft-union rates of >90%2. IMPORTANT TIPS: Initiating the procedure with an arthroscopic evaluation allows for a complete diagnostic examination, including the Hill-Sachs lesion, articular cartilage, and rotator cuff, as well as removal of any loose bodies, which are frequently present and sometimes difficult to visualize and access during the open procedure.A subscapularis split allows for maintenance of the subscapularis insertion on the lesser tuberosity as well as minimal disruption of the muscle fibers.A conjoined tendon tenotomy can provide improved access for hardware removal if the coracoid bone graft from the prior transferred coracoid is present.A 5.5-mm arthroscopic burr is utilized to decorticate the anterior aspect of the glenoid, which facilitates graft union because the burr allows built-in suction capability during constant irrigation, minimizing the possibility of heat necrosis.The distal tibial allograft is thoroughly lavaged to remove residual marrow elements prior to insertion in order to diminish potential immunogenicity.Two solid, fully threaded 3.5-mm cortical screws are placed in a lagged fashion to fix the distal tibial allograft to the glenoid.

Posterior Glenoid Reconstruction Using a Distal Tibial Allograft.

Posterior shoulder instability is increasingly recognized and diagnosed in young athletes. These patients often present with vague shoulder pain rather than the frank instability commonly seen with anterior instability. Three common causes of posterior shoulder instability are congenital retroversion, a single traumatic event, or repetitive microtrauma with erosive effects. The critical determination when deciding on the appropriate treatment of posterior shoulder instability is the presence and degree of glenoid bone loss. In patients without bone loss, arthroscopic procedures have a high success rate with a failure rate of less than 10% and an 89% return-to-sport rate. The determination of the critical amount of bone loss that would permit an arthroscopic procedure is controversial, but recent reports that attempt to quantify the critical bone loss value posteriorly have ranged from 13.5% to 20%. This Technical Note describes our preferred method of open surgical treatment of posterior shoulder instability with posterior glenoid bone loss using an intra-articular distal tibial allograft.

Pullout Strength of All-Suture and Metallic Anchors in Repair of Lateral Collateral Ligament Injuries of the Elbow.

PURPOSE: To compare the biomechanical properties of metallic anchor (MA) and all-suture anchor (ASA) constructs in the anatomic reattachment of the lateral ulnar collateral ligament complex to its humeral insertion. METHODS: Twenty paired male human cadaveric elbows with a mean age of 46.3 years (range: 33-58 years) were used in this study. Each pair was randomly allocated across 2 groups of either MA or ASA. A single 3.5-mm MA or 2.6-mm ASA was then inserted flush into the lateral epicondyle. A dynamic tensile testing machine was used to perform cyclic loading followed by a load to failure test. During the cyclic loading phase, the anchors were sinusoidally tensioned from 10 N to 100 N for 1,000 cycles at a frequency of 0.5 Hz. In the load to failure test, the anchors were pulled at a rate of 3 mm/s. Load at 1-mm and 2-mm displacement, as well as load to ultimate failure were assessed. Clinical failure was defined as displacement of more than 2 mm. Normality of data was assessed with the Shapiro-Wilk test. Continuous data are presented as medians and compared with the Mann-Whitney U test and categorical data was compared with the χ2 test or Fisher exact test. RESULTS: Displacement was significantly greater for the ASA group during cyclic loading starting from the tenth cycle (P < .05). Displacement of more than 5 mm within the first 100 cycles was observed in 2 anchors in the ASA group. No difference was observed in loads required to displace 1 mm (MA: 146 N [6-169] vs ASA: 144 N [2-153]; P = .53) and 2 mm (MA: 171 N [13-202] vs ASA: 161 N [9-191]; P = .97), but there was a statistically significant difference between ultimate loads in favor of ASA in the load to failure test (MA: 297 N [84-343] vs 463 N [176-620]; P < .01). CONCLUSIONS: In the cyclic test, no difference in clinical failure defined as pull-out of more than 2 mm was observed between 3.5 mm MAs and 2.6 mm ASAs. In the ultimate load to failure analysis, no difference was observed between groups in force causing 1 and 2 mm of displacement, but there was a significant difference in favor of ASA in the pull to ultimate failure test. CLINICAL RELEVANCE: Potential benefits of all-suture anchors include preservation of bone stock, reduced radiographic artifacts, and easier revisions. Although their use has been investigated thoroughly in the shoulder, there remains a paucity of literature regarding displacement and pull-out strength in the elbow.

Mid-Term Outcomes of Arthroscopically-Assisted Anatomic Coracoclavicular Ligament Reconstruction Using Tendon Allograft for High-Grade Acromioclavicular Joint Dislocations.

PURPOSE: The purposes of this study were to assess clinical and radiographic outcomes of arthroscopically-assisted, anatomic coracoclavicular ligament reconstruction using tendon allograft (AA-ACCR) for the treatment of Rockwood type III-V injuries at minimum 2-year follow-up and to perform subgroup analyses of clinical and radiographic outcomes for acute versus chronic and type III versus type IV-V injuries. METHODS: In this retrospective study of prospectively collected data, patients who underwent primary AA-ACCR for the treatment of type III-V dislocations and had minimum 2-year follow-up were included. Preoperative and postoperative patient-reported outcome scores (PROs) were collected, including American Shoulder and Elbow Surgeons score, Single Numeric Assessment Evaluation score, Short Form-12 Physical Component Summary, Quick Disabilities of the Arm Shoulder and Hand score, and patient satisfaction. Preoperative and postoperative coracoclavicular distance (CCD) was obtained. PROs and CCD were reported for the total cohort and for the subgroups. Complication and revision rates were demonstrated. RESULTS: In total, 102 patients (10 women, 92 men) with a mean age of 45.0 years (range, 18-73 years) were included. There were 13 complications (12.7%) resulting in revision surgery. After exclusion of revised patients, PROs were available for 69 (77.5%). At mean follow-up of 4.7 years (range, 2.0-12.8 years), all PROs improved significantly (P < .001). Median patient satisfaction was 9.0 (interquartile range, 8.0-10.0). Median preoperative to postoperative CCD decreased significantly (P < .001). Subgroup analyses revealed significant improvements in all PROs and CCD from preoperative to postoperative for both acute and chronic, and type III and type IV-V dislocations (P < .05) with no significant differences in postoperative PROs and satisfaction between (P > .05). CONCLUSION: AA-ACCR for high-grade acromioclavicular joint injuries resulted in high postoperative PROs and patient satisfaction with significant improvements from before to after surgery in those who did not undergo revision surgery. Furthermore, subgroup analyses revealed that acute and chronic, and type III and type IV-V injuries benefitted similarly from AA-ACCR. LEVEL OF EVIDENCE: Level IV; therapeutic case series.

Total Shoulder Arthroplasty After Previous Arthroscopic Surgery for Glenohumeral Osteoarthritis: A Case-Control Matched Cohort Study.

BACKGROUND: When comprehensive arthroscopic management (CAM) for glenohumeral osteoarthritis fails, total shoulder arthroplasty (TSA) may be needed, and it remains unknown whether previous CAM adversely affects outcomes after subsequent TSA. PURPOSE: To compare the outcomes of patients with glenohumeral osteoarthritis who underwent TSA as a primary procedure with those who underwent TSA after CAM (CAM-TSA). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients younger than 70 years who underwent primary TSA or CAM-TSA and were at least 2 years postoperative were included. A total of 21 patients who underwent CAM-TSA were matched to 42 patients who underwent primary TSA by age, sex, and grade of osteoarthritis. Intraoperative blood loss and surgical time were assessed. Patient-reported outcome (PRO) scores were collected preoperatively and at final follow-up including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), visual analog scale, and patient satisfaction. Revision arthroplasty was defined as failure. RESULTS: Of 63 patients, 56 of them (19 CAM-TSA and 37 primary TSA; 88.9%) were available for follow-up. There were 16 female (28.6%) and 40 male (71.4%) patients with a mean age of 57.8 years (range, 38.8-66.7 years). There were no significant differences in intraoperative blood loss (P > .999) or surgical time (P = .127) between the groups. There were 4 patients (7.1%) who had failure, and failure rates did not differ significantly between the CAM-TSA (5.3%; n = 1) and primary TSA (8.1%; n = 3) groups (P > .999). Additionally, 2 patients underwent revision arthroplasty because of trauma. A total of 50 patients who did not experience failure (17 CAM-TSA and 33 primary TSA) completed PRO measures at a mean follow-up of 4.8 years (range, 2.0-11.5 years), with no significant difference between the CAM-TSA (4.4 years [range, 2.1-10.5 years]) and primary TSA (5.0 years [range, 2.0-11.5 years]) groups (P = .164). Both groups improved significantly from preoperatively to postoperatively in all PRO scores (P < .05). No significant differences in any median PRO scores between the CAM-TSA and primary TSA groups, respectively, were seen at final follow-up: ASES: 89.9 (interquartile range [IQR], 74.9-96.6) versus 94.1 (IQR, 74.9-98.3) (P = .545); SANE: 84.0 (IQR, 74.0-94.0) versus 91.5 (IQR, 75.3-99.0) (P = .246); QuickDASH: 9.0 (IQR, 3.4-27.3) versus 9.0 (IQR, 5.1-18.1) (P = .921); SF-12 PCS: 53.8 (IQR, 50.1-57.1) versus 49.3 (IQR, 41.2-56.5) (P = .065); and patient satisfaction: 9.5 (IQR, 7.3-10.0) versus 9.0 (IQR, 5.3-10.0) (P = .308). CONCLUSION: Patients with severe glenohumeral osteoarthritis who failed previous CAM benefited similarly from TSA compared with patients who opted directly for TSA.

Quantitative and Qualitative Surgical Anatomy of the Acromioclavicular Joint Capsule and Ligament: A Cadaveric Study.

BACKGROUND: The acromioclavicular (AC) capsule and ligament have been found to play a major role in maintaining horizontal stability. To reconstruct the AC capsule and ligament, precise knowledge of their anatomy is essential. PURPOSE/HYPOTHESIS: The purposes of this study were (1) to determine the angle of the posterosuperior ligament in regard to the axis of the clavicle, (2) to determine the width of the attachment (footprint) of the AC capsule and ligament on the acromion and clavicle, (3) to determine the distance to the AC capsule from the cartilage border of the acromion and clavicle, and (4) to develop a clockface model of the insertion of the posterosuperior ligament on the acromion and clavicle. It was hypothesized that consistent angles, attachment areas, distances, and insertion sites would be identified. STUDY DESIGN: Descriptive laboratory study. METHODS: A total of 12 fresh-frozen shoulders were used (mean age, 55 years [range, 41-64 years]). All soft tissue was removed, leaving only the AC capsule and ligament intact. After a qualitative inspection, a quantitative assessment was performed. The AC joint was fixed in an anatomic position, and the attachment angle of the posterosuperior ligament was measured using a digital protractor. The capsule and ligament were removed, and a coordinate measuring device was utilized to assess the width of the AC capsule footprint and the distance from the footprint to the cartilage border of the acromion and clavicle. The AC joint was then disarticulated, and the previously marked posterosuperior ligament insertion was transferred into a clockface model. The mean values across the 12 specimens were demonstrated with 95% CIs. RESULTS: The mean attachment angle of the posterosuperior ligament was 51.4° (95% CI, 45.2°-57.6°) in relation to the long axis of the entire clavicle and 41.5° (95% CI, 33.8°-49.1°) in relation to the long axis of the distal third of the clavicle. The mean clavicular footprint width of the AC capsule was 6.4 mm (95% CI, 5.8-6.9 mm) at the superior clavicle and 4.4 mm (95% CI, 3.9-4.8 mm) at the inferior clavicle. The mean acromial footprint width of the AC capsule was 4.6 mm (95% CI, 4.2-4.9 mm) at the superior side and 4.0 mm (95% CI, 3.6-4.4 mm) at the inferior side. The mean distance from the lateral clavicular attachment of the AC capsule to the clavicular cartilage border was 4.3 mm (95% CI, 4.0-4.6 mm), and the mean distance from the medial acromial attachment of the AC capsule to the acromial cartilage border was 3.1 mm (95% CI, 2.9-3.4 mm). On the clockface model of the right shoulder, the clavicular attachment of the posterosuperior ligament ranged from the 9:05 (range, 8:00-9:30) to 11:20 (range, 10:00-12:30) position, and the acromial attachment ranged from the 12:20 (range, 11:00-1:30) to 2:10 (range, 13:30-14:40) position. CONCLUSION: The finding that the posterosuperior ligament did not course perpendicular to the AC joint but rather was oriented obliquely to the long axis of the clavicle, in combination with the newly developed clockface model, may help surgeons to optimally reconstruct this ligament. CLINICAL RELEVANCE: Our results of a narrow inferior footprint and a short distance from the inferior AC capsule to cartilage suggest that proposed reconstruction of the AC joint capsule should focus primarily on its superior portion.

Quantitative T2 mapping of the glenohumeral joint cartilage in asymptomatic shoulders and shoulders with increasing severity of rotator cuff pathology.

PURPOSE: To examine the relationship between glenohumeral cartilage T2 mapping values and rotator cuff pathology. METHOD: Fifty-nine subjects (age 48.2 ±â€¯13.5 years, 15 asymptomatic volunteers and 10 tendinosis, 13 partial-thickness tear, 8 full-thickness tear, and 13 massive tear patients) underwent glenohumeral cartilage T2 mapping. The humeral head cartilage was segmented in the sagittal and coronal planes. The glenoid cartilage was segmented in the coronal plane. Group means for each region were calculated and compared between the groups. RESULTS: Massive tear group T2 values were significantly higher than the asymptomatic group values for the humeral head cartilage included in the sagittal (45 ±â€¯7 versus 32 ±â€¯4 ms, p <  .001) and coronal (44 ± 6 versus 38 ± 1 ms, p =  0.01) plane images. Mean T2 was also significantly higher for massive than full-thickness tears (45 ± 7 versus 38 ± 5 ms, p =  0.02), massive than partial-thickness tears (45 ± 7 versus 34 ± 4 ms, p <  0.001), and massive tears than tendinosis (45 ± 7 versus 35 ± 4 ms, p =  0.001) in the sagittal-images humeral head region and significantly higher for massive tears than asymptomatic shoulders (44 ± 6 versus 38 ± 1 ms, p =  0.01) in the coronal-images humeral head region. CONCLUSION: Humeral head cartilage T2 values were significantly positively correlated with rotator cuff pathology severity. Massive rotator cuff tear patients demonstrated significantly higher superior humeral head cartilage T2 mapping values relative to subjects with no/lesser degrees of rotator cuff pathology.