Understanding Noise Exposure During Cast Removal: The Effect of Cast Saw Type and Casting Material.

BACKGROUND: Cast removal can be associated with considerable noise exposure, especially impacting the pediatric patient and provider. Although noise generation from cast saws has been deemed safe by the U.S. Occupational Safety and Health Administration and the U.S. Centers for Disease Control and Prevention standards, there are no current studies on the effects of cast material on noise levels generated. METHODS: A simulated casting model utilizing plaster, fiberglass, and plaster with fiberglass overwrapping was used for experimental testing. Four different casting conditions were tested, with 5 samples in each group. Samples were tested using 2 different cast saws: a standard cast saw and a quiet saw. Each saw was used for 30 seconds of continuous cutting for each sample, measuring peak, mean, and minimum sound levels in decibels with sound level meters. Noise levels were measured at 18, 36, and 72 in (20, 91, and 183 cm) from the saw, comparing saw and cast types against ambient noise and baseline cast-saw noises. Between-group comparisons were performed using univariate analyses. RESULTS: Mean noise generation differed between casting materials, with plaster material demonstrating significantly greater noise levels than fiberglass casts at all distances for each saw type. Increasing fiberglass thickness significantly increased the mean noise levels with standard (18-in distance for 10 and 5 ply: 87.4 and 85.8 dB; p = 0.0004) and quiet cast saws (78.3 and 76.1 dB; p = 0.041. Additionally, the quiet cast saw provided a 5.7 to 10.6 dB reduction in mean and peak noise levels, varying by casting material and distance. CONCLUSIONS: Occupational noise exposure can be mitigated with the use of fiberglass casting material that is not >5 ply in thickness, with a quiet cast saw for removal. The use of a quiet cast saw substantially decreased noise exposure to patients and staff members over standard orthopaedic cast saws.

Primary Medial Patellofemoral Ligament Reconstruction in Military Servicemembers: Can We Reliably Restore Preinjury Function and Stability?

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction for patellar instability is a commonly performed procedure with a reported high rate of return to preinjury activity. However, no previous study has assessed the functional outcomes of military servicemembers undergoing MPFL reconstruction. HYPOTHESIS: Primary MPFL reconstruction confers patellar stability, but with limited return to preinjury function and ability to maintain unrestricted military active duty status. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Using the Management Analysis and Reporting Tool database, we conducted a retrospective review of active duty servicemembers throughout the US Department of Defense Health System who underwent primary MPFL reconstruction between 2012 and 2015. Demographic variables were recorded as well as ability to return to impact activities-defined as running, jumping, rucking with a load >40 pounds (18 kg), and returning to airborne operations-and to remain on active duty status. The rates of recurrent instability and the need for subsequent surgeries were identified and assessed for statistical significance using uni- and multivariate analyses. Patients were evaluated for a minimum of 2 years postoperatively. RESULTS: Of the 213 patients who underwent primary MPFL reconstruction, including 34 with concomitant tibial tubercle osteotomy, 19 (8.9%) patients developed recurrent instability. The presence of bilateral patellar instability was associated with higher recurrence rate. Patients with bilateral instability comprised 47.3% of those with recurrence but only 24.9% of patients without recurrence (P = .019). Impact activity restrictions were present in 57.6% of patients (n = 121), with 86 patients (52.1%) undergoing medical separation from the military. Patients who were prescribed activity restriction before surgery were significantly more likely to have postoperative activity restrictions (64.5%; P = .019), and junior enlisted servicemembers were more likely to be medically separated from service postoperatively than higher ranking senior enlisted members or officers. CONCLUSION: Only 42.4% of US military servicemembers undergoing primary MPFL reconstruction were able to return to unrestricted impact activity after surgery. Bilateral instability negatively affected return to impact activities. Military servicemembers, particularly junior enlisted members, should be counseled on this poor prognosis for a full return to unrestricted activity postoperatively.

Decision making in treatment after a first-time anterior glenohumeral dislocation: A Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons.

BACKGROUND: The treatment of patients who sustain a first-time anterior glenohumeral dislocation (FTAGD) is controversial. The purpose of this study was to find consensus among experts using a validated iterative process in the treatment of patients after an FTAGD. METHODS: The Neer Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons. Consensus among 72 identified experts from this group was sought with a series of surveys using the Delphi process. The first survey used open-ended questions designed to identify patient-related features that influence treatment decisions after an FTAGD. The second survey used a Likert scale to rank each feature's impact on treatment decisions. The third survey used highly impactful features to construct 162 clinical scenarios. For each scenario, experts recommended surgery or not and reported how strongly they made their recommendation. These data were analyzed to find clinical scenarios that had >90% consensus for recommending treatment. These data were also used in univariate and multivariate mixed-effects models to identify odds ratios (ORs) for different features and to assess how combining these features influenced the probability of surgery for specific populations. RESULTS: Of the 162 scenarios, 8 (5%) achieved >90% consensus for recommending surgery. All of these scenarios treated athletes with meaningful bone loss at the end of their season. In particular, for contact athletes aged > 14 years who were at the end of the season and had apprehension and meaningful bone loss, there was >90% consensus for recommending surgery after an FTAGD, with surgeons feeling very strongly about this recommendation. Of the scenarios, 22 (14%) reached >90% consensus for recommending nonoperative treatment. All of these scenarios lacked meaningful bone loss. In particular, surgeons felt very strongly about recommending nonoperative treatment after an FTAGD for non-athletes lacking apprehension without meaningful bone loss. The presence of meaningful bone loss (OR, 6.85; 95% confidence interval, 6.24-7.52) and apprehension (OR, 5.60; 95% confidence interval, 5.03-6.25) were the strongest predictors of surgery. When these 2 features were combined, profound effects increasing the probability of surgery for different populations (active-duty military, non-athletes, noncontact athletes, and contact athletes) were noted, particularly non-athletes. CONCLUSION: Consensus for recommending treatment of the FTAGD patient was not easily achieved. Certain combinations of patient-specific factors, such as the presence of meaningful bone loss and apprehension, increased the probability of surgery after an FTAGD in all populations. Over 90% of shoulder instability experts recommend surgery after an FTAGD for contact athletes aged > 14 years at the end of the season with both apprehension and meaningful bone loss. Over 90% of experts would not perform surgery after a first dislocation in patients who are not athletes and who lack apprehension without meaningful bone loss.

Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response.

BACKGROUND: There is no consensus on the treatment of irreparable massive rotator cuff tears. The goal of this systematic review and meta-analysis was to (1) compare patient-reported outcome scores, (2) define failure and reoperation rates, and (3) quantify the magnitude of patient response across treatment strategies. METHODS: The MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus databases were searched for studies including physical therapy and operative treatment of massive rotator cuff tears. The criteria of the Methodological Index for Non-randomized Studies were used to assess study quality. Primary outcome measures were patient-reported outcome scores as well as failure, complication, and reoperation rates. To quantify patient response to treatment, we compared changes in the Constant-Murley score and American Shoulder and Elbow Surgeons (ASES) score with previously reported minimal clinically important difference (MCID) thresholds. RESULTS: No level I or II studies that met the inclusion and exclusion criteria were found. Physical therapy was associated with a 30% failure rate among the included patients, and another 30% went on to undergo surgery. Partial repair was associated with a 45% retear rate and 10% reoperation rate. Only graft interposition was associated with a weighted average change that exceeded the MCID for both the Constant-Murley score and ASES score. Latissimus tendon transfer techniques using humeral bone tunnel fixation were associated with a 77% failure rate. Superior capsular reconstruction with fascia lata autograft was associated with a weighted average change that exceeded the MCID for the ASES score. Reverse arthroplasty was associated with a 10% prosthesis failure rate and 8% reoperation rate. CONCLUSION: There is a lack of high-quality comparative studies to guide treatment recommendations. Compared with surgery, physical therapy is associated with less improvement in perceived functional outcomes and a higher clinical failure rate.

Revision anterior glenohumeral instability: is arthroscopic treatment an option?

BACKGROUND: The purpose of this study was to determine the short-term outcomes for patients who underwent revision surgery for shoulder instability, including both revision arthroscopic repair and Latarjet. METHODS: This study included patients who underwent revision of a prior arthroscopic labral repair to arthroscopic labral repair or Latarjet at our institution from 2012 to 2017. After collection of preoperative demographic data, preoperative 3-dimensional imaging was reviewed to determine percent glenoid bone loss (%GBL) and to determine whether each shoulder was on-track or off-track. Patients were contacted to obtain postoperative patient-reported outcome metrics including visual analog scale pain, Simple Shoulder Test, American Shoulder and Elbow Surgeons scores, and instability recurrence (full dislocation, subluxation, or subjective apprehension) data at a minimum of 2 years postoperatively. RESULTS: Of 62 patients who met criteria, 45 patients were able to be contacted. Of them, 21 underwent revision arthroscopy and 24 underwent a Latarjet procedure. In the revision arthroscopy group, 5 of 15 had %GBL >20% and 4 of 21 were contact athletes. In the Latarjet group, 11 of 22 had %GBL >20% and 5 of 24 were contact athletes. Of 21 revision arthroscopy patients, 8 underwent concomitant remplissage. Eight of 21 patients in the revision arthroscopy group and 7 of 21 patients in the Latarjet group reported instability postoperatively. Three of 21 patients in the revision arthroscopy group and 2 of 21 patients in the Latarjet group reported full dislocations postoperatively. Zero patients in the revision arthroscopy group and 1 of 21 patients in the Latarjet group underwent reoperation. CONCLUSION: Our results suggest that both revision Latarjet and arthroscopic stabilization can be of benefit in select circumstances. However, in revision settings, postoperative instability symptoms are common with both procedures.

Acromial morphology is not associated with rotator cuff tearing or repair healing.

BACKGROUND: The purposes of this study were to determine whether acromial morphology (1) could be measured accurately on magnetic resonance images (MRIs) as compared to computed tomographs (CTs) as a gold standard, (2) could be measured reliably on MRIs, (3) differed between patients with rotator cuff tears (RCTs) and those without evidence of RCTs or glenohumeral osteoarthritis, and (4) differed between patients with rotator cuff repairs (RCRs) that healed and those that did not. METHODS: This is a retrospective comparative study. We measured coronal, axial, and sagittal acromial tilt; acromial width, acromial anterior and posterior coverage, and glenoid version and inclination on MRI corrected into the plane of the glenoid. We determined accuracy by comparison with CT via intraclass correlation coefficients (ICCs). To determine reliability, these same measurements were made on MRI by 2 observers and ICCs calculated. We compared these measurements between patients with a full-thickness RCT and patients aged >50 years without evidence of an RCT or glenohumeral osteoarthritis. We then compared these measurements between those patients with healed RCRs and those with a retorn rotator cuff on MRI. In this portion, we only included patients with both a preoperative MRI and a postoperative MRI at least 1 year from RCR. Only those patients without tendon defects on postoperative MRIs were considered to be healed. In these patients, we also radiographically measured the critical shoulder angle. RESULTS: In a validation cohort of 30 patients with MRI and CT, all ICCs were greater than 0.86. In these patients, the inter-rater ICCs of the MRI measurements were >0.53. In our RCT group of 110 patients, there was greater acromial width [mean difference (95% confidence interval) = 0.1 (0, 0.2) mm, P = .012] and significantly less sagittal acromial tilt [9° (5°-12°), P < .001] than in our comparison group of 107 patients. A total of 110 RCRs were included. Postoperative MRI scans were obtained at a mean follow-up of 24.2 ± 15.8 months, showing 84 patients (76%) had healed RCRs. Aside from acromial width, which was 0.2 mm different and thus did not have clinical significance, there was no association between healing and any of the measured morphologic characteristics. Patients with healed repairs had significantly smaller tears in terms of both width (P < .001) and retraction (P < .001). CONCLUSION: Although the acromion is wider in RCTs, the difference of 0.1 mm likely has no clinical significance. The acromion is more steeply sloped from posteroinferior to anterosuperior in those with RCTs. These findings call into question subacromial impingement due to native acromial morphology as a cause of rotator cuff tearing. Acromial morphology, critical shoulder angle, and glenoid inclination were not associated with healing after RCR. This study does not support lateral acromioplasty.

Defining massive rotator cuff tears: a Delphi consensus study.

BACKGROUND: A standard definition for massive rotator cuff tears (MRCTs) has not been identified. The purpose of this study is to use the modified Delphi technique to determine a practical, consensus definition for MRCTs. METHODS: This study is based on responses from 20 experts who participated in 4 rounds of surveys to determine a consensus definition for MRCT. Consensus was achieved when at least 70% of survey responders rated an item at least a 4 on a 5-point scale. A set of core characteristics was drafted based on literature review and then refined to achieve a consensus MRCT definition. RESULTS: The following core characteristics reached consensus in the first round: tear size, number of tendons torn, and degree of medial retraction. Magnetic resonance imaging (MRI) and intraoperative findings reached consensus as the modalities of diagnosis. The second round determined that tear size should be measured as a relative value. An initial definition for MRCT was proposed in the third round: retraction of tendon(s) to the glenoid rim and/or a tear with ≥67% greater tuberosity exposure (65% approval). A modified definition was proposed that specified that degree of retraction should be measured in the coronal or axial plane and that the amount of greater tuberosity exposure should be measured in the sagittal plane (90% approval). CONCLUSIONS: This study determined with 90% agreement that MRCT should be defined as retraction of tendon(s) to the glenoid rim in either the coronal or axial plane and/or a tear with ≥67% of the greater tuberosity exposed measured in the sagittal plane. The measurement can be performed either with MRI or intraoperatively.

Minimal clinically important differences in the American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale pain scores after arthroscopic rotator cuff repair.

BACKGROUND: Minimal clinically important differences (MCIDs) for different patient outcome scores have been reported for various shoulder diseases, including shoulder arthroplasty and the nonoperative treatment of rotator cuff disease. The purpose of this study was to assess the MCID for the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) measuring pain, after arthroscopic rotator cuff repair. METHODS: A total of 202 patients who underwent arthroscopic rotator cuff repair were retrospectively reviewed. ASES, SST, and VAS pain scores were collected preoperatively and at 1 year postoperatively. The MCID was then calculated via a 4-question anchor-based method. RESULTS: The MCID results for the ASES, SST, and VAS pain scores were 27.1, 4.3, and 2.4, respectively. Age at time of surgery, sex, anteroposterior tear size, and worker's compensation status were not associated with MCID values (P > .05). CONCLUSION: The MCID values determined in the current study are higher than those previously identified for the nonoperative treatment of rotator cuff disease using the same anchor questions. Use of these higher values should be considered when evaluating improvements of individual patients after rotator cuff repair, to determine comparative effectiveness of various rotator cuff repair techniques and to determine sample sizes for prospective comparative trials of rotator cuff repair methods.

A Cost-Minimization Analysis of Intraoperative Costs in Arthroscopic Bankart Repair, Open Latarjet, and Distal Tibial Allograft.

BACKGROUND: The optimal surgical treatment of anterior shoulder instability remains controversial. HYPOTHESIS: (1) Implants and facility-related costs are the primary drivers of variation in direct costs between arthroscopic Bankart and Latarjet procedures, and (2) distal tibial allograft (DTA) is more costly than Latarjet as a function of the graft expense. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Intraoperative cost data were derived for all arthroscopic anterior stabilizations and Latarjet and DTA procedures performed at a single academic institution from January 2012 to September 2017. Cost comparisons were made between those undergoing arthroscopic stabilization and Latarjet and between Latarjet and DTA. Multivariate regressions were performed to determine the difference in direct costs accounting for various patient- and surgery-related factors. RESULTS: A total of 87 arthroscopic stabilizations, 44 Latarjet procedures, and 5 DTA procedures were performed during the study period. Arthroscopic Bankart repair was found to be 17% more costly than Latarjet, with suture anchor implant cost being the primary driver of cost. DTA was 2.9-fold more costly than Latarjet, with greater costs across all domains. Multivariate analysis also found the number of prior arthroscopic procedures performed (P = .007) and whether the procedure was performed in an ambulatory or inpatient setting (P < .0001) to be significantly associated with higher direct costs. CONCLUSION: Latarjet is less costly than arthroscopic Bankart repair, largely because of implant cost. Value-driven strategies to narrow the cost differential could focus on performing these procedures in an outpatient setting in addition to reducing overall implant cost for arthroscopic procedures. Perceived potential benefits of DTA over Latarjet may be outweighed by higher costs.

Editorial Commentary: All-Suture Anchor for Medial-Row Fixation in Rotator Cuff Repair-Ready for Prime Time?

We, orthopaedic surgeons, are always on the watch for suture anchor approaches that will enhance our potential for success with tendon-to-bone healing or at least make their use easier or more applicable in certain situations. It is always best to have some biomechanical testing to compare recently introduced suture anchors with established and more studied conventional anchors. Although this is a good start, unfortunately, secondary aspects of an anchor sometimes are only observed after use in a biological setting. An all-suture anchor certainly can be inserted with a smaller starting defect in the proximal humerus, which could help in different settings when trying to accomplish a rotator cuff repair. However, as in many biomechanical studies, we need to be cautious about how the findings apply to the actual clinical situation.

Preoperative Factors Associated With Subsequent Distal Clavicle Resection After Rotator Cuff Repair.

BACKGROUND: Acromioclavicular osteoarthritis and rotator cuff tears are commonly coincident. PURPOSE: To determine the rate of subsequent distal clavicle excision (DCE) when rotator cuff repair (RCR) is performed without DCE and the risk factors for subsequent DCE after RCR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: The operative logs of 2 surgeons from 2007 to 2016 were retrospectively reviewed for all patients who underwent RCR with or without DCE. Preoperative demographic data, symptoms, physical examination, and standardized outcomes (visual analog scale for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) were noted. Acromioclavicular (AC) arthritis was classified on preoperative radiographs. The rate of subsequent surgery on the AC joint was determined via chart review, and univariate and multivariate analyses were conducted to determine risk factors for revision. RESULTS: In total, 894 patients underwent isolated RCR, and 46 underwent concomitant RCR and DCE. On retrospective chart review, of those who underwent isolated RCR, the revision rate for any reason was 7.5% (67 patients), and the rate of subsequent AC surgery was 1.1% (10 patients). Preoperatively, 88% of the total cohort was considered to have a radiographically normal AC joint. On multivariate analysis of patients who underwent isolated RCR, the risk factors for subsequent AC surgery included preoperative tenderness to palpation at the AC joint (10% vs 63%, P < .001), female sex (35% vs 80%, P < .001), and surgery on the dominant side (60% vs 100%, P = .002). On multivariate analysis, these 3 factors explained 50% of the variance in revision AC surgery. When these 3 factors were present in combination, there was a 40% rate of revision AC surgery. CONCLUSION: This records review found that 10 of 894 (1.1%) rotator cuff repairs underwent subsequent distal clavicle resection. Risk factors for subsequent DCE included tenderness to palpation at the AC joint, female sex, and surgery on the dominant side, with subsequent DCE performed in 40% of cases with a combination of these 3 factors. Because the duration of follow-up was short and the number of reoperations small, some caution is recommended in interpreting these results, as the analyses may be underpowered.

Patient- and Procedure-Specific Variables Driving Total Direct Costs of Outpatient Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Few studies have investigated the influence of patient-specific variables or procedure-specific factors on the overall cost of anterior cruciate ligament reconstruction (ACLR) in an ambulatory surgery setting. PURPOSE: To determine patient- and procedure-specific factors influencing the overall direct cost of outpatient arthroscopic ACLR utilizing a unique value-driven outcomes (VDO) tool. STUDY DESIGN: Cohort study (economic and decision analysis); Level of evidence, 3. METHODS: All ACLRs performed by 4 surgeons over 2 years were retrospectively reviewed. Cost data were derived from the VDO tool. Patient-specific variables included age, body mass index, comorbidities, American Society of Anesthesiologists (ASA) classification, smoking status, preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Testing (PF-CAT) score, and preoperative Single Assessment Numeric Evaluation (SANE) score. Procedure-specific variables included graft type, revision status, associated injuries and procedures, time from injury to ACLR, surgeon, and operating room (OR) time. Multivariate analysis determined patient- and procedure-related predictors of total direct costs. RESULTS: There were 293 autograft reconstructions, 110 allograft reconstructions, and 31 hybrid reconstructions analyzed. Patient-specific factors did not significantly influence the ACLR cost. The mean OR time was shorter for allograft reconstruction (P < .001). Predictors of an increased direct cost included the use of an allograft or hybrid graft (44.5% and 33.1% increase, respectively; P < .001), increased OR time (0.3% increase per minute; P < .001), surgeon 3 or 4 (9.1% or 5.9% increase, respectively; P < .001 or P = .001, respectively), and concomitant meniscus repair (24.4% increase; P < .001). Within the meniscus repair cohort, all-inside, root, and combined repairs correlated with a 15.5%, 31.4%, and 53.2% increased mean direct cost, respectively, compared with inside-out repairs (P < .001). CONCLUSION: This study failed to identify modifiable patient-specific factors influencing direct costs of ACLR. Allografts and hybrid grafts were associated with an increased total direct cost. Meniscus repair independently predicted an increased direct cost, with all-inside, root, and combined repairs being costlier than inside-out repairs. The time-saving potential of all-inside meniscus repair was not realized in this study, making implant use a significant factor in the overall cost of ACLR with meniscus repair.

Revisiting the Anterior Glenoid: An Analysis of the Calcified Cartilage Layer, Capsulolabral Complex, and Glenoid Bone Density.

PURPOSE: In this cadaveric study, we aim to define the basic anatomy of the anterior glenoid with attention to the relationships of calcified cartilage, capsulolabral complex, and osseous morphology of the anterior glenoid. METHODS: Seventeen cadaveric glenoid specimens (14 male, 3 female, mean age 53.9 ± 10) were imaged with micro-computed tomography (CT) and embedded in poly-methyl-methacrylate. Specimens were included for final analysis only if the entire glenoid articular cartilage, labrum, capsule, and biceps insertion were pristine and without evidence of injury, degeneration, or damage during the preparation process. Group 1 members (n = 9) were axially sectioned through 3 to 9 o'clock and 4 to 8 o'clock; group 2 members (n = 8) were radially sectioned through 3, 4, 5, and 9 o'clock. A scanning electron microscope (SEM) analysis quantified the percentage of bone within a 5 × 2.5 mm region at the glenoid rim. Micro-CT, SEM, and light microscopy evaluated the capsulolabral complex and calcified fibrocartilage. RESULTS: A 7 ± 2.1 mm region of calcified fibrocartilage at 4 o'clock was identified from the articular face to the medial glenoid neck supporting the overlying capsulolabral footprint and was >3× thicker at the articular attachment (316 ± 153 µm) versus the glenoid neck (92 ± 66 µm). At 3 to 9 o'clock and 4 to 8 o'clock 79.2% ± 5.4% and 75.2% ± 7.8% of the glenoid osseous width was covered with articular cartilage. The labrum accounted for 13.1% ± 3.4% of the glenoid width at 4 o'clock. SEM analysis demonstrated decreased glenoid bone density at 3, 4, and 5 o'clock (P ≤ .015) and no difference (P = .448) at 9 o'clock versus central subchondral bone. CONCLUSIONS: The capsulolabral footprint contributes significantly to the glenoid face, inserts directly adjacent to the articular cartilage, and extends medially along the glenoid neck. A layer of calcified fibrocartilage lies immediately beneath the capsulolabral footprint and is 3× thicker at the articular insertion compared with the glenoid neck. Lastly, there is a bone density gradient at the anterior-inferior rim versus the central subchondral bone. CLINICAL RELEVANCE: Arthroscopic Bankart repair has been reported to have a significant failure rate in many settings. It is felt that reproducing anatomy with the repair could help improve outcomes. Based on this study's findings, an arthroscopic Bankart technique that most closely reproduces native anatomy and potentially optimizes soft-tissue healing could be performed. This includes removal of 1 to 2 mm of articular cartilage from the glenoid face with anchor placement at this location to appropriately reposition the capsulolabral complex.

Editorial Commentary: To Cyst or Not to Cyst: Shoulder SLAP Lesions With Concomitant Spinoglenoid Notch Ganglion Cysts.

When a patient presents with shoulder pain and the workup reveals a spinoglenoid notch cyst, it is presumed by most to be related to an intra-articular SLAP tear. When managing this condition cyst excision has been advocated to alleviate suprascapular nerve pressure and also perhaps minimize recurrence assuming that the SLAP has also been treated. Cyst excision can endanger the suprascapular nerve and takes additional operating room time. The question is whether repairing the SLAP and therefore removing the starting point for the cyst would be adequate as the only surgical management. My preference is to leave the operating room with some indication that the pressure on the suprascapular nerve has been dealt with by at least decompressing the cyst. But on the basis of recent published experience, we may need to re-evaluate this.

The critical acromial point: the anatomic location of the lateral acromion in the critical shoulder angle.

BACKGROUND: Acromioplasty has been proposed as a means of altering elevated critical shoulder angles (CSAs). We aimed to localize the critical acromion point (CAP) responsible for the acromial contribution of the CSA and determine whether resection of the CAP can alter the CSA to a normal range. METHODS: The CAP and 3-dimensional (3D) CSAs were determined on 3D computed tomography reconstructions of 88 cadaveric shoulders and compared with corresponding CSAs on digitally reconstructed radiographs. The position of the CAP was fluoroscopically isolated in 20 of these specimens and the resulting fluoroscopic CSA compared with the corresponding 3D CAP and 3D CSA. We investigated the CSA before and after a virtual acromioplasty of 2.5 and 5 mm at the CAP in specimens with a CSA greater than 35°. RESULTS: The mean CAP was 21% ± 10% of the acromial anterior-posterior length from the anterolateral corner. There was no difference between the mean 3D CSA and the CSA on digitally reconstructed radiographs (32° vs 32°, P = .096). No difference between the mean fluoroscopic CSA and 3D CSA was found (31° vs 31°, P = .296). A 2.5-mm acromial resection failed to reduce the CSA to 35° or less in 7 of 13 shoulders, whereas a 5-mm resection reduced the CSA to 35° or less in 12 of 13. CONCLUSION: The CAP was localized to the anterolateral acromial edge and was easily identified fluoroscopically. A 5-mm acromial resection was effective in reducing the CSA to 35° or less. These data can guide surgeons in where and how to alter the CSA if future studies demonstrate a clinical benefit to surgically modifying this radiographic parameter.

Factors influencing direct clinical costs of outpatient arthroscopic rotator cuff repair surgery.

BACKGROUND: Very limited information exists about factors affecting direct clinical costs of rotator cuff repair surgery. The purpose of this study was to determine the direct cost of outpatient arthroscopic rotator cuff repair surgery using a unique value-driven outcomes tool and to identify patient- and treatment-related variables affecting cost. METHODS: Cost data were derived for arthroscopic rotator cuff repairs performed by 3 surgeons from March 2014 to June 2015 using the value-driven outcomes tool. Costs included overall total direct cost, which included facility utilization costs, medication costs, supply costs, and other ancillary costs. Univariate and multivariate regressions were performed to determine the effect of various patient-related and surgical-related factors on costs. RESULTS: There were 170 arthroscopic rotator cuff repairs performed during the study period. Multivariate analysis showed significant correlations between higher total direct cost and the presence of a subscapularis repair being performed (P = .015) and total number of anchors used (P < .0001). Higher body mass index, severe systemic illness, 1 of the 3 surgeons, biceps tenodesis using an anchor, and total sum of anchors were correlated with higher facility utilization costs (P < .04). Severe systemic illness, addition of a subscapularis repair, 1 of the 3 surgeons, and additional subacromial decompression were correlated with higher pharmacy costs (P < .006). The addition of a subscapularis repair, total sum of anchors, and severe muscle changes to the supraspinatus were correlated with higher supply costs (P < .015). CONCLUSIONS: From a direct cost perspective, implementation of strategies to reduce overall costs should focus on reducing overall anchor quantity or price.

Biomechanical Comparison of Transosseous Knotless Rotator Cuff Repair Versus Transosseous Equivalent Repair: Half The Anchors With Equivalent Biomechanics?

PURPOSE: To compare the biomechanics of a transosseous equivalent (TOE) repair using medial and lateral anchors with tape to a transosseous knotless (TOK) tape repair with only laterally placed intraosseous anchors. METHODS: One of 2 different repairs were performed on 8 paired specimens: (1) transosseous equivalent (TOE) tape repair or (2) transosseous knotless (TOK) tape repair. Specimens were mounted on a materials testing machine and loaded in uniaxial tension to measure cyclic construct gap formation, followed by failure testing. Paired t tests were used to compare gapping, ultimate stiffness, and failure loads. Fisher exact test was used to compare modes of failure (soft tissue failure vs construct failure). RESULTS: Peak cyclic gapping, failure stiffness, and ultimate failure loads did not differ between TOE and TOK repairs (P = .140 for gapping, P = .106 for stiffness, and P = .672 for peak failure loads). All TOK repairs failed via soft tissue failure medial to the medial suture line, with no construct failures. TOE repairs failed more often through construct failure (anchor migration or suture-bone interface cut through) than TOK repairs (P = .026). CONCLUSION: TOK repairs only failed through soft tissue whereas TOE repairs failed through both soft tissue and the repair construct. Despite 50% fewer suture anchors in the TOK repairs than the TOE repairs, cyclic gapping and ultimate stiffness and failure loads were not significantly different. CLINICAL RELEVANCE: The transosseous knotless construct presented is a 2-anchor construct that is equivalent in biomechanical function to a traditional 4-anchor construct, reducing anchor load in the tuberosity.

Findings Associated With Knee Pathology on MRI in Patients Without Osteoarthritis.

INTRODUCTION: We conducted a retrospective study in patients with minimal or no radiographically evident knee osteoarthritis to determine whether presenting signs and symptoms were predictive of knee pathology that was evident on MRI and could be treated with nonarthroplasty knee surgery or could alter nonsurgical treatment. METHODS: We reviewed records of patients for whom sports medicine orthopaedic surgeons had ordered an MRI of the knee. Univariate analysis identified factors that were associated with positive MRI findings (eg, surgically treatable lesion, meniscal tear) or a finding that could alter treatment. We used multivariate logistic regression to determine independent predictors of evidence of pathology on MRI. RESULTS: Of the 434 patients in the study, 281 (64.7%) had evidence of knee pathology on MRI. Acute injury, effusion, and ligamentous instability were among the independent predictors of positive MRI results. Patients with evidence of knee pathology on MRI were more likely to have undergone surgery. DISCUSSION: Specific aspects of patient history and physical examination are associated with evidence of knee pathology on MRI. CONCLUSIONS: In patients without osteoarthritis, positive findings on knee MRI could be associated with a number of presenting signs and symptoms, and this information could aid physicians in deciding which patients should undergo knee MRIs. Additional prospective research is needed to validate the relationships discovered in our study. LEVEL OF EVIDENCE: Level III retrospective study.

Should We Have a Better Definition of Pseudoparalysis in Patients With Rotator Cuff Tears?

Pseudoparalysis has been previously described as the inability to elevate the arm over 90° in the setting of a rotator cuff tear. Controversy exists regarding the optimal treatment for patients with a pseudoparalytic shoulder with a rotator cuff tear with options including rotator cuff repair and reverse shoulder arthroplasty. Recent literature suggests that pseudoparalysis can reliably be corrected with a rotator cuff repair and is more cost effective than reverse shoulder arthroplasty. We believe that the arbitrary cutoff of 90° is too generous and leads to confusion. We believe that the definition of pseudoparalysis needs to be refined to clarify indications for treatment and not base a decision on a simple measurement without other factors considered. We suggest that pseudoparalysis as a description should include elevation limited to up to 45°. The patient should also be described as having a chronic and essentially atraumatic onset of symptoms and the rotator cuff tear is massive with at least grade II to III fatty infiltration. Only with increasing precision and describing the actual patient situation and limitations will we be more able to correctly compare treatment alternatives.