Editorial Commentary: Serum Cartilage Oligomeric Matrix Protein Appears to Be the Most Useful Biomarker for Tracking Early Osteoarthritis of the Knee in Anterior Cruciate Ligament Deficient Patients (But May Also Reflect Synovitis).

Owing to chondral or meniscal pathology sustained at the time of injury, patients who sustain anterior cruciate ligament injury are at risk of knee osteoarthritis (OA). Thus, recognition of early OA is critical. Detection of joint space narrowing on radiography has been described as outdated, and furthermore, the different descriptions of the Kellgren-Lawrence criteria have an impact on the classification of OA of the lowest grade (Kellgren-Lawrence grade ≥ 1). Serum cartilage oligomeric matrix protein (COMP) may allow detection of early OA in patients with anterior cruciate ligament deficiency because significantly higher levels have been observed in patients with early OA than in patients with non-early OA. Serum COMP appears to be the most useful of the biomarkers studied. Prior studies have shown correlations with OA in animal models and via magnetic resonance imaging evaluation. However, I would be hesitant about widespread use. It is possible that the serum COMP level reflects not only cartilage damage but also synovitis. This may be particularly misleading in patients with diagnoses of rheumatologic disorders and/or undiagnosed genetic HLA-B27 variants.

A validated algorithm using current literature to judge the appropriateness of anatomic total shoulder arthroplasty utilizing the RAND/UCLA appropriateness method.

BACKGROUND: Currently, appropriateness criteria evaluating when to perform total shoulder arthroplasty (TSA) is lacking. In the absence of society guidelines and limited quality evidence, the RAND/University California in Los Angeles (UCLA) method provides a suitable alternative to evaluate appropriateness and assist in clinical decision making. Given the rise in utilization, appropriateness criteria for TSA have the potential to be an extremely powerful tool for improving quality of care and controlling costs. Thus, the goal of this study was to test explicit criteria to assess the appropriateness of TSA decision making using the RAND/UCLA appropriateness method. METHODS: A review of recent scientific literature to gather available evidence about the use, effectiveness, efficiency, and the risks involved in surgical intervention was performed by a shoulder/elbow fellowship trained physician. Based on pertinent variables including age, rotator cuff status, previous surgical management, mobility, symptomatology, and imaging classifications, 186 clinical scenarios were created. Appropriateness criteria for TSA were developed using a modified Delphi method with a panel consisting of American Shoulder and Elbow Surgeons (ASES) members. A second panel of ASES members rated the same scenarios, with reliability testing performed to compare groups. RESULTS: Panel members reached agreement in 40 (64%) indications. TSA was appropriate in 15 (24%) of indications. For patients with severe symptomatology, TSA was often appropriate for patients aged <75 years and inconclusive or inappropriate for patients aged >75 years. Among patients aged <65 years, TSA varied between appropriate and inconclusive, often dependent on Walch classification. For patients with moderate symptomatology, TSA was inappropriate or inconclusive for patients aged <65 or >75 years. When compared to the second panel's results, moderate agreement was obtained with a weighted kappa statistic of 0.56. CONCLUSIONS: Using the RAND/UCLA method, ASES members created an appropriateness decision tree for pertinent patient variables. This presents the data in a manner that streamlines the clinical decision-making process and allows for rapid and more reliable determination of appropriateness for practitioners. The decision tree is based on a combination of clinical experience from high-volume ASES-member surgeons and a comprehensive review of current evidence. This tool can be used as part of a broader set of factors, including individual patient characteristics, prior studies, and expert opinion, to inform clinical decision making, improve quality of care, and control costs.

Editorial Commentary: Revision Anterior Cruciate Ligament Using Soft Tissue Autograft Quadriceps Is Effective but Not Recommended for All Comers.

The average revision rate is between 3.2% and 11.1%following primary anterior cruciate ligament (ACL) reconstructions,1 and an objective failure rate of 13.7% has been reported for revision ACLR.2 Prior implants, positioning of tunnels, and muscle weakness from the prior reconstruction present challenges. Additionally, graft choice for the revision reconstruction is restricted, depending on the primary reconstruction. Revision ACL reconstruction with the all-soft tissue quadriceps tendon autograft is a viable option with 83.3% of the patients surpassing the minimally clinically significant difference for International Knee Documentation Committee (IKDC) scores, which is similar to outcomes for revision ACL reconstruction (ACLR) using bone-patella-bone and hamstring tendon autografts. Furthermore, objective strength data suggest that it is possible to achieve equal limb symmetry index strength ratios even in the setting of prior bone-patella tendon-bone autograft. However, although I am cautiously optimistic regarding soft tissue quadriceps autograft in revision ACLR, I would be hesitant to recommend it for all comers. In my experience, young high school/collegiate female athletes with primary reconstruction using BPTB autograft may not be able to tolerate a secondary insult to the extensor mechanism via quadriceps tendon (QT) autograft harvest, where hematoma and arthrofibrosis could be concerns. Furthermore, increased posterior tibial slope may require evaluation and treatment, and the addition of a lateral extra-articular tenodesis may reduce residual rotatory laxity in ACL revision patients.

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean 6-Year Follow-Up.

PURPOSE: To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR. METHODS: A institutional registry review of all AA-CCR using free tendon grafts from 2007 to 2016 was performed. Clinical assessment included Single Assessment Numeric Evaluation (SANE) score and return to preinjury activity level at final follow-up. Treatment failure was defined as (1) revision acromioclavicular stabilization surgery, (2) unable to return to preinjury activity level, or (3) radiographic loss of reduction (RLOR, >25% CC distance compared with contralateral side). SANE scores, return to activity, and RLOR were compared between patients within each category of treatment failure, by grade of injury, and whether concomitant pathology was treated. RESULTS: There were 88 patients (89.8% male) with mean age of 39.6 years and minimum 2-year clinical follow-up (mean 6.1 years). Most injuries were Rockwood grade V (63.6%). Mean postoperative SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%: 8.0% were unable to return to activity, 5.7% had RLOR, and 3.4% underwent revision surgery due to traumatic reinjury. SANE score was lower among patients who were unable to return to activity compared with those with RLOR and compared with nonfailures (P = .0002). There were no differences in revision surgery rates, return to activity, or SANE scores according to Rockwood grade or if concomitant pathology was treated. CONCLUSIONS: AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to preinjury activity level. RLOR did not correlate with return to preinjury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to preinjury activity level may be a more clinically relevant outcome measure than radiographic maintenance of acromioclavicular joint reduction. LEVEL OF EVIDENCE: IV (Case Series).

Superior capsule reconstruction using a single 6-mm-thick acellular dermal allograft for massive rotator cuff tears: a biomechanical cadaveric comparison to fascia lata allograft.

BACKGROUND: Success of superior capsule reconstruction (SCR) using both fascia lata (FL) and human acellular dermal (ACD) allografts have been reported. One possible explanation for a discrepancy in outcomes may be attributed to graft thickness. SCR with commercially available 3-mm-thick ACD allograft is not biomechanically equivalent to FL. Our hypothesis was that SCR with a single 6-mm-thick ACD allograft will restore the subacromial space distance (SubDist) and peak subacromial contact pressures (PSCPs) to intact shoulder and will be comparable to SCR with an 8-mm FL allograft. METHODS: Eight cadaveric shoulders were tested in 4 conditions: intact, irreparable supraspinatus tear (SST), SCR FL allograft (8-mm-thick), and SCR single ACD allograft (6-mm-thick). SubDist and PSCP were measured at 0°, 30°, and 60° of glenohumeral abduction in the scapular plane. Parameters were compared using a repeated measures analysis of variance with Tukey post hoc test, and graft dimensions were compared using a Student t test. RESULTS: SST had decreased SubDist (P < .05) and increased PSCP (P < .05) compared with the intact state. At all angles, the SCR ACD allograft demonstrated increased SubDist compared with the tear condition (P < .001), with no difference between grafts. Furthermore, there was decreased PSCP after both ACD and FL SCR compared with the intact condition, with no difference between grafts at 0° (P = .006, P = .028) and 60° abduction (P = .026, P = .013). Both ACD and FL grafts elongated during testing. CONCLUSIONS: Our results suggest SCR with a single 6-mm-thick ACD allograft is noninferior to FL regarding SubDist and PSCP while completely restoring the superior stability of the glenohumeral joint compared with the intact state.

Influence of implant design and parasagittal acromial morphology on acromial and scapular spine strain after reverse total shoulder arthroplasty: a cadaveric and computer-based biomechanical analysis.

BACKGROUND: The purpose was to analyze the influence of deltoid lengthening due to different implant designs and anatomic variations of the acromion and scapular spine (SS) in the parasagittal plane on strain patterns after reverse shoulder arthroplasty (RSA). METHODS: Ten cadaveric shoulders with strain rosettes placed on the surface of the acromial body (Levy II) and SS (Levy III) were tested using a shoulder simulator. RSA using humeral onlay (+3, +5, +8, +10, +13 mm) and glenosphere lateralization (0, +6 mm) was performed. Arm lengthening and magnitude of strain on acromion/SS were measured. The length of deltoid was assessed using validated computer modeling. Anatomic variance of the SS angle and position of acromion in relation to the scapular plane was examined. For comparison of strain as a function of deltoid lengthening, 25 mm was used as a threshold value for comparison based on previous literature demonstrating a decrease in Constant score and active anterior elevation in patients with arm lengthening >25 mm. RESULTS: At maximal deltoid lengthening (30.8 mm), average strains were 1112 µÎµ (acromion) and 1165 µÎµ (SS) (P < .01). There was an 82.6% increase in acromial strain at maximum lengthening compared with 25 mm (P = .02) and a strain increase of 79 µÎµ/mm deltoid lengthening above a threshold of 25 mm. The strain results delineated 2 anatomic groups: 5 of 10 specimens (group A) showed higher strain on SS (1445 µÎµ) vs. acromion (862 µÎµ, P = .02). Group A had a more posteriorly oriented acromion, whereas group B was anteriorly oriented (P < .001). CONCLUSION: Deltoid lengthening above 25 mm produced large strains on the acromion/SS. Anatomic variation may indicate that as the acromion is more posteriorly oriented, the SS takes more strain from the deltoid vs. the acromion. Our study's data may help surgeons identify a high-risk population for increased strain patterns after RSA.

Hip Range of Motion: Which Plane of Motion Is More Predictive of Lower Extremity Injury in Elite Soccer Players? A Prospective Study.

The objective of this study was to determine which plane of hip motion (rotational or sagittal) is more predictive of lower extremity (LE) injury in elite soccer players. A total of 69 athletes (43 professional and 26 collegiate) were examined (mean age, 22.6 years). Bilateral hip internal rotation (IR), external rotation, extension, and flexion measurements were taken along with the modified Thomas test during preseason physicals. There were 42 LE injuries (injury rate 3.74/1000 athlete exposures). Mean IR was 25.2. and 29.9° for injured versus noninjured extremities, respectively (p = .009). There was a significant association between decreased IR (categorized as IR < 28°) and incidence of ipsilateral LE injury (p = .042). Extremities with IR < 28° were 2.81 times more likely to sustain a LE injury (95% CI, 1.15.6.84; p = .023). With a utilitarian focus, the current study has identified a measurement of decreased hip IR with potential for substantial clinical value in collegiate and professional soccer players. (Journal of Surgical Orthopaedic Advances 28(3):201-208, 2019).

Higher complication rates following primary total shoulder arthroplasty in patients presenting from areas of higher social deprivation.

Aims: The aim of this study was to characterize the influence of social deprivation on the rate of complications, readmissions, and revisions following primary total shoulder arthroplasty (TSA), using the Social Deprivation Index (SDI). The SDI is a composite measurement, in percentages, of seven demographic characteristics: living in poverty, with < 12 years of education, single-parent households, living in rented or overcrowded housing, households without a car, and unemployed adults aged < 65 years. Methods: Patients aged ≥ 40 years, who underwent primary TSA between 2011 and 2017, were identified using International Classification of Diseases (ICD)-9 Clinical Modification and ICD-10 procedure codes for TSA in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperation, and other complications were analyzed using multivariable Cox proportional hazards regression controlling for SDI, age, ethnicity, insurance status, and Charlson Comorbidity Index. Results: A total of 17,698 patients with a mean age of 69 years (SD 9.6), of whom 57.7% were female, underwent TSA during this time and 4,020 (22.7%) had at least one complication. A total of 8,113 patients (45.8%) had at least one comorbidity, and the median SDI in those who developed complications 12 months postoperatively was significantly greater than in those without a complication (33 vs 38; p < 0.001). Patients from areas with higher deprivation had increased one-, three-, and 12-month rates of readmission, dislocation, humeral fracture, urinary tract infection, deep vein thrombosis, and wound complications, as well as a higher three-month rate of pulmonary embolism (all p < 0.05). Conclusion: Beyond medical complications, we found that patients with increased social deprivation had higher rates of humeral fracture and dislocation following primary TSA. The large sample size of this study, and the outcomes that were measured, add to the literature greatly in comparison with other large database studies involving TSA. These findings allow orthopaedic surgeons practising in under-served or low-volume areas to identify patients who may be at greater risk of developing complications.

Nonoperative Treatment of Single-Tendon Proximal Hamstring Avulsions in Recreational Athletes.

The purpose of this study was to evaluate the patient-reported and objective functional outcomes of those patients who underwent nonoperative management of a single-tendon retracted proximal hamstring avulsion. A retrospective case series of consecutive patients with an MRI-confirmed diagnosis of single-tendon proximal hamstring avulsion treated nonoperatively with at least one year of follow-up was performed. Patient-reported outcome measures (PROMs) including SF-12v2, Lower Extremity Functional Score (LEFS), Hip Outcome Score-activities of daily living and sport subscale (HOS-ADL, HOS-SS) were prospectively collected. Objective measurements included strength testing of the affected and unaffected limbs with a handheld dynamometer and single-leg hop test. Student's t-tests were used to determine differences between limbs. Eleven of fourteen patients were available for PROMs (79%); five completed functional testing. Subjective scores revealed a mean SF-12v2 mental component score of 56.53±8.2, and a physical component score of 50.1±12.7. LEFS was 84%±19.8, HOS-ADL 87.9%±17.2, and HOS-SS 80.9%±24. The differences between limbs were not statistically significant for strength at 45 or 90 degrees of knee flexion, nor for single-leg hop distance. Patients in a non-professional athlete population who undergo nonoperative management of single-tendon retracted proximal hamstring avulsions can expect good subjective and objective outcomes.

Evidence for Utilization of Injectable Biologic Augmentation in Primary Rotator Cuff Repair: A Systematic Review of Data From 2010 to 2022.

Background: Biologic healing after rotator cuff repair remains a significant challenge. Injectable biologic augmentation may improve tissue quality at the suture-tendon interface. Purpose: To investigate the effect of injectable biologic supplementation in rotator cuff repair and to assess the quality and adherence to evolving reporting standards. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were 40 studies: 29 preclinical (in vivo animal models) and 11 clinical. Each clinical study was assessed for quality, risk of bias, and adherence to relevant MIBO (Minimum Information for Studies Evaluating Biologics in Orthopaedics) guidelines. The outcomes of interest were reported load to failure, load to gap, gap size, and stiffness in the preclinical studies, and healing rate and any patient-reported outcome measures in the clinical studies. Results: Injectables reported included growth factors (eg, transforming growth factor-beta 3, erythropoietin), bone marrow-derived mesenchymal stem cells and adipose-derived mesenchymal stem cells (ADSCs), and other agents such as platelet-rich plasma (PRP) and hyaluronic acid. The most common findings for preclinical injectables were increased load to failure (16/29 studies; 55.2%) and improved collagen histological quality (11/29 studies; 37.9%). All 11 clinical studies (10 PRP, 1 ADSC) indicated no adverse events, with similar or improved patient-reported outcomes compared with repairs in the control groups. In 1 study utilizing an innovative delivery technique, a concentrated PRP globule with fibrin matrix was shuttled over a suture to maintain concentrated PRP at the repair site and demonstrated a significant decrease in retears (P = .03) at a 31-month follow-up. A matched-cohort study investigating augmentation with ADSCs demonstrated a significantly lower retear rate in the ADSC-augmented group than the control group at a 28-month follow-up (P < .001). On average, the clinical studies adhered to 66% of relevant MIBO reporting guidelines and had a low risk of bias. Conclusion: Approximately 83% of preclinical studies found a positive biomechanical or histological effect, with no studies showing an overall negative effect. Clinically, utilization of innovative delivery techniques may reduce the risk of arthroscopic washout of PRP and improve retear rates. ADSCs were shown to reduce retear rates at a 28-month follow-up.

Relationship of Subtalar Joint Range of Motion to Ankle Injuries in NBA G League and Collegiate Basketball Players.

BACKGROUND: This study sought to determine whether range of motion (ROM) of the ankle and subtalar joint complex (STJ) is correlated with ankle injuries in National Basketball Association (NBA) G-league and collegiate basketball players to identify an at-risk population that may benefit from participation in an ankle injury prevention program. METHODS: This prospective cohort study encompassed 103 player-seasons (68 collegiate, 35 NBA G-League). Patient demographics, passive ankle and STJ range of motion measurements, anterior drawer, and talar tilt tests were collected at preseason physicals along with plain radiographs. Subtalar eversion and inversion measurements were added to assess the Combination Motion (CM) of the STJ and subtracted to calculate the Subtalar Difference (SD). We defined the ratio of CM to SD as Subtalar Mobility Index (SMI=CM/SD). RESULTS: Twenty-one ankle injuries occurred with 10 405 player exposures yielding an incidence of 2.11/1000 exposures, resulting in 113 days of missed playing time. No direct measures of ankle, subtalar, or combined motion were associated with risk of injury, rejecting our original hypothesis that increased STJ ROM would predispose to ankle injuries. However, we did find that athletes with CM >16 degrees in combination with either SD <6 degrees (P = .025) or SMI >3.75 (P = .032) were nearly 3 times more likely to have an ankle injury (3.14 vs 2.97, respectively). CONCLUSION: Using the predictive subtalar mobility thresholds found in this study may help identify at-risk players that may benefit from targeted ankle injury prevention programs. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Local Intraoperative Marrow-Derived Augmentation for Primary Rotator Cuff Repair: An Updated Systematic Review and Meta-analysis of Studies From 2010 to 2022.

Background: Recurrent tears of the rotator cuff pose a substantial problem despite advances in repair technique. Biologic augmentation via marrow stimulation or vented anchors may strengthen the suture-tendon junction and improve healing rates of native tissue, thereby enhancing outcomes of primary surgical repair. Purpose: To provide a focused systematic review and meta-analysis of local, intraoperative marrow-derived augmentation techniques in clinical primary rotator cuff repair. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of PubMed, Embase, and Cochrane was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 2131 studies from 2010 to 2022, focused on either marrow stimulation or vented anchors, were isolated and classified as either preclinical or clinical. Meta-analysis was performed for comparative marrow stimulation and vented anchor studies. Heterogeneity was tested through calculation of I 2. Results: A total of 13 clinical studies were included in the review. All 9 comparative studies included in the meta-analysis demonstrated high methodologic quality or a low risk of bias. The pooled retear rate across all 9 clinical studies for patients undergoing marrow stimulation was 11%. For the 5 studies in the meta-analysis, the pooled retear rates were 15% for marrow stimulation and 30% for controls. Meta-analysis demonstrated a significant difference in the overall retear rate that favored marrow stimulation (odds ratio [OR], 0.41; 95% CI, 0.25-0.66; P = .0003; I 2 = 0%). Similarly, meta-analysis of the Constant score at final follow-up demonstrated a statistically significant difference between the 2 groups that favored a higher Constant score in the marrow stimulation group (mean difference, 2.84; 95% CI, 1.02-4.66; P = .002; I 2 = 29%). Vented anchors demonstrated improved ossification and bone density at the anchor site, but no difference in outcomes or retear. Pooled retear rates were 22.5% for vented anchors and 27.8% for controls. Conclusion: Current evidence demonstrates that marrow-stimulation techniques may have a positive impact on healing and retear rate, while vented anchors have a muted impact relative to nonvented anchors. Although available evidence is limited and more research is needed, findings to date suggest that marrow stimulation techniques may be an inexpensive, straightforward technique to consider in qualifying patients to prevent rotator cuff retears.

A novel comorbidity risk score for predicting postoperative 30-day complications in total shoulder arthroplasty and elucidation of potential racial disparities.

Background: Efficient and effective preoperative identification of those patients with elevated risk may allow for more cost-effective interventions, accurate bundled payment adjustments, and overall improved patient care. Few comorbidity indices have provided clinical utility and adequate discriminative ability in the setting of complications after shoulder arthroplasty (SA). Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for anatomic and/or reverse SA procedures between 2010 and 2019. A subset of comorbidities were utilized including end-stage renal disease, history of hypertension, chronic obstructive pulmonary disease, functional status, history of bleeding disorder, and disseminated cancer. Results: A total of 25,927 patients with an average age of 69.2 (standard deviation ±9.5) years were included in the study. Patients with a comorbidity risk score (CRS) at or above 2 were indicated to have at least a 29.6% 30-day postoperative complication rate after undergoing total shoulder arthroplasty, significantly higher than the described average of approximately 15%. The area under receiver operator curve for the novel CRS scoring system was 0.595, indicating fair discriminative ability to predict 30-day postoperative complications after SA. This illustrates a discriminative ability similar to that of the American Society of Anesthesiologists classification (0.584, confidence interval [CI] 0.578-0.589), modified Charlson Comorbidity Index (0.567, CI 0.561-0.573), and modified Frailty Index (0.534, CI 0.529-0.539), each of which are common comorbidity indices used for the National Surgical Quality Improvement Program database. The average CRS for the population was 0.8537 (CI 0.8011-0.8150; P < .05) while that for the Black demographic was 1.08 (CI 1.03-1.13; P < .001). Our results suggest that if the disparity in CRS among races was corrected, the average complication rate would be decreased by 2.0%. Discussion and Conclusion: A higher CRS score resulted in higher rates of 30-day postoperative complications following SA. Black patients had a higher average CRS than all other races illustrating a racial disparity in comorbidity risk. Although the average complication rate of each race would still be unequal, this could mitigate some of the racial disparities observed and decrease the overall 30-day complication rate in SA. With the rise of bundled payments further increasing the need to preoperatively identify patients at high risk for costly complications, the CRS is based on easily identified, relevant comorbidities that may be an advantageous tool to identify patients at increased risk of complications following SA.

Acute Proximal Hamstring Tears Can be Defined Using an Imaged-Based Classification.

Purpose: To develop a clinically meaningful proximal hamstring tear classification system and to present outcome data for defined subtypes. Methods: Retrospective review was undertaken of patients diagnosed with proximal hamstring tears at a single institution from 2012 to 2019. Images were reviewed by an orthopedic surgeon and musculoskeletal radiologist. Tears were classified as Type 1: partial with subtypes (1A, 1 cm or mild complete tear; 1B, 1-2 cm or full tear with <2 cm retraction), Type 2: complete single-tendon tears with subtypes (2c conjoint tendon only; 2s semimembranosus tendon only); or Type 3: complete tears with >2 cm retraction. Demographics, patient-reported outcome measures including Hip Outcome Score, Activities of Daily Living Subscore (HOS-ADL) and patient satisfaction were evaluated. A poor outcome was defined as HOS-ADL < 80%, and the patient acceptable symptom state (PASS) was defined as HOS-ADL 89.7%. Results: At a mean follow-up of 38.6 (range: 12-94) months for 114 patients, distributions were as follows: 18.4% Type 1A, 19.2% Type 1B, 7.8% Type 2c, 3.5% Type 2s, and 50.9% Type 3. Intra-observer and inter-observer reliability had a mean Kappa of 0.985 (95% CI: .956, 1.01) and .905 (95% CI: .895 .915). 66 patients underwent surgery, with 68.97% of them being Type 3. The mean HOS-ADL and PASS rate were higher for operatively treated patients (95%, 93.4%) than for nonoperatively treated patients (81.86%, 44.7%). There were significantly more patients satisfied in the surgery group in both Type 1 and Type 3 tears (P = .046 and P = .049). Body mass index was a significant predictor of a poor outcome in Type 3 tears (P = .039). History of corticosteroid or PRP injection, smoking, and diabetes were not significant predictors of a poor outcome. Conclusion: We present an MRI-based classification system for proximal hamstring injuries with both excellent intra-observer and inter-observer reliability. Outcome measures were improved in patients who underwent surgery. Level of Evidence: IV, cohort study: diagnostic case series.

Clinical Outcomes After Reverse Total Shoulder Arthroplasty in Patients With Primary Glenohumeral Osteoarthritis Compared With Rotator Cuff Tear Arthropathy: Does Preoperative Diagnosis Make a Difference?

INTRODUCTION: The primary purpose of this study was to evaluate the clinical outcomes of patients who underwent reverse total shoulder arthroplasty performed for primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff compared with rotator cuff tear arthropathy (CTA). METHODS: This was a retrospective review of prospectively collected data including consecutive patients who underwent primary reverse total shoulder arthroplasty for GHOA or CTA with a minimum of 2-year follow-up. Baseline patient demographics and clinical outcomes including active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation, and visual analog scale for pain were collected. Univariate and multivariate regression analyses were performed to evaluate the effect of preoperative diagnosis on clinical outcomes. RESULTS: Patients with a preoperative diagnosis of GHOA demonstrated significantly better postoperative active forward elevation (138.6° versus 127.3°; P < 0.01), external rotation (54.2° versus 43.8°; P < 0.01), and change in internal rotation (Δ 2.1 points versus Δ 1.2 points; P < 0.01). Patients with GHOA demonstrated significantly better postoperative ASES (86.8 versus 76.6; P < 0.01), Single Assessment Numerical Evaluation (89.7 versus 78.5; P < 0.01), and visual analog scale scores (0.63 versus 1.2; P < 0.01). Minimal clinically important difference for ASES score was achieved by 97.5% of patients with GHOA compared with 86.7% of patients with CTA (P < 0.01), whereas substantial clinical benefit was achieved by 90.4% of patients with GHOA and 71.7% of patients with CTA (P < 0.01). After a multivariate linear regression analysis, postoperative ASES scores were independently associated with previous ipsilateral shoulder surgery (P = 0.042), preoperative ASES score (P = 0.01), and primary diagnosis of GHOA (P < 0.01). CONCLUSION: RTSA performed in patients with GHOA and an intact rotator cuff is associated with improved functional and clinical outcomes compared with those patients treated for CTA. LEVEL OF EVIDENCE: Level III Therapeutic Study.

Prevalence and Clinical Impact of Incidental Findings on Preoperative 3D Planning Computed Tomography for Total Shoulder Arthroplasty.

INTRODUCTION: 3D planning software for shoulder arthroplasty recently emerged for aiding in intraoperative determination of native glenoid. These protocols often require increased scan resolution, however, raising the question of an increased prevalence and clinical impact of incidental findings (IFs) from preoperative imaging. METHODS: A retrospective review of preoperative shoulder CT reports was conducted for 333 consecutive patients planning anatomic or reverse total shoulder arthroplasties. Patients with thin-sliced CT scans (1.25 mm) were compared with those with standard CT scans (2.5 mm). Poisson regression was performed with baseline characteristics and potentially pathologic IFs (PPIFs). RESULTS: IFs were present in 131 of the 333 scans (39.3%), and 38 of the 333 scans (11.4%) included PPIFs. Only 8 of the 333 scans (2.4%) required workup, with 2 of the 333 (0.6%) leading to new cancer diagnoses. Thin-sliced CT scans detected a higher mean number of IFs (1.12 versus 0.22, P < 0.001) while the mean number of PPIFs remained similar (0.13 versus 0.10, P = 0.43). CONCLUSION: IFs are frequent; however, only 0.6% scans led to new cancer diagnoses. Comparison of thin-sliced with standard CT scans revealed a higher frequency of IFs but similar PPIFs, indicating increased burden of IFs without the benefit of identifying additional malignancies. As demand rises for shoulder arthroplasties, surgeons should consider the potential hidden costs of IFs when using 3D planning programs.

Scientific Developments and Clinical Applications Utilizing Chondrons and Chondrocytes with Matrix for Cartilage Repair.

Injuries to articular cartilage of the knee are increasingly common. The operative management of these focal chondral lesions continues to be problematic for the treating orthopedic surgeon secondary to the limited regenerative capacity of articular cartilage. The pericellular matrix (PCM) is a specialized, thin layer of the extracellular matrix that immediately surrounds chondrocytes forming a unit together called the chondron. The advancements in our knowledge base with regard to the PCM/chondrons as well as interterritorial matrix has permeated and led to advancements in product development in conjunction with minced cartilage, marrow stimulation, osteochondral allograft, and autologous chondrocyte implantation (ACI). This review intends to summarize recent progress in chondrocytes with matrix research, with an emphasis on the role the PCM/extracellular matrix (ECM) plays for favorable chondrogenic gene expression, as a barrier/filtration unit, and in osteoarthritis. The bulk of the review describes cutting-edge and evolving clinical developments and discuss these developments in light of underlying basic science applications. Clinical applications of chondrocytes with matrix science include Reveille Cartilage Processor, Cartiform, and ACI with Spherox (which was recently recommended for the treatment of grade III or IV articular cartilage defects over 2 cm2 by the National Institute of Health and Care Excellence [NICE] in the United Kingdom). The current article presents a comprehensive overview of both the basic science and clinical results of these next-generation cartilage repair techniques by focusing specifically on the scientific evolution in each category as it pertains with underlying chondrocytes with matrix theory.

Next-Generation Marrow Stimulation Technology for Cartilage Repair: Basic Science to Clinical Application.

¼: Given the relatively high prevalence of full-thickness articular cartilage lesions, including in patients who are <40 years of age, and an inability to detect some of these lesions until the time of arthroscopy, there is value in performing a single-stage cartilage procedure such as marrow stimulation (MS). ¼: While the positive outcomes of first-generation MS (namely microfracture) have been observed to drop off after 24 months in several studies, improvements have been seen when compared with preoperative conditions for lesions that are 2 to 3 cm2 in size, and MS is considered to be a procedure with technical simplicity, fairly short surgical times, and relatively low morbidity. A recent study showed that autologous chondrocyte implantation (ACI) and osteochondral allograft (OCA) transplantation remain viable treatment options for chondral defects of the knee in the setting of failed MS. ¼: Basic science principles that have been elucidated in recent years include (1) the creation of vertical walls during defect preparation, (2) an increased depth of subchondral penetration, (3) a smaller awl diameter, and (4) an increased number of subchondral perforations, which are all thought to help resolve issues of access to the mesenchymal stromal cells (MSCs) and the subchondral bone structure/overgrowth issues. ¼: Pioneering and evolving basic science and clinical studies have led to next-generation clinical applications, such as a hyaluronic acid-based scaffold (ongoing randomized controlled trial [RCT]), an atelocollagen-based gel (as described in a recently published RCT), a micronized allogeneic cartilage scaffold (as described in a recently completed prospective cohort study), and a biosynthetic hydrogel that is composed of polyethylene glycol (PEG) diacrylate and denatured fibrinogen (as described in an ongoing prospective study). ¼: This review summarizes important points for defect preparation and the recent advances in MS techniques and identifies specific scaffolding augmentation strategies (e.g., mesenchymal augmentation and scaffold stimulation [MASS]) that have the capacity to advance cartilage regeneration in light of recent laboratory and clinical studies.

The modern use of the extended humeral head (cuff tear arthropathy) hemiarthroplasty.

Today, the treatment of osteoarthritis in the rotator cuff-deficient population is largely dominated by reverse shoulder arthroplasty (RSA). Despite the popularity of and increased familiarity with this procedure, the complication rate of RSA remains significant. An extended humeral head hemiarthroplasty may provide a less invasive alternative for select patients with cuff tear arthropathy (CTA) and preserved glenohumeral active elevation. With the indications for reverse arthroplasty expanding to younger patients, there are concerns about the longevity of this implant, as well as the associated revision burden. In the setting of failed RSA, the bone stock available for glenosphere baseplate fixation can be inadequate for reimplantation. The treatment strategies for complex shoulder deformities and failed RSA are limited by patient-specific issues, such as anatomy and risk factors. In this review, we discuss the potential role of extended humeral head hemiarthroplasty (CTA hemiarthroplasty) as a primary surgical option in select patients (1) who have preserved elevation > 90°, (2) who have maintained stability (intact coracoacromial ligament), and (3) who desire to circumvent the complications associated with RSA. Furthermore, CTA hemiarthroplasty may be used for severe glenoid erosion, for a fragmented acromion, and in the revision setting for failed RSA aimed at a reliable salvage procedure.

The Flexion Initiation Test and an Evidence-Based Diagnostic Algorithm for Distal Biceps Tendon Tears.

PURPOSE: The purpose of this study was (1) to assess the flexion initiation test's (FIT) ability to detect distal biceps tendon tears (DBTT) in a cohort of consecutive patients presenting with elbow pain and (2) to generate a reliable evidence-based diagnostic algorithm using a combination of both the FIT and hook tests. METHODS: We performed a retrospective review of 125 consecutive patients who presented with elbow pain, all of which had the FIT and hook test performed prior to imaging/further intervention. The integrity of the tendon was determined during surgery or by magnetic resonance imaging. Sensitivity, specificity, positive predictive value, and negative predictive value were determined for the FIT and hook test. RESULTS: Our evidence-based diagnostic algorithm showed that when both test results are in agreement, there is a 100% diagnostic accuracy for detecting what prior authors have termed surgically indicated tears (complete ruptures and high-grade partial tears) and biceps pathology that can be treated with nonoperative management. The FIT demonstrated 100% sensitivity for surgically indicated tears. The hook test demonstrated 100% sensitivity for complete ruptures, but 18% sensitivity for diagnosing partial tears. CONCLUSIONS: The FIT, which is aimed at improving diagnostic acuity of high-grade partial thickness tears, demonstrated a 93% sensitivity and 96% specificity overall and a 100% sensitivity for complete ruptures and high-grade partial tears. The evidence-based diagnostic algorithm using the combination of the FIT and hook test demonstrates high accuracy for the diagnosis of both complete and high-grade partial DBTTs. The methodology may help to prevent diagnosis delays, improve patient education, and preserve the option for timely primary surgical repair in the treatment of DBTTs. LEVEL OF EVIDENCE: Level IV, diagnostic.