Open Suprascapular Nerve Decompression at the Spinoglenoid Notch.

Suprascapular nerve (SSN) entrapment is a rare but significant cause of posterior shoulder pain and weakness. Compression of the nerve at the level of the spinoglenoid notch leads to weakness and atrophy of the infraspinatus. A detailed history and physical examination along with appropriate workup are paramount to arrive at this diagnosis. Surgical decompression is indicated in cases refractory to conservative management. In this Technical Note, we describe our technique for open decompression of the SSN at the spinoglenoid notch. This approach permits direct visualization of the SSN and allows for a safe, reliable, and thorough decompression.

The Effect of Surgeon Volume on Complications Following Total Shoulder Arthroplasty: A Nationwide Assessment.

BACKGROUND: Increased surgeon volume has been demonstrated to correlate with improved outcomes after orthopedic surgery. However, there is a lack of data demonstrating the effect of surgeon volume on outcomes after total shoulder arthroplasty. METHODS: The PearlDiver Mariner database was retrospectively queried from the years 2010-2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472 (Total Shoulder Arthroplasty). Patients under 40 years of age, those undergoing revision arthroplasty and cases of bilateral arthroplasty were excluded. Additionally, cases with a history of fracture, infection, or malignancy prior to surgery were excluded. Only surgeons who performed a minimum of 10 cases were selected and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90 day, 1-year, and 2-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at p≤0.00082 RESULTS: A total of 155,560 patients met inclusion criteria and were retained for analysis. The 90th percentile for surgeon volume was determined to be 112 cases during the study period. Surgeons above the 90th percentile (n=340) operated on 68,531 patients whereas surgeons below the 90th percentile (n=3,038) operated on 87,029 patients. Surgeons in the high-volume group were significantly more likely to have completed a Shoulder and Elbow fellowship (p<0.001) and less likely to have no fellowship training or fellowship training outside of Shoulder and Elbow or Sports Medicine (p<0.001). Low-volume surgeons operated on patients with higher baseline comorbidities (CCI: 2.01 vs 1.85, p<0.001). After adjusting for age, gender, CCI, obesity, and tobacco use, high-volume surgeons experienced lower rates of medical complications including renal failure (p<0.001), anemia (p<0.001), and UTI (p<0.001). All cause readmission (0.90, p<0.001), reoperation at 90 days (OR 0.75, p<0.001) and reoperation at 1 year (OR: 0.86, p<0.001) were significantly lower among high-volume surgeons. High-volume surgeons exhibited lower rates of various complications including prosthetic joint infection (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001), periprosthetic fracture (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001) and all complications (90d: p<0.001; 1yr: p<0.001). CONCLUSION: Surgeons who perform a high volume of total shoulder arthroplasty are more likely to operate on healthier patients than surgeons who perform a lower volume of cases. When compared to low-volume surgeons, and after adjusting for age, gender, and CCI, high-volume surgeons have a significantly lower overall complication rate. Despite this lower complication rate, high-volume surgeons are responsible for a decreasing portion of shoulder arthroplasty since 2016.

Trends in Payments for Facility and Surgeon Professional Fees for Shoulder Surgeries Performed at Ambulatory Surgery Centers.

BACKGROUND: It has previously been demonstrated that utilization of ambulatory surgery centers (ASCs) results in cost savings and improved outcomes. Despite these benefits, Medicare reimbursement for professional fees at ASCs are decreasing over time. In this study, we sought to analyze the discrepancy between facility fee and professional fee reimbursements for ASCs by Medicare for common shoulder procedures over time. We hypothesized that professional fees for shoulder procedures would decrease over the study period while facility fees kept pace with inflation. METHODS: Current Procedural Terminology (CPT) codes were used to identify shoulder specific procedures approved for ASCs by Centers for Medicare and Medicaid Services (CMS). Procedures were grouped into arthroscopic and open categories. Publicly available data from CMS was accessed via the Medicare Physician Fee Schedule Lookup Tool and used to determine professional fee payments from 2018-2024. Additionally, Medicare ASC Payment Rates files were accessed to determine facility fee reimbursements to ASCs from 2018-2024. Descriptive statistics were used to calculate means and percent change over time. Compound annual growth rates (CAGR) were calculated and discrepancies in inflation were corrected for using the Consumer Price Index. The Benjamini and Hochberg method was used to correct P values in the setting of multiple comparisons. RESULTS: A total of 33 common shoulder procedures were included for analysis (10 arthroscopic codes and 23 open codes). Reimbursements for facility fees have remained significantly higher than corresponding professional fees for both open and arthroscopic procedures (p<0.01). On average, facility fee reimbursements for common shoulder surgeries have risen on an annual basis in a manner consistent with inflation (p=0.838). However, professional fees for these procedures have experienced a nearly uniform decline over the study period both nominally and in inflation-adjusted dollars (p=0.064 and p=0.005, respectively). CONCLUSION: Facility fee payments for outpatient approved shoulder surgeries have matched or outpaced inflation. Over the same time period, professional fee reimbursements for surgeons are consistently decreasing, both in absolute and inflation-adjusted dollars. Reform to the physician fee schedule is necessary to ensure that Medicare patients retain access to high-quality physician care.

Anatomic or Reverse Total Shoulder Arthroplasty? How Fellowship Training Affects Selection of Arthroplasty Type.

BACKGROUND: While both anatomic (ATSA) and reverse total shoulder arthroplasty (RTSA) have been popularized as a means of treating individuals with degenerative shoulder conditions, the indications for each can vary widely amongst providers. While surgeons with differing fellowship training commonly perform these procedures, it is not understood how fellowship training influences choice of implant. METHODS: A national database was queried to identify surgeons performing anatomic and reverse total shoulder arthroplasty. For all surgeons who performed more than 10 cases between 2010-2022, fellowship data was individually collected via online search. For each fellowship group, rates of anatomic and reverse total shoulder arthroplasty were identified using International Classification of Diseases (ICD) procedural codes. Those undergoing revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Primary outcome measures included the proportion of primary and revision ATSA and RTSA by fellowship in addition to the rate of RTSA performed for a primary diagnosis of glenohumeral osteoarthritis. RESULTS: A total of 131,974 patients met the inclusion criteria and were retained for this study. RTSA increased from 50.1% of all primary shoulder arthroplasty cases in 2011 to 72.0% in 2022. After adjusting for age and comorbidities, Sports Medicine fellowship-trained (Sports) surgeons opted for primary RTSA over ATSA at a significantly higher rate than Shoulder and Elbow fellowship-trained (Shoulder) surgeons and surgeons who completed another type of fellowship or no fellowship (Other). Sports surgeons also chose RTSA more frequently for the diagnosis of glenohumeral osteoarthritis compared to Shoulder surgeons. Surgeons in the Other cohort were more likely to perform primary ATSA rather than RTSA in comparison to surgeons in the Shoulder and Sports cohorts. Sports surgeons were responsible for the greatest increase in percentage of all shoulder arthroplasty procedures from 2010-2022 (28.4% to 40.4%) while the Other group decreased by a comparable amount (45.9% to 32.4%) over the same period. CONCLUSION: Surgeons who have completed a Sports Medicine fellowship choose RTSA over ATSA at a higher rate than Shoulder and Elbow surgeons, both for all indications and also for a primary diagnosis of glenohumeral osteoarthritis. Those who have no fellowship training or fellowship training outside of Sports Medicine and Shoulder and Elbow surgery have the highest percentage of ATSA in their arthroplasty practice. Revision anatomic and revision reverse total shoulder arthroplasty represents a larger percentage of overall case volume for Shoulder and Elbow surgeons.

High Variability in Standardized Outcome Thresholds of Clinically Important Changes in Shoulder Instability Surgery: A Systematic Review.

PURPOSE: To examine reported minimal clinically important difference (MCID) and patient-acceptable satisfactory state (PASS) values for patient-reported outcome measures (PROMs) after shoulder instability surgery and assess variability in published values depending on the surgery performed. Our secondary aims were to describe the methods used to derive MCID and PASS values in the published literature, including anchor-based, distribution-based, or other approaches, and to assess the frequency of MCID and PASS use in studies on shoulder instability surgery. METHODS: A systematic review of MCID and PASS values after Bankart, Latarjet, and Remplissage procedures was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The Embase, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were queried from 1985 to 2023. Inclusion criteria included studies written in English and studies reporting use of MCID or PASS for patient-reported outcome measures (PROMS) after Latarjet, Bankart, and Remplissage approaches for shoulder instability surgery. Extracted data included study population characteristics, intervention characteristics, and outcomes of interest. Continuous data were described using medians and ranges. Categorical variables, including PROMs and MCID/PASS methods, were described using percentages. Because MCID is a patient-level rather than a group-level metric, the authors confirmed that all included studies reported proportions (%) of subjects who met or exceeded the MCID. RESULTS: A total of 174 records were screened, and 8 studies were included in this review. MCID was the most widely used outcome threshold and was reported in all 8 studies, with only 2 studies reporting both the MCID and the PASS. The most widely studied PROMs were the American Shoulder and Elbow Surgeons (range 5.65-9.6 for distribution MCID, 8.5 anchor MCID, 86 anchor PASS); Single Assessment Numeric Evaluation (range 11.4-12.4 distribution MCID, 82.5-87.5 anchor PASS); visual analog scale (VAS) (range 1.1-1.7 distribution MCID, 1.5-2.5 PASS); Western Ontario Shoulder Instability Index (range 60.7-254.9 distribution MCID, 126.43 anchor MCID, 571-619.5 anchor PASS); and Rowe scores (range 5.6-8.4 distribution MCID, 9.7 anchor MCID). Notably, no studies reported on substantial clinical benefit or maximal outcome improvement. CONCLUSIONS: Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. Although MCID has been the most frequently reported metric, there is considerable interstudy variability observed in their values. CLINICAL RELEVANCE: Knowing the outcome thresholds such as MCID and PASS of the PROMs frequently used to evaluate the results of glenohumeral stabilization surgery is fundamental because they allow us to know what is a clinically significant improvement for the patient.

Patients return to sport after repair of anterior humeral avulsion of the glenohumeral ligament lesions: a systematic review.

Background: Anterior humeral avulsions of the glenohumeral ligament (aHAGL) lesions are relatively rare causes of shoulder instability that affect athletes at a higher rate than other populations. The purpose of this study is to evaluate rate of return to sport (RTS) after HAGL repair. Methods: A search of the PubMed (MEDLINE), Scopus, and Cochrane CENTRAL databases was conducted on April 13, 2022 with the search terms "HAGL" or "humeral avulsion glenohumeral ligament" was used to conduct the systematic review. Inclusion criteria required that lesions were limited to aHAGL, axillary pouch or central HAGL, or both anterior and posterior HAGL lesions as specified by lesion description or direction of instability. Results: Screening and full-text manuscript review identified 7/967 studies eligible for inclusion with a total of 46 aHAGL lesions in athletes. Average rate of RTS was 93.5% (standard deviation [SD] = 13.4%, n = 43/46) with rate of RTS at previous levels of play averaging 80.0% (SD = 22.1%, n = 28/35). Neither rates of concomitant procedures nor concomitant pathology were associated with variation in RTS rates overall or level of RTS. Weighted average Rowe, subjective shoulder value, and Constant scores were 87.5 (SD = 4.9), 86.0 (SD = 2.0), and 82.2 (SD = 5.1), respectively, and 78.6% (n = 22/28) of patients reported postoperative satisfaction or "good/excellent" ratings following aHAGL repair. Adverse events occurred in 18.5% of patients (n = 10/54), most frequently recurrent instability (n = 3/54). Ultimately, 6.2% of patients eventually underwent reoperation (n = 3/17). Conclusion: As with other forms of anterior shoulder instability, RTS rates after aHAGL repair are high and many patients achieve their previous level of play. The most frequent adverse event was subjective recurrent instability with reoperation in 6.2% of patients. The findings from this study provide valuable pooled data on outcomes specific to aHAGL repair, particularly in the athlete population, and contribute to further understanding of outcomes regarding operative management of this rare pathology.

How fellowship training affects complication rate after shoulder arthroplasty: a nationwide assessment.

BACKGROUND: Total shoulder arthroplasty is performed by orthopedic surgeons with various fellowship training backgrounds. Whether surgeons performing shoulder arthroplasty with different types of fellowship training have differing rates of complications and reoperation remains unknown. METHODS: The PearlDiver Mariner database was retrospectively queried from the years 2010 to 2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472. Those undergoing revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Fellowship was determined and verified via online search. Only surgeons who performed a minimum of 10 cases were selected; and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90-day, 1-year, and 5-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at P ≤ .00023. RESULTS: In total, 150,385 patients met the inclusion criteria and were included in the study. Analysis of surgical trends revealed that Sports Medicine and Shoulder and Elbow fellowship-trained surgeons are performing an increasing percentage of all shoulder arthroplasty over time, with each cohort exhibiting an 11.3% and 4.2% increase from 2010 to 2022, respectively. The geographic region with the highest proportion of cases performed by Sports Medicine surgeons was the West, while the Northeast has the highest proportion of cases performed by Shoulder and Elbow surgeons. Shoulder and Elbow surgeons operated on patients that were significantly younger and had fewer comorbidities. Both Shoulder and Elbow and Sports Medicine surgeons had lower rates of postoperative complications at 90 days, 1 year, and 5 years in comparison to surgeons who completed another type of fellowship or no fellowship. Across each time point, the rates of individual complications between Sports Medicine and Shoulder and Elbow were comparable, but the pooled complication rate was lowest in the Shoulder and Elbow cohort. CONCLUSION: Surgeons who have completed either a Sports Medicine or Shoulder and Elbow fellowship are performing an increasing proportion of shoulder arthroplasty over time. Sports Medicine and Shoulder and Elbow-trained surgeons have significantly lower complication rates at 90 days, 1 year, and 5 years postoperatively. The individual complication rates between Sports Medicine and Shoulder and Elbow are comparable, but Shoulder and Elbow have the lowest pooled complication rates overall.

Posterior Interosseous Nerve Palsy in Rheumatoid Arthritis: A Systematic Review.

The purpose of this systematic review is to describe the pathoanatomy, presentation, diagnostic workup, treatment modalities, and outcomes of posterior interosseous nerve (PIN) palsy in patients with rheumatoid arthritis (RA). All reported cases of PIN palsy in patients with RA were reviewed to yield 72 cases of PIN palsy in 70 patients. The male-to-female ratio was 1:2.7. Pain involving the elbow was very common (20/33 cases reporting this information), and paralysis or weakness of digit extension was noted in 27/33 cases and 6/33 cases, respectively. Only 1 of the 54 cases undergoing surgical intervention reported persistent weakness, and this 1 patient had undergone a 3-month trial of conservative management. In conclusion, Appropriate pharmacologic management in conjunction with magnetic resonance imaging (MRI) and ultrasound monitoring may be used for conservative management, but surgical decompression should still be utilized for patients with a compressive disease pathology who fail to improve with 6 weeks of conservative treatment, or for those with advanced disease on initial presentation.

Acute Simple Elbow Dislocations in the United States: An Epidemiological Analysis of Trends Including COVID-19.

Background Elbows are one of the most frequently dislocated large joints; however, there is limited epidemiological data, especially during the coronavirus disease 2019 (COVID-19) pandemic. This study characterizes elbow dislocations presenting to Emergency Departments (EDs) over the last decade. Methods This study is a cross-sectional, descriptive, epidemiologic analysis of isolated elbow dislocations presenting to EDs from 2011-2020 using the National Electronic Injury Surveillance System (NEISS) database. Patients under 10, those with radial head subluxation, and those with complex fractures were excluded. Data on incidence ratios, patient demographics, mechanisms of injury, and incident locales were analyzed. Results Approximately 83,996 simple, primary elbow dislocations occurred from 2011-2020 (n=2,328), generating an incidence of 2.98/100,000 person-years. Incidence was higher among males (3.26 versus 2.69/100,000 person-years). Dislocations peaked in patients aged 10-19, with higher rates in males (11.12 versus 5.31/100,000 person-years; injury rate ratio 2.09, CI=2.05-2.14, p<0.001). Rates of elbow dislocations decreased with age in males (age 20-29=11.12, age >80=0.63/100,000) but increased in females over 40 (age 40-49=1.59, age 70-79=2.83/100,000). Athletic activities accounted for 55% of dislocations (n=45,902), with 15% from football and 14% from wrestling. The fewest annual dislocations occurred during COVID-19 (n=6440). Injuries occurring at schools and during contact and indoor sports decreased, while those from soccer increased. Conclusions Elbow dislocations are common, with trends of decreasing incidence with age among men and increasing incidence in women over 40. COVID-19 impacted sports-related and epidemiologic injury patterns. Ultimately, understanding population-level risks for elbow dislocations enables orthopaedic surgeons to predict injury trends and conceive educational preventative measures.

The Influence of Obesity on Outcomes Following Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-Analysis of 118,331 Patients Internationally.

Background: Given the rising prevalence of obesity, the number of patients with obesity undergoing arthroscopic rotator cuff repair (RCR) will likely increase; however, there have been mixed results in the existing literature with regard to the effect of elevated body mass index (BMI) on functional outcomes and complications. Methods: The patient-reported outcome measures included the visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, range of motion, and adverse events. Results: Fourteen studies (118,331 patients) were included. There were significant decreases in VAS pain scores for both patients with obesity (mean difference, -3.8 [95% confidence interval (CI), -3.9 to -3.7]; p < 0.001) and patients without obesity (mean difference, -3.2 [95% CI, -3.3 to -3.1]; p < 0.001). There were also significant increases in ASES scores for both patients with obesity (mean difference, 24.3 [95% CI, 22.5 to 26.1]; p < 0.001) and patients without obesity (mean difference, 24.3 [95% CI, 21.4 to 26.0]; p < 0.001). There were also significant increases in ASES scores for both patients with obesity (mean difference, 24.3 [95% CI, 22.5 to 26.1]; p < 0.001) and patients without obesity (mean difference, 24.3 [95% CI, 21.4 to 26.0]; p < 0.001). However, there were no significant differences in final VAS pain scores, ASES scores, or range of motion between the groups. The mean rates of complications were higher among patients with obesity (1.2% ± 1.7%) than among patients without obesity (0.59% ± 0.11%) (p < 0.0001), and the mean rates of postoperative admissions were also higher among patients with obesity (5.9%) than patients without obesity (3.7%) (p < 0.0001). Although the mean rates of reoperation were similar between groups (5.2% ± 2.8% compared with 5.2% ± 4.2%), the meta-analysis revealed lower odds of reoperation in patients without obesity (odds ratio [OR], 0.76 [95% CI, 0.71 to 0.82]). Conclusions: No significant or clinically important differences in postoperative pain, ASES scores, or range of motion were found between patients with and without obesity following arthroscopic RCR. However, populations with obesity had higher rates of complications, postoperative admissions, and reoperation following arthroscopic RCR. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Concomitant Glenohumeral Stabilization After Arthroscopic Rotator Cuff Repair in Military Patients Younger Than 40 Years.

Background: While concomitant rotator cuff and inferior labral tears are relatively uncommon in young civilians, military populations represent a unique opportunity to study this injury pattern. Purpose: To (1) evaluate the long-term outcomes after combined arthroscopic rotator cuff and inferior labral repair in military patients <40 years and (2) compare functional outcomes with those after isolated arthroscopic rotator cuff repair. Study Design: Cohort study; Level of evidence, 3. Methods: Military patients who underwent arthroscopic rotator cuff repair between January 2011 and December 2016 and had a minimum of 5-year follow-up data were included in this study. The patients were categorized into those who had undergone combined arthroscopic rotator cuff and inferior labral repair (RCIL cohort) and those who had isolated arthroscopic rotator cuff repair (ARCR cohort). Pre- and postoperative outcome measures-visual analog scale for pain, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons shoulder score, Rowe Instability Score, and range of motion-were compared between the groups. Results: A total of 50 shoulders (27 in the RCIL cohort and 23 in the ARCR cohort) were assessed. The RCIL and ARCR groups were similar in terms of age (mean, 33.19 years [range, 21-39 years] vs 35.39 years [range, 26-39 years], respectively) and sex (% male, 88.46% vs 82.61%, respectively). All patients were active-duty military at the time of surgery. The mean final follow-up was at 106.93 ± 16.66 months for the RCIL group and 105.70 ± 7.52 months for the ARCR group (P = .75). There were no differences in preoperative outcome scores between groups. Postoperatively, both groups experienced statistically significant improvements in all outcome scores (P < .0001 for all), and there were no significant group differences in any final postoperative outcome measures. At the final follow-up, 26 (96.30%) patients in the RCIL cohort and 20 (86.96%) in the ARCR cohort had returned to unrestricted active-duty military service (P = .3223). Conclusion: The study findings indicate that concomitant glenohumeral stabilization does not prevent worse outcomes after arthroscopic rotator cuff repair in this military cohort. Combined repair produced statistically and clinically significant improvements in outcome scores at the long-term follow-up, indicating that simultaneous repair of combined lesions was an appropriate treatment option in this patient population.

The Perfect Circle Technique Shows Poor Inter-rater Reliability in Measuring Anterior Glenoid Bone Loss on Magnetic Resonance Imaging.

Purpose: To evaluate the reliability of the perfect circle methodology for measurement of glenoid bone loss in patients with anterior glenohumeral instability. Methods: We performed a chart review of retrospectively collected patients who underwent isolated arthroscopic anterior labral repair between January 1 and June 30, 2021, using our institution's electronic medical records. The inclusion criteria included isolated anterior shoulder instability with anterior labral repair and corroborated tears on magnetic resonance imaging. A total of 9 raters, either sports or shoulder and elbow fellowship-trained orthopaedic surgeons, each evaluated the affected shoulder magnetic resonance imaging scans twice, with a minimum of 2 weeks between measurements. Measurements followed the "perfect circle" technique and included projected anterior-to-posterior glenoid diameter, amount of posterior bone loss, and percentage of posterior bone loss. Intrarater reliability and inter-rater reliability were then determined by calculating intraclass correlation coefficients (ICCs). Results: Ten consecutive patients meeting the selection criteria were chosen for inclusion in this analysis. Average estimated bone loss for the cohort was 2.45 mm, and the mean estimated glenoid diameter of the involved shoulder was 28.82 mm. The average percentage of bone loss measured 8.54%. The ICC for interobserver reliability was 0.55 for the perfect circle diameter and 0.17 for the anterior bone loss measurement (poorly to moderately reliable). The ICC for intraobserver reliability was 0.69 for the perfect circle diameter and 0.71 for anterior bone loss (moderately reliable). Conclusions: The perfect circle technique for estimating anterior glenoid bone loss on magnetic resonance imaging was found to have moderate intrarater reliability; however, reliability between observers was found to be moderate to poor. Level of Evidence: Level IV, diagnostic case series.

The Perfect-Circle Technique Demonstrates Poor Inter-Rater Reliability in Measuring Posterior Glenoid Bone Loss on Magnetic Resonance Imaging.

Purpose: To evaluate the reliability of the "perfect-circle" methodology for measurement of glenoid bone loss with magnetic resonance imaging (MRI) in patients with posterior glenohumeral instability. Methods: A prospective chart review was performed on patients who underwent isolated arthroscopic posterior labral repairs in our institution's electronic medical records between January 1, 2021, and June 30, 2021. Inclusion criteria included isolated posterior shoulder instability with posterior labral repair and corroborated tears on MRI. A total of 9 raters, either sports or shoulder and elbow fellowship-trained orthopaedic surgeons, each evaluated the affected shoulder MRI scans twice, at over 2 weeks apart. Measurements followed the "perfect-circle" technique and included projected anterior-to-posterior (AP) glenoid diameter, amount of posterior bone loss, and percentage of posterior bone loss. Results: Ten consecutive patients between the ages of 17 and 46 years with diagnosed posterior glenohumeral instability were selected. The average age was 28 ± 10 years, and 60% of patients were male. The patient's dominant arm was affected in 40%, and 50% of cases involved the right shoulder. The average glenoid diameter was 29.62 ± 3.69 mm, and the average measured bone loss was 2.8 ± 1.74 mm. The average percent posterior glenoid bone loss was 9.41 ± 5.78%. The inter-rater reliability was poor for the AP diameter and for the posterior glenoid bone loss with intraclass correlation coefficients at 0.30 (0.12-0.62) and 0.22 (0.07-0.54) respectively. The intrarater reliability was poor for AP diameter and moderate for posterior glenoid bone loss, with intraclass correlation coefficients at 0.41 (0.22-0.57) and 0.50 (0.33-0.64), respectively. Conclusions: Using the "perfect-circle" technique for evaluating posterior glenohumeral bone loss has poor-to-moderate inter- and intrarater reliability from MRI. Level of Evidence: Level IV, prospective diagnostic study.

Editorial Commentary: Older Patients Without Degenerative Joint Disease Can Have Excellent Outcomes After Hip Arthroscopy.

Early research on hip arthroscopy for femoroacetabular impingement syndrome identified patient age as a risk factor for poor outcomes and heightened revision rates. However, more recent research challenges this dogma. Disparities between chronologic and physiologic age exist among patients. In addition, orthopaedic pathology (such as degenerative chondral or labral pathology) can correlate with age, so the use of age, and using age as a predictor of outcome, may be biased by this confounding effect. Older patients without degenerative joint disease can have excellent outcomes after hip arthroscopy. Recent research shows that patients older than the age of 40 years undergoing hip arthroscopy for femoroacetabular impingement syndrome demonstrate outcomes comparable with younger patients at 10-year follow-up. However, older patients were at greater risk for conversion to total hip arthroplasty. In our experience, in the absence of joint degeneration, patients older than the age of 40 years experience predictable and durable relief following arthroscopic management of femoroacetabular impingement syndrome. These outcomes result from sound surgical indications, appropriate preoperative counseling, and meticulous surgical technique. We ought not replace joints we can preserve, and age is not the most determinative factor regarding outcome of otherwise well-indicated and performed hip arthroscopy.

Editorial Commentary: At Least 2 out of 3 Adolescent Athletes Can Return to Preinjury Sports After Marrow Stimulation for Osteochondritis Dissecans of the Elbow.

Osteochondritis dissecans (OCD) of the capitellum is a common cause of elbow pain in young throwers and gymnasts, symptoms of which can rob these young athletes of valuable time participating in sporting activities. The optimal treatment of adolescent capitellar OCD lesions is dependent on a variety of patient- and lesion-specific factors, including, but not limited to, lesion size, lesion location, physeal status, and lesion chronicity. Promisingly, marrow stimulation with or without debridement appears to confer high return-to-sport rates coupled with a low complication rate for young athletes suffering from this condition. Furthermore, these outcomes appear to remain consistent across the spectrum of OCD lesions typically encountered. There is concern, however, with the inconsistent reporting of patient- and lesion-specific factors across the literature, which greatly interferes with our ability to synthesize knowledge from multiple published studies and may lead surgeons astray when deciding on the optimal treatment for their patients. It is clear that no two OCD lesions are the same, and each patient requires a thorough history and physical exam, a complete radiographic workup, and a surgeon comfortable with a variety of surgical interventions if outcomes are to be maximized.

Establishing the Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient Acceptable Symptomatic State After Arthroscopic Posterior Labral Repair for Posterior Glenohumeral Instability.

BACKGROUND: Posterior glenohumeral instability is an increasingly recognized cause of shoulder pain and dysfunction among young, active populations. Outcomes after posterior stabilization procedures are commonly assessed using patient-reported outcome measures including the Single Assessment Numeric Evaluation (SANE), the Rowe instability score, the American Shoulder and Elbow Surgeons (ASES) score, and the visual analog scale (VAS) for pain. The clinical significance thresholds for these measures after arthroscopic posterior labral repair (aPLR), however, remain undefined. PURPOSE: We aimed to define the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for the SANE, Rowe score, and ASES score as well as the VAS pain after aPLR. Additionally, we sought to determine preoperative factors predictive of reaching, as well as failing to reach, clinical significance. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This study was a retrospective analysis of patient-reported outcome scores collected from patients who underwent aPLR between January 2011 and December 2018. To determine the clinically significant threshold that corresponded to achieving a meaningful outcome, the MCID, SCB, and PASS were calculated for the SANE, Rowe score, ASES score, and VAS pain utilizing either an anchor- or distribution-based method. Additionally, univariate and multivariate logistic regression analyses were performed to determine the factors associated with achieving, or not achieving, the MCID, SCB, and PASS. RESULTS: A total of 73 patients with a mean follow-up of 82.55 ± 24.20 months were available for final analysis. MCID, SCB, and PASS values for the VAS pain were 1.10, 6, and 3, respectively; for the ASES score were 7.8, 34, and 80, respectively; for the SANE were 10.15, 33, and 85, respectively; and for the Rowe score were 11.3, 60, and 90, respectively. To meet the MCID, male sex (odds ratio [OR], 1.1639; P = .0293) was found to be a positive predictor for the VAS pain, and a lower preoperative SANE score (OR, 0.9939; P = .0003) was found to be a negative predictor for the SANE. Dominant arm involvement was associated with lower odds of achieving the PASS for the ASES score (OR, 0.7834; P = .0259) and VAS pain (OR, 0.7887; P = .0436). Patients who reported a history of shoulder trauma were more likely to reach the PASS for the SANE (OR, 1.3501; P = .0089), Rowe score (OR, 1.3938; P = .0052), and VAS pain (OR, 1.3507; P = .0104) as well as the SCB for the ASES score (OR, 1.2642; P = .0469) and SANE (OR, 1.2554; P = .0444). A higher preoperative VAS pain score was associated with higher odds of achieving the SCB for both the VAS pain (OR, 1.1653; P = .0110) and Rowe score (OR, 1.1282; P = .0175). Lastly, concomitant biceps tenodesis was associated with greater odds of achieving the SCB for the ASES score (OR, 1.3490; P = .0130) and reaching the PASS for the SANE (OR, 1.3825; P = .0038) and Rowe score (OR, 1.4040; P = .0035). CONCLUSION: To our knowledge, this study is the first to define the MCID, SCB, and PASS for the ASES score, Rowe score, SANE, and VAS pain in patients undergoing aPLR. Furthermore, we found that patients who reported a history of shoulder trauma and those who underwent concomitant biceps tenodesis demonstrated a greater likelihood of achieving clinical significance. Dominant arm involvement was associated with lower odds of achieving clinical significance.

Geriatric proximal humerus fracture operative management: a Truven Health Analytics database study (2015-2020).

BACKGROUND: The purpose of this study is to assess the trends in operative management of geriatric (≥65 years) proximal humerus fractures during a 6-year period (2015-2020) within an insurance claims database. METHODS: This retrospective database cohort study used data gathered from the 2015-2020 IBM Truven MarketScan Commercial and IBM Truven MarketScan Medicare Supplemental databases. The International Statistical Classification of Disease and Related Health Problems, Tenth Revision, data was correlated to the Current Procedural Terminology code for shoulder arthroplasty (proximal humeral prosthetic replacement: 23616, shoulder hemiarthroplasty [HA]: 23470, reverse total shoulder arthroplasty [rTSA]: 23472) or open reduction internal fixation (ORIF; open treatment of proximal humerus fracture with internal fixation: 23615, open treatment of proximal humerus fracture-dislocation with internal fixation: 23680). We investigated the number of proximal humerus fracture operative cases per year, percentage arthroplasty used per year, rTSA and HA per year, hospital cost information, as well as percentage arthroplasty per US geographic region. RESULTS: A total of 8057 operative proximal humerus fractures cases were identified in 7697 patients aged >65 years, with 0.45% (360 of 8057) being bilateral. There was a 40.8% decrease in the rate of operative management of proximal humerus fractures between the first half (2015-2017, 1687.3 ± 146.6) and the second half of the study period (2018-2020, 998.3 ± 258.7). Arthroplasty accounted for 78.7% of all surgeries, 91% of those being rTSA. The total number of cases of rTSA and ORIF performed decreased per year (P = .01). The downward trend of percentage ORIF per year approached significance (P = .054). Arthroplasty was a more expensive option of payment for total case by almost $850.00 (P = .001). There was a larger percentage of arthroplasty performed in the Northeast and North Central US geographic regions. CONCLUSION: Despite the rise of both the elderly population and related geriatric proximal humerus fractures, they were less operatively represented in this insurance claims database across the 6-year period. There may be a trend to use less ORIF when addressing these fractures. Although it incurred a higher in-hospital cost, arthroplasty was being performed at a higher percentage in the Northeast and North Central regions of the United States.

Subacromial Balloon Placement Demonstrates No Advantage Over Debridement in the Treatment of Massive Irreparable Rotator Cuff Tears: A Dual-Armed Systematic Review and Meta-analysis of Over 1000 Patients.

BACKGROUND: In recent years, the placement of a subacromial balloon (SAB) spacer has emerged as a treatment option for massive irreparable rotator cuff tears (MIRCTs); however, there is significant controversy regarding its utility in comparison with other surgical interventions. PURPOSE: To compare outcomes after SAB spacer placement versus arthroscopic debridement for MIRCTs. STUDY DESIGN: Dual-armed systematic review and meta-analysis (level IV evidence). METHODS: A literature search of PubMed (MEDLINE), Scopus, and CINAHL Complete databases for articles published before May 7, 2022, was conducted to identify patients with MIRCTs undergoing the 2 procedures. For the SAB arm, 14 of 449 studies were considered eligible for inclusion, while 14 of 272 studies were considered eligible for inclusion in the debridement arm. RESULTS: In total, 528 patients were eligible for inclusion in the SAB arm and 479 patients in the debridement arm, and 69.9% of patients undergoing SAB placement also underwent concomitant debridement. Decreases in the visual analog scale (VAS) pain score and increases in the Constant score were found to be significantly larger after debridement (-0.7 points [P < .001] and +5.5 points [P < .001], respectively), although the Patient Acceptable Symptom State for the VAS was not achieved after either procedure. Both SAB placement and debridement significantly improved range of motion in forward flexion/forward elevation, internal and external rotation, and abduction (P < .001). Rates of general complication were higher after debridement versus SAB placement (5.2% ± 5.6% vs 3.5% ± 6.3%, respectively; P < .001); however, there were no significant differences between SAB placement and debridement in rates of persistent symptoms requiring a reintervention (3.3% ± 6.2% vs 3.8% ± 7.3%, respectively; P = .252) or reoperation rates (5.1% ± 7.6% vs 4.8% ± 8.4%, respectively; P = .552). The mean time to conversion to reverse total shoulder arthroplasty was 11.0 versus 25.4 months, respectively, for the SAB versus debridement arm. CONCLUSION: While SAB placement was associated with acceptable postoperative outcomes in the treatment of MIRCTs, there was no clear benefit over debridement alone. Shorter operative times coupled with better postoperative outcomes and longer times to conversion to reverse total shoulder arthroplasty rendered debridement a more attractive option. While there may be a role for SAB placement in poor surgical candidates, there is burgeoning evidence to support debridement alone without SAB placement for the treatment of MIRCTs.