Preoperative patient factors that predict achieving the minimal clinically important difference following arthroscopic treatment of snapping scapula syndrome.

BACKGROUND: The aim of this study was to define the minimal clinically important difference (MCID) values for patient-reported outcomes (PROs) after arthroscopic treatment of snapping scapula syndrome (SSS) using a distribution-based method, and to identify demographic, clinical, and intraoperative factors significantly associated with the achievement of MCID. It was hypothesized that subjective satisfaction scores after the procedure would be strongly associated with the achievement of MCID thresholds for the PROs and that pain, preoperative response to injection, and a scapulectomy in addition to bursal resection would be predictive of clinically relevant improvement. METHODS: Patients who underwent arthroscopic treatment of SSS between October 2005 and September 2020 with a minimum of 2-year short-term postoperative follow-up were enrolled in this retrospective single-center study. The MCID was calculated using a distribution-based approach for the following PROs: 12-Item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) pain "today" and "at worst." The association between achievement of the MCID and postoperative subjective satisfaction was investigated, and factors associated with achievement of MCID were determined using bivariate analysis. RESULTS: Of a total of 190 patients assessed for eligibility, 77 patients (38.1 ± 14.3 years; 36 females) were included. Within the study population, statistically significant improvements in postoperative SF-12 physical component summary (PCS) (P < .001) and mental component summary (MCS) (P < 0.034), ASES (P < .001), QuickDASH (P < .001), SANE (P < .001), and VAS pain (P < .001) scores were observed at the minimum 2-year follow-up. The calculated MCID threshold values based on the study population were 5.0 for SF-12 PCS, 5.8 for SF-12 MCS, 11.3 for ASES, -10.5 for QuickDASH, 14.7 for SANE, 1.5 for VAS pain, and 1.7 for VAS pain at worst. Reaching the MCID was strongly associated with postoperative satisfaction (rated on a scale of 1-10). Across the PROs, younger age, favorable preoperative response to injection, partial scapuloplasty or scapulectomy, no prior surgery, and pain and function at baseline were significantly associated with attaining MCID. CONCLUSIONS: Patients who underwent arthroscopic treatment for SSS experienced clinically significant improvements in functional scores, pain, and quality of life. This study demonstrated predictive roles for certain patient-specific factors and diagnostic variables for achieving MCID in PROs, which may help surgeons preoperatively assess the probability of success and manage patient expectations.

Management of Glenoid Bone Loss in Shoulder Instability: Where We Are in 2023.

The management of glenoid bone loss in shoulder instability can be challenging. Although shoulder instability can often be managed with arthroscopic soft-tissue procedures alone, the extent of glenoid bone loss and bipolar bone defects may require bone augmentation procedures for restoration of stability. In this setting, patient evaluation, examination, treatment options, and surgical pearls are vital. Furthermore, a treatment algorithm is established to guide both indications and the technical application of procedures including Bankart repair with remplissage, Latarjet procedure, and glenoid bone graft options. The limitations, complications, and current research pertinent to each treatment assist in guiding treatment.

Biomechanical comparison of 3 latissimus dorsi transfer sites for reverse total shoulder arthroplasty in the absence of teres minor.

BACKGROUND: Reverse total shoulder arthroplasty is often performed to treat rotator cuff tear arthropathy with irreparable rotator cuff tears. Patients with full-thickness tears involving the posterior cuff and teres minor specifically lose active external rotation of the humerus, limiting activities of daily living. A latissimus dorsi transfer has been described as one potential solution, but few studies have compared different latissimus dorsi transfer sites. This study assesses the biomechanics of 3 latissimus dorsi transfer sites, examining external rotation, deltoid muscle forces, and force across the glenoid for specific activities. METHODS: The Newcastle Shoulder Model was modified to include a Delta III reverse shoulder arthroplasty and was used to model the effects of 3 latissimus dorsi transfer sites-anterior, posterolateral, and posterodistal-in the setting of teres minor deficiency. The latissimus dorsi was represented by 5 muscle elements approximating anatomic fascicle divisions. Kinematic data sets representing common activities were input into the model, allowing calculation of muscle forces and glenoid loads. RESULTS: Each of the 3 latissimus dorsi transfer sites demonstrated a change of moment arm from internal to external rotation with increased magnitude. Average maximum deltoid muscle forces and glenoid loading across all motions decreased for each of the 3 transfer sites, with the greatest decreased force noted for the posterior deltoid. This decrease in deltoid force and glenoid loading was significantly greater with the anterior and posterolateral transfer sites, relative to the posterodistal site. DISCUSSION: Latissimus dorsi transfer to all 3 sites in the setting of reverse total shoulder arthroplasty and posterior rotator cuff deficiency resulted in large external rotation moment arms. The transferred latissimus dorsi shared the external rotation load and resulted in decreased deltoid forces and glenoid loading with very small differences between the 3 transfer sites. The posterodistal location reduced deltoid force and glenoid loading to a lower degree compared with other sites, but it also showed that it did not alter the tendon length compared with the native shoulder.

Arthroscopic distal clavicle excision is associated with fewer postoperative complications than open.

BACKGROUND: The rate of complications of open compared to arthroscopic distal clavicle excision remain poorly studied. Therefore, the purpose of this investigation was to (1) Identify most recent national trends in the usage of open vs. arthroscopic approaches for distal clavicle excision (DCE) from 2007 to 2017; (2) to identify and compare the complication rates for both approaches, and to identify patient-specific risk factors for complications; (3) to identify and compare the revision rate for both approaches; and (4) to identify and compare the reimbursement of each approach. METHODS: The PearlDiver database was reviewed for patients undergoing DCE from 2007 to 2017. Patients were stratified into 2 cohorts: those undergoing arthroscopic DCE (n = 8933) and those undergoing open DCE (n = 2295). The rate of postoperative complications within 90 days was calculated and compared. The revision rate and reimbursement of the arthroscopic and open approach were compared. Statistical analysis included chi-square testing to compare the rates of postoperative complications and multivariate logistic regression analysis to identify risk factors for complications within 90 days. Results were considered significant at P < .05. RESULTS: The percentage of DCEs performed arthroscopically has significantly increased from 53.9% in 2007 to 69.8% in 2016, with a concomitant decrease in the use of open DCE from 46.1% in 2007 to 30.2% in 2016. The open approach was associated with significantly more postoperative complications, including a significantly greater incidence of surgical site infection (1.9% vs. 0.3%; P < .001), wound disruption (0.3% vs. 0.1%; P < .001), hematoma (0.9% vs. 0.2%; P = .001), and transfusion (0.6% vs. 0.1%; P < .001), than arthroscopic DCE. Several risk factors, including open approach, diabetes, heart disease, tobacco use, chronic kidney disease, and female gender, were identified as independent risk factors for complications after DCE. There was no significant difference in revision rate between open and arthroscopic approaches (P = .126). The reimbursement of open and arthroscopic DCE procedures were comparable, with median reimbursements of $5408 and $5,447, respectively (P = .853). CONCLUSION: Both arthroscopic and open DCE techniques were found to have similar reimbursement amounts, with a low rate of complications, although the open technique had a higher rate of early complications such as surgical site infection. Over the study period, there was an increase in the utilization of arthroscopic DCE, while the incidence of the open technique remained constant.

Return to Sport After Bone-Patellar Tendon-Bone Autograft ACL Reconstruction in High School-Aged Athletes.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are occurring with increasing frequency in the adolescent population. Outcomes after ACL reconstruction (ACLR) are inconsistently reported in homogeneous patient populations. PURPOSE/HYPOTHESIS: To evaluate outcomes after bone-patellar tendon-bone (BTB) autograft ACLR in competitive high school-aged athletes by examining return to sport (RTS), patient satisfaction, and reinjury rates. Our hypothesis was that RTS rates and satisfaction will be high and reinjury rates will be low. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: An institutional ACL registry was utilized to identify competitive high school-aged athletes (14-18 years old) who underwent primary ACLR using BTB autograft with a minimum 2-year follow-up. A postoperative questionnaire was administered to determine rates and types of RTS, quality of sports performance, reinjury, and satisfaction. Uni- and multivariable analyses were used to identify demographic, sport-specific, and clinical factors related to RTS. RESULTS: A total of 53 patients were included (mean ± SD age at the time of surgery, 16.6 ± 1.34 years). Mean follow-up was 3.78 ± 0.70 years (range, 2.60-4.94 years). The overall ipsilateral ACL retear rate was 7.5% (n = 4). There were 10 subsequent ACL tears to the contralateral knee (19%). Forty-four (83%) patients successfully returned to at least their prior level of sport at a mean 10.5 ± 8.7 months (range, 3-48 months). Overall satisfaction was high, with 91% of patients very satisfied with the outcome. Higher confidence levels regarding performance of the reconstructed knee were associated with increased probability of RTS on multivariate analysis. CONCLUSION: BTB autograft ACLR results in high rates of RTS and satisfaction and low rates of subsequent ipsilateral ACL injuries in competitive high school-aged athletes. Patients with higher confidence in performance of the reconstructed knee are more likely to return to at least their prior level of sport.

How to Address the Medial Patellofemoral Ligament, Tibial Tubercle, and Articular Cartilage in Patients With Recurrent Patellar Instability.

Patellofemoral instability is a common pathology especially in the adolescent female population.1,2 Prompt diagnosis and management is critical to prevent future episodes of instability as well as to reduce the risk of cartilaginous injury to the patellofemoral articular surface. Initial management of a first-time patellar dislocation has historically been nonsurgical; however, the presence of intra-articular loose bodies or osseocartilaginous injury may require surgical intervention.3,4 More recent evidence has shown patients with specific risk factors such as skeletal immaturity, an incompetent medial soft-tissue sleeve, family history of patellar dislocation, elevated tibial tubercle to trochlear groove distance, patella alta, and high-grade trochlear dysplasia experience high rates of re-dislocation after initial nonsurgical management.4-9 Based on this, the provider needs to consider these risk factors and the possibility of initial surgical management in these patient populations following a first-time patellar dislocation. Surgical options for management of patellar instability and cartilaginous injury include medial patellofemoral ligament repair, medial patellofemoral ligament reconstruction, tibial tubercle osteotomy, and various cartilaginous repair/restoration procedures. It is important to be knowledgeable about the clinical and anatomic/radiographic risk factors associated with patients presenting with patellar instability, the algorithm for treatment, the indications and surgical technique for medial patellofemoral ligament reconstruction and tibial tubercle osteotomy, and management of cartilaginous injury to the patellofemoral joint.

Computed Tomography-Based Preoperative Planning Provides a Pathology and Morphology-Specific Approach to Glenohumeral Instability With Bone Loss.

PURPOSE: To use computed tomography (CT) to determine a reproducible method of coracoid measurement to compare the ability of the classic Latarjet technique and the congruent arc modification (CAM) to restore native glenoid diameter and to develop a preoperative planning algorithm for glenoid restoration with a goal of achieving an on-track shoulder. METHODS: Coracoid dimensions were measured on multiplanar reconstructed shoulder CT scans of patients aged 18 to 45 years obtained between December 1, 2019, and March 13, 2020. Patients were excluded if CT demonstrated osteophyte formation, glenoid dysplasia, coracoid fracture, or tumor. The proportion of glenoid diameter able to be restored using classic Latarjet technique and CAM were calculated. A treatment algorithm was proposed considering the amount of bone loss present and coracoid dimensions. RESULTS: Coracoid dimensions of 117 consecutive patients were measured and varied considerably (length: 17.5-31.8 mm, width: 9.1-20.5 mm, thickness: 6.1-15.7 mm). While most patients had harvestable coracoid length ≥20 mm (male: 96.3% vs female: 94.4%, P = .65), only 27.8% of female patients had coracoid thickness ≥10 mm. When comparing Latarjet techniques, there was no difference in the proportion of patients in whom 30% glenoid diameter could be fully restored, but CAM was able to restore at least 35% in more male and female patients (98.8% vs 79.0% and 100% vs 61.1%, respectively, P = .00001). Intra- and inter-rater reliability was excellent ( intraclass correlation coefficient ≥0.950 for all dimensions). CONCLUSIONS: We describe a reliable method of measuring coracoid dimensions for preoperative planning of glenoid restoration. The classic Latarjet technique reliably restores the glenoid anteroposterior diameter with bone loss of up to 30%. The majority of female patients have coracoid thickness <10 mm, which may increase the risk of graft fracture when using CAM. The decision to use the classic Latarjet technique or CAM considers each individual's glenoid and coracoid dimensions with a goal of achieving an on-track shoulder. CLINICAL RELEVANCE: Our reliable method of coracoid measurement demonstrated the differing abilities of the classic Latarjet and CAM to restore the native glenoid diameter. An evidence-based algorithm using these measurements was developed to assist in preoperative planning for glenohumeral instability in the setting of bone loss, with a goal of achieving an on-track shoulder. Alternative techniques may be considered if an on-track shoulder cannot be achieved with Latarjet.

The impact of prior ipsilateral arthroscopy on infection rates after shoulder arthroplasty.

BACKGROUND: Patients frequently undergo interventions before shoulder arthroplasty, including injections and arthroscopy. Although the potential impact of injections on postoperative outcomes such as infection has been well studied, it is less clear whether prior arthroscopy has an impact on infection rates after shoulder arthroplasty. The purpose of this study was to determine whether prior ipsilateral shoulder arthroscopy is associated with an increased risk of postoperative infection after shoulder arthroplasty. METHODS: Patients who underwent shoulder arthroplasty, including hemiarthroplasty, total shoulder arthroplasty, or reverse shoulder arthroplasty with a minimum of 1-year preoperative database exposure, were queried using Current Procedural Terminology codes from 2 large insurance databases, including both private-payer (Humana, 2008-2017) and Medicare (2006-2014) data. Patients with procedures for infection, fractures, or without laterality data were excluded. Those who underwent ipsilateral shoulder arthroscopy within 2 years before their arthroplasty were identified and compared with controls who did not undergo prior arthroscopy. Each database was analyzed separately. Periprosthetic infection within 1 year after arthroplasty was queried for each group and compared using a logistic regression analysis with control for demographic and comorbidity confounders. RESULTS: A total of 9362 Medicare patients and 17,716 private-payer patients were included in the study. Of these, 486 (5.2%) Medicare patients and 685 (3.9%) private-payer patients underwent prior arthroscopy. In the Medicare database, prior arthroscopy was also associated with a postarthroplasty infection rate of 3.9% as compared with 1.9% in the control group (odds ratio: 1.96, 95% confidence interval: 1.20-3.22, P = .003). Similarly, in the private insurance cohort, prior shoulder arthroscopy was associated with a postarthroplasty infection rate of 2.9% as compared with 1.4% in the control group (odds ratio: 1.85, 95% confidence interval: 1.13-3.03, P = .005). CONCLUSION: Shoulder arthroscopy performed within 2 years before shoulder arthroplasty is associated with a higher infection rate in the first year after shoulder arthroplasty.

Correction to: At the US Epicenter of the COVID-19 Pandemic, an Orthopedic Residency Program Reorganizes.

[This corrects the article DOI: 10.1007/s11420-020-09765-5.].

Self-reported allergies correlate with a worse patient-reported outcome after hip arthroscopy: a matched control study.

Patient-reported outcome measures (PROMs) in patients with and without at least one self-reported allergy undergoing hip arthroscopy were compared. Data on 1434 cases were retrospectively reviewed, and 267 patients were identified with at least one self-reported allergy and randomly matched to a control group on a 1:2 ratio. Four PROMs [Modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports (HOS-Sport) and 33-item International Hip Outcome Tool (iHOT-33)] were collected preoperatively, and at 5-11, 12-23 and 24-35 months postoperatively. Significant PROM differences were found 5-11 months postoperative on mHHS (P < 0.001), HOS-ADL (P = 0.002), HOS-Sport (P < 0.001) and iHOT-33 (P < 0.001). At 12-23 months postoperative, the allergy cohort had significantly worse scores on mHHS (P = 0.002), HOS-ADL (P = 0.001), HOS-Sport (P < 0.001) and iHOT-33 (P < 0.001). They also had significantly worse measures 24-35 months postoperative on mHHS (P = 0.019), HOS-Sport (P = 0.006) and iHOT-33 (P < 0.001). Multivariable logistic regression showed that each additional allergy reported significantly increased the risk of failing to meet the minimal clinically important difference 5-11 months after surgery on mHHS by 1.15 [OR (95% CI): 1.15 (1.03, 1.30), P = 0.014], on HOS-ADL by 1.16 [OR (95% CI): 1.16 (1.02, 1.31), P = 0.021] and on iHOT-33 by 1.20 [OR (95% CI): 1.20 (1.07, 1.36), P = 0.002]. Results suggest self-reported allergies increase the likelihood of a patient-perceived worse outcome after hip arthroscopy. An understanding of this association by the physician is essential during presurgical planning and in the management of postoperative care.

Clinical Outcomes After Biceps Tenodesis or Tenotomy Using Subpectoral Pain to Guide Management in Patients With Rotator Cuff Tears.

PURPOSE: To assess whether preoperative subpectoral tenderness in patients with rotator cuff tears was associated with arthroscopic findings of tendinopathy of the long head of the biceps, as well as whether they had resolution of their subpectoral tenderness postoperatively after tenodesis or tenotomy. METHODS: Patients presenting between 2011 and 2016 undergoing arthroscopic rotator cuff repair were evaluated preoperatively with the subpectoral biceps test (SBT). This test is performed with the arm adducted and internally rotated to allow palpation of the biceps as it courses under the pectoralis major tendon. Preoperative SBT findings determined operative management with either tenodesis or tenotomy during rotator cuff repair. Patients were followed up postoperatively to assess resolution of subpectoral tenderness with a repeated SBT. Preoperative and postoperative Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons, and Constant-Murley scores were recorded in all patients. RESULTS: A total of 128 patients were enrolled in the study, with a mean age of 58 years (range, 33-82 years). Patients with a positive preoperative SBT (n = 68) had significantly lower SANE and Constant-Murley scores preoperatively (P < .01) than patients with a negative SBT (n = 60). All patients with a positive preoperative SBT underwent either tenodesis or tenotomy, with 94% of patients (n = 64) having resolution of subpectoral pain and tenderness at final follow-up. Intraoperatively, 93% of patients with a positive SBT showed gross pathologic changes in the tendon (fraying, erythema, tears, or subluxation) compared with only 65% of patients with negative preoperative examination findings (P < .01). American Shoulder and Elbow Surgeons, Constant-Murley, and SANE scores were significantly increased postoperatively in all patients (P = .02). CONCLUSIONS: In this group of patients with rotator cuff tears surgically treated with concomitant biceps tenodesis or tenotomy, 94% had resolution of their subpectoral tenderness. A positive SBT was associated with gross pathologic changes of the biceps in 93% of patients. LEVEL OF EVIDENCE: Level III, prospective comparative study.

The Use of Bone Marrow Concentrate in the Treatment of Full-Thickness Chondral Defects.

This article is a critical analysis of a study, "Minimally Manipulated Bone Marrow Concentrate Compared with Microfracture Treatment of Full-Thickness Chondral Defects: A One-Year Study in an Equine Model," by Chu et al. (J Bone Joint Surg Am. 100(2):138-146, 2018). The investigation compared two interventions in the management of full-thickness chondral defects in an equine model: autologous bone marrow concentrate without concomitant microfracture treatment versus microfracture treatment alone. This review analyzes the methodology and results of their investigation and examines how their findings may influence the continued development of therapeutic options for full-thickness cartilage injuries. The study utilized in vitro analysis, arthroscopic assessment, magnetic resonance imaging (MRI) evaluation, and histological analysis to compare the treatments and their influence on the quality of cartilage repair. Although Chu et al. reported similar results between groups, their findings offer insight into the role of arthroscopy, MRI, and histology in the evaluation of repair quality. We compare their findings to those of similar investigations, highlighting the limited therapeutic options and variable clinical outcomes related to the treatment of full-thickness articular cartilage defects.

The Effect of Early Range of Motion on Quality of Life, Clinical Outcome, and Repair Integrity After Arthroscopic Rotator Cuff Repair.

PURPOSE: To compare the effect of early versus delayed motion protocols on quality of life, clinical outcomes, and repair integrity in patients who have undergone arthroscopic single-tendon rotator cuff repair. METHODS: This was a prospective, randomized, investigator-blinded clinical trial. Seventy-three patients from a single surgeon's practice who underwent arthroscopic repair of a single-tendon rotator cuff tear were randomized to either an early motion protocol (starting 2 to 3 days after surgery) or a delayed motion protocol (starting 28 days after surgery). The primary outcome measure was the Western Ontario Rotator Cuff index (WORC). Secondary outcome measures included clinical outcome scores, integrity of the repair on 6-month magnetic resonance imaging scans, pain scores, physical examination data, and ultrasonography. Study participants were followed up at 3, 6, and 12 weeks; 6 months; and 1 year postoperatively. RESULTS: There was no statistically significant difference in WORC scores at 6 months (529 ± 472 in delayed group vs 325 ± 400 in early group, P = .08). Mixed-effects analysis indicated the early group maintained lower WORC scores throughout the postoperative period (estimated difference of 191, P = .04). The proportions of patients with tears on the 6-month postoperative magnetic resonance imaging scan were comparable (31% in delayed group vs 34% in early group, P = .78). CONCLUSIONS: There was no difference between the delayed and early motion groups in WORC scores at 6 months after surgery. Early motion was associated with lower WORC scores throughout the postoperative period; however, both groups had a similar trajectory of improvement, suggesting both protocols have the same effect on patient-reported improvement. Although failure rates were similar between the groups, the sample size was not sufficient to support a statement regarding the relation between tear morphology and the rehabilitation protocol. LEVEL OF EVIDENCE: Level II, lesser-quality randomized controlled trial.

A Systematic Review of Meta-analyses Published in Arthroscopy: The Journal of Arthroscopic and Related Surgery.

PURPOSE: To determine whether the number of meta-analyses published by Arthroscopy: The Journal of Arthroscopic and Related Surgery has increased from the inception of the Journal through 2014. METHODS: A literature search of the Journal's Web site and Medline was carried out. All studies described as a "meta-analysis" as well as systematic reviews that pooled data were included. The number of published meta-analyses was calculated and summarized by year of publication, region, topic, and level of evidence. RESULTS: The Journal's Web site search resulted in 517 citations for review, and the Medline search resulted in 400. After the results of each search were combined and duplicates were removed, a total of 60 studies were included in this review. The first published meta-analysis appeared in 2001. Of the 60 meta-analyses, 36 (60%) were published between 2013 and 2014. In light of the increase in the number of publications, a review of the design and conduct of a meta-analysis is presented in a straightforward question-and-answer format. CONCLUSIONS: The number of meta-analyses appearing in Arthroscopy has increased over the past 2 decades. This increase highlights the importance of developing an understanding of the premise and components of a meta-analysis to allow the reader to critically appraise these studies. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV meta-analyses.