Novel all-arthroscopic biceps tenodesis technique incorporated into rotator cuff repair-two hundred cases with minimum 2-year follow-up.

Background: Biceps tendon pathology is a common source of pain in the shoulder. It is frequently seen in conjunction with symptomatic rotator cuff tears. Biceps tendon management during arthroscopic rotator cuff repairs can be achieved via tenodesis with various techniques or tenotomy. Tenodesis of the biceps generally results in less deformity and reduced exertion-related cramping. However, most techniques require the addition of some type of hardware to provide fixation for the biceps tendon, which adds cost, time, and complexity. This study presents a technique for an all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair, requiring no additional hardware. Methods: This study is a retrospective review of data that were prospectively collected for 200 consecutive patients for whom the procedure was performed. Patients were seen postoperatively at 2 weeks, 6 weeks, 4 months, and 6 months and in addition massive rotator cuff repairs were seen at 8 months. Additionally all patients were contacted at a minimum 2-year follow-up to access for the presence deformity, the American Shoulder and Elbow Surgeons (ASES) score, and SANE score. Descriptive statistics and comparisons to known minimal clinical important differences (MCIDs) for the patient recorded outcome measures were recorded. Results: Two hundred patients were included in the study and 152 responded to the telephone interviews. The mean age of the patients at the time of surgery was 65.3 year old (standard deviation ± 9.1, range of 46-84), and the mean postoperative phone interview was 3.2 years postsurgery (standard deviation of ± 1.0, range of 2-5 years). The average ASES score improved from 52.6 to 94.6, which is 3 times greater than the minimal clinical important difference. The average postoperative SANE score was 94. Seven procedures out of the 200 were labeled as failures due to 1 patient's nonsatisfaction with the procedure and 3 for a Popeye deformity and 3 that had a revision RCR. Discussion: The described method of an arthroscopic biceps tenodesis performed with a rotator cuff repair uses no extra hardware, requires minimal additional operative time, and is clinically effective. At a minimum 2-year follow-up, the all-arthroscopic biceps tenodesis in conjunction with a double-row rotator cuff repair resulted in a marked improvement in their ASES score with a 3.5% failure rate. Conclusion: The all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair demonstrated improved clinical outcome, without requiring any additional hardware to tenodese the biceps, at a minimum 2-year follow-up.

Obesity and sex influence fatty infiltration of the rotator cuff: the Rotator Cuff Outcomes Workgroup (ROW) and Multicenter Orthopaedic Outcomes Network (MOON) cohorts.

BACKGROUND: Fatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited. METHODS: We recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n = 80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n = 158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates. RESULTS: A total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m2 was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men. CONCLUSIONS: Among patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients.

Reliability of the modified Walch classification for advanced glenohumeral osteoarthritis using 3-dimensional computed tomography analysis: a study of the ASES B2 Glenoid Multicenter Research Group.

BACKGROUND: Variations in glenoid morphology affect surgical treatment and outcome of advanced glenohumeral osteoarthritis (OA). The purpose of this study was to assess the inter- and intraobserver reliability of the modified Walch classification using 3-dimensional (3D) computed tomography (CT) imaging in a multicenter research group. METHODS: Deidentified preoperative CTs of patients with primary glenohumeral OA undergoing anatomic or reverse total shoulder arthroplasty (TSA) were reviewed with 3D imaging software by 23 experienced shoulder surgeons across 19 institutions. CTs were separated into 2 groups for review: group 1 (96 cases involving all modified Walch classification categories evaluated by 12 readers) and group 2 (98 cases involving posterior glenoid deformity categories [B2, B3, C1, C2] evaluated by 11 readers other than the first 12). Each case group was reviewed by the same set of readers 4 different times (with and without the glenoid vault model present), blindly and in random order. Inter- and intraobserver reliabilities were calculated to assess agreement (slight, fair, moderate, substantial, almost perfect) within groups and by modified Walch classification categories. RESULTS: Interobserver reliability showed fair to moderate agreement for both groups. Group 1 had a kappa of 0.43 (95% confidence interval [CI]: 0.38, 0.48) with the glenoid vault model absent and 0.41 (95% CI: 0.37, 0.46) with it present. Group 2 had a kappa of 0.38 (95% CI: 0.33, 0.43) with the glenoid vault model absent and 0.37 (95% CI: 0.32, 0.43) with it present. Intraobserver reliability showed substantial agreement for group 1 with (0.63, range 0.47-0.71) and without (0.61, range 0.52-0.69) the glenoid vault model present. For group 2, intraobserver reliability showed moderate agreement with the glenoid vault model absent (0.51, range 0.30-0.72), which improved to substantial agreement with the glenoid vault model present (0.61, range 0.34-0.87). DISCUSSION: Inter- and intraobserver reliability of the modified Walch classification were fair to moderate and moderate to substantial, respectively, using standardized 3D CT imaging analysis in a large multicenter study. The findings potentially suggest that cases with a spectrum of posterior glenoid bone loss and/or dysplasia can be harder to distinguish by modified Walch type because of a lack of defined thresholds, and the glenoid vault model may be beneficial in determining Walch type in certain scenarios. The ability to reproducibly separate patients into groups based on preoperative pathology, including Walch type, is important for future studies to accurately evaluate postoperative outcomes in TSA patient cohorts.

Surgeon Agreement on the Presence of Pathologic Anterior Instability on Shoulder Imaging Studies.

BACKGROUND: In the setting of anterior shoulder instability, it is important to assess the reliability of orthopaedic surgeons to diagnose pathologic characteristics on the 2 most common imaging modalities used in clinical practice: standard plain radiographs and magnetic resonance imaging (MRI). PURPOSE: To assess the intra- and interrater reliability of diagnosing pathologic characteristics associated with anterior shoulder instability using standard plain radiographs and MRI. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Patient charts at a single academic institution were reviewed for anterior shoulder instability injuries. The study included 40 sets of images (20 radiograph sets, 20 MRI series). The images, along with standardized evaluation forms, were distributed to 22 shoulder/sports medicine fellowship-trained orthopaedic surgeons over 2 points in time. Kappa values for inter- and intrarater reliability were calculated. RESULTS: The overall response rate was 91%. For shoulder radiographs, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.49), estimate of glenoid lesion surface area (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.35), and estimate of Hill-Sachs surface area (κ = 0.50). Intrarater agreement was moderate for radiographs (κ = 0.48-0.57). For shoulder MRI, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.44), glenoid lesion surface area (κ = 0.35), Hill-Sachs lesion (κ = 0.33), Hill-Sachs surface area (κ = 0.28), humeral head edema (κ = 0.41), and presence of a capsulolabral injury (κ = 0.36). Fair agreement was found for specific type of capsulolabral injury (κ = 0.21). Intrarater agreement for shoulder MRI was moderate for the presence of glenoid lesion (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.52), estimate of Hill-Sachs surface area (κ = 0.50), humeral head edema (κ = 0.51), and presence of a capsulolabral injury (κ = 0.53), and agreement was substantial for glenoid lesion surface area (κ = 0.63). Intrarater agreement was fair for determining the specific type of capsulolabral injury (κ = 0.38). CONCLUSION: Fair to moderate agreement by surgeons was found when evaluating imaging studies for anterior shoulder instability. Agreement was similar for identifying pathologic characteristics on radiographs and MRI. There was a trend toward better agreement for the presence of glenoid-sided injury. The lowest agreement was observed for specific capsulolabral injuries.

One and two-year clinical outcomes for a polyethylene glenoid with a fluted peg: one thousand two hundred seventy individual patients from eleven centers.

PURPOSE: Clinical shoulder science lacks a benchmark against which the early clinical value of new glenoid components can be compared; such a benchmark may be derived from a multicenter study of patients receiving an established, internationally used design of glenoid component. METHODS: We obtained data from 11 centers on 1270 patients having total shoulder arthroplasty using an all-polyethylene component with a fluted central peg. We analyzed individual patient outcomes at 1 and 2 years after surgery. We compared the improvement for each patient to the minimal clinically important difference (MCID) and calculated each patient's improvement as a percent of maximal possible improvement (MPI). RESULTS: The preoperative scores improved from SST 3 ± 2, ASES 37 ± 15, Constant score 36 ± 16, and Penn score 30 ± 19 to SST 10 ± 2, ASES 90 ± 12, Constant 76 ± 13, and Penn 80 ± 24 (p < 0.001 for each). A high percentage of patients improved by more than the MCID (SST 96%, ASES 98%, Constant 94%, Penn 93%) and obtained improvement of at least 30% of the MPI (SST 95%, ASES 98%, Constant 91%, Penn 87%). The clinical outcomes realized with this glenoid design were not worse for the 41% of shoulders with preoperative type B glenoids or for the 30% of shoulders with more than 15 degrees of glenoid retroversion. CONCLUSIONS: Individual patients from 11 international practices having total shoulder arthroplasty using a basic glenoid component design obtained highly significant clinical outcomes, providing a benchmark against which the early outcomes of new designs can be compared to determine whether they provide increased clinical value.

Shoulder Instability: Interobserver and Intraobserver Agreement in the Assessment of Labral Tears.

BACKGROUND: The glenohumeral joint combines large range of motion and insufficient bony stabilization, making it susceptible to instability and dislocations. Arthroscopic surgery is routinely used as a diagnostic tool and has been considered the gold standard for the diagnosis of shoulder lesions. However, several studies have demonstrated variability in intraobserver and interobserver agreement. PURPOSE: To evaluate interobserver and intraobserver agreement in the assessment of intra-articular lesions associated with shoulder instability among fellowship-trained shoulder surgeons. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 24 arthroscopic videos from patients treated for recurrent shoulder instability were shown to a group of 10 fellowship-trained shoulder surgeons who are members of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group. They were presented to the surgeons on 2 different occasions at least 2 months apart. They were asked to classify labral tears by their position, type, extension, other intra-articular abnormality, and preferred treatment. No patient history or physical examination data were provided. The primary outcome was the median overall percentage of agreement for the surgeons performing a video review, measured for each variable evaluated. Intraclass correlation coefficients were used to evaluate continuous variables, and kappa values were used for categorical items. RESULTS: Interobserver agreement was good for anterior labral lesions; good for Hill-Sachs lesions; and moderate for lesions of the superior labrum, posterior labrum, anterior sublabral foramen, and position and extension of the tear. Intraobserver agreement was either good or very good for all variables evaluated, except for being poor for inferior labral lesions and moderate for lesions of the meniscoid superior labrum. CONCLUSION: Interobserver and intraobserver reliability for the arthroscopic assessment of labral tears in patients with recurrent shoulder instability were good to moderate for the majority of anatomic structures assessed. There was relatively good agreement between shoulder instability surgeons on assessing and documenting shoulder instability-associated abnormalities. These findings are important when interpreting collaborative clinical cohort studies with numerous surgeons involved in the research.

Radiographic results of augmented all-polyethylene glenoids in the presence of posterior glenoid bone loss during total shoulder arthroplasty.

BACKGROUND: Chronic osteoarthritis can result in glenohumeral subluxation and loss of posterior glenoid bone. This can alter normal glenohumeral biomechanics and affect the stress placed on the glenoid implant after total shoulder arthroplasty. This study evaluated the clinical and radiographic results of an augmented all-polyethylene glenoid for the treatment of glenoid osteoarthritis in the presence of posterior glenoid bone loss and determined whether any failures or complications occurred with short-term follow-up. METHODS: During a 2-year period, 21 patients were treated with an augmented glenoid for an index diagnosis of osteoarthritis with a biconcave glenoid and average posterior glenoid bone loss of 4.7 mm. Clinical outcomes were recorded for the American Shoulder and Elbow Surgeons Shoulder Assessment, Simple Shoulder Test, and active motion. Radiographic analysis included glenoid version, humeral head subluxation, component seating, ingrowth, and loosening. RESULTS: Significant improvements were demonstrated for American Shoulder and Elbow Surgeons Shoulder Assessment (52.3), Simple Shoulder Test (8.1), forward flexion (50°), external rotation (32°), and pain. Radiographic improvements were found for glenoid version (12°), humeral scapular alignment (23%), and humeral glenoid alignment (8%). Central peg ingrowth was demonstrated in all patients, and complete component seating was achieved in 19 patients. No complications were encountered, and no clinical or radiographic failures were identified. CONCLUSION: Augmented polyethylene glenoid components demonstrated improved clinical outcome, without implant failure or complications, during short-term follow-up.

2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears.

BACKGROUND: The purpose of this study is to help define the indications for rotator cuff repair by identifying predictors of failure of nonoperative treatment. METHODS: A prospective, multicenter, cohort study design was used. All patients with full-thickness rotator cuff tears on magnetic resonance imaging were offered participation. Baseline data from this cohort were used to examine risk factors for failing a standard rehabilitation protocol. Patients who underwent surgery were defined as failing nonoperative treatment. A Cox proportional hazards model was fit to determinethe baseline factors that predicted failure. The dependent variable was time to surgery. The independent variables were tear severity and baseline patient factors: age, activity level, body mass index, sex, Single Assessment Numeric Evaluation score, visual analog scale score for pain, education, handedness, comorbidities, duration of symptoms, strength, employment, smoking status, and patient expectations. RESULTS: Of the 433 subjects in this study, 87 underwent surgery with 93% follow-up at 1 year and 88% follow-up at 2 years. The median age was 62 years, and 49% were female patients. Multivariate modeling, adjusted for the covariates listed previously, identified patient expectations regarding physical therapy (P < .0001) as the strongest predictor of surgery. Higher activity level (P = .011) and not smoking (P = .023) were also significant predictors of surgery. CONCLUSION: A patient's decision to undergo surgery is influenced more by low expectations regarding the effectiveness of physical therapy than by patient symptoms or anatomic features of the rotator cuff tear. As such, patient symptoms and anatomic features of the chronic rotator cuff tear may not be the best features to use when deciding on surgical intervention.

Five- to ten-year follow-up with a partially cemented all-polyethylene bone-ingrowth glenoid component.

BACKGROUND: Although total shoulder arthroplasty has demonstrated better clinical outcomes than hemiarthroplasty, glenoid component loosening is a common complication. Recently, a novel partially cemented all-polyethylene fluted central peg bone-ingrowth component was introduced. METHODS: Forty-two consecutive total shoulder arthroplasties from 2003 to 2007 performed by a single surgeon were evaluated radiographically and clinically with American Shoulder and Elbow Surgeons (ASES) scores and range of motion. RESULTS: The average follow-up was 80 months (63-114); the average forward elevation improved from 107° to 137°, and external rotation improved from 30° to 37° at the latest follow-up. The average ASES score improved from 50 to 84. There was a strong correlation with the mean peripheral peg lucent line score (Lazarus score), which was 0.81, with the mean anchor peg lucent line score, which was 0.50 (P < .001). An analysis of polyethylene before and after cross-linking revealed a strong correlation between components with cross-linking and the Lazarus scores and the central fluted peg scores. Overall, there was 97% survivorship at 80 months. On radiographs, 81% of the central fluted pegs had complete incorporation with no lucent lines. These lucent lines correlated with lower ASES scores, suggesting that loosening of the glenoid decreases functional outcome. CONCLUSION: Care should be taken in preparing the central fluted peg as perforation of the vault can lead to central flute peg lucent line formation, whereas perforation of the peripheral pegs does not seem to negatively affect the outcome.

Quantification of B2 glenoid morphology in total shoulder arthroplasty.

BACKGROUND: B2 glenoid morphology is challenging to address with shoulder reconstruction. Deformity often renders current techniques inadequate, necessitating compromises that limit long-term implant durability. The purpose of this study was to perform in vivo measurements of glenoid deformity to better appreciate the orientation of the B2 biconcavity demarcation and erosion that surgeons face intraoperatively. MATERIALS AND METHODS: A consecutive 106 total shoulder arthroplasty cases for primary glenohumeral osteoarthritis were studied. We classified glenoids by direct visualization and noted lines of biconcavity demarcation and erosion in B2s. We then calculated the "angle of erosion" as that between the back side of the unsupported, smooth-backed glenoid sizer disk and the neoglenoid. We obtained depth measurements throughout the reaming process and monitored subchondral bone. RESULTS: We classified 43 of 106 glenoids (41%) as B2. A biconcavity demarcation line between the paleoglenoid and the neoglenoid was present, on average, from the 1-o'clock to the 7-o'clock position for a left shoulder. Mean depth of erosion was 4.4 mm, occurring at 114° on a Cartesian coordinate system for a left shoulder. The mean angle of erosion was 18° (range, 8°-43°). Despite reaming, 20 of 43 B2 glenoids (47%) had incompletely supported components at final seating. CONCLUSIONS: Arthritic B2 glenoids are common, and their maximal erosion is usually posteroinferior. Use of standard glenoid components to reconstruct them may require significant subchondral bone removal to achieve complete bone support. Alternatively, as a compromise, maintenance of subchondral bone in these cases requires implanting components with incomplete bony support.

Shoulder prosthetic arthroplasty options in 2014: what to do and when to do it.

The number of shoulder arthroplasty procedures performed in the United States is steadily increasing as a result of an expansion in implant options, clinical indications, and surgical experience. Available options include stemmed implants, short-stemmed or stemless prostheses, fracture-specific designs, resurfacing implants, partial surface replacement, metal-backed or polyethylene glenoid components designed for cementation or bone ingrowth, and reverse total shoulder arthroplasty. Efforts to re-create anatomy, improve outcomes, and avoid complications have resulted in many changes in prosthesis design. Despite these changes, failures still occur, and revision surgery is sometimes necessary. A thorough knowledge of current arthroplasty options, indications, and the principles of implantation is necessary to optimize outcomes after shoulder arthroplasty.

Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear.

BACKGROUND: For many orthopaedic disorders, symptoms correlate with disease severity. The objective of this study was to determine if pain level is related to the severity of rotator cuff disorders. METHODS: A cohort of 393 subjects with an atraumatic symptomatic full-thickness rotator-cuff tear treated with physical therapy was studied. Baseline pretreatment data were used to examine the relationship between the severity of rotator cuff disease and pain. Disease severity was determined by evaluating tear size, retraction, superior humeral head migration, and rotator cuff muscle atrophy. Pain was measured on the 10-point visual analog scale (VAS) in the patient-reported American Shoulder and Elbow Surgeons (ASES) score. A linear multiple regression model was constructed with use of the continuous VAS score as the dependent variable and measures of rotator cuff tear severity and other nonanatomic patient factors as the independent variables. Forty-eight percent of the patients were female, and the median age was sixty-one years. The dominant shoulder was involved in 69% of the patients. The duration of symptoms was less than one month for 8% of the patients, one to three months for 22%, four to six months for 20%, seven to twelve months for 15%, and more than a year for 36%. The tear involved only the supraspinatus in 72% of the patients; the supraspinatus and infraspinatus, with or without the teres minor, in 21%; and only the subscapularis in 7%. Humeral head migration was noted in 16%. Tendon retraction was minimal in 48%, midhumeral in 34%, glenohumeral in 13%, and to the glenoid in 5%. The median baseline VAS pain score was 4.4. RESULTS: Multivariable modeling, controlling for other baseline factors, identified increased comorbidities (p = 0.002), lower education level (p = 0.004), and race (p = 0.041) as the only significant factors associated with pain on presentation. No measure of rotator cuff tear severity correlated with pain (p > 0.25). CONCLUSIONS: Anatomic features defining the severity of atraumatic rotator cuff tears are not associated with the pain level. Factors associated with pain are comorbidities, lower education level, and race. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

What went wrong and what was done about it: pitfalls in the treatment of common shoulder surgery.

When performing revision shoulder surgery, it is important that the surgeon understands why the index procedure failed and has a clear plan to address problems in the revision procedure. The most common cause of failure after anterior instability shoulder surgery is a failure to treat the underlying glenoid bone loss. For most defects, a Latarjet transfer can effectively restore anterior glenoid bone stock and restore shoulder stability. Persistent anterior shoulder pain after rotator cuff surgery may be the result of missed biceps pathology. This can be effectively treated via a biceps tenodesis. The most difficult failures to treat after acromioclavicular joint reconstruction surgery are those involving fractures of either the coracoid or the clavicle. Clavicle hook plates can be used as supplemental fixation during the treatment of these fractures to help offload the fracture site and allow healing while restoring stability to the acromioclavicular articulation. A failed hemiarthroplasty for a proximal humeral fracture frequently results when the tuberosities fail to heal correctly. This complication can be avoided by paying close attention to the implant position and the tuberosity fixation. If hemiarthroplasty is unsuccessful, the patient is best treated with conversion to a reverse shoulder arthroplasty.

The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross-sectional study of patients with atraumatic, full-thickness rotator cuff tears.

HYPOTHESIS: The purpose of this cross-sectional study is to determine whether the duration of symptoms influences the features seen in patients with atraumatic, full-thickness rotator cuff tears. Our hypothesis is that an increasing duration of symptoms will correlate with more advanced findings of rotator cuff tear severity on magnetic resonance imaging, worse shoulder outcome scores, more pain, decreased range of motion, and less strength. METHODS: We enrolled 450 patients with full-thickness rotator cuff tears in a prospective cohort study to assess the effectiveness of nonoperative treatment and factors predictive of success. The duration of patient symptoms was divided into 4 groups: 3 months or less, 4 to 6 months, 7 to 12 months, and greater than 12 months. Data collected at patient entry into the study included (1) demographic data, (2) history and physical examination data, (3) radiographic imaging data, and (4) validated patient-reported measures of shoulder status. Statistical analysis included a univariate analysis with the Kruskal-Wallis test and Pearson test to identify statistically significant differences in these features for different durations of symptoms. RESULTS: A longer duration of symptoms does not correlate with more severe rotator cuff disease. The duration of symptoms was not related to weakness, limited range of motion, tear size, fatty atrophy, or validated patient-reported outcome measures. CONCLUSIONS: There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease.

Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study.

PURPOSE: To assess the effectiveness of a specific nonoperative physical therapy program in treating atraumatic full-thickness rotator cuff tears using a multicenter prospective cohort study design. MATERIALS AND METHODS: Patients with atraumatic full-thickness rotator cuff tears who consented to enroll provided data via questionnaire on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcome assessments (Short Form 12 score, American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff score, Single Assessment Numeric Evaluation score, and Shoulder Activity Scale). Physicians recorded physical examination and imaging data. Patients began a physical therapy program developed from a systematic review of the literature and returned for evaluation at 6 and 12 weeks. At those visits, patients could choose 1 of 3 courses: (1) cured (no formal follow-up scheduled), (2) improved (continue therapy with scheduled reassessment in 6 weeks), or (3) no better (surgery offered). Patients were contacted by telephone at 1 and 2 years to determine whether they had undergone surgery since their last visit. A Wilcoxon signed rank test with continuity correction was used to compare initial, 6-week, and 12-week outcome scores. RESULTS: The cohort consists of 452 patients. Patient-reported outcomes improved significantly at 6 and 12 weeks. Patients elected to undergo surgery less than 25% of the time. Patients who decided to have surgery generally did so between 6 and 12 weeks, and few had surgery between 3 and 24 months. CONCLUSION: Nonoperative treatment using this physical therapy protocol is effective for treating atraumatic full-thickness rotator cuff tears in approximately 75% of patients followed up for 2 years.

Agreement in the classification and treatment of the superior labrum.

BACKGROUND: The Snyder classification scheme is the most commonly used system for classifying superior labral injuries. Although this scheme is intended to be used for arthroscopic visual classification only, it is thought that other nonarthroscopic historical variables also influence the classification. PURPOSE: This study was conducted to evaluate the intrasurgeon and intersurgeon agreement in classifying variable presentations of the superior labrum and to evaluate the influence of clinical variables on the classification and treatment choices of surgeons. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A group of arthroscopic shoulder surgeons were asked to rank in order of importance clinical variables considered in diagnosing and treating the superior labrum. The surgeons then watched 50 arthroscopic videos of the superior labrum, ranging from normal to pathologic, on 3 different occasions. The first and third viewings were accompanied by no clinical information. The second viewing was accompanied by a detailed clinical vignette for each video. The surgeons selected a classification and treatment for each video. RESULTS: A patient's job/sport, age, and physical examination findings were considered the most important clinical variables surgeons consider during management of the superior labrum. Comparing the 2 viewings without clinical information, surgeons selected a different classification 28.5% of the time from the first to the second time. A different classification was chosen 71.5% of the time when the surgeon was supplied a clinical vignette at the subsequent viewing. Similarly, the treatment selected changed in 36% and 69.1% of cases when viewed again without vignettes and with vignettes, respectively. Intersurgeon agreement was moderate without clinical vignettes and fair with vignettes. Historical, physical examination, and surgical observations were found to influence the odds of change of classification. CONCLUSION: There is significant intrasurgeon and intersurgeon variability in classification and treatment of the superior labrum. Clinical historical, examination, and surgical findings influence classification and treatment choices.

Reliability of determining and measuring acromial enthesophytes.

BACKGROUND: Although the reliability of determining acromial morphology has been examined, to date, there has not been an analysis of interobserver and intraobserver reliability on determining the presence and measuring the size of an acromial enthesophyte. QUESTIONS/PURPOSES: The hypothesis of this study was that there will be poor intraobserver and interobserver reliability in the (1) determination of the presence of an acromial enthesophyte, (2) determination of the size of an acromial enthesophyte, and (3) determination of acromial morphology. PATIENTS AND METHODS: Fifteen fellowship-trained orthopedic shoulder surgeons reviewed the radiographs of 15 patients at two different intervals. Measurement of acromial enthesophytes was performed using two techniques: (1) enthesophyte length and (2) enthesophyte-humeral distance. Acromial morphology was also determined. Interobserver and intraobserver agreement was determined using intraclass correlation and kappa statistical methods. RESULTS: The interobserver reliability was fair to moderate and the intraobserver reliability moderate for determining the presence of an acromial enthesophyte. The measurement of the enthesophyte length showed poor interobserver and intraobserver reliability. The measurement of the enthesophyte-humeral distance showed poor interobserver reliability and moderate intraobserver reliability. The interobserver and intraobserver reliability in determining acromial morphology was found to be moderate and good, respectively. CONCLUSIONS: There is fair to moderate reliability among fellowship-trained shoulder surgeons in determining the presence of an acromial enthesophyte. However, there is poor reliability among observers in measuring the size of the enthesophyte. This study suggests that the enthesophyte-humeral distance may be more reliable than the enthesophyte length when measuring the size of the enthesophyte.

Partial-thickness articular surface rotator cuff tears: an all-inside repair technique.

BACKGROUND: Treatment of partial-thickness articular surface rotator cuff tears varies from simple débridement with or without an acromioplasty to various repair techniques. These repair techniques have included in situ transtendinous methods, as well as completion of the tear and repairing the full-thickness defect. The transtendinous techniques can be associated with stiffness and completing the tear takes down normal intact tissue. Therefore, a technique was developed that repairs the articular-side partial- thickness rotator cuff tears with an all-inside approach that does not violate the intact bursal tissue and does not complete the tear. QUESTIONS/PURPOSES: To compare the preoperative and postoperative Penn shoulder scores (PSS) associated with an in situ all-inside repair technique and the effects of such a repair on postoperative stiffness. METHODS: Twenty patients with partial-thickness articular rotator cuff tears greater than 50% of the width of the tendon repaired with an all-inside repair technique were retrospectively reviewed. Two of the patients were high school athletes and the rest self-described as recreational athletes. The minimum followup was 16 months (average, 29 months; range, 16-41 months). A validated outcome measure (PSS) was used to assess clinical outcome, and postoperative ROM was measured. RESULTS: The average PSS score improved from 74 (range, 56-84) to 92 (range, 86-99). All but one patient was able to return to the same level of play or higher. CONCLUSIONS: In situ repairs of partial-thickness articular surface tears using an all-inside approach resulted in a substantial increase in PSS with no cases of major postoperative clinical stiffness. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.