Functional Return-to-Sport Testing Demonstrates Inconsistency in Predicting Short-Term Outcomes Following Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To systematically review the relationship between functional testing at the time of return to sport (RTS) and short-term outcomes, such as second anterior cruciate ligament (ACL) tear and return to a preinjury level of sport, among athletes who underwent anterior cruciate ligament reconstruction (ACLR). METHODS: A systematic literature search was performed in MEDLINE, EMBASE, Scopus, and Web of Science to identify studies examining athletes who underwent functional RTS testing and were followed for at least 12 months following ACLR. Studies were screened by 2 reviewers. A standardized template was used to extract information regarding study characteristics, ACLR information, functional test results, and risk factors associated with retear or reduced RTS. RESULTS: Of the 937 studies identified, 22 met the inclusion criteria. The average time between ACLR and RTS testing was 8.5 months. Single leg hop for distance performance had no association with retear risk in any study and no association with RTS rates in most studies. Quadriceps strength had conflicting results in relation to retear risk, whereas it had no relationship with RTS rates. Rates of reinjury and RTS were similar between patients who passed and did not pass combined hop and strength batteries. Asymmetric knee extension and hip moments, along with increased knee valgus and knee flexion angles, demonstrated increased risk of retear. CONCLUSIONS: Individual hop and strength tests that are often used in RTS protocols following ACLR may have limited and inconsistent value in predicting ACL reinjury and reduced RTS when used in isolation. Combined hop and strength test batteries also demonstrate low sensitivity and negative predictive value, highlighting conflicting evidence to suggest RTS testing algorithm superiority. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Magnetic Resonance Imaging Analysis Demonstrates Improved Reliability in Measuring Shoulder Glenoid Bone Loss Using a Two-Thirds Glenoid Height Technique Compared to the "Best-fit Circle".

PURPOSE: To evaluate the superior to inferior glenoid height as a reliable reference in best-fit circle creation for glenoid anatomy. METHODS: The morphology of the native glenoid was evaluated using magnetic resonance imaging (MRI) in patients without shoulder instability. Using T1 sagittal MRI images, 2 reviewers independently estimated glenoid size using the two-thirds technique and the "best-fit circle" technique at 2 different times. A Student t-test was used to determine significant difference between the two methodologies. Inter- and intra-rater reliability were calculated using interclass and intraclass coefficients. RESULTS: This study included 112 patients. Using the results of glenoid height and "best-fit circle" diameter, the diameter of the "best-fit circle" was found to intersect the glenoid line at 67.8% of the glenoid height on average. We found no significant difference between the 2 measures of glenoid diameter (27.6 vs 27.9, P = .456). The interclass and intraclass coefficients for the two-third method were 0.85 and 0.88, respectively. The interclass and intraclass coefficients for the perfect circle methods were 0.84 and 0.73, respectively. CONCLUSIONS: We determined that the diameter of a circle placed on the inferior glenoid using the "best-fit circle" technique corresponds to 67.8% of the glenoid height. Additionally, we found that constructing a perfect circle using a diameter equal to two-thirds the height of the glenoid may improve intraclass reliability. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

The impact of 3-dimensional humeral planning and standard transfer instrumentation on reconstruction of native humeral anatomy for anatomic total shoulder arthroplasty.

BACKGROUND: Preoperative 3-dimensional (3D) computed tomography (CT)-based planning for anatomic total shoulder arthroplasty (TSA) has grown in popularity in the past decade with the primary focus on the glenoid. Little research has evaluated if humeral planning has any effect on the surgical execution of the humeral cut or the positioning of the prosthesis. METHODS: Three surgeons performed a prospective study using 3D-printed humeri printed from CTs of existing patients, which were chosen to be -3, -1, 0, 1, and 3 standard deviations of all patients in a large database. A novel 3D printing process was used to 3D print not only the humerus but also all 4 rotator cuff tendons. For each surgical procedure, the printed humerus was mounted inside a silicone shoulder, with printed musculature and skin, and with tensions similar to human tissue requiring standard retraction and instruments to expose the humerus. Three phases of the study were designed. In phase 1, humeral neck cuts were performed on all specimens without any preoperative humeral planning; in phase 2, 3D planning was performed, and the cuts and implant selection were repeated; in phase 3, a neck-shaft angle (NSA) guide and digital calipers were used to measure humeral osteotomy thickness to aid in the desired humeral cut. All humeri were digitized. The difference between the prosthetic center of rotation (COR) and ideal COR was calculated. The percentage of patients with a varus NSA was calculated for each phase. The difference in planned and actual cut thickness was also compared. RESULTS: For both 3D change in COR and medial to lateral change in COR, use of preoperative planning alone and with standard transfer instrumentation resulted in a significantly more anatomic restoration of ideal COR. The deviations from planned cut thickness decreased with each phase: phase 1: 2.6 ± 1.9 mm, phase 2: 2.0 ± 1.3 mm, phase 3: 1.4 ± 0.9 mm (P = .041 for phase 3 vs. phase 1). For NSA, in phase 1, 7 of 15 (47%) cases were in varus; in phase 2, 5 of 15 (33%) were in varus; and in phase 3, 1 of 15 (7%) cases was in varus (P = .013 for phase 3 vs. phase 1). CONCLUSIONS: Use of preoperative 3D humeral planning for stemless anatomic TSA improved prosthetic humeral COR, whether performed with or without standard transfer instrumentation. The use of an NSA cut guide and calipers to measure cut thickness significantly reduced the percentage of varus humeral cuts and deviation from planned cut thickness.

Regional differences in reimbursement, volume, and patient characteristics exist for rotator cuff repairs: a temporal analysis from 2013 to 2021.

BACKGROUND: Prior studies have demonstrated declining reimbursement and changing procedural utilization across multiple orthopedic subspecialties, yet a comprehensive examination of this has not been performed for rotator cuff repair (RCR), particularly at a geographic level. The purpose of this study was to evaluate changes in reimbursement, utilization, and patient populations for open and arthroscopic RCRs from 2013 to 2021 at a national and regional level. METHODS: The Medicare Physician and Other Practitioners database from years 2013 to 2021 were queried to extract all episodes of open chronic RCR, open acute RCR, and arthroscopic RCR. Utilization was measured as procedural volume per 10,000 Medicare beneficiaries. Inflation-adjusted reimbursement, utilization, surgeon information, and patient characteristics were extracted for each procedure for each year. Data was stratified geographically based on US Census regions and rural-urban commuting codes. Kruskal-Wallis tests and linear regressions were performed to compare geographical areas. RESULTS: Between 2013 and 2021, arthroscopic RCR utilization increased by 9.4% (11.0/10,000-12.0/10,000), while open chronic RCR utilization decreased by 58.8% (2.0/10,000-0.8/10,000). During that time, average inflation-adjusted reimbursement declined by 10.0% and 11.3% for arthroscopic and open chronic RCR, respectively. The increase in utilization and decrease in reimbursement was greatest in the Midwest. In 2021, arthroscopic RCR utilization was 12.0/10,000, while average reimbursement was $846.87, nationally. Utilization was highest in the South (14.5/10,000) and lowest in the Northeast (8.1/10,000) (P < .001). Alternatively, reimbursement was highest in the Northeast ($904.60) and lowest in the South ($830.80) (P < .001). The proportion of patients who were male, Medicaid eligible, or non-White was highest in the West (P < .001). Patients in the West also had the fewest comorbidities. Increased patient comorbidities, when controlling patient demographics, were associated with lower reimbursement nationally and within the Northeast (P < .001). CONCLUSION: Geographical discrepancies in RCR utilization and reimbursement exist. The South consistently demonstrates the highest utilization of RCR, while also having the lowest reimbursement. Alternatively, the Northeast has the lowest utilization but the highest reimbursement. Increased patient population comorbidities were associated with reduced RCR reimbursement for surgeons in the Northeast, but not in other regions.

Regional variation from 2013 to 2021 in primary total shoulder arthroplasty utilization, reimbursement, and patient populations.

BACKGROUND: Total shoulder arthroplasty (TSA), encompassing both anatomical and reverse TSA, has increased in popularity worldwide. The purpose of this study was to assess how TSA utilization, reimbursement, surgeon practices, and patient populations have evolved within the Medicare population from 2013 to 2021 at a national and regional level. METHODS: The Medicare Physician and Other Practitioners dataset was queried for all episodes of primary TSA (CPT-23472), both anatomic and reverse, between years 2013 and 2021. TSA utilization was assessed as volume per 10,000 Medicare beneficiaries. Average inflation-adjusted reimbursement, physician practice styles, and patient demographics of each TSA surgeon were extracted each year. Data were stratified geographically based on US census classifications and rural-urban commuting codes. Kruskal-Wallis and multivariate regressions were utilized to determine differences between regions. RESULTS: Between 2013 and 2021 TSA utilization increased by 121.8%, nationally. The increase was greatest in the Northeast (+147.2%) and least in the Midwest (+115.5%). Average TSA reimbursement declined by 8.8% nationally, with the least decline in the Northeast (6.4%) and the greatest decline in the Midwest (-11.9%). In 2021, the Midwest had the highest TSA utilization (18.1/10,000), while having the lowest average reimbursement ($1108.59; P < .001). The Northeast had the lowest utilization (11.5/10,000) and highest reimbursement ($1223.44; P < .001) in 2021. Nationally, the number of Medicare beneficiaries per surgeon performing shoulder arthroplasty declined by 5.9%, while the average number of TSAs per surgeon (+8.5%) and average number of billable services per beneficiary (+16.6%) both increased. Surgeons in the South performed the most services per beneficiary in 2021 (9.0; P < .001). The average comorbidity burden of patients was decreased by 4.8% between 2013 and 2021, with the West having the healthiest patients in 2021. Higher patient comorbidities were associated with lower physician reimbursement nationally (P < .001). CONCLUSION: This study demonstrates that TSA utilization in the Medicare population has more than doubled between 2013 and 2021, while average inflation-adjusted reimbursement has declined by nearly 10%. The Midwest has the highest per-capita TSA utilization, while simultaneously having the lowest average reimbursement per TSA. Over time, TSA surgeons are seeing fewer and healthier beneficiaries but performing more services per beneficiary. Additionally, increased patient complexity may be associated with lower reimbursement. Together, these findings are concerning for long-term equitable access to care within shoulder surgery.

Editorial Commentary: Revision Arthroscopic Bankart Is Not Recommended: The Sad Country Song We Just Can't Quit.

The approach to revision after an arthroscopic Bankart is a controversial topic. Several studies have shown an increased failure after revision compared with primary procedures, and many papers have recommended an open approach with or without bone augmentation. It seems intuitive that if an approach fails, that we ought to try a different one. And yet we do not. When facing this condition, it is far more common that we talk ourselves into performing another arthroscopic Bankart. It's relatively easy, familiar, and comforting. We find a reason to give this operation one more chance due to some patient-specific factor, like bone loss, number of anchors, or contact athlete status. Recent research shows that none of these factors matter, yet many of us find something that leads us to conclude that in our hands, with this patient, this time, the surgery will work. As data continue to emerge, the indications for this approach continue to narrow. It is becoming increasingly difficult to find a reason to go back to this operation as our best choice for the failed arthroscopic Bankart.

Treatment Following a First-Time Shoulder Dislocation: What Should I Do?

A first-time shoulder dislocation is a challenging topic that requires consideration of anatomic and patient-specific factors. Initial management is predicated on determining functional demands, activity level, and expectations of the patient, in addition to assessing the risk of recurrent instability. When considering surgical indications, it is imperative to understand the biomechanical implications of injury to the glenohumeral joint complex and how specific surgical procedures can restore stability. It is important to provide an overview of the current treatment algorithm for management of first-time shoulder dislocation, with a special focus on diagnosis and intervention in the young athlete.

Survival of anterior cruciate ligament reconstructions in active-duty military populations.

PURPOSE: Anterior cruciate ligament tears and anterior cruciate ligament reconstruction (ACLR) are common in young athletes. The modifiable and non-modifiable factors contributing to ACLR failure and reoperation are incompletely understood. The purpose of this study was to determine ACLR failure rates in a physically high-demand population and identify the patient-specific risk factors, including prolonged time between diagnosis and surgical correction, that portend failure. METHODS: A consecutive series of military service members with ACLR with and without concomitant procedures (meniscus [M] and/or cartilage [C]) done at military facilities between 2008 and 2011 was completed via the Military Health System Data Repository. This was a consecutive series of patients without a history of knee surgery for two years prior to the primary ACLR. Kaplan-Meier survival curves were estimated and evaluated with Wilcoxon test. Cox proportional hazard models calculated hazard ratios (HR) with 95% confidence intervals (95% CI) to identify demographic and surgical factors that influenced ACLR failure. RESULTS: Of the 2735 primary ACLRs included in the study, 484/2,735 (18%) experienced ACLR failure within four years, including (261/2,735) (10%) undergoing revision ACLR and (224/2,735) (8%) due to medical separation. The factors that increased failure include Army Service (HR 2.19, 95% CI 1.67, 2.87), > 180 days from injury to ACLR (HR 1.550, 95% CI 1.157, 2.076), tobacco use (HR 1.429 95% CI 1.174, 1.738), and younger patient age (HR 1.024, 95% CI 1.004, 1.044). CONCLUSION: The overall clinical failure rate of service members with ACLR is 17.7% with minimum four-year follow-up, where more patients are likely to fail due to revision surgery than medical separation. The cumulative probability of survival at 4 years was 78.5%. Smoking cessation and treating ACLR patients promptly are modifiable risk factors impacting either graft failure or medical separation. LEVEL OF EVIDENCE: Level III.

The long head of the biceps tendon: a valuable tool in shoulder surgery.

ANATOMY AND FUNCTION: The long head of the biceps tendon (LHBT) has different properties and characteristics that render it a valuable tool in the hands of shoulder surgeons. Its accessibility, biomechanical strength, regenerative capabilities, and biocompatibility allow it to be a valuable autologous graft for repairing and augmenting ligamentous and muscular structures in the glenohumeral joint. SHOULDER SURGERY APPLICATIONS: Numerous applications of the LHBT have been described in the shoulder surgery literature, including augmentation of posterior-superior rotator cuff repair, augmentation of subscapularis peel repair, dynamic anterior stabilization, anterior capsule reconstruction, post-stroke stabilization, and superior capsular reconstruction. Some of these applications have been described meticulously in technical notes and case reports, whereas others may require additional research to confirm clinical benefit and efficacy. CONCLUSION: This review examines the role of the LHBT as a source of local autograft, with biological and biomechanical properties, in aiding outcomes of complex primary and revision shoulder surgery procedures.

Autograft Long Head Biceps Tendon Can Be Used as a Scaffold for Biologically Augmenting Rotator Cuff Repairs.

PURPOSE: We create a viable, mechanically expanded autograft long head biceps tendon (LHBT) scaffold for biologically augmenting the repair of torn rotator cuffs. METHODS: The proximal aspect of the tenotomized LHBTs was harvested from patients during rotator cuff repair surgery and was mechanically formed into porous scaffolds using a surgical graft expander. LHBT scaffolds were evaluated for change in area, tensile properties, and tenocyte viability before and after expansion. The ability of endogenous tenocytes derived from the LHBT scaffold to promote tenogenic differentiation of human adipose-derived mesenchymal stromal cells (ADMSCs) was also determined. RESULTS: Autograft LHBTs were successfully expanded using a modified surgical graft expander to create a porous scaffold containing viable resident tenoctyes from patients undergoing rotator cuff repair. LHBT scaffolds had significantly increased area (length: 24.91 mm [13.91, 35.90] × width: 22.69 mm [1.87, 34.50]; P = .011) compared with the native LHBT tendon (length: 27.16 mm [2.70, 33.62] × width: 6.68 mm [5.62, 7.74]). The structural properties of the autograft were altered, including the ultimate tensile strength (LHBT scaffold: .56 MPa [.06, 1.06] vs. native LHBT: 2.35 MPa [1.36, 3.33]; P = .002) and tensile modulus (LHBT scaffold: 4.72 MPa [-.80, 1.24] versus native LHBT: 37.17 MPa [24.56, 49.78]; P = .001). There was also a reduction in resident tenocyte percent viability (LHBT scaffold: 38.52% [17.94, 59.09] vs. native LHBT: 68.87% [63.67, 74.37]; P =.004). Tenocytes derived from the LHBT scaffold produced soluble signals that initiated ADMSC differentiation into an immature tenocyte-like phenotype, as indicated by an 8.7× increase in scleraxis (P = .040) and a 3.6× increase in collagen type III mRNA expression (P = .050) compared with undifferentiated ADMSC controls. CONCLUSIONS: The ability to produce a viable autologous scaffold from the proximal biceps tendon having dimensions, porosity, mechanical characteristics, native ECM components, and viable tenocytes that produce bioactive signals conducive to supporting the biologic augmentation of rotator cuff repair surgery has been demonstrated. CLINICAL RELEVANCE: This biologically active construct may help to improve the quality of healing and regeneration at the repair site of rotator cuff tears, especially those at high risk for retear.

Getting paid less for more: shoulder arthroplasty incidence and reimbursement within Medicare from 2000 to 2019.

BACKGROUND: Shoulder arthroplasty has grown in popularity in the past 2 decades, especially following US Food and Drug Administration approval of reverse total shoulder arthroplasty (TSA) in 2003. Studies have shown that Medicare reimbursement for a variety of orthopedic procedures has decreased significantly over the past 2 decades. No study has evaluated this trend in the setting of shoulder arthroplasty, however. The purpose of this study was to assess true reimbursement trends in primary and revision shoulder arthroplasty since 2000. METHODS: Information was collected from the publicly available Medicare Part B National Summary Data Files for the period of 2000 to 2019. Data from Current Procedural Terminology codes 23470 (shoulder hemiarthroplasty), 23472 (TSA), 23473 (single-component revision shoulder arthroplasty), and 23474 (both-component revision shoulder arthroplasty) were analyzed. Reimbursement amounts were adjusted for inflation to May 2021 dollars. RESULTS: From 2000 to 2019, the number of shoulder hemiarthroplasty procedures billed to Medicare decreased 70% (from 5847 to 1750) whereas the number of TSA procedures increased 1527% (from 4044 to 65,477). During the same period, per-procedure Medicare reimbursement for hemiarthroplasty decreased 35% (from $1545.71 to $1003.43) after adjustment for inflation to 2021 dollars. Similarly, TSA reimbursement decreased 22% (from $1600.98 to $1248.76) after adjustment for inflation. For revision procedures, the number of single- and both-component revisions billed to Medicare increased 381% (from 344 to 1655) and 1331% (from 220 to 3147), respectively. Adjusted reimbursement per procedure decreased 36% (from $1931.62 to $1244.49) and 37% (from $2293.08 to $1449.43), respectively. CONCLUSION: This study shows an increase in the annual volume of primary and revision shoulder arthroplasty procedures from 2000 to 2019. During the same period (2000-2019), true Medicare reimbursement to physicians for TSA decreased when adjusted for inflation. This study provides data that may be useful for surgeons, hospitals, and policy makers to maintain access to quality shoulder arthroplasty care moving forward.

Recurrent Instability and Surgery Are Common After Nonoperative Treatment of Posterior Glenohumeral Instability in NCAA Division I FBS Football Players.

BACKGROUND: In-season return to play after anterior glenohumeral instability is associated with high rates of recurrent instability and the need for surgical stabilization. We are not aware of previous studies that have investigated in-season return to play after posterior glenohumeral instability; furthermore, as posterior shoulder instability in collision athletes occurs frequently, understanding the expected outcome of in-season athletes may improve the ability of physicians to provide athletes with a better understanding of the expected outcome of their injury and their ability to return to sport. QUESTIONS/PURPOSES: (1) What proportion of athletes returned to play during the season after posterior instability in collegiate football players? (2) How much time did athletes lose to injury, what proportion of athletes opted to undergo surgery, and what proportion of athletes experienced recurrent instability after a posterior instability episode during a collegiate football season? METHODS: A multicenter, prospective, observational study of National Collegiate Athletic Association (NCAA) Division 1 Football Bowl Subdivision athletes was performed at three US Military Service Academies. Ten athletes who sustained a posterior instability event during the regular football season and who pursued a course of nonoperative treatment were identified and prospectively observed through the subsequent season. All athletes in the observed cohort attempted an initial course of nonoperative treatment during the season. All athletes sustained subluxation events initially identified through history and physical examination at the time of injury. None of the athletes sustained a dislocation event requiring a manual reduction. Intraarticular pathology consisting of posterior labral pathology was further subsequently identified in all subjects via MRI arthrogram. Return to play was the primary outcome of interest. Time lost to injury, surgical intervention, and subsequent instability were secondary outcomes. RESULTS: Of the 10 athletes who opted for a trial of initial nonoperative management, seven athletes were able to return to play during the same season. Although these seven athletes returned within 1 week of their injury (median of 1 day), 5 of 7 athletes sustained recurrent subluxation events with a median (range) of four subluxation events per athlete (0 to 8) during the remainder of the season. Seven athletes were treated surgically after the completion of their season, four of whom returned to football. CONCLUSION: This study suggests that although collegiate football players are able to return to in-season sport after a posterior glenohumeral instability event, they will likely sustain multiple recurrent instability events and undergo surgery after the season is completed. The results of this study can help guide in-season management of posterior shoulder instability by allowing more appropriate postinjury counseling and decision making through the identification of those athletes who may require additional attention from medical staff during the season and possible modifications to training regimens to minimize long-term disability. Further prospective studies involving a larger cohort over several seasons should be performed through collaborative studies across the NCAA that better assess function and injury risk factors before beginning collegiate athletics. This would better characterize the natural history and associated functional limitations that athletes may encounter during their collegiate careers. LEVEL OF EVIDENCE: Level IV, prognostic study.

Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Shoulder: An Orthoregeneration Network (ON) Foundation Review.

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the shoulder including the rotator cuff tendons, glenohumeral articular cartilage, glenoid labrum, the joint capsule, and bone. Promising and established treatment modalities include hyaluronic acid (HA); platelet-rich plasma (PRP) and platelet rich concentrates (PRC); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs alternatively termed medicinal signaling cells and frequently, misleadingly labelled "mesenchymal stem cells"); MSC harvested from adipose, umbilical, or placental sources; factors including vascular endothelial growth factors (VEGF), basic fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), transforming growth factor-beta (TGFß), bone morphogenic protein (BMP), and matrix metalloproteinases (MMPs); prolotherapy; pulsed electromagnetic field therapy; microfracture and other marrow-stimulation techniques; biologic resurfacing using acellular dermal allografts, allograft Achilles tendons, allograft lateral menisci, fascia lata autografts, and porcine xenografts; osteochondral autograft or allograft); and autologous chondrocyte implantation (ACI). Studies involving hyaluronic acid, platelet rich plasma, and medicinal signaling cells of various origin tissues have shown mixed results to-date as isolated treatments and as surgical adjuncts. Despite varied results thus far, there is great potential for improved efficacy with refinement of current techniques and translation of burgeoning preclinical work. LEVEL OF EVIDENCE: Level V, expert opinion.

Complications Following Biologic Therapeutic Injections: A Multicenter Case Series.

PURPOSE: To describe the complications that occur following biologic therapeutic injections. METHODS: We queried physician members of the Biologic Association, a multidisciplinary organization dedicated to providing a unified voice for all matters related to musculoskeletal biologics and regenerative medicine. Patients included in this study must have (1) received a biologic injection, (2) sustained an adverse reaction, and (3) had a minimum of 1-year follow-up after the injection. Patient demographic information, medical comorbidities, diagnoses, and previous treatments were recorded. The type of injection, injection setting, injection manufacturers, and specific details about the complication and outcome were collected. RESULTS: In total, 14 patients were identified across 6 institutions in the United States (mean age 63 years, range: 36-83 years). The most common injections in this series were intra-articular knee injections (50%), followed intra-articular shoulder injections (21.4%). The most common underlying diagnosis was osteoarthritis (78.5%). Types of injections included umbilical cord blood, platelet-rich plasma, bone marrow aspirate concentrate, placental tissue, and unspecified "stem cell" injections. Complications included infection (50%), suspected sterile inflammatory response (42.9%), and a combination of both (7.1%). The most common pathogen identified from infection cases was Escherichia coli (n = 4). All patients who had isolated infections underwent treatment with at least one subsequent surgical intervention (mean: 3.6, range: 1-12) and intravenous antibiotic therapy. CONCLUSIONS: This study demonstrates that serious complications can occur following treatment with biologic injections, including infections requiring multiple surgical procedures and inflammatory reactions. LEVEL OF EVIDENCE: Level IV, case series.

Evaluation and Management of Glenohumeral Instability With Associated Bone Loss: An Expert Consensus Statement Using the Modified Delphi Technique.

PURPOSE: To establish an international expert consensus, using the modified Delphi technique, on the evaluation and management of glenohumeral instability with associated bone loss. METHODS: A working group of 6 individuals generated a list of statements related to history and physical examination, imaging and specialized diagnostic tests, bone loss quantification and classification, treatment outcomes and complications, and rehabilitation for the management of glenohumeral instability associated with bone loss to form the basis of an initial survey for rating by a group of experts. The expert group (composed of 22 high-volume glenohumeral instability experts) was surveyed on 3 occasions to establish a consensus on the statements. Items with over 70% agreement and less than 10% disagreement achieved consensus. RESULTS: After a total of 3 rounds, 31 statements achieved consensus. Eighty-six percent of the experts agreed that a history of multiple dislocations and failed soft-tissue surgery should raise suspicion about the possibility of an associated bone deficit. Ninety-five percent of the experts agreed that 3-dimensional (3D) computed tomography (CT) is the most accurate diagnostic method to evaluate and quantify bone loss. Eighty-six percent of the experts agreed that any of the available methods to measure glenoid bone deficiency is adequate; however, 91% of the experts thought that an en face view of the glenoid using 3D CT provides the most accurate method. Ninety-five percent of the experts agreed that Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Ninety percent of the experts agreed that in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed and any of the available options is valid. There was no consensus among experts on how Hill-Sachs injuries should be managed or on how postoperative rehabilitation should be carried out. CONCLUSIONS: The essential statements on which the experts reached consensus included the following: A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit. Three-dimensional CT is the most accurate diagnostic method to evaluate and quantify bone loss. Although any of the available methods to measure glenoid bone deficiency is adequate, an en face view of the glenoid using 3D CT provides the most accurate method. Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Finally, in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed. LEVEL OF EVIDENCE: Level V, consensus statement.

Heads Up Football Training Decreases Concussion Rates in High School Football Players.

OBJECTIVE: The objective of this study was to determine whether football players receiving heads up (HU) training would display a lower rate of sport-related concussion (SRC) compared to those without HU training. DESIGN: Prospective cohort. SETTING: Scholastic football fields. PATIENTS: Two thousand five hundred fourteen scholastic football players during the 2015 to 2016 football season were monitored throughout the football season. INTERVENTIONS: Before the preseason, 1 coach from 14 schools received HU training from US football. These schools were matched with 10 control schools performing standard football training [non-heads up (NHU)]. Random monitoring for proper coaching instruction was performed during the season. School athletic trainers monitored injuries and return to sport over the season for all schools. MAIN OUTCOME MEASURES: The outcome measures of concussions and associated time loss were determined before data collection began. Injury incidence and rate ratios were calculated to determine program effectiveness. RESULTS: During the season, football players sustained 117 concussions (HU = 75; NHU = 42). The HU players displayed a significantly lower concussion rate (4.1 vs 6.0/100 players) compared with NHU teams [rate ratio = 1.5; 95% confidence interval (CI), 1.1-5.4]. The HU group returned to full participation 27% faster than athletes in the NHU group [time loss: 18.2 days (95% CI, 15.8-20.6) vs 24.8 days (95% CI, 19.9-29.7)], respectively. CONCLUSIONS: This is the first study to evaluate the impact of the HU program on the incidence of SRC in high school football players. Our data demonstrated that the HU program reduced SRC rates by 33% supporting the use of US HU football training as an effective method to decrease the rate of SRCs in scholastic football. CLINICAL RELEVANCE: This study is the first to prospectively explore the effect of HU training on the incidence and recovery from SRC in high school football players.

Technical Pearls for Shoulder Instability.

Glenohumeral instability is one of the most common conditions of the upper extremity, especially in athletes and active individuals. Over the past two decades, there has been a transformation of surgical treatment from traditionally open repair/reconstruction to arthroscopic management. This has especially been true with management of both anterior and posterior instability without significant bone loss. In this setting, and in certain patient populations (eg, contact/collision athletes), arthroscopic treatment may not be sufficient. Therefore, open techniques, such as coracoid bone transfer, also occupy an important role in management of glenohumeral instability. The goal of this review is to provide technical "pearls" in management of glenohumeral instability. Specifically, the review will highlight treatments such as arthroscopic anterior and posterior instability repair, posterior glenoid bone augmentation, and open coracoid transfer (Latarjet) for anterior instability with bone loss. We will also review management of complications related to coracoid transfer.

Management of Shoulder Instability in 2020: What, When, and How.

Anterior glenohumeral instability remains a common clinical problem in the athletic and working patient populations, and further, recurrence rates following stabilization surgery continue to be problematic. Over the past 5 years, there have been substantial improvements in the understanding of anterior shoulder instability. To better counsel and treat patients, it is imperative for surgeons to have a comprehensive understanding of the epidemiology of shoulder instability, the anatomy of the glenohumeral joint particularly as it relates to glenoid and humeral head bone loss, surgical indications, and surgical techniques. These critical topics are summarized in an effort to provide a complete guide to managing anterior shoulder instability in 2020.

Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial.

BACKGROUND: Interscalene brachial plexus blocks are a common modality used to provide adjunctive pain relief with shoulder replacement surgery. In 2018, the Federal Drug Administration approved the use of liposomal bupivacaine (LB) for such nerve blocks. We sought to evaluate whether this formulation of bupivacaine would provide superior pain relief for shoulder replacement patients over standard bupivacaine alone. Our hypotheses were that in the LB cohort the average postoperative pain score over the first 72 hours would be significantly lower, time to block cessation would be longer, total opioid consumption would be lower, and the average patient satisfaction score regarding their pain management would be higher. MATERIALS AND METHODS: A randomized, double-blinded study was designed comparing primary shoulder replacement surgery after an interscalene block with 25 mL of 0.5% plain bupivacaine vs. 133 mg of LB with 7.5 mL of 0.5% and 7.5 mL of 0.25% plain bupivacaine. A total of 104 patients were included in the study, with an equal number in each study arm. Patients' visual analog pain scores (VAPS) were followed for their inpatient stay, first 3 full outpatient days, and at a 3-week follow-up. Use of opioid medication was recorded for the same intervals and converted to morphine milligram equivalents. The time to first opioid rescue was documented, as well as the patients' satisfaction with their pain management at both the 3-day and 3-week intervals. RESULTS: No clinically relevant advantage to the use of LB over plain bupivacaine was found. During the second postoperative day, the mean VAPS was 2.4 with LB vs. 3.3 in the standard cohort (P = .0409). The only other statistically significant finding was a higher VAPS with LB during the third full day home compared with standard bupivacaine (4.0 vs. 2.8, respectively, P = .0197). Both of these differences were less than the minimal clinically important difference of 2 for the VAPS. Analysis of the VAPS for the first and third postoperative days, the first and second full days home, and at 3 weeks revealed no significant difference. Similarly, there was no significant difference in time to first opioid rescue, total morphine milligram equivalent use, and patient satisfaction with pain management. CONCLUSION: When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine.

Athletes diagnosed with anterior and posterior shoulder instability display different chief complaints and disability.

BACKGROUND: Anterior shoulder instability is a common complaint of young athletes. Posterior instability in this population is less well understood, and the standard of care has not been defined. The purpose of the study is to compare index frequency, treatment choice, and athlete disability following an incident of anterior or posterior shoulder instability in high school and collegiate athletes. METHODS: A total of 58 high school and collegiate athletes (n=30 athletes with anterior instability; n=28 athletes with posterior instability) were included. Athletes suffering from a traumatic sport-related shoulder instability episode during a team-sponsored practice or game were identified by their school athletic trainer. Athletes were referred to the sports medicine physician or orthopedic surgeon for diagnosis and initial treatment choice (operative vs. nonoperative). Athletes diagnosed with traumatic anterior or posterior instability who completed the full course of treatment and provided pre- and post-treatment patient-reported outcome measures were included in the study. The frequency of shoulder instability was compared by direction, mechanism of injury (MOI), and treatment choice through χ2 analyses. A repeated measures analysis of variance was used to compare the functional outcomes by treatment type and direction of instability (α = 0.05). RESULTS: Athletes diagnosed with anterior instability were more likely to report a chief complaint of instability (70%), whereas those diagnosed with posterior instability reported a primary complaint of pain interfering with function (96%) (P = .001). The primary MOI classified as a contact event was similar between anterior and posterior instability groups (77% vs. 54%, P = .06) as well as the decision to proceed with surgery (60% vs. 72%, P = .31). In patients with nonoperative care, athletes with anterior instability had significantly more initial disability than those with posterior instability (32±6.1 vs. 58±8.1, P = .001). Pre- and post-treatment Penn Shoulder Scores for athletes treated with early surgery were similar (P > .05). There were no differences in functional outcomes at discharge in those treated nonoperatively regardless of direction of instability (P = .24); however, change in Penn score was significantly greater in those with anterior (61±18.7) than those with posterior (27 ± 25.2) instability (P = .002). CONCLUSION: Athletes with anterior instability appear to have different mechanisms and complaints than those with posterior instability. Among those that receive nonoperative treatment, athletes with anterior instability have significantly greater initial disability and change in disability than those with posterior disability during course of care.