Arthroscopic Visualization Is a Reliable Method of Confirming Femoral Button Placement During Anterior Cruciate Ligament Reconstruction.

Purpose: To compare arthroscopic visualization with intraoperative fluoroscopy for confirming proper femoral button placement during ACLR. Methods: Fifty consecutive patients undergoing soft-tissue ACLR between March 2021 and February 2022 were evaluated for inclusion in this study. Both primary and revision ACLR cases using suspensory fixation were included. Surgeons rated their confidence of proper button placement from both an intra-articular perspective (through the femoral tunnel) and an extra-articular perspective (through the iliotibial band) by grading confidence with a Likert scale. Fluoroscopy was also performed for confirmation of proper button placement. Results: Fifty consecutive patients (35.1 ± 14.5 years of age) with soft-tissue ACLR were included. Mean surgeon Likert confidence scores for accurate button placement were as follows: 4.1 of 5 ± 0.9 from an intra-articular perspective, 4.6 of 5 ± 0.7 from an extra-articular perspective, and 8.7 of 10 ± 1.4 based on the sum of intra- and extra-articular perspectives. Fluoroscopic findings demonstrated that 48 of 50 cases had an appropriate flipped button on the lateral cortex of the femur. I total, 2 of 50 had soft-tissue interposition. Cases in which surgeons had high confidence from both intra- and extra-articular perspectives (≥9/10 sum score) were indicative of proper button placement 97% of the time. Conclusions: Arthroscopic visualization is a reliable method of confirming femoral button placement during ACLR and is sufficient to rule out intraoperative fluoroscopy during surgery. ACLR cases with high surgeon confidence from both intra- and extra-articular perspectives (sum score of 9 or greater out of 10) resulted in proper femoral button placement in 97% of cases as confirmed by intraoperative fluoroscopy. Level of Evidence: Level II, prospective cohort study.

Opioid Requirement After Anterior Cruciate Ligament Surgery: Opioid Use After Anterior Cruciate Ligament Surgery Is Low With a Multimodal Approach, and Fifteen Oxycodone 5-mg Tablets Are Sufficient.

Purpose: To prospectively determine opioid consumption in patients undergoing anterior cruciate ligament (ACL) repair and reconstruction and to develop evidence-based prescription guidelines following ACL surgery. Methods: This multicenter prospective study enrolled patients undergoing ACL reconstruction and repair. Subject demographics and opioid prescriptions were recorded at enrollment. All patients were given education on opiate use and followed the same perioperative, multimodal analgesic regimen. Following surgery, patients were given postoperative "pain journals" to document visual analog scale pain scores and daily opioid consumption for the first 7 postoperative days and on postoperative visit at 14 days. Results: In total, 50 patients were included in this analysis between the ages of 14 and 65 years. Patients were prescribed a median of 15 oxycodone 5-mg pills and consumed a median of 2 pill postoperatively (range 0-19 pills). 38% of patients consumed 0 opioid pills, 74% of patients consumed ≤5 opioid pills, and 96% of patients consumed ≤15 opioid pills. Patients reported a mean daily visual analog scale value of 2.8 of 10; mean satisfaction with pain management was high at 4.1/5 on a Likert satisfaction score. Overall, patients consumed a mean 34% of their opioid prescriptions, leaving 436 opioid pills not consumed. Conclusions: This study suggests that current expert panels may be recommending an excessive volume of opioids. Based on our findings, we recommend that patients be prescribed no more than 15 Oxycodone 5-mg tablets following ACL surgery. Despite this lower volume prescription, mean pain scores remained below 3 of 10, patient satisfaction with pain control remained high, and 66% of opiate medication prescribed was not used. Level of Evidence: II, prospective prognostic cohort investigation.

Biomechanical evaluation of subscapularis peel repairs augmented with the long head of the biceps tendon for anatomic total shoulder arthroplasty.

BACKGROUND: Subscapularis failure is a troublesome complication following anatomic total shoulder arthroplasty (aTSA). Commonly discarded during aTSA, the long head of the biceps tendon (LHBT) may offer an efficient and cheap autograft for the augmentation of the subscapularis repair during aTSA. The purpose of this study was to biomechanically compare a standard subscapularis peel repair to 2 methods of subscapularis peel repair augmented with LHBT. METHODS: 18 human cadaveric shoulders (61 ± 9 years of age) were used in this study. Shoulders were randomly assigned to biomechanically compare subscapularis peel repair with (1) traditional single-row repair, (2) single row with horizontal LHBT augmentation, or (3) single row with V-shaped LHBT augmentation. Shoulders underwent biomechanical testing on a servohydraulic testing system to compare cyclic displacement, load to failure, and stiffness. RESULTS: There were no significant differences in the cyclic displacement between the 3 techniques in the superior, middle, or inferior portion of the subscapularis repair (P > .05). The horizontal (436.7 ± 113.3 N; P = .011) and V-shape (563.3 ± 101.0 N; P < .001) repair demonstrated significantly greater load to failure compared with traditional repair (344.4 ± 82.4 N). The V-shape repair had significantly greater load to failure compared to the horizontal repair (P < .001). The horizontal (61.6 ± 8.4 N/mm; P < .001) and the V-shape (62.8 ± 6.1; P < .001) repairs demonstrated significantly greater stiffness compared to the traditional repair (47.6 ± 6.2 N). There was no significant difference in the stiffness of the horizontal and V-shape repairs (P = .770). CONCLUSIONS: Subscapularis peel repair augmentation with LHBT autograft following aTSA confers greater time zero load to failure and stiffness when compared to a standard subscapularis peel repair.

Periarticular liposomal bupivacaine mixture injection vs. single-shot interscalene block for postoperative pain in arthroscopic rotator cuff repair: a prospective randomized controlled trial.

BACKGROUND: The pain control efficacy, postoperative opioid requirements, and costs among patients undergoing major shoulder surgery using different perioperative analgesia modalities have been topics of active debate. Several studies have compared periarticular injection (PAI) to interscalene block (ISB) in shoulder arthroplasty, but there is a paucity of data comparing them in arthroscopic rotator cuff repair. METHODS: Patients aged 18-80 years with full-thickness rotator cuff tears and undergoing primary arthroscopic rotator cuff repair at 2 different shoulder centers were screened and subsequently randomized to receive either periarticular injection (PAI) of liposomal bupivacaine mixed with 0.25% bupivacaine (n = 41) or single-shot interscalene nerve block (ISB) (n = 36). Visual analog scale (VAS) pain scores, oral morphine equivalent (OME) use, Single Assessment Numerical Evaluation (SANE) scores, and costs were collected. Differences with P <.05 were considered statistically significant. RESULTS: Day of surgery VAS score and OME usage were significantly reduced with ISB vs. PAI (0.69 vs. 4.65, P < .001, and 18.66 vs. 34.39, P < .001, respectively). There were no significant differences between groups regarding VAS score on postoperative days (PODs) 1-3; however, OME usage on PODs 1 (50.5 vs. 38.8, P = .03) and 2 (48.1 vs. 37.8, P = .04) was significantly more in the ISB group. At POD 3, VAS score (4.13 vs. 3.97, P = .60) and OME use (28.60 vs. 31.16, P = .51) were similar. At 6 and 12 weeks, there were also no significant differences between groups regarding VAS and OME use. There was no difference in SANE score at 12 weeks following surgery between groups and no difference between average 12-week cumulative OME use between groups. The average charge for the PAI was $455, and the average charge for ISB was $745. CONCLUSION: Both ISB and PAI provide acceptable pain control following arthroscopic rotator cuff repair. Patients have less pain on the day of surgery with ISB, but rebound pain is significant after the block wears off, resulting in substantially increased opioid use in the first 2 PODs. However, cumulative opioid use between groups was similar. There were also no significant differences at the end of the 12-week episode of care in any of the other variables studied. The charge per patient for PAI is approximately $300 less than ISB. Thus, PAI may offer surgeons and patients an effective postoperative analgesic modality as an alternative to ISB.

Narcotic requirements after shoulder arthroplasty are low using a multimodal approach to pain.

BACKGROUND: Recent "multimodal" approaches to pain, although understudied, have shown promise in reducing reliance on narcotics in shoulder arthroplasty (SA). Many surgeons report being unsure of how many narcotic pills to prescribe after the surgery. As result, patients are prescribed upwards of 60 oxycodone 5-mg pills for a 6-to-12-week treatment period despite studies showing postoperative pain can be managed without any medication at all. PURPOSE: The purpose of this multicenter study was to prospectively determine the number of opiate pills required after SA to develop generalizable, evidence-based prescription guidelines for surgeons. We hypothesized that opioid prescription would be low using a multimodal approach to pain management. METHODS: The study enrolled 63 patients undergoing SA. Subjects received either an interscalene nerve block with liposomal bupivacaine, standard bupivacaine, or a local infiltration standard bupivacaine field block based on preference. All subjects were provided with postoperative "Pain Journals" to document their daily pain on a Numerical Rating Scale and daily opioid consumption during the 14-day postoperative period. RESULTS: Overall, patients consumed an average of 8.6 oxycodone 5-mg pills (64.5 morphine milligram equivalents) after SA. Seventy-nine percent of patients required 15 or fewer oxycodone 5-mg pills, and 27% successfully managed their postoperative pain with zero opioids. Average pain remained low for patients in all groups. CONCLUSION: With a multimodal approach, most patients undergoing SA can manage postoperative pain with 15 or fewer oxycodone 5-mg tablets, or 112.5 morphine milligram equivalents. The addition of a liposomal bupivacaine interscalene nerve block may further reduce the consumption of postoperative narcotics compared with a standard interscalene nerve block. This study provides evidence that may be used for surgeon guidelines in the effort to reduce opioid prescriptions after SA.

Differences in Patient and Physician Perceptions of Urgency for Musculoskeletal Conditions During the COVID-19 Pandemic.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic limited musculoskeletal care to urgent or "nonelective" office visits and procedures. No guidelines exist to inform patients or physicians what meets these criteria. The purpose of this multi-institutional study was to describe the differences in perceptions of urgency for musculoskeletal complaints between patients and providers during the COVID-19 pandemic. An anonymous survey was distributed to patients who visited the authors' orthopedic clinics in January and February 2020 and practicing orthopedic surgeons. The surveys were administered in May 2020 after COVID-19 was officially labeled a pandemic and included questions regarding demographic information and perceptions of orthopedic urgency. A total of 1491 patients and 128 physicians completed the surveys. A significantly higher percentage of physicians considered the following diagnoses an appropriate indication for an urgent visit compared with patients: fracture (P<.001), acute dislocation (P<.001), infection (P<.001), neurologic compromise (P<.001), tumor (P<.001), acute tendon injury (P<.001), weakness (P<.001), inability to bear weight (P<.001), post-surgical problem (P<.001), and painful joint effusion (P<.001). There were no significant differences in the perception of urgency for the following conditions: bursitis/tendonitis (P=1.00), joint/extremity deformity without pain (P=.113), and loss of range of motion of a joint (P=.467). Younger patients and those with higher levels of education were significantly more likely to consider their conditions urgent. Patients may require additional education to prevent delay in treatment of urgent conditions-especially time-sensitive conditions such as neurologic compromise, tumors, and infections-when access to physicians is limited. [Orthopedics. 2021;44(4):e534-e538.].

Opioid Consumption After Knee Arthroscopy.

PURPOSE: To prospectively observe opioid consumption in patients undergoing knee arthroscopy and to create an evidence-based guideline for opioid prescription. METHODS: This prospective multicenter observational study enrolled patients undergoing outpatient knee arthroscopy for meniscal repair, meniscectomy, or chondroplasty. Patients were provided with a pain journal to record postoperative opioid consumption, Numeric Pain Rating Scale (NPRS) pain scores, and Likert scale satisfaction scores for 1 week postoperatively. State databases were reviewed for additional opioid prescriptions. RESULTS: One hundred patients were included in this study. Patients were prescribed a median of 5 pills (37.5 oral morphine equivalent [OME]). Median postoperative opioid consumption was 0 pills, with a mean of 0.6 pills (4.4 OME), and 74% of patients did not consume any opioid medication postoperatively. All patients consumed ≤5 pills (37.5 OME), and no patient required a refill. Patients reported a mean daily NPRS value of 1.9 out of 10 and a mean Likert score of 4.4 out of 5. CONCLUSION: We found that current opioid prescribing habits exceed the need for postoperative pain management. Overall, all patients consumed ≤5 opioid pills, and 92% of patients discontinued opioids by the second postoperative day. In spite of the low prescription quantity, patients reported high satisfaction rates and low NPRS pain scores and required no refills. Therefore, we recommend that patients undergoing knee arthroscopy are prescribed no more than 5 oxycodone 5-mg pills. LEVEL OF EVIDENCE: II, prospective prognostic cohort investigation.

Opioid requirement after rotator cuff repair is low with a multimodal approach to pain.

BACKGROUND: Current practices may aim to blunt rather than understand postoperative pain. Perhaps the most common serious complication of arthroscopic rotator cuff repair (ARCR) is persistence of opiate medication intake. Patients still receive upwards of 80 oxycodone 5 mg pills, or 600 morphine milligram equivalents (MMEs), leading more than 20% of opioid-naïve subjects to continue to fill opioid prescriptions beyond 180 days after surgery. Developing evidence-based guidelines for narcotic prescription after ARCR presents an opportunity for orthopedic surgeons to address the opioid epidemic. PURPOSE: The purpose of this study was (1) to prospectively determine the requirements for opiate medications after ARCR, and (2) to create an evidence-based guideline for postoperative prescription, in contrast to the anecdotal or expert panel recommendations that currently exist. We further investigated whether a liposomal bupivacaine (LB) interscalene never block (ISNB) would reduce pain and opiate consumption compared with standard bupivacaine ISNB (control) for ARCR. METHODS: The study enrolled 100 patients who underwent primary ARCR surgery. Patients were provided with postoperative "pain journals" to document their daily pain on a numerical rating scale, satisfaction with pain management using the Likert scale, and track their daily oxycodone 5 mg pill consumption during the 14-day postoperative period. Enrolled patients were further randomized to receiving an LB (experimental) or standard bupivacaine (control) ISNB. RESULTS: A total of 77% of all patients required fewer than 15 pills postoperatively. The LB group consumed an average of 1.7 fewer pills (13.0 MMEs) on postoperative day (POD) 1 (P = .02) and reported statistically lower pain during PODs 1 and 2 (P = .01 and P = .006), as well as cumulatively throughout the study period (P = .03). In addition, LB patients remained opioid-free at a higher rate (44% vs. 15% in controls, P = .03). CONCLUSION: With a multimodal approach, the majority of patients undergoing ARCR can manage postoperative pain with 15 or fewer oxycodone 5 mg tablets (112.5 MMEs) and maintain a high degree of satisfaction. The addition of an LB ISNB may further reduce the consumption of postoperative narcotics compared with a standard ISNB. This study provides evidence that may be used for surgeon guidelines in the effort to reduce opioid prescriptions after ARCR.

The interaction between human rotator cuff tendon and subacromial bursal tissue in co-culture.

BACKGROUND: The role of subacromial bursa in rotator cuff pathology is unclear. Along with recognized inflammatory potential, current data demonstrate the presence of mesenchymal stem cells and potential regenerative properties of the bursa. The purpose of this study was to (1) approximate an in vitro co-culture model that represents interaction between torn rotator cuff tendon and subacromial bursa, (2) quantify the cellular activity of tendon and bursa and their interactions, (3) use this model to induce a state of inflammation present with rotator cuff pathology. METHODS: In part 1, tendon and bursa samples were obtained from 6 patients undergoing rotator cuff repair. Tendon and bursa were cultured alone and together in co-culture wells for 21 days. Markers specific for tenocyte gene expression (tenascin C, decorin, etc) were measured in both tendon and bursa alone and compared to co-culture models. In part 2 of the study, an inflammatory state was induced with interleukin-1ß treatment, and markers of inflammation were measured via protein assay at 0 and 21 days in samples from 7 additional patients. RESULTS: There was an increase in tendon and bursa markers in nearly all groups as evidenced by increased gene expression of known tendon and bursa markers. There was a significant increase in gene expression when torn tendon was co-cultured with bursa compared with culturing alone. Additionally, a state of inflammation was induced as evidenced by increased markers of inflammation, inflammatory protein concentration, and inflammatory cells and disruption of histologic morphology. CONCLUSION: There is a clear interaction between rotator cuff tendon and the milieu produced by the subacromial bursa in this in vitro co-culture system that is significantly different when compared to an isolated culture of tendon and bursa. This system was successfully used to induce a state of inflammation that may represent in vivo inflammation. This in vitro model of rotator cuff pathology can aid investigators in testing effects of agents proposed to improve rotator cuff healing. This can lead to further knowledge regarding effective treatment options.

Determining anatomic accuracy of shoulder field injection: triangular injection technique does adequately reach pain transmitters.

BACKGROUND: Controlling pain after shoulder surgery is a critical component of postsurgical care. Several recent studies have described the use of periarticular, local infiltration anesthesia, and field blocks (FBs) with clinical efficacy after shoulder surgery. The anatomic accuracy and safety of these FBs have not been well described. The purpose of this study was to determine the accuracy of a surgeon performed shoulder field injection. We hypothesized that our field injection would adequately reach the pain transmitters responsible for postsurgical shoulder pain. METHODS: A total of 10 cadaveric specimens were used in the study. A mixture of liposomal bupivacaine, normal saline, and methylene blue totaling 60 cc was prepared. After injection, the specimens were left for 4 hours to allow medication diffusion. The dissection of specimens was performed to identify 4 areas: axillary nerve, suprascapular nerve, supraclavicular nerves, and joint capsule. On dissection, accuracy rates were determined for each area. RESULTS: All 10 cadaveric specimens were injected and dissected to completion. The dissection of the axillary nerve showed methylene blue dye surrounding the nerve in 10 of 10 (100%) specimens, the suprascapular nerve in 9 of 10 (90%), and the supraclavicular nerves in 10 of 10 (100%). Zero of 10 (0%) specimens had any dye penetrate into the glenohumeral joint or capsule. CONCLUSION: The accuracy rates of the injection of the mixture into the shoulder specimens suggest potential to reproduce an FB to the tissues that are responsible for postoperative pain after shoulder surgery. This may represent an option when interscalene nerve block is not desired or contraindicated.

Perioperative pain management for shoulder surgery: evolving techniques.

Improving management of postoperative pain following shoulder surgery is vital for optimizing patient outcomes, length of stay, and decreasing addiction to narcotic medications. Multimodal analgesia (ie, controlling pain via multiple different analgesic methods with differing mechanisms) is an ever-evolving approach to enhancing pain control perioperatively after shoulder surgery. With a variety of options for the shoulder surgeon to turn to, this article succinctly reviews the pros and cons of each approach and proposes a potential pain management algorithm.

Opioid Use After Knee Arthroscopy.

PURPOSE: To quantify the use of 5 mg oxycodone by patients who have undergone knee arthroscopy. METHODS: Patients who underwent knee arthroscopy at 2 institutions between May 2018 and May 2019 were identified retrospectively. Patients were called and queried about the following metrics: total postoperative opioid consumption, preoperative opioid consumption (defined as within 3 months of surgery), smoking status, and history of depression. The total number of opioids prescribed and number of refills were determined according to each patient's chart. State databases were reviewed for additional opioid prescriptions. RESULTS: A total of 100 patients were included in this study. Patients were prescribed a median of 5 pills (range, 5 to 40). Median postoperative opioid consumption was 0 pills, with a mean of 1.9 pills (14.3 oral morphine equivalents) and a range of 0 to 25 pills of oxycodone 5 mg. Of the patients, 97% did not obtain refills, and 58% of the patients did not consume any opioids. Overall, 90% of all patients consumed ≤ 5 pills. CONCLUSIONS: Of the patients, 90% o consumed 5 or fewer opioid pills (oxycodone 5 mg) following knee arthroscopy, with more than half of the patients consuming 0 pills. As a result, we recommend that 5 oxycodone 5 mg pills serve as an objective guideline for opioid prescription following knee arthroscopy. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Strategies to decolonize the shoulder of Cutibacterium acnes: a review of the literature.

Cutibacterium acnes is the most prevalent cause of joint infection after shoulder surgery. Current methods for decolonizing this bacterium from the shoulder region have proved ineffective owing to its unique niche within dermal sebaceous glands and hair follicles. When we are making decisions to decolonize the skin of C acnes, the risks associated with decolonization must be balanced by the potential benefits of reduced deep tissue inoculation. The purpose of this review was to describe currently available methods of decolonization and their efficacy.

Acellular dermal matrix augmentation significantly increases ultimate load to failure of pectoralis major tendon repair: a biomechanical study.

BACKGROUND: Biomechanical studies have demonstrated that standard pectoralis major tendon (PMT) repairs have inferior strength compared with native tendon. HYPOTHESIS: Augmentation of PMT repair with an acellular dermal matrix (ADM) will increase the ultimate load to failure. METHODS: Eighteen cadaveric specimens were allocated to 3 repair groups: standard repair (SR); augmented repair (AR) with ADM; and intact, native tendon (NT). Specimens were tested for cyclic elongation, linear stiffness, load to 5 mm displacement, maximum load to failure, and method of failure. RESULTS: Maximum load to failure in AR (1450 ± 295 N) was significantly higher than SR (921 ± 159 N; P = .0042) and equivalent to NT (1289 ± 240 N; P = .49). NT required the highest load to displace 5 mm (709 ± 202 N), which was higher than AR (346 ± 95 N; P < .001) and SR (375 ± 55; P = .0015). NT stiffness (125 ± 42 N/mm) was greater than the AR (69 ± 19 N/mm; P = .0073) or SR (75 ± 11 N/mm; P = .015). The mode of failure for SR was suture pullout from the PMT as opposed to button pullout from the humerus (fracture) for AR. CONCLUSION: ADM augmentation of PMT repair significantly increases ultimate load to failure.

Liposomal bupivacaine reduces opiate consumption after rotator cuff repair in a randomized controlled trial.

BACKGROUND: Arthroscopic rotator cuff repair (ARCR) provides excellent clinical outcomes but is often associated with significant postoperative pain. The use of intraoperative anesthesia in conjunction with multimodal pharmacologic strategies is a widely accepted approach for managing surgical pain and reducing opiate use. The purpose of this study was to determine whether using a combined field and suprascapular nerve block with liposomal bupivacaine (LB) in addition to an interscalene block would provide greater pain relief and a reduction in opiate consumption compared with an interscalene block alone. METHODS: The study enrolled 50 patients with full-thickness rotator cuff tears undergoing primary ARCR surgery. Patients were randomized to receive intraoperative LB (n = 25) or not (n = 25) and given postoperative "pain journals" to document visual analog scale pain scores and to track their daily opioid consumption during the first 5 postoperative days. RESULTS: Patients in the LB group reported statistically and clinically lower pain scores during postoperative days 1 and 2 (P < .0001 and P = .03, respectively). In addition, patients in the LB group consumed significantly fewer narcotics than the control group during the 5-day period, demonstrating a 64% reduction in total narcotic consumption (P = .002). CONCLUSION: The findings of this study suggest that the addition of LB to multimodal anesthetic protocols significantly reduces the acute perioperative pain experienced following rotator cuff repair and the number of narcotic pills consumed in the first 5 days after ARCR. Furthermore, the findings provide guidelines for postoperative narcotic prescribing to reduce the quantity of opiates prescribed.

Macroscopic Rotator Cuff Tendinopathy and Histopathology Do Not Predict Repair Outcomes of Rotator Cuff Tears.

BACKGROUND: Numerous studies have identified factors that may affect the chances of rotator cuff healing after surgery. Intraoperative tendon quality may be used to predict healing and to determine type of repair and/or consideration of augmentation. There are no data that correlate how gross tendon morphology and degree of tendinopathy affect patient outcome or postoperative tendon healing. Purpose/Hypothesis: The purposes of this study were to (1) compare the gross appearance of the tendon edge during arthroscopic rotator cuff repair with its histological degree of tendinopathy and (2) determine if gross appearance correlated with postoperative repair integrity. The hypothesis was that gross (macroscopic) tendon with normal thickness, no delamination, and elastic tissue before repair would have a correlation with low Bonar scores, higher postoperative American Shoulder and Elbow Surgeons (ASES) scores, and increased rates of postoperative tendon healing on ultrasound. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 105 patients undergoing repair of medium-size (1-3 cm) full-thickness rotator cuff tears were enrolled in the study. Intraoperatively, the supraspinatus tendon was rated on thickness, fraying, and stiffness. Tendon tissue was recovered for histological analysis based on the Bonar scoring system. Postoperative ASES and ultrasound assessment of healing were obtained 1 year after repair. Correlation between gross appearance of the tendon and rotator cuff histology was determined. RESULTS: Of the 105 patients, 85 were followed the study to completion. The mean age of the patients was 61.6 years; Bonar score, 7.5; preoperative ASES score, 49; and postoperative ASES score, 86. Ninety-one percent of repairs were intact on ultrasound. Gross appearance of torn rotator cuff tendon tissue did not correlate with histological appearance. Neither histological (Bonar) score nor gross appearance correlated with multivariate analysis of ASES score, postoperative repair status, or demographic data. CONCLUSION: The degree of tendinopathy did not correlate with morphological appearance of the tendon. Neither of these parameters correlated with healing or patient outcome. This study suggests that the degree of tendinopathy, unlike muscle atrophy, may not be predictive of outcomes and that, on appearance, poor quality tendon has adequate healing capacity. Therefore, abnormal gross tendon appearance should not affect the repair effort or technique.

Distal Triceps Tendon Injuries.

Acute triceps ruptures are an uncommon entity, occurring mainly in athletes, weight lifters (especially those taking anabolic steroids), and following elbow trauma. Accurate diagnosis is made clinically, although MRI may aid in confirmation and surgical planning. Acute ruptures are classified on an anatomic basis based on tear location and the degree of tendon involvement. Most complete tears are treated surgically in medically fit patients. Partial-thickness tears are managed according to the tear severity, functional demands, and response to conservative treatment. We favor an anatomic footprint repair of the triceps to provide optimal tendon to bone healing and, ultimately, functional outcome.

Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery.

BACKGROUND: Propionibacterium acnes infection is a significant problem after shoulder surgery. Residual P. acnes is found on the skin up to 29% of the time immediately after surgical skin preparation and in 70% of dermal biopsy specimens. These residual bacteria may be a source for infection. Identifying more ideal skin preparation may help reduce the risk of infection. The purpose of this study was to evaluate the effect that topical benzoyl peroxide (BPO), with chlorhexidine skin preparation, would have on the presence of P. acnes cultured at the time of shoulder surgery. We hypothesized that adding topical BPO to our skin preparation would reduce the number of positive P. acnes cultures identified during surgery. METHODS: Fifty patients undergoing first-time shoulder surgery were treated with topical 5% BPO cream 48 hours before surgery. After skin preparation, 13 samples per subject were obtained. Cultures were held for 14 days. RESULTS: Fifty patients underwent arthroscopic shoulder surgery; 650 culture specimens were obtained. The skin was positive at the initiation of surgery in 6% of cases. Tissue samples were positive in 6%. The skin was positive in 10% at the end of surgery. None of these rates of positive culture were different from the 4% rate observed with a control swab. CONCLUSION: Application of BPO is an effective way to reduce P. acnes on skin at the beginning and, importantly, at the end of a surgical procedure. This may result in a lower risk for postoperative infection.

Safety of open suprapectoral and subpectoral biceps tenodesis: an anatomic assessment of risk for neurologic injury.

BACKGROUND: Surgical techniques for proximal biceps tenodesis that include penetration of the posterior humeral cortex for fixation may pose risk to the surrounding neurovascular structures. HYPOTHESIS: The risk of neurologic injury with techniques that involve penetration of the posterior humeral cortex for fixation in proximal biceps tenodesis will increase as the tenodesis site moves proximally from the subpectoral to the suprapectoral location. METHODS: Proximal biceps tenodesis was performed on 10 cadaveric upper extremities with 3 separate techniques. The proximity of the hardware to the relevant neurovascular structures was measured. The distances between the tenodesis site and the relevant neurovascular structures were measured. RESULTS: The guide pin was in direct contact with the axillary nerve in 20% of the suprapectoral tenodeses. The distance between the axillary nerve and the tenodesis site was 10.5 ± 5.5 mm for the suprapectoral location, 36.7 ± 11.2 mm in the subpectoral scenario, and 24.1 ± 11.2 mm in the 30° cephalad scenario (P = .003). The distance between the radial nerve and the anterior tenodesis site was 41.3 ± 9.3 mm for the suprapectoral location and 48.0 ± 10.7 mm for the subpectoral location. The distance of the musculocutaneous nerve from the tenodesis site was 28.4 ± 9.2 mm for the suprapectoral location and 37.4 ± 11.2 mm for the subpectoral location. CONCLUSION: In a cadaveric model of open biceps tenodesis, penetration of the posterior humeral cortex at the suprapectoral location results in proximity to the axillary nerve and should be avoided. Subpectoral bicortical button fixation drilled perpendicular to the axis of the humerus was a uniformly safe location with respect to the axillary nerve.