Human Rotator Cuff Tears Reveal an Age-Dependent Increase in Markers of Cellular Senescence and Selective Removal of Senescent Cells With Dasatinib + Quercetin Increases Genetic Expression of COL1A1 In Vitro.

PURPOSE: To quantify cellular senescence in supraspinatus tendon and subacromial bursa of humans with rotator cuff tears and to investigate the in vitro efficacy of the senolytic dasatinib + quercetin (D+Q) to eliminate senescent cells and alter tenogenic differentiation. METHODS: Tissue was harvested from 41 patients (mean age, 62 years) undergoing arthroscopic rotator cuff repairs. In part 1 (n = 35), senescence was quantified using immunohistochemistry and gene expression for senescent cell markers (p16 and p21) and the senescence-associated secretory phenotype (SASP) (interleukin [IL] 6, IL-8, matrix metalloproteinase [MMP] 3, monocyte chemoattractant protein [MCP] 1). Senescence was compared between patients <60 and ≥60 years old. In part 2 (n = 6) , an in vitro model of rotator cuff tears was treated with D+Q or control. D+Q, a chemotherapeutic and plant flavanol, respectively, kill senescent cells. Gene expression analysis assessed the ability of D+Q to kill senescent cells and alter markers of tenogenic differentiation. RESULTS: Part 1 revealed an age-dependent significant increase in the relative expression of p21, IL-6, and IL-8 in tendon and p21, p16, IL-6, IL-8, and MMP-3 in bursa (P < .05). A significant increase was seen in immunohistochemical staining of bursa p21 (P = .028). In part 2, D+Q significantly decreased expression of p21, IL-6, and IL-8 in tendon and p21 and IL-8 in bursa (P < .05). Enzyme-linked immunosorbent assay analysis showed decreased release of the SASP (IL-6, MMP-3, MCP-1; P = .002, P = .024, P < .001, respectively). Tendon (P = .022) and bursa (P = .027) treated with D+Q increased the expression of COL1A1. CONCLUSIONS: While there was an age-dependent increase in markers of cellular senescence, this relationship was not consistently seen across all markers and tissues. Dasatinib + quercetin had moderate efficacy in decreasing senescence in these tissues and increasing COL1A1 expression. CLINICAL RELEVANCE: This study reveals that cellular senescence may be a therapeutic target to alter the biological aging of rotator cuffs and identifies D+Q as a potential therapy.

Anterior Bankart Repair With Superior Capsular Plication Causes Increased Mean Tension in Posterior Glenohumeral Capsule.

Purpose: The purpose of this study is to investigate if a biomechanical difference exists in the prerepair and postrepair states of the posterior inferior glenohumeral ligament (PIGHL) following anterior Bankart repair with respect to capsular tension, labral height, and capsular shift. Methods: In this study, 12 cadaveric shoulders were dissected to the glenohumeral capsule and disarticulated. The specimens were loaded to 5-mm displacement using a custom shoulder simulator, and measurements were taken for posterior capsular tension, labral height, and capsular shift. We measured the capsular tension, labral height, and capsular shift of the PIGHL in its native state and following repair of a simulated anterior Bankart lesion. Results: We found that there was a significant increase in the mean capsular tension of the posterior inferior glenohumeral ligament (Δ = 2.12 ± 2.10 N; P = .005), as well as posterior capsular shift (Δ = .362 ± 0.365 mm; P = .018). There was no significant change in posterior labral height (Δ = 0.297 ± 0.667 mm; P = .193). These results demonstrate the sling effect of the inferior glenohumeral ligament. Conclusion: Although the posterior inferior glenohumeral ligament is not directly manipulated during an anterior Bankart repair, when the anterior inferior glenohumeral ligament is plicated superiorly, some of the tension is transmitted to the posterior glenohumeral ligament as a result of the sling effect. Clinical Relevance: Anterior Bankart repair with superior capsular plication results in an increased mean tension of the PIGHL. Clinically, this may contribute to shoulder stability.

Biomechanical Evaluation of the Efficacy of Suture Tape Augmentation for Subscapularis Peel Repair.

Background: Failure of a subscapularis repair construct after anatomic total shoulder arthroplasty can result in difficulty with internal rotation and an increased likelihood of dislocation. Although suture tape has been demonstrated to be an efficacious augment for tendonous repairs elsewhere in the body, it has not been investigated as a method for augmenting subscapularis peel repairs. Purpose: To determine the biomechanical efficacy of suture tape augmentation for the repair of a subscapularis peel. Study Design: Controlled laboratory study. Methods: Twelve human cadaveric shoulders underwent a subscapularis peel. Specimens were randomly split into 2 groups: 6 specimens underwent repair using a transosseous bone tunnel technique with 3 high-strength sutures placed with a Mason-Allen configuration (control group), and 6 specimens underwent the control repair using augmentation with 2 suture tapes placed in an inverted mattress fashion and secured to the proximal humerus using a suture anchor (augmentation group). Shoulders underwent biomechanical testing to compare repair displacement with cyclic loading, load at ultimate failure, and construct stiffness. Results: There were no significant between-group differences in displacement after cyclic loading at the superior (P = .87), middle (P = .47), or inferior (P = .77) portions of the subscapularis tendon. Load to failure was significantly greater in the augmentation group (585.1 ± 97.4 N) than in the control group (358.5 ± 81.8 N) (P = .001). Stiffness was also greater in the augmentation group (71.8 ± 13.7 N/mm) when compared with the control group (48.7 ± 5.7 N/mm) (P = .003). Conclusion: Subscapularis peel repair with augmentation via 2 inverted mattress suture tapes secured with an anchor in the proximal humerus conferred significantly greater load at ultimate failure and construct stiffness when compared with a traditional repair using 3 Mason-Allen sutures. There was no difference in repair displacement with cyclic loading between the repair groups. Clinical Relevance: Suture tape augmentation of subscapularis peel repairs after shoulder arthroplasty provides an effective segment to the strength of the repair.

Deltotrapezial Stabilization of Acromioclavicular Joint Rotational Stability: A Biomechanical Evaluation.

Background: Despite advances in surgical management of acromioclavicular (AC) joint reconstruction, many patients fail to maintain sustained anatomic reduction postoperatively. Purpose: To determine the biomechanical support of the deltoid and trapezius on AC joint stability, focusing on the rotational stability provided by the muscles to posterior and anterior clavicular rotation. A novel technique was attempted to repair the deltoid and trapezius anatomically. Study Design: Controlled laboratory study. Methods: Twelve human cadaveric shoulders (mean ± SD age, 60.25 ± 10.25 years) underwent servohydraulic testing. Shoulders were randomly assigned to undergo serial defects to either the deltoid or trapezius surrounding the AC joint capsule, followed by a combined deltotrapezial muscle defect. Deltotrapezial defects were repaired with an all-suture anchor using an anatomic technique. The torque (N·m) required to rotate the clavicle 20° anterior and 20° posterior was recorded for the following conditions: intact (native), deltoid defect, trapezius defect, combined deltotrapezial defect, and repair. Results: When compared with the native condition, the deltoid defect decreased the torque required to rotate the clavicle 20° posteriorly by 7.1% (P = .206) and 20° anteriorly by 6.1% (P = .002); the trapezial defect decreased the amount of rotational torque posteriorly by 5.3% (P = .079) and anteriorly by 4.9% (P = .032); and the combined deltotrapezial defect decreased the amount of rotational torque posteriorly by 9.9% (P = .002) and anteriorly by 9.4% (P < .001). Anatomic deltotrapezial repair increased posterior rotational torque by 5.3% posteriorly as compared with the combined deltotrapezial defect (P = .001) but failed to increase anterior rotational torque (P > .999). The rotational torque of the repair was significantly lower than the native joint in the posterior (P = .017) and anterior (P < .001) directions. Conclusion: This study demonstrated that the deltoid and trapezius play a role in clavicular rotational stabilization. The proposed anatomic repair improved posterior rotational stability but did not improve anterior rotational stability as compared with the combined deltotrapezial defect; however, neither was restored to native stability. Clinical Relevance: Traumatic or iatrogenic damage to the deltotrapezial fascia and the inability to restore anatomic deltotrapezial attachments to the acromioclavicular joint may contribute to rotational instability. Limiting damage and improving the repair of these muscles should be a consideration during AC reconstruction.

Arthroscopic Rotator Cuff Repair: A Review of Surgical Techniques and Outcomes.

Arthroscopic rotator cuff repair (ARCR) has become the gold standard management for rotator cuff repair. Double-row repairs have shown increased biomechanical strength and enhanced anatomic footprint coverage. The advancement of knotless techniques has led to decreased operating room time and reduced overall costs. We prefer a suture-bridging double-row repair for most rotator cuff repairs and incorporate a knotless medial mattress sutures (double-pulley technique) for additional support as needed.

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.

Management of Failed Rotator Cuff Repairs: A Review.

Failed rotator cuff repairs present a complex issue for treating surgeons. Many methods of management exist for this pathology including revision repair with biologic augmentation, repairs with allograft, tendon transfers, superior capsular reconstruction, balloon arthroplasty, bursal acromial reconstruction, and reverse total shoulder arthroplasty. This review discusses the current literature associated with these management options.

Surgical Treatment of Pediatric Scoliosis: Historical Origins and Review of Current Techniques.

The treatment of scoliosis has been explored and debated in medicine since the first recorded texts. Scoliosis treatment has shifted over time from external modalities, such as traction and bracing, to internal stabilization techniques that leverage surgical advances. Surgical fixation constructs can generally be separated into two different modalities: dynamic vs. static constructs. For skeletally immature individuals with progressive deformities, surgical options range from traditional or magnetically controlled growing rods to vertebral body staples or tethering. For individuals who have reached skeletal maturity, many devices have been developed that provide static length constructs. Understanding the surgical options available is critical for the appropriate management of this varied patient population. With this article, we sought to provide a summary of past and present techniques and devices used in the treatment of scoliosis.

Arthroscopic Rotator Cuff Repair with a Fibrin Scaffold Containing Growth Factors and Autologous Progenitor Cells Derived From Humeral cBMA Improves Clinical Outcomes in High Risk Patients.

Purpose: To report the clinical outcomes after biologically augmented rotator cuff repair (RCR) with a fibrin scaffold derived from autologous whole blood and supplemented with concentrated bone marrow aspirate (cBMA) harvested at the proximal humerus. Methods: Patients who underwent arthroscopic RCR with biologic augmentation using a fibrin clot scaffold ("Mega- Clot") containing progenitor cells and growth factors from proximal humerus BMA and autologous whole blood between April 2015 and January 2018 were prospectively followed. Only high-risk patients in primary and revision cases that possessed relevant comorbidities or physically demanding occupation were included. Minimum follow-up for inclusion was 1 year. The visual analog score for pain (VAS), American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), Single Assessment Numerical Evaluation (SANE), and Constant-Murley scores were collected preoperatively and at final follow-up. In vitro analyses of the cBMA and fibrin clot using nucleated cell count, colony forming units, and live/dead assays were used to quantify the substrates. Results: Thirteen patients (56.9 ± 7.7 years) were included. The mean follow-up was 26.9 ± 17.7 months (n = 13). There were significant improvements in all outcome scores from the preoperative to the postoperative state: VAS (5.6 ± 2.5 to 3.1 ± 3.2; P < .001), ASES (42.0 ± 17.1 to 65.5 ± 30.6; P < .001), SST (3.2 ± 2.8 to 6.5 ± 4.7; P = .002), SANE (11.5 ± 15.6 to 50.3 ± 36.5; P < .001), and Constant-Murley (38.9 ± 17.5 to 58.1 ± 26.3; P < .001). Six patients (46%) had retears on postoperative MRI, despite all having improvements in pain and function except one. All failures were chronic rotator cuff tears, and all were revision cases except one (1.6 ± 0.5 previous RCRs). The representative sample of harvested cBMA showed an average of 28.5 ± 9.1 × 106 nucleated cells per mL. Conclusions: Arthroscopic rotator cuff repairs that are biologically augmented with a fibrin scaffold containing growth factors and autologous progenitor cells derived from autologous whole blood and humeral cBMA can improve clinical outcomes in primary, as well as revision cases in high-risk patients. However, the incidence of retears remains a concern in this population, demanding further improvements in biologic augmentation. Level of Evidence: IV, therapeutic case series.

The Role of the Trapezius in Stabilization of the Acromioclavicular Joint: A Biomechanical Evaluation.

Background: Acromioclavicular joint (ACJ) injuries are common, and many are adequately treated nonoperatively. Biomechanical studies have mainly focused on static ligamentous stabilizers. Few studies have quantified ACJ stabilization provided by the trapezius. Purpose/Hypothesis: To elucidate the stabilization provided by the trapezius to the ACJ during scapular internal and external rotation (protraction and retraction). It was hypothesized that sequential trapezial resection would result in increasing ACJ instability. Study Design: Controlled laboratory study. Methods: A biomechanical approach was pursued, with 10 cadaveric shoulders with the trapezius anatomically force loaded to normal. The trapezius was then serially transected over 8 trials, which alternated between clavicular defects (CD) and scapular defects (SD); each sequential defect consisted of 25% of the clavicular or scapular trapezial attachment. After each defect, specimens were tested with angle-controlled scapular internal and external rotation (12°) with rotary torque measurements to evaluate ACJ stability. Results: The mean resistance in rotary torque for 12° of scapular internal rotation (protraction) with native specimens was 7.0 ± 2.0 N·m. Overall, internal rotation demonstrated a significant decrease in ACJ stability with trapezial injury (P < .001). Eight sequential defects resulted in the following significant percentage decreases in rotary torque from native internal rotation: 1.5% (25% CD; 0% SD), 5.6% (25% CD; 25% SD), 5.1% (50% CD; 25% SD), 6.5% (50% CD; 50% SD), 3.8% (75% CD; 50% SD), 7.1% (75% CD; 75% SD), 6.7% (100% CD; 75% SD), and 12.3% (100% CD 100% SD) (P < .001). The mean resistance in rotary torque for 12° of scapular external rotation (retraction) with native specimens was 7.1 ± 1.7 N·m. External rotation did not demonstrate a significant decrease in ACJ stability with trapezial injury (P = .596). The 8 sequential defects resulted in decreases in rotary torque from native external rotation of 0%, 3.8%, 4.0%, 3.2%, 3.5%, 3.4%, 4.2%, and 0.7%. Conclusion: Trapezial injury resulted in increased instability in the setting of scapular internal rotation (protraction) of the ACJ. Clinical Relevance: These findings validate the inclusion of deltotrapezial fascial injury consideration in the modified Rockwood classification system. Repair of the trapezial insertion on the ACJ may provide improved outcomes in the setting of ACJ reconstruction.

Ability to Retension Knotless Suture Anchors: A Biomechanical Analysis of Simulated Bankart Lesions.

Background: Knotless suture anchors are gaining popularity in arthroscopic glenohumeral labral repairs. The ability to retension knotless designs after initial anchor placement has been reported; however, no studies have quantified this claim or investigated the biomechanical consequence of retensioning. Purpose/Hypothesis: To determine whether knotless and knotted suture anchors have biomechanical or anatomic differences with regard to labral repairs and to determine whether retensioning of knotless suture anchors affects capsular tension, labral height, and capsular shift. We hypothesized that retensioning of knotless anchors would result in improved capsular tension compared with conventional knotted suture anchors. Study Design: Controlled laboratory study. Methods: A total of 18 fresh-frozen cadaveric shoulders with a mean age of 56 years were dissected to the capsule and disarticulated at the humeral capsular insertion. The scapula was potted and placed in a custom shoulder simulator to tension the capsule via braided sutures localized to the anteroinferior glenohumeral ligament. Specimens were randomized into 3 groups: (1) Knotted (KT), (2) Knotless with end retensioning (KLend), and (3) Knotless with stepwise retensioning (KLstepwise). All repairs were completed using all-suture anchors placed at the 5-, 4-, and 3-o'clock positions. KLstepwise was used to simulate an intraoperative technique. Resultant mean capsular tension under 5 mm of displacement (subfailure loading) was measured for each anchor placement and retensioning step. Labral height and capsular shift were measured using a MicroScribe digitizer. Results: The intact, defect, 1-anchor, 2-anchor, and 3-anchor tensions were not significantly different between the KT and KLend groups. For the latter, retensioning of all knotless anchors increased capsular tension by 2.1 N compared with its 3-anchor state, although this was not statistically significant (P = .081). The KLstepwise group explored an alternative method to retension the capsule using knotless anchors, with similar final capsular tensions compared with the other groups. All repairs had similar improvements in capsulolabral height and superior capsular shift. Conclusion: Knotted and knotless suture anchors provided similar overall restorations in anteroinferior glenohumeral ligament tension. However, knotless devices were capable of small but statistically insignificant improvements in capsular tension with retensioning. Clinical Relevance: Retensioning of knotless anchors allows the surgeon to tighten regions of the glenohumeral capsule that remain lax after repair.

Cervical and Lumbar Disc Arthroplasty: A Review of Current Implant Design and Outcomes.

While spinal disc pathology has traditionally been treated using fusion-based procedures, recent interest in motion-preserving disc arthroplasties has grown. Traditional spinal fusion is associated with loss of motion, alteration of native spine kinematics, and increased risks of adjacent segment disease. The motion conferred by disc arthroplasty is believed to combat these complications. While the first implant designs resulted in poor patient outcomes, recent advances in implant design and technology have shown promising radiographic and clinical outcomes when compared with traditional fusion. These results have led to a rapid increase in the utilization of disc arthroplasty, with rates of cervical arthroplasty nearly tripling over the course of 7 years. The purpose of this review was to discuss the evolution of implant design, the current implant designs utilized, and their associated outcomes. Although disc arthroplasty shows significant promise in addressing some of the drawbacks associated with fusion, it is not without its own risks. Osteolysis, implant migration, and the development of heterotopic ossification have all been associated with disc arthroplasty. As interest in these procedures grows, so does the interest in developing improved implant designs aimed at decreasing these adverse outcomes. Though they are still relatively new, cervical and lumbar disc arthroplasty are likely to become foundational methodologies for the treatment of disc pathology.

Readability assessment of patient educational materials for shoulder arthroplasty from top academic orthopedic institutions.

BACKGROUND: Previous studies have demonstrated that online patient educational materials are written at reading levels too advanced for the average patient. The average American reads at the eighth-grade reading level. To date, the readability of online educational material of academic centers for shoulder arthroplasty has not been analyzed. METHODS: Online patient educational materials from the top 25 orthopedic institutions, as ranked by U.S. News & World Report, were assessed utilizing the following readability assessments: Flesch-Kincaid (FK), Flesch Reading Ease, Gunning Fog Index, Coleman-Liau Index, Simple Measure of the Gobbledygook Index, Automated Readability Index, FORCAST, and the New Dale and Chall Readability. All of these scores, with the exception of the Flesch Reading Ease, provide an output indicating reading difficulty based on grade level. Correlations between academic institutional ranking and FK scores were evaluated using a Spearman regression. Lastly, additional factors including geographical location, private versus public institution, and use of concomitant multi-media modalities that may impact institutional readability scores (as determined by FK) were evaluated. RESULTS: Only 16.0% of the top 25 institutions included online material at or below the eighth-grade reading level. Moreover, half of the online resources evaluated (those with FK score ≥9.3) were not at a suitable reading level for more than two-thirds of the general United States population (∼70%). Overall, the composite mean scores were 9.5 ± 2.1 for FK, 52.8 ± 9. for 4 Flesch Reading Ease, 12.2 ± 2.4 for Gunning Fog, 11.6 ± 1.8 for Coleman-Liau, 12.3 ± 1.7 for Simple Measure of the Gobbledygook Index, 9.6 ± 2.6 for Automated Readability, 11.1 ± 0.6 for FORCAST, and 5.9 ± 0.6 for New Dale and Chall. There was no correlation between institutional ranking and FK scores (ρ = -0.15; P = .946). Geographical location, private versus public institution, and use of concomitant multi-media modalities were not significantly associated with readability. CONCLUSION: Shoulder arthroplasty online patient educational material at top-ranked orthopedic institutions have poor readability and are likely not suitable for the majority of patients in the United States.

Augmentation of Distal Biceps Tendon Ruptures With the Lacertus Fibrosus: A Biomechanical Study in a Tendon-Deficient Model.

BACKGROUND: Chronic distal biceps tendon ruptures may require tendon graft augmentation secondary to tendon attrition or retraction. The lacertus fibrosus is a local, cost-effective graft that can be used to supplement reconstruction. PURPOSE: To compare the biomechanical strength of distal biceps tendon repairs with and without lacertus fibrosus augmentation in a tendon-deficient cadaveric model. STUDY DESIGN: Controlled laboratory study. METHODS: Sixteen fresh-frozen matched cadaveric pairs of elbows were randomized into 2 groups: (1) standard distal biceps tendon repair and (2) tendon-deficient (50% step cut) repair with lacertus fibrosus augmentation. All repairs were completed using an oval bone trough and 2 double-loaded No. 2 braided nonabsorbable sutures in a locked Krackow fashion tied over a lateral bone bridge. For the lacertus augmentation group, the lacertus was wrapped circumferentially in a tubular fashion around the tendon to restore the native size and incorporated into the Krackow suture. All specimens underwent cyclic loading and then were loaded to failure. Displacement, stiffness, load to failure, and mode of failure were recorded. RESULTS: The standard repair and lacertus augmentation groups had similar displacements on cyclic loading (1.66 ± 0.62 vs 1.62 ± 0.58 mm, respectively; P = .894). The stiffness was significantly greater for the standard repair group (21.3 ± 2.5 vs 18.5 ± 3.5 N/mm; P = .044). Both groups provided excellent mean peak load to failure strengths, despite the standard repair group having significantly greater strength (462.4 ± 140.5 vs 377.3 ± 101.1 N; P = .022). The primary mode of failure in the standard repair group was fracture at the bone bridge (n = 5/8) compared with suture pullout (n = 4/8) in the lacertus augmentation group. CONCLUSION: Lacertus fibrosus augmentation of a tendon-deficient biceps repair was less stiff and had lower mean load to failure compared with repair of the native tendon in this cadaveric model, but these values remained biomechanically acceptable above critical thresholds. Consequently, lacertus fibrosus augmentation is a viable option for chronic distal biceps tendon ruptures with tendon attrition. CLINICAL RELEVANCE: Chronic distal biceps tendon ruptures may require autograft or allograft reconstruction secondary to tendon scarring, shortening, attrition, and degeneration. The lacertus fibrosus is a cost-effective and low-morbidity local autograft that can be used to augment repairs.

Comparison of the Coracoid, Distal Clavicle, and Scapular Spine for Autograft Augmentation of Glenoid Bone Loss: A Radiologic and Cadaveric Assessment.

BACKGROUND: Glenohumeral instability caused by bone loss requires adequate bony restoration for successful surgical stabilization. Coracoid transfer has been the gold standard bone graft; however, it has high complication rates. Alternative autologous free bone grafts, which include the distal clavicle and scapular spine, have been suggested. STUDY DESIGN: Controlled laboratory study. PURPOSE: The purpose of this study was to determine the percentage of glenoid bone loss (GBL) restored via coracoid, distal clavicle, and scapular spine bone grafts using a patient cohort and a cadaveric evaluation. METHODS: Autologous bone graft dimensions from a traditional Latarjet, congruent arc Latarjet, distal clavicle, and scapular spine were measured in a 2-part study using 52 computed tomography (CT) scans and 10 unmatched cadaveric specimens. The amount of GBL restored using each graft was calculated by comparing the graft thickness with the glenoid diameter. RESULTS: Using CT measurements, we found the mean percentage of glenoid restoration for each graft was 49.5% ± 6.7% (traditional Latarjet), 45.1% ± 4.9% (congruent arc Latarjet), 42.2% ± 7.7% (distal clavicle), and 26.2% ± 8.1% (scapular spine). Using cadaveric measurements, we found the mean percentage of glenoid restoration for each graft was 40.2% ± 5.0% (traditional Latarjet), 53.4% ± 4.7% (congruent arc Latarjet), 45.6% ± 8.4% (distal clavicle), and 28.2% ± 7.7% (scapular spine). With 10% GBL, 100% of the coracoid and distal clavicle grafts, as well as 88% of scapular spine grafts, could restore the defect (P < .001). With 20% GBL, 100% of the coracoid and distal clavicle grafts but only 66% of scapular spine grafts could restore the defect (P < .001). With 30% GBL, 100% of coracoid grafts, 98% of distal clavicle grafts, and 28% of scapular spine grafts could restore the defect (P < .001). With 40% GBL, a significant difference was identified (P = .001), as most coracoid grafts still provided adequate restoration (congruent arc Latarjet, 82.7%; traditional Latarjet, 76.9%), but distal clavicle grafts were markedly reduced, with only 51.9% of grafts maintaining sufficient dimensions. CONCLUSIONS: The coracoid and distal clavicle grafts reliably restored up to 30% GBL in nearly all patients. The coracoid was the only graft that could reliably restore up to 40% GBL. CLINICAL RELEVANCE: With "subcritical" GBL (>13.5%), all autologous bone grafts can be used to adequately restore the bony defect. However, with "critical" GBL (≥20%), only the coracoid and distal clavicle can reliably restore the bony defect.

Three-Dimensional Footprint Mapping of the Deltoid and Trapezius: Anatomic Pearls for Acromioclavicular Joint Reconstruction.

PURPOSE: To perform a quantitative anatomic evaluation of the deltoid and trapezius footprints in relation to the lateral clavicle and acromioclavicular (AC) joint capsule to assist in surgical technique of AC joint reconstructions. METHODS: Fourteen fresh-frozen human cadaveric shoulders from 9 donors were analyzed. Meticulous dissection of the deltoid origin and trapezius insertions to the clavicle and AC joint was performed. Footprints were reconstructed using a MicroScribe digitizer. The inferior extension of the deltoid origin beneath the lateral clavicle and the footprints of the deltoid and trapezius onto the acromioclavicular ligamentous complex (ACLC) were quantified. Reproducibility was assessed by redigitizing 5 shoulders in a blinded and random fashion. RESULTS: The anterior deltoid fibers extended on average 4.0 ± 1.6 mm inferiorly with respect to the anteroinferior clavicular ridge and attached to 90.9 ± 7.3% of the anterior ACLC. The trapezius inserted onto the posterior and superior ACLC, covering 15.3 ± 3.4% of the anterior-posterior width of the superior capsule. The deltopectoral interval was 6 cm, or 37% the length of the clavicle from the distal end of the clavicle. CONCLUSIONS: The deltoid has superior, anterior, and not as well described, inferior attachments to the lateral clavicle. Furthermore, the deltoid and trapezius muscles have intimate attachments to the AC joint capsule, particularly the trapezius to the posterior and posterosuperior capsule. Lastly, the deltoid origin attaches to the lateral 6 cm of the clavicle. CLINICAL RELEVANCE: Subperiosteal elevation of the deltoid off the lateral clavicle starting superiorly, anteriorly, and lastly inferiorly will reduce deltoid muscle injury and improve visibility of the coracoid process during reconstruction. Furthermore, knowledge of the attachments of the deltoid and trapezius to the ACLC may help limit iatrogenic injury to these dynamic stabilizers.

Arthroscopic rotator cuff repair with biologically enhanced patch augmentation.

OBJECTIVE: The purpose of this guide is to illustrate an arthroscopic rotator cuff repair (RCR) with two techniques for biologically enhanced patch augmentation. INDICATIONS: Massive rotator cuff tears (> 5 cm) and revision RCR. CONTRAINDICATIONS: Active joint or systemic infection; severe fatty muscle atrophy; severe glenohumeral arthropathy; American Society of Anesthesiologists Physical Status (ASA PS) IV. SURGICAL TECHNIQUE: Dermal allograft patch augmented with concentrated bone marrow aspirate (cBMA), platelet-rich plasma (PRP) and platelet-poor plasma (PPP); or Regeneten patch augmented with bursa, PRP, PPP, and autologous thrombin. POSTOPERATIVE MANAGEMENT: A 30° abduction sling for 6 weeks; unrestricted active-assisted external rotation and forward elevation after 12 weeks; focus on restoration of scapular stability and strength. RESULTS: A total of 22 patients received revision massive RCR using a dermal allograft patch enhanced with cBMA and PRP with a mean follow-up of 2.5 years (1.0-5.8 years). There was a significant improvement in the preoperative Simple Shoulder Test (SST). There was also a trend towards improved pain and American Shoulder and Elbow Surgeons (ASES) Shoulder Score. In this cohort, 45% reached the minimal clinically important difference (MCID), 41% achieved substantial clinical benefit (SCB), and 32% had a patient-acceptable symptomatic state (PASS) for the ASES score. Preliminary data using the Regeneten patch technique with bursa, PRP, PPP, and autologous thrombin was prospectively collected in five patients between 05/2020 and 03/2021 at the author's institution. Mean follow-up was 6.5 ± 1.3 (6-8 months). There was an improvement from preop to postop in pain, ASES, SANE, Constant-Murley (CM) score and active range of motion.

Minimum 10-Year Clinical Outcomes After Arthroscopic 270° Labral Repair in Traumatic Shoulder Instability Involving Anterior, Inferior, and Posterior Labral Injury.

BACKGROUND: Current literature reports highly satisfactory short- and midterm clinical outcomes in patients with arthroscopic 270° labral tear repairs. However, data remain limited on long-term clinical outcomes and complication and redislocation rates in patients with traumatic shoulder instability involving anterior, inferior, and posterior labral injury. PURPOSE: To investigate, at a minimum follow-up of 10 years, the clinical outcomes, complications, and recurrent instability in patients with 270° labral tears involving the anterior, inferior, and posterior labrum treated with arthroscopic stabilization using suture anchors. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective outcomes study was completed for all patients with a minimum 10-year follow-up who underwent arthroscopic 270° labral tear repairs with suture anchors by a single surgeon. Outcome measures included pre- and postoperative Rowe score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test, visual analog scale for pain, and Single Assessment Numeric Evaluation (SANE). Western Ontario Shoulder Instability Index (WOSI) scores were collected postoperatively. Complication data were collected, including continued instability, subluxation or dislocation events, and revision surgery. Failure was defined as any cause of revision surgery. RESULTS: In total, 21 patients (mean ± SD age, 27.1 ± 9.6 years) with 270° labral repairs were contacted at a minimum 10-year follow-up. All outcome measures showed statistically significant improvements as compared with those preoperatively: Rowe (53.9 ± 11.4 to 88.7 ± 8.9; P = .005), ASES (72.9 ± 18.4 to 91.8 ± 10.8; P = .004), Simple Shoulder Test (8.7 ± 2.4 to 11.2 ± 1.0; P = .013), visual analog scale (2.5 ± 2.6 to 0.5 ± 1.1; P = .037), and SANE (24.0 ± 15.2 to 91.5 ± 8.3; P = .043). The mean postoperative WOSI score at minimum follow-up was 256.3 ± 220.6. Three patients had postoperative complications, including a traumatic subluxation, continued instability, and a traumatic dislocation, 2 of which required revision surgery (14.2% failure rate). CONCLUSION: Arthroscopic repairs of 270° labral tears involving the anterior, inferior, and posterior labrum have highly satisfactory clinical outcomes at 10 years, with complication and redislocation rates similar to those reported at 2 years. This suggests that repairs of extensile labral tears are effective in restoring and maintaining mechanical stability of the glenohumeral joint in the long term.

Analysis of Patient Factors Affecting In Vitro Characteristics of Subacromial Bursal Connective Tissue Progenitor Cells during Rotator Cuff Repair.

Unsatisfactory failure rates following rotator cuff (RC) repair have led orthopaedic surgeons to explore biological augmentation of the healing enthesis. The subacromial bursa (SB) contains abundant connective tissue progenitor cells (CTPs) that may aid in this process. The purpose of the study was to investigate the influence of patient demographics and tear characteristics on the number of colony-forming units (CFUs) and nucleated cell count (NCC) of SB-derived CTPs. In this study, we harvested SB tissue over the supraspinatus tendon and muscle in 19 patients during arthroscopic RC repair. NCC of each sample was analyzed on the day of the procedure. After 14 days, CFUs were evaluated under a microscope. Spearman's rank correlation coefficient was then used to determine the relationship between CFUs or NCC and patient demographics or tear characteristics. The study found no significant correlation between patient demographics and the number of CFUs or NCC of CTPs derived from the SB (p > 0.05). The study did significantly observe that increased tear size was negatively correlated with the number of CFUs (p < 0.05). These results indicated that increased tear size, but not patient demographics, may influence the viability of CTPs and should be considered when augmenting RCrepairs with SB.