Displaced Posterior Cruciate Avulsion Fracture Fixation With Medial Collateral Ligament and Lateral Meniscus Injury Using Combined Open and Arthroscopic Methods.

Tibial-sided posterior cruciate ligament avulsion fractures are challenging injuries that often occur concomitantly in the setting of multiligament knee and other soft-tissue injuries. There is no consensus on the optimal surgical approach or timing of treatment for these injuries. This Technical Note describes the fixation of a displaced posterior cruciate ligament avulsion fracture with concomitant grade 3 medial collateral ligament injuries and bucket-handle lateral meniscus tears using open and arthroscopic techniques. This method allows the surgeon to address multiple pathologies in a single stage, although it requires strategic planning and rehabilitation considerations.

Popliteal Cyst Compressive Tibial Neuropathy and Venous Insufficiency: A Case Report.

Popliteal cysts are a collection of synovial fluid found in the popliteal fossa that typically form in adults in association with traumatic injuries, degenerative conditions, or inflammatory arthritis of the knee. While often asymptomatic, popliteal cysts may become problematic as enlarging and ruptured cysts may compress surrounding neurovascular structures, resulting in lower extremity edema or peripheral neuropathy. We report a unique case of a symptomatic popliteal cyst in a patient with both compressive neuropathy and venous congestion in the setting of a non-ruptured popliteal cyst after a surgically repaired intraarticular injury. Magnetic resonance imaging (MRI) showed a synovial cyst abutting the posterior neurovascular bundle and evidence of avascular necrosis. An open posterior cyst decompression was done, and the patient was able to report significant symptomatic improvement over the course of two weeks postoperatively. The previously noted varicose veins also demonstrated noticeable resolution. While relatively common, popliteal cysts may require prompt surgical decompression in order to provide effective symptomatic relief.

Biomechanical Analysis of Tibial Motion and ACL Graft Forces After ACLR With and Without LET at Varying Tibial Slopes.

BACKGROUND: Lateral extra-articular tenodesis (LET) is being performed more frequently with anterior cruciate ligament (ACL) reconstruction (ACLR) to decrease graft failure rates. The posterior tibial slope (PTS) affects ACL graft failure rates. The effect of ACLR + LET on tibial motion and graft forces with increasing PTS has not been elucidated. HYPOTHESIS: LET would decrease anterior tibial translation (ATT), tibial rotation, and ACL graft force versus ACLR alone with increasing tibial slope throughout knee range of motion. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve fresh-frozen cadaveric knees (mean donor age, 40.5 years; all female) were tested in 4 conditions (intact, ACL cut, ACLR, and ACLR + LET) with varying PTSs (5°, 10°, 15°, and 20°) at 3 flexion angles (0°, 30°, and 60°). Specimens were mounted to a load frame that applied a 500-N axial load with 1 N·m of internal rotation (IR) torque. The amount of tibial translation, IR, and graft force was measured. RESULTS: Increasing PTS revealed a linear and significant increase in graft force at all flexion angles. LET reduced graft force by 8.3% (-5.8 N) compared with ACLR alone at 30° of flexion. At the same position, slope reduction resulted in reduced graft force by 17% to 22% (-12.3 to -15.2 N) per 5° of slope correction, with a 46% (-40.7 N) reduction seen from 20° to 5° of slope correction. For ATT, ACLR returned tibial translation to preinjury levels, as did ACLR + LET at all flexion angles, except full extension, where ACLR + LET reduced ATT by 2.5 mm compared with the intact state (P = .019). CONCLUSION: Increased PTS was confirmed to increase graft forces linearly. Although ACLR + LET reduced graft force compared with ACLR alone, slope reduction had a larger effect across all testing conditions. No other clinically significant differences were noted between ACLR with versus without LET in regard to graft force, ATT, or IR. CLINICAL RELEVANCE: Many authors have proposed LET in the setting of ACLR, revision surgery, hyperlaxity, high-grade pivot shift, and elevated PTS, but the indications remain unclear. The biomechanical performance of ACLR + LET at varying PTSs may affect daily practice and provide clarity on these indications.

A Systemic and Local Comparison of Senescence in an Acute Anterior Cruciate Ligament Injury-A Pilot Case Series.

BACKGROUND: Senescence, a characteristic of cellular aging and inflammation, has been linked to the acceleration of osteoarthritis. The purpose of this study is to prospectively identify, measure, and compare senescent profiles in synovial fluid and peripheral blood in patients with an acute knee injury within 48 h. METHODS: Seven subjects, aged 18-60 years, with an acute ACL tear with effusion were prospectively enrolled. Synovial fluid and peripheral blood samples were collected and analyzed by flow cytometry, using senescent markers C12FDG and CD87. The senescent versus pro-regenerative phenotype was probed at a gene and protein level using qRT-PCR and multiplex immunoassays. RESULTS: C12FDG and CD87 positive senescent cells were detected in the synovial fluid and peripheral blood of all patients. Pro-inflammatory IL-1ß gene expression measured in synovial fluid was significantly higher (p = 0.0156) than systemic/blood expression. Senescent-associated factor MMP-3 and regenerative factor TIMP-2 were significantly higher in synovial fluid compared to blood serum. Senescent-associated factor MMP-9 and regenerative factor TGFß-2 were significantly elevated in serum compared to synovial fluid. Correlation analysis revealed that C12FDG++/CD87++ senescent cells in synovial fluid positively correlated with age-related growth-regulated-oncogene (ρ = 1.00, p < 0.001), IFNγ (ρ = 1.00, p < 0.001), IL-8 (ρ = 0.90, p = 0.0374), and gene marker p16 (ρ = 0.83, p = 0.0416). CONCLUSIONS: There is an abundance of senescent cells locally and systemically after an acute ACL tear without a significant difference between those present in peripheral blood compared to synovial fluid. This preliminary data may have a role in identifying strategies to modify the acute environment within the synovial fluid, either at the time of acute ligament injury or reconstruction surgery.

Reanalysis of the Posterior Oblique Ligament: Quantitative Anatomy, Radiographic Markers, and Biomechanical Properties.

Background: The posterior oblique ligament (POL) is the largest structure of the posteromedial knee that is at risk of injury in conjunction with the medial collateral ligament (MCL). Its quantitative anatomy, biomechanical strength, and radiographic location have not been assessed in a single investigation. Purpose: To evaluate the 3-dimensional and radiographic anatomy of the posteromedial knee and the biomechanical strength of the POL. Study Design: Descriptive laboratory study. Methods: Ten nonpaired fresh-frozen cadaveric knees were dissected and medial structures were elevated off bone, leaving the POL. The anatomic locations of the related structures were recorded with a 3-dimensional coordinate measuring machine. Anteroposterior and lateral radiographs were taken with radiopaque pins inserted into the pertinent landmarks, and the distances between the collected structures were calculated. Each knee was then mounted to a dynamic tensile testing machine, and pull-to-failure testing was performed to record the ultimate tensile strength, stiffness, and failure mechanism. Results: The POL femoral attachment was a mean of 15.4 mm (95% CI, 13.9-16.8 mm) posterior and 6.6 mm (95% CI, 4.4-8.8 mm) proximal to the medial epicondyle. The tibial POL attachment center was a mean of 21.4 mm (95% CI, 18.1-24.6 mm) posterior and 2.2 mm (95% CI, 0.8-3.6 mm) distal to the center of the deep MCL tibial attachment and a mean of 28.6 mm (95% CI, 24.4-32.8 mm) posterior and 41.9 mm (95% CI, 36.8-47.0 mm) proximal to the center of the superficial MCL tibial attachment. On lateral radiographs, the femoral POL was a mean of 17.56 mm (95% CI, 14.83-21.95 mm) distal to the adductor tubercle and 17.32 mm (95% CI, 14.6-21.7 mm) posterosuperior to the medial epicondyle. On the tibial side, the center of the POL attachment was a mean of 4.97 mm (95% CI, 3.85-6.79 mm) distal to the joint line on anteroposterior radiographs and 6.34 mm (95% CI, 5.01-8.48 mm) distal to the tibial joint line on lateral radiographs, at the far posterior tibial aspect. The biomechanical pull-to-failure demonstrated a mean ultimate tensile strength of 225.2 ± 71.0 N and a mean stiffness of 32.2 ± 13.1 N. Conclusion: The anatomic and radiographic locations of the POL and its biomechanical properties were successfully recorded. Clinical Relevance: This information is useful to better understand POL anatomy and biomechanical properties as well as to clinically address an injury with repair or reconstruction.

Treatment of the 'The Naked Humeral Head': Repair of Supraspinatus Avulsion, Subscapularis Tear, and Humeral Avulsion of the Glenohumeral Ligament.

A humeral avulsion of the glenohumeral ligament, or HAGL, lesion is a rare yet debilitating shoulder injury, which can lead to recurrent instability, pain, and overall shoulder dysfunction. The diagnosis is often difficult, requiring both high clinical suspicion, as well as identification on magnetic resonance imaging. In patients with an anterior HAGL, repair often requires an open approach. In extremely rare circumstances, the initial traumatic event that causes a HAGL can also cause disruption of the supraspinatus and subscapularis insertions on the humeral head. We have termed this the "naked humeral head". The purpose of this technical note is to describe our preferred technique to surgically treat the naked humeral head by repairing a supraspinatus avulsion fracture, HAGL lesion, and complete subscapularis tear.

Anterior to Posterior Bone Plug Suture Tunnels Provide Optimal Biomechanics for Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Graft.

Purpose: To evaluate different bone-patellar tendon-bone (BPTB) plug suture configurations for pull through strength, stiffness, and elongation at failure in a biomechanical model of suspensory fixation. Methods: Forty nonpaired, fresh-frozen human cadaveric BPTB allografts with an average age of 65.6 years were tested. Tensile testing was performed with the use of a custom-designed fixture mounted in a dynamic tensile testing machine. A preload of 90 N was applied to the graft and held for 5 minutes. Following this, a tensile load-to-failure test was performed. The ultimate failure load, elongation at failure, and mode of failure were recorded, and the resulting load-elongation curve was documented. Results: The drill tunnel through the cortical surface (anterior to posterior) was found to be significantly stronger than the drill tunnel through the cancellous surface (medial to lateral). There were no significant differences found when comparing the strength of the suture augmentation through the tendon and the drill tunnel alone (P = .13 among cancellous groups, P = .09 among cortical groups). The cortical drill tunnel with suture augmentation through the tendon showed significantly greater elongation values (13.7 ± 3.2) at failure when compared with either the cancellous or cortical drill tunnel only test groups (P = .0003 compared with cancellous alone, P = .009 when compared with cortical alone). Conclusions: The BPTB suture configuration with an anterior to posterior-directed suture tunnel without a suture through tendon augmentation provides the optimal strength and stiffness while minimizing graft elongation after fixation in a biomechanical model. This configuration is best for preventing suture pull through and failure when passing sutures through the BPTB plug. Clinical Relevance: This study biomechanically evaluates the optimal suture configuration in the proximal bone plug for suspensory fixation in the setting of BPTB grafts.

The recovery curve of anatomic total shoulder arthroplasty for primary glenohumeral osteoarthritis: midterm results at a minimum of 5 years.

Background: Excellent results have been reported for anatomic total shoulder arthroplasty (TSA) for the treatment of primary glenohumeral osteoarthritis (GHOA). We aim to assess the recovery curve and longitudinal effects of time, age, sex, and glenoid morphology on patient-reported outcomes (PROs) after primary anatomic TSA for primary GHOA. Methods: Patients who underwent primary anatomic TSA over 5 years ago were included: Short-Form 12 Physical Component Summary, American Shoulder and Elbow Surgeons scores, Quick Disabilities of the Arm Shoulder and Hand Score, Single Assessment Numeric Evaluation, and patient satisfaction were assessed. Linear mixed-effects models were used to model progression in PROs longitudinally. Unadjusted models and models controlling for sex and age were constructed. Results: Eighty-one patients (91 shoulders) were included. Significant improvements from the preoperative period to 1 year postoperatively in the median American Shoulder and Elbow Surgeons (48 to 93; P < .001), Quick Disabilities of the Arm Shoulder and Hand Score (42 to 11; P < .001), Single Assessment Numeric Evaluation (50 to 91; P < .001), and Short-Form 12 Physical Component Summary (35 to 53; P = .004) scores were noted. No significant decrease was observed for any of the outcome scores. Median satisfaction at the final follow-up was 10 out of 10. At 1, 2, 3, 4, 5, 6, and 7 years postoperatively, 77%, 64%, 79%, 57%, 86%, 56%, and 78% of patients, respectively, reported sports participation equal to or slightly below preinjury level. There was no association between the glenoid morphology and functional outcomes. Conclusion: Patients undergoing anatomic TSA for primary GHOA showed excellent improvement in PROs and satisfaction in the first year, and these results were maintained postoperatively for a minimum of 5 years. Age- and sex-adjusted models or glenoid morphology did not substantially alter any trends in PROs postoperatively.

Arthroscopic Segmental Medial Meniscus Allograft Transplant Using Three Fixation Techniques.

Partial meniscectomy or failed meniscus repair can lead to pain, dysfunction, and cartilage degradation due to increased contact forces. Meniscus transplantation can lead to favorable outcomes and cartilage preservation with careful patient selection. Limited data exist on segmental meniscus allograft transplantation, with promising results using synthetic grafts and early animal and biomechanical studies on segmental allograft transplantation, showing similar results to full meniscus allograft transplantation. This article presents a technique for arthroscopic segmental medial meniscus allograft transplant and a brief review of the literature.

Editorial Commentary: Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction Makes More Sense Than Triple-Bundle: Three's a Crowd.

Recent research reports impressive patient-reported and objective stability outcomes after triple-bundle anterior cruciate ligament (ACL) reconstruction with hamstring autograft. However, the results are similar to those reported in the orthopaedic literature for single-bundle ACL reconstruction. If the triple-bundle technique does not reduce graft failure rates, and bearing in mind that it is more complex, more expensive, and more difficult to revise, then an anatomically-positioned single-bundle ACL reconstruction makes more sense. If the data supporting double-bundle ACL reconstruction is inconclusive, then why add a third bundle?

Postoperative Stiffness and Pain After Arthroscopic Labral Stabilization: Consider Anchor Arthropathy.

PURPOSE: To describe the key clinical, imaging, and arthroscopic characteristics of anchor arthropathy after arthroscopic shoulder stabilization procedures and, secondarily, to define risk factors for the development of anchor-induced arthropathy. METHODS: A total of 23 patients who underwent revision arthroscopic shoulder surgery and were diagnosed with glenohumeral arthropathy were retrospectively identified from prospectively collected data registries between January 2000 and May 2018. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, and examination findings before revision surgery. Pre-revision imaging was used to assess presence of glenohumeral osteoarthritis and chondromalacia, anchors/sutures, loose bodies, and labral pathology. The same parameters were recorded intraoperatively during revision surgery. Descriptive statistics were performed for demographic data and means with standard deviations were calculated for continuous data. A McNemar-Bowker test was used to analyze marginal homogeneity between preoperative imaging and intraoperative findings. RESULTS: Mean age at presentation was 33.4 ± 11.7 years (range 16-59, 17 male patients; 6 female patients). More than one half (13/23) developed symptoms within 10 months after index arthroscopic procedure (mean 32.2 ± 59.9 months, range <1 to 165.2 months) with 87% presenting with pain and 100% presenting with loss of motion on examination. Plain radiographs demonstrated humeral osteoarthritis in 57% (13/23) of patients, magnetic resonance imaging (MRI) revealed recurrent labral pathology in 19 of 23 (83%) patients, potential proud implants in 12 of 23 (52%), and loose bodies in 12 of 23 (52%). Intraoperatively, all had evidence of osteoarthritis; 22 of 23 (96%) had prominent implants. Humeral head chondromalacia was present in 21 of 23 patients (91%), the majority of which was linear stripe wear, and 6 of 23 (26%) had severe global glenohumeral osteoarthritis. Statistical analysis revealed a 54.5% (95% confidence interval 0.327-0.749) sensitivity of MRI identification of proud implants with a specificity of 100% (95% confidence interval 0.055-1). The ability of MRI to accurately assess chondromalacia of the humeral head (P = .342) or glenoid (P = .685) was not statistically significant. CONCLUSIONS: Anchor arthropathy is characterized by symptoms of pain and stiffness on examination and in many cases develops early after stabilization surgery (<10 months). Implants were implicated in the majority of cases of humeral head chondromalacia. MRI scans may produce false-negative identification of proud implants and can be a poor predictor of the severity of chondromalacia and intra-articular pathology; thus, a high index of clinical suspicion is necessary in patients with motion loss and pain postoperatively. LEVEL OF EVIDENCE: Level IV, case series.

Anchor Arthropathy of the Shoulder Joint After Instability Repair: Outcomes Improve With Revision Surgery.

PURPOSE: To report clinical and patient-reported outcome measures (PROMs) in patients undergoing revision surgery after diagnosis of anchor-induced arthropathy. METHODS: Patients who underwent revision arthroscopic shoulder surgery and were diagnosed with post-instability glenohumeral arthropathy performed from January 2006 to May 2018 were included in the current study. Patients were excluded if they underwent prior open shoulder procedures, if glenoid bone loss was present, or if prerevision imaging and records were incomplete or not available. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, exam findings before revision surgery, and surgical intervention. PROMs were prospectively collected before surgery and at minimum 2-year follow-up. RESULTS: Fourteen patients were included with a mean (± standard deviation) age at presentation of 35.2 ± 12.1 years (range 16 to 59). The follow-up rate was 86%, with a mean follow-up of 3.8 years (range 1.1 to 10.6). Mean time to development of arthropathy symptoms was 48.2 months (range <1 month to 13.8 years), all presenting with pain and decreased range of motion on exam. At time of revision surgery, all patients underwent either open or arthroscopic removal of previous implants, including anchors and suture material. Six patients underwent additional revision stabilization procedures, 1 underwent total shoulder arthroplasty, and 7 underwent arthroscopic intraarticular debridement, capsular release, and chondroplasty with or without microfracture. Pain significantly improved in 79% of patients (P = .05). Significant improvements in all PROMs were observed, including 12-item Short Form (43.8 to 54.8, P < .01); Disabilities of the Arm, Shoulder, and Hand, shortened version (31.8 to 8.4, P < .01); Single Assessment Numeric Evaluation (47.0 to 84.5, P < .05); and American Shoulder and Elbow Surgeons (61.6 to 92.1, P < .01). Average external rotation significantly improved, from 31° ± 22° to 52° ± 24° (P = .02). CONCLUSION: Rapid intervention after diagnosis, through either revision arthroscopic or open debridement and stabilization, can lead to significant improvement in range of motion, pain, and overall patient function and satisfaction. LEVEL OF EVIDENCE: IV, retrospective case series.

Open Popliteal Tendon Repair.

Popliteal tendon tears without concomitant damage to the cruciate ligaments or other posterolateral corner ligaments are rare entities with few studies reporting on their existence, with rare case reports discussing their treatment. Continued pain, instability, and effusions are typical symptoms, with magnetic resonance imaging being the main tool for diagnosis. Furthermore, monosodium urate crystals that induce gout have been shown to collect in the popliteal groove and thus may lead to degeneration and isolated tearing. Most case reports have reviewed arthroscopic debridement of the tendon in patients with continued pain. However, in the young athletic population, open repair, if the tissue appears to be of adequate quality, should be a consideration. The use of suture anchors to restore the popliteus to its anatomic footprint is desired. This Technical Note describes a safe and reliable technique for open popliteal tendon repair of an isolated avulsion injury.

Clinical Outcomes of Arthroscopic Suprascapular Nerve Decompression for Suprascapular Neuropathy.

PURPOSE: To report clinical outcomes following arthroscopic suprascapular nerve (SSN) decompression for suprascapular neuropathy at the suprascapular and/or spinoglenoid notch in the absence of major concomitant pathology. METHODS: We retrospectively reviewed prospectively collected data of 19 patients who underwent SSN release at the suprascapular and/or spinoglenoid notch between April 2006 and August 2017 with ≥2 years of follow-up. Patients who underwent concomitant rotator cuff or labral repairs or had severe osteoarthritis were excluded. Pre- and postoperative strength and patient-reported outcomes were collected, including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numerical Evaluation (SANE), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), 12-item Short Form (SF-12), and satisfaction. Complications and revisions were recorded. RESULTS: At a mean final follow-up of 4.8 years, pre- to postoperative ASES (64.9 ± 18.7 versus 83.5 ± 23.1; P = .018), QuickDASH (28.7 ± 17.2 versus 12.7 ± 17.1; P = .028), SANE (64.3 ± 16.4 versus 80.8 ± 22.3; P = .034), and SF-12 PCS (41.1 ± 10.8 versus 52.3 ± 5.8; P = .007) scores all significantly improved. Median strength for external rotation improved significantly (4 [range 2 to 5] versus 5 [range 3 to 5]; P = .014). There was no statistically significant improvement in median strength for abduction (4 [range 3 to 5] versus 5 [5]; P = .059). Median postoperative satisfaction was 9 (range 1 to 10), with 8 patients (50%) rating satisfaction ≥9. No complications were observed, and no patients went on to revision surgery. CONCLUSION: Arthroscopic SSN decompression for suprascapular neuropathy at the suprascapular and/or spinoglenoid notch in the absence of major concomitant glenohumeral pathology results in good functional outcomes with significant improvements from before to after surgery. LEVEL OF EVIDENCE: IV, therapeutic case series.

Predictive Modeling to Determine Functional Outcomes After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Arthroscopic rotator cuff repair (ARCR) is one of the most commonly performed orthopaedic surgical procedures; however, patient-reported outcomes have varied greatly in the literature. PURPOSE: To identify preoperative factors that affect outcomes and to develop prognostic tools for predicting functional outcomes in future ARCR cases. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients were included who underwent ARCR for repairable full-thickness rotator cuff tears with at least 2 years of follow-up. Twelve predictors were entered as candidate predictors in each model: age, sex, workers' compensation (WC) status, previous cuff repair, tear size, tear shape, multiple-tendon involvement, tendon stump length, Goutallier classification, critical shoulder angle, length of follow-up, and baseline subjective outcomes score. Postoperative American Shoulder and Elbow Surgeons (ASES), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand), and patient satisfaction were each modeled through proportional odds ordinal logistic regression. Model results were presented with marginal covariate effect plots and predictive nomograms. RESULTS: Overall, 552 shoulders fit inclusion criteria. The mean age at surgery was 60.2 years (range, 23-81 years). Twenty-five (4.5%) shoulders underwent revision cuff repair or reverse arthroplasty at a mean 1.9 years (range, 0.1-7.9 years) postoperatively. Overall, 509 shoulders were eligible for follow-up, and minimum 2-year postoperative patient-reported outcomes were obtained for 449 (88.2%) at a mean 4.8 years (range, 2-11 years). The ASES score demonstrated significant improvement from pre- to postoperative median (interquartile range): 58 (44.9-71.6) to 98.3 (89.9-100; P < .001). Women demonstrated significantly higher 2-year reoperation rates than men (5.8% vs 1.6%; odds ratio, 2.8 [95% CI, 0.73-9.6]; P = .023). Independently significant predictors for lower postoperative ASES scores included previous ARCR (P < .001), female sex (P < .001), and a WC claim (P < .001). Significant predictors for worse QuickDASH scores included WC claim (P < .001), female sex (P < .001), previous ARCR (P = .007), and ≥7 years of follow-up time. Significant predictors for lower SF-12 PCS scores included WC claim (P < .001), female sex (P = .001), and lower baseline SF-12 PCS. Last, significant independent predictors of patient satisfaction included previous ARCR (P = .004), WC claim (P = .011), female sex (P = .041), and age (P = .041). CONCLUSION: Excellent clinical outcomes and low failure rates were obtained after ARCR by using careful patient selection and modern surgical techniques for ARCR. Female sex, WC claim, and previous ARCR were significant predictors of poorer outcomes in at least 3 patient-reported outcome models. Prognostic nomograms were developed to aid in future patient selection, clinical decision making, and patient education.

Minimum Five-year Outcomes and Clinical Survivorship for Arthroscopic Transosseous-equivalent Double-row Rotator Cuff Repair.

INTRODUCTION: Despite the widespread use of arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair (RCR) techniques, midterm outcome data are limited. The purpose of this article was to assess midterm clinical outcomes of patients following arthroscopic TOE RCR using either a knotless tape bridge (TB) repair or knotted suture bridge (SB) repair technique. We hypothesized that there would be significant improvements in patient-reported outcomes with TOE RCR that would be durable over time. We also hypothesized that the knotless TB technique would yield equivalent clinical results to the knotted SB technique, but that there would be differences in retear types between the two TOE techniques. METHODS: Patients included were a minimum of 5 years from an index arthroscopic double-row TOE repair using either a knotless TB or knotted SB technique for one, two, or three tendon full-thickness rotator cuff tears involving the supraspinatus tendon. Preoperative and postoperative American Shoulder and Elbow Surgeons, Short-Form 12 Physical Component Summary, Quick Disabilities of the Arm, Shoulder, and Hand, Single Assessment Numeric Evaluation, and satisfaction scores were collected. Scores were also stratified and compared based on primary and revision repair, tear location, and tear chronicity. Outcomes between techniques were contrasted, and survivorship analysis was conducted, with failure defined as progression to revision surgery. RESULTS: One-hundred ninety-two shoulders were included with a mean follow-up of 6.6 years (range, 5.0 to 11.0 years). Fifteen shoulders (7.8%) underwent revision cuff repair. All scores improved significantly for TB repair (P < 0.001). For SB repair, all scores improved, but only American Shoulder and Elbow Surgeons and Short-Form 12 Physical Component Summary scores (P < 0.05) demonstrated statistical significance. No statistically significant differences were found between the repair techniques when stratified by primary and revision repairs, tear location, or chronicity. Postoperative clinical survivorship was 96.6% and 93.6% for knotted SB repairs and 96.7% and 93.9% for knotless TB repairs at 2 and 5 years, respectively. CONCLUSION: TOE RCR results in significant clinical improvement and excellent survivorship at a minimum of 5 years of follow-up, using either knotted SB or knotless TB repair techniques in primary and revision cases and in small and large tears. Equivalent results were obtained with both TOE techniques. Patients undergoing repair with a TOE showed significant improvements in patient-reported outcomes that were durable at a minimum of 5 years postoperatively.

Impact of Age and Subscapularis Tendon Reparability on Return to Recreational Sports Activities and 2-Year Outcomes After Reverse Total Shoulder Arthroplasty.

BACKGROUND: As the indications for reverse total shoulder arthroplasty (RTSA) have continued to expand, the average age of patients undergoing RTSA has decreased. PURPOSE/HYPOTHESIS: The purpose of this study was to report the minimum 2-year outcomes after RTSA and to evaluate the impact of surgical variables on outcomes. We hypothesized that younger patients, patients with larger glenosphere, and patients with irreparable subscapularis tendons would experience worse subjective patient-reported outcome scores (PROS) and that younger patients and those with a reparable subscapularis would demonstrate a higher rate of return to recreational sports activities. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent RTSA by a single surgeon between November 2005 and September 2014 were considered for this study. Patient characteristics, surgical details, PROS, and rates of return to recreational sports activity were prospectively collected and retrospectively reviewed. We assessed correlations between PROS and both patient age and subscapularis reparability. PROS collected included the American Shoulder and Elbow Surgeons (ASES) score, Short Form 12 (SF-12), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Single Assessment Numeric Evaluation (SANE), and postoperative patient satisfaction. RESULTS: A total of 110 patients with an average age of 68.0 years (range, 45-87 years) were included. Minimum 2-year follow-up was obtained in 94 patients (85.4%), with a mean follow-up of 3.6 years (range, 2.0-9.3 years). The subscapularis was reparable in 58 patients (57.4%). All PROS significantly improved from pre- to postoperatively (P < .001). The median patient postoperative satisfaction was 9 out of 10 (range, 1-10). Increasing patient age was correlated with significant improvements in QuickDASH and ASES scores. Postoperatively, 76.1% (67/88) of patients were able to return to recreational sports activity. However, of those who did return, 68.2% indicated that they had to modify their activity in some way. Glenosphere size was not significantly associated with PROS or the rate of return to recreational sports activity, but patients with reparable subscapularis tendons demonstrated higher PROS and return to activity rates. CONCLUSION: Patients who had a reparable subscapularis tendon showed a significantly higher rate of return to recreational sports activity than patients who had a irreparable subscapularis tendon. Older age was correlated with greater improvement in several, although not all, patient-reported outcome measures. Glenosphere size was not significantly associated with higher PROS or rate of return to recreational sports activity.

Systematic Review of the Anatomic Descriptions of the Glenohumeral Ligaments: A Call for Further Quantitative Studies.

PURPOSE: To perform a systematic review of the glenohumeral ligament anatomic attachments on the glenoid and humeral neck. METHODS: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and Embase from 1980 to present. The inclusion criteria were as follows: cadaveric or clinical anatomic studies that qualitatively or quantitatively described the glenoid and humeral attachments of the glenohumeral ligaments in the English-language literature. Imaging and animal studies, editorial articles, and surveys were excluded from this study. RESULTS: The 15 included studies analyzed a total of 983 shoulders. Only 5 studies reported quantitative measurements. The most common glenoid superior glenohumeral ligament attachment described was in the anterolateral region of the supraglenoid tubercle and was inserting on the humerus in close vicinity to the subscapularis tendon insertion. The superior labrum and lesser tuberosity were the most commonly reported middle glenohumeral ligament attachments. The inferior glenohumeral ligament was most commonly described to attach between the 2- and 4-o'clock positions of the glenoid and distally near the surgical neck of the humerus. CONCLUSIONS: There were limited quantitative data on the attachments of the glenohumeral ligaments. Although the literature was discordant, the most common descriptions of the attachments were as follows: The anterolateral region of the supraglenoid tubercle, the superior labrum, and the glenoid (between the 2- and 4-o'clock positions) were the medial attachments for the superior glenohumeral ligament, middle glenohumeral ligament, and inferior glenohumeral ligament, respectively. Laterally, they inserted on the humerus in close vicinity to the subscapularis tendon insertion, on the lesser tuberosity, and near the surgical neck of the humerus, respectively. CLINICAL RELEVANCE: The glenohumeral ligaments are important anatomic structures contributing to the dynamic stability of the glenohumeral joint. Further detailed quantitative descriptions of their attachments are required for truly anatomically based repairs.

Primary Acromioclavicular-Coracoclavicular Reconstruction Using 2 Allografts, TightRope, and Stabilization to the Acromion.

Acromioclavicular (AC) joint injuries are a common cause of shoulder pain, particularly among young athletes participating in contact sports. Injuries to the AC joint most commonly occur from direct impact at the acromion and are classified as types I to VI. Although most AC joint injuries can be treated nonoperatively, types IV to VI are best treated with surgery, with type III being controversial and most surgeons recommending an initial trial of nonoperative treatment. Although numerous surgical techniques have been described, no gold standard technique has been established. Biomechanical testing suggests that anatomic reconstruction of both the AC and coracoclavicular ligaments results in a superior surgical construct. The objective of this Technical Note is to describe our preferred technique for the primary treatment of AC joint instability in the acute and chronic setting. Using 2 free tendon grafts in combination with a cortical button suspensory device combines the advantages of a nonrigid biologic and anatomic AC and coracoclavicular ligament reconstruction while benefiting from the strength of a cortical suspensory device in resisting displacement of the AC joint.