Subacromial Surgery for Irreparable Posterosuperior Rotator Cuff Tears.

The irreparable posterosuperior rotator cuff tear describes a tear of the supraspinatus and/or infraspinatus tendon that is massive, contracted, and immobile in both the anterior-posterior and medial-lateral directions. Patients with an intact subscapularis and preserved forward elevation are challenging to treat because there is not a consensus treatment algorithm. For low-demand, elderly patients, several subacromial surgical options are available that can provide pain relief without the risks or burden of rehabilitation posed by reverse total shoulder arthroplasty or a complex soft-tissue reconstruction (e.g., superior capsular reconstruction, tendon transfer, bridging grafts). Debridement, more specifically the "smooth-and-move" procedure, offers a reliable outcome with documented improvements in pain and function at long-term follow-up. Similarly, the biodegradable subacromial balloon spacer (InSpace; Stryker, Kalamazoo, MI) has been shown to significantly improve pain and function in patients who are not responsive to nonoperative treatment. Disease progression with these options is possible, with a small percentage of patients progressing to rotator cuff arthropathy. Biologic tuberoplasty and bursal acromial reconstruction are conceptually similar to the balloon spacer but instead use biologic grafts to prevent bone-to-bone contact between the humeral head and the acromion. Although there is no single gold standard treatment, the variety of surgical techniques allows patients and surgeons to effectively manage these challenging situations.

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.

Bone Block Augmentation of the Posterior Glenoid for Recurrent Posterior Shoulder Instability Is Associated With High Rates of Clinical Failure: A Systematic Review.

PURPOSE: To determine whether posterior glenoid bone block augmentation performed for the treatment of recurrent posterior shoulder instability succeeds in restoring stability and is associated with rates of complications or clinical failures comparable to other glenoid bone augmentation procedures. METHODS: A comprehensive search of PubMed, MEDLINE, and EMBASE databases was performed. Level of evidence studies I to IV pertaining to posterior bone block augmentation reporting on outcomes or complications were included. The search was carried out in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: Screening of titles, abstracts, and manuscripts with application of inclusion and exclusion criteria yielded 17 full-text articles reporting on 269 shoulders undergoing bone block augmentation. Surgical technique varied between studies with regard to graft type (iliac crest, 13 studies; scapular spine, 2; acromion, 1; distal tibia allograft, 1), graft positioning (medial to 1.5 cm lateral to glenoid surface, equatorial to subequatorial), and open versus arthroscopic technique (open, 10 studies; arthroscopic, 4; both, 3). Four of the 8 studies with pre- and postoperative patient-reported outcomes (PROs) showed significant improvements in these outcomes at final follow-up. The postoperative outcomes ranged from 60 to 90 for Rowe scores (n = 7 studies) and 79 to 90 for Walch-Duplay scores (n = 7 studies). Complications were commonly encountered, with high rates of recurrent instability (0% to 73%) and revision procedures (0% to 67%) across different studies. CONCLUSION: Posterior bone block augmentation for recurrent posterior shoulder instability does not reliably yield substantial improvements in PROs, and complications are frequently observed. The substantial heterogeneity across studies and the small number of patients precludes any substantive judgements as to the superiority of one surgical technique over another. LEVEL OF EVIDENCE: IV, systematic review of level III and IV studies.

Surgeon acceptance of an initial 3D glenoid preoperative plan: rates and risk factors.

BACKGROUND: Although the effect of 3-dimensional (3D) planning for total shoulder arthroplasty (TSA) on component positioning and patient outcomes has been increasingly studied, the effect of 3D planning on surgeon decision making has not been well studied. METHODS: A retrospective review was performed of a database containing TSA cases for which the glenoid component was planned with a commercially available 3D computed tomography software program (Virtual Implant Positioning; Arthrex, Inc.) from 2016 to 2019. A total of 6483 cases planned by 417 surgeons were included. The glenoid version (Vtech) and inclination (Itech) of the Virtual Implant Positioning technician plan as well as the surgeon's final plan for version (Vsurg) and inclination (Isurg) were extracted. When the version and/or inclination of the surgeon plan matched that of the technician, that variable was defined as "accepted." The rates of acceptance of Vtech and Itech were calculated and analyzed for association with implant type, native version and inclination, and running case count. A subgroup analysis of high-volume users (n > 30 cases) was analyzed to determine if any of the variables independently was associated with surgeon acceptance. RESULTS: There was a very high rate of matching of version (66%), inclination (72%), or both (55%) and a low rate (18%) where neither parameter of the glenoid plan matched that of the technician. In univariate analysis, as the case count and retroversion increased the rate of accepting of version dropped noticeably (70%-50% and 47%, respectively [ P< .0001]). The rate of accepting the plan for inclination did not vary much as case count changed. In the multivariate analysis, 23 of 56 high-volume surgeons had at least 1 independent factor associated with accepting the technician-planned glenoid version, and 5 surgeons had 2 independent factors. In the multivariate analysis of matching glenoid inclination, 27 of 56 high-volume surgeons had at least 1 independent factor associated with accepting the technician-planned glenoid version, and 9 surgeons had 2 or more independent factors. CONCLUSIONS: In a large database of TSAs with 3D-planned glenoids, there were high rates of cases with surgeon agreement with an initial plan provided by an industry technician: 66% in version, 72% in inclination, 55% for both version and inclination. Surgeon acceptance of the initial plan decreased as pathoanatomy increased and case count increased. Shoulder surgeons should be aware that an initial 3D preoperative plan provided by industry represents a potential source of cognitive bias in shoulder arthroplasty planning.

Histologic case series of human acellular dermal matrix in superior capsule reconstruction.

BACKGROUND: Acellular dermal matrix (ADM) allografts are commonly used in the surgical treatment of complex and irreparable rotator cuff tears. Multiple studies report that superior capsule reconstruction (SCR) using ADM has resulted in short-term clinical success as assessed via radiographic and patient-reported outcomes. However, limited information is available regarding the biologic fate of these grafts in human subjects. This case series describes histologic results from 8 patients who had reoperations, during which the previously implanted ADMs were removed. These explanted ADMs were subjected to histologic analysis with the hypothesis that they would have evidence of recellularization, revascularization, and active remodeling. METHODS: Eight patients, 38-82 years old, underwent reoperation 6-38 months after undergoing SCR. ADM explants were voluntarily shipped to the manufacturer for histologic analysis. Each graft's structure and composition were qualitatively evaluated by 1 or more of the following histologic stains: hematoxylin and eosin, safranin O, and Russell-Movat pentachrome. Pan-muscle actin staining also assessed the level of neovascularization, potential myoblast or myocyte infiltration, and muscle tissue development in the graft, and was analyzed to determine the proportion of graft that had been recellularized in situ. RESULTS: Grafts showed varying levels of gross and microscopic incorporation with the host. An uneven, but high, overall degree of recellularization, revascularization, and active remodeling was observed. The degree of remodeling correlated with implant duration. These results are consistent with successful biologic reconstruction of the superior shoulder capsule. CONCLUSIONS: The present histologic analysis suggests that ADMs used in SCR undergo active recellularization, revascularization, and remodeling as early as 6 months after implantation, and that graft recellularization positively correlates with duration of implantation. These results represent a significant advancement in our knowledge regarding biologic incorporation of ADMs used in SCR.

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.

Editorial Commentary: Safety in Anteromedial Elbow Portal Placement? Go North!

Since iatrogenic injury to surrounding structures is more likely in the elbow than in the other major joints, many studies have examined the relationship of elbow arthroscopy portals to the at-risk anatomy. In accessing the anterior compartment of the elbow from the medial side, the brachial artery and median, ulnar, and medial antebrachial cutaneous nerves are at risk. Factors that improve the safety of this approach include the use of a proximal versus distal anteromedial portal, a distended versus and nondistended joint, and a flexed versus extended elbow position, all of which result in an approximate margin of safety of 2 cm from the deep at-risk structures.

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.

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.

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.

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.

Remplissage of an Off-track Hill-Sachs Lesion Is Necessary to Restore Biomechanical Glenohumeral Joint Stability in a Bipolar Bone Loss Model.

PURPOSE: To validate the glenoid track concept in a cadaveric bipolar bone loss model and to test whether "on-track" and "off-track" lesions can be stabilized with Bankart repair (BR) with or without Hill-Sachs remplissage (HSR). METHODS: Eight fresh-frozen cadaveric shoulders were tested in a custom apparatus with passive axial rotation and then progressive translational loading (10 to 40 N) at mid-range (60°) and end-range external rotation (90°). Injury conditions included glenoid bone loss of 15% with on-track (15%) and off-track (30%) Hill-Sachs lesions. Repair conditions included BR with HSR and BR without HSR. RESULTS: For on-track lesions, engagement occurred with translation testing in one shoulder (12.5%) at end-range rotation. After BR, engagement was prevented for this shoulder. For off-track lesions, engagement with translation testing occurred in 8 shoulders (100%) at end-range rotation and in 6 (75%) at mid-range rotation. After BR, engagement was prevented in 4 of 6 engaging shoulders (67%) at mid-range rotation but was prevented in zero of 8 (0%) at end-range rotation. Adding HSR prevented engagement in all 14 engaging shoulders with off-track lesions (100%). BR with HSR resulted in supraphysiological stiffness for off-track lesions at mid- and end-range rotation (13.3 N/m vs 7.0 N/m and 10.0 N/m vs 5.0 N/m, P = .0002) and for on-track lesions at end-range rotation (10.1 N/m vs 5.0 N/m, P = .0002). Stiffness of BR with HSR was not different from the intact shoulder for on-track lesions at mid-range rotation (7.2 N/m vs 7.0 N/m, P > .99). CONCLUSIONS: The patterns of engagement of Hill-Sachs lesions with a 15% glenoid defect in this model give support to the glenoid track concept. BR plus remplissage resulted in supraphysiological shoulder stiffness but was necessary to prevent engagement of off-track bipolar bone lesions. CLINICAL RELEVANCE: This biomechanical study provides evidence to aid in surgical decision making by examining the effects of bipolar bone loss and soft-tissue reconstruction on shoulder stability.

Arthroscopic proximal biceps tenodesis at the articular margin: evaluation of outcomes, complications, and revision rate.

PURPOSE: The purpose of this study was to evaluate the incidence of residual pain, outcomes, and the revision rate of arthroscopic proximal biceps tenodesis high in the groove at the articular margin of the humeral head by interference screw fixation. METHODS: Seven surgeons pooled data on patients who underwent an arthroscopic biceps tenodesis at the articular margin by interference screw fixation. All patients had a minimum of 50 weeks' follow-up. Preoperative and postoperative patient data including visual analog scale scores (obtained by all surgeons), objective shoulder scores (Simple Shoulder Test and University of California, Los Angeles scores obtained by 2 and 4 surgeons, respectively), and need for revision surgery (obtained by all surgeons) were retrospectively analyzed, the results are reported, and statistical analysis was performed. RESULTS: After the application of our exclusion criteria, 1,083 patients were included in the analysis. The mean follow-up period was 136 weeks. The overall revision surgery rate for this group was 4.1% (44 of 1,083). Revision for biceps tenodesis-related issues was needed in only 4 cases (for a biceps tenodesis-related revision rate of 0.4%). Pain scores improved from 6.47 preoperatively to 1.08 postoperatively (P < .0001). University of California, Los Angeles scores improved from 14.9 preoperatively to 30.1 postoperatively (P < .0001), and Simple Shoulder Test scores improved from 2.7 preoperatively to 10.2 postoperatively (P < .0001). CONCLUSIONS: Arthroscopic biceps tenodesis performed at the articular margin results in a low surgical revision rate, a low rate of residual pain, and significant improvement in objective shoulder outcome scores. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Reverse shoulder arthroplasty for massive rotator cuff tear: risk factors for poor functional improvement.

BACKGROUND: Some patients unexpectedly have poor functional improvement after reverse shoulder arthroplasty (RSA) for massive rotator cuff tear without glenohumeral arthritis. Our aim was to identify risk factors for this outcome. We also assessed the value of RSA for cases with poor functional improvement vs. METHODS: The study was a retrospective case-control analysis for primary RSA performed for massive rotator cuff tear without glenohumeral arthritis with minimum 2-year follow-up. Cases were defined as Simple Shoulder Test (SST) score improvement of ≤1, whereas controls improved SST score ≥2. Risk factors were chosen on the basis of previous association with poor outcomes after shoulder arthroplasty. Latissimus dorsi tendon transfer results were analyzed as a subgroup. Value was defined as improvement in American Shoulder and Elbow Surgeons (ASES) score per $10,000 hospital cost. RESULTS: In a multivariate binomial logistic regression analysis, neurologic dysfunction (P = .006), age <60 years (P = .02), and high preoperative SST score (P = .03) were independently associated with poor functional improvement. Latissimus dorsi tendon transfer patients significantly improved in active external rotation (-0.3° to 38.7°; P < .01). The value of RSA (ΔASES/$10,000 cost) for cases was 0.8 compared with 17.5 for controls (P < .0001). CONCLUSIONS: Young age, high preoperative function, and neurologic dysfunction were associated with poor functional improvement. Surgeons should consider these associations in counseling and selection of patients. Concurrent latissimus dorsi transfer was successful in restoring active external rotation in a subgroup of patients. The critical economic importance of improved patient selection is emphasized by the very low value of the procedure in the case group.

Glenosphere dissociation after reverse shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is gaining popularity for the treatment of debilitating shoulder disorders. Despite marked improvements in patient satisfaction and function, the RSA complication rate is high. Glenosphere dissociation has been reported and may result from multiple mechanisms. However, few RSA retrieval studies exist. METHODS: We reviewed our RSA database and identified patients with glenosphere dissociation between 1999 and 2013. Prosthesis type, glenosphere size, and contributing factors to dissociation were noted. Five retrieved implants were available for analysis, and evidence of wear or corrosion on the Morse taper was documented. Further, we biomechanically investigated improper Morse taper engagement that may occur intraoperatively as a potential cause of acute dissociation. RESULTS: Thirteen patients with glenosphere dissociation were identified (0.5 months to 7 years postoperatively). Glenosphere size distribution was as follows: 32 mm (n = 1), 36 mm (n = 4), 40 mm (n = 6), and 44 mm (n = 2). Incidence of dissociation was correlated to glenosphere size (P < .001). Taper damage was limited to fretting wear, and there was minimal evidence of taper corrosion. Biomechanically, improper taper engagement reduced the torsional capacity of the glenosphere-baseplate interface by 60% from 19.2 ± 1.0 N-m to 7.5 ± 1.5 N-m. CONCLUSION: We identified several mechanisms contributing to glenosphere dissociation after RSA, including trauma and improper taper engagement. Limited evidence of corrosive wear on the taper interface was identified. Although it is rare, the incidence of glenosphere dissociation was higher when 40- and 44-mm glenospheres were implanted compared with smaller glenospheres (32 and 36 mm), probably because of the larger exposed surface area for potential impingement.

Transverse coronoid fracture: when does it have to be fixed?

BACKGROUND: After elbow fracture-dislocation, surgeons confront numerous treatment options in pursuing a stable joint for early motion. The relative contributions of the radial head and coronoid, in combination, to elbow stability have not been defined fully. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the effect of an approximately 50% transverse coronoid fracture and fixation in the setting of an intact or resected radial head on coronal (varus/valgus) and axial (internal and external rotational) laxity in (1) gravity varus stress; and (2) gravity valgus stress models. METHODS: Kinematic data were collected on six fresh-frozen cadaveric upper extremities tested with passive motion throughout the flexion arc under varus and valgus gravity stress with lateral collateral ligaments reconstructed. Testing included coronoid fracture and osteosynthesis with and without a radial head. RESULTS: In the varus gravity stress model, fixation of the coronoid improved varus stability (fixed: 1.6° [95% confidence interval, 1.0-2.2], fractured: 5.6° [4.2-7.0], p < 0.001) and internal rotational stability (fixed: 1.8° [0.9-2.7], fractured: 5.4° [4.0-6.8], p < 0.001), but radial head fixation did not contribute to varus stability (intact head: 2.7° [1.3-4.1], resected head: 3.8° [2.3-5.3], p = 0.4) or rotational stability (intact: 2.7° [0.9-4.5], resected head: 3.9° [1.5-6.3], p = 0.4). With valgus stress, coronoid fixation improved valgus stability (fixed: 2.1° [1.0-3.1], fractured: 3.8° [1.8-5.8], p < 0.04) and external rotation stability (fixed: 0.8° [0.1-1.5], fractured: 2.1° [0.9-3.4], p < 0.04), but the radial head played a more important role in providing valgus stability (intact: 1.4° [0.8-2.0], resected head: 7.1° [3.5-10.7], p < 0.001). CONCLUSIONS: Fixation of a 50% transverse coronoid fracture improves varus and internal rotatory laxity but is unlikely to meaningfully improve valgus or external rotation laxity. The radial head, on the other hand, is a stabilizer to resist valgus stress regardless of the status of the coronoid. CLINICAL RELEVANCE: Determination as to whether it is necessary to fix a coronoid fracture should be based on the stability of the elbow when tested with a varus load. The elbow may potentially be stable with fractures involving less than 50% of the coronoid. Under all circumstances, the radial head should be fixed or replaced to ensure valgus external rotatory stability.