Short-Term Indwelling Foley Catheters Do Not Reduce the Risk of Postoperative Urinary Retention in Uncomplicated Primary THA and TKA: A Randomized Controlled Trial.

BACKGROUND: The purpose of this randomized controlled trial was to determine whether a short-term Foley catheter (inserted in the operating room and removed upon arrival to the orthopaedic floor) would reduce the risk of postoperative urinary retention (POUR) in patients undergoing primary total hip (THA) and total knee arthroplasty (TKA). METHODS: Three hundred and eighty-eight patients undergoing inpatient primary TKA (n = 228) or THA (n = 160) with spinal anesthesia were randomized to receive a short-term Foley catheter (n = 194) or no Foley (n = 194). There were 143 male and 245 female patients. The primary outcome was POUR, defined as requiring ≥2 straight catheterizations or the placement of an indwelling urinary catheter when indicated by retention of ≥450 mL on bladder scans. Secondary outcomes included urinary tract infections (UTIs) within 3 weeks and the need for ≥1 straight catheterization. A power analysis determined that 194 patients per group were required to detect a 7% minimal clinically important difference in POUR rates at 80% power and alpha of 0.05. Intention-to-treat and as-treated analyses were performed (2 patients received the non-allocated treatment). Outcomes were compared between the groups using univariate and multivariate analyses, with alpha < 0.05. RESULTS: Nine patients developed POUR: 4 in the short-term Foley group and 5 in the control group (2.1% versus 2.6%; p = 1.00). Of those who developed POUR, 8 were male and 1 was female (88.9% versus 11.1%; p = 0.002). Twenty-four patients required ≥1 straight catheterization: 10 in the Foley group and 14 in the control group (5.2% versus 7.2%; p = 0.40). Four patients developed UTIs: 3 in the Foley group and 1 in the control group (1.5% versus 0.5%; p = 0.62) on intention-to-treat analysis, and 4 in the Foley group and none in the control group (2.1% versus 0.0%; p = 0.12) on as-treated analysis. CONCLUSIONS: The use of a short-term Foley catheter inserted in the operating room and removed on arrival to the orthopaedic floor does not decrease the rate of POUR. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Long-term outcomes and improved risk of revision following tumor endoprosthetic replacement of the distal femur: Single institutional results.

PURPOSE: This study assessed revision characteristics following distal femur tumor endoprosthetic replacement. METHODS: Fifty-seven procedures were performed between 2005 and 2019. The cumulative incidence of implant revision was calculated with death as a competing risk. RESULTS: The all-cause revision rate was 21.1% (n = 12) at a mean 65.3 ± 47.3 months. Competing risk analysis revealed a cumulative revision incidence of 12.0% (95% CI, 3.6-25.9%) at five years and 36.5% (95% CI, 12.8-61.0%) at ten years. CONCLUSIONS: We provide an accurate assessment of revision risk which is slightly lower than historical controls, with identification of failure modes to reliably inform patient expectations. LEVEL OF EVIDENCE: III. Retrospective Study.

Conjoint Tendon Tenotomy for Glenoid Exposure in the Setting of Previous Coracoid Transfer.

Surgical exposure of the glenoid after previous coracoid process transfer is technically challenging as a result of distorted anatomy, obliterated soft-tissue planes, and adhesive scar tissue, which poses additional risk to adjacent neurovascular structures. The purpose of this article is to present a technique for glenoid exposure following coracoid transfer that involves tenotomy of the conjoint tendon to minimize the risk for neurovascular injury while leaving the well-healed coracoid bone graft in place.

Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Preoperative Factors Predictive of Treatment Failure.

BACKGROUND: Patient selection is critical when choosing between arthroscopic joint preservation and total shoulder arthroplasty in young patients with glenohumeral osteoarthritis (GHOA). PURPOSE: To identify prognostic factors predictive of early failure in patients undergoing comprehensive arthroscopic management (CAM) for GHOA. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 107 shoulders in 98 patients with minimum 2-year follow-up who underwent CAM were identified and evaluated. All shoulders met clinical and radiographic criteria for total shoulder arthroplasty (TSA), but the patients opted for joint preservation with arthroscopic management. Radiographic and preoperative factors were analyzed to determine predictors of early failure, defined as progression to TSA within the study period. RESULTS: There were 72 men and 26 women with a mean age of 52 years (range, 29-77 years). Seventeen (15.8%) of 107 shoulders progressed to TSA at a mean of 2 years (range, 0.46-8.2 years). Shoulder status for the rest had a mean follow-up of 3.9 years (range, 2-9.4 years). There were a number of radiographic features that were correlated with early failure. Patients who failed had significantly less preoperative joint space than did those who succeeded (1.3 vs 2.6 mm; P = .004). Higher Kellgren-Lawrence grades for osteoarthritis and age older than 50 were also associated with failure. Shoulders with Walch type B2 and C glenoid were significantly more likely to fail than were Walch types A1, A2, and B1 ( P < .05). CONCLUSION: The CAM procedure has been shown to reliably improve pain and function in active patients with advanced GHOA; however, it is important to inform patients about the limitations of the procedure. Patients with less joint space and abnormal posterior glenoid shape were significantly more likely to progress to early failure.

Cost-Effectiveness of Arthroscopic Rotator Cuff Repair Versus Reverse Total Shoulder Arthroplasty for the Treatment of Massive Rotator Cuff Tears in Patients With Pseudoparalysis and Nonarthritic Shoulders.

PURPOSE: To determine the most cost-effective treatment strategy for patients with massive rotator cuff tears and pseudoparalysis of the shoulder without osteoarthritis of the glenohumeral joint (PP without OA). Specifically, we aimed to compare arthroscopic rotator cuff repair (ARCR) versus reverse total shoulder arthroplasty (RTSA) and investigate the effect of patient age on this decision. METHODS: A Markov decision model was used to compare 3 treatment strategies for addressing PP without OA: (1) ARCR with option to arthroscopically revise once, (2) ARCR with immediate conversion to RTSA on potential failure, and (3) primary RTSA. Hypothetical patients were cycled through the model according to transition probabilities, meanwhile accruing financial costs, utility for time in health states, and disutilities for surgical procedures. Utilities were derived from the Short Form-6D scale and expressed as quality-adjusted life-years. Model parameters were derived from the literature and from expert opinion, and thorough sensitivity analyses were conducted. TreeAge Pro 2015 software was used to construct and assess the Markov model. RESULTS: For the base-case scenario (60-year-old patient), ARCR with conversion to RTSA on potential failure was the most cost-effective strategy when we assumed equal utility for the ARCR and RTSA health states. Primary RTSA became cost-effective when the utility of RTSA exceeded that of ARCR by 0.04 quality-adjusted life-years per year. Age at decision did not substantially change this result. CONCLUSIONS: Primary ARCR with conversion to RTSA on potential failure was found to be the most cost-effective strategy for PP without OA. This result was independent of age. Primary ARCR with revision ARCR on potential failure was a less cost-effective strategy. LEVEL OF EVIDENCE: Level IV, economic and decision analysis.

Arthroscopic Double-Row Transosseous Equivalent Rotator Cuff Repair with a Knotless Self-Reinforcing Technique.

BACKGROUND: Rotator cuff tears are a significant cause of shoulder morbidity. Surgical techniques for repair have evolved to optimize the biologic and mechanical variables critical to tendon healing. Double-row repairs have demonstrated superior biomechanical advantages to a single-row. METHODS: The preferred technique for rotator cuff repair of the senior author was reviewed and described in a step by step fashion. The final construct is a knotless double row transosseous equivalent construct. RESULTS: The described technique includes the advantages of a double-row construct while also offering self reinforcement, decreased risk of suture cut through, decreased risk of medial row overtensioning and tissue strangulation, improved vascularity, the efficiency of a knotless system, and no increased risk for subacromial impingement from the burden of suture knots. CONCLUSION: Arthroscopic knotless double row rotator cuff repair is a safe and effective method to repair rotator cuff tears.

Risk Factors, Pathobiomechanics and Physical Examination of Rotator Cuff Tears.

BACKGROUND: It is important to appreciate the risk factors for the development of rotator cuff tears and specific physical examination maneuvers. METHODS: A selective literature search was performed. RESULTS: Numerous well-designed studies have demonstrated that common risk factors include age, occupation, and anatomic considerations such as the critical shoulder angle. Recently, research has also reported a genetic component as well. The rotator cuff axially compresses the humeral head in the glenohumeral joint and provides rotational motion and abduction. Forces are grouped into coronal and axial force couples. Rotator cuff tears are thought to occur when the force couples become imbalanced. CONCLUSION: Physical examination is essential to determining whether a patient has an anterosuperior or posterosuperior tear. Diagnostic accuracy increases when combining a series of examination maneuvers.

The Role of Platelet Rich Plasma (PRP) and Other Biologics for Rotator Cuff Repair.

BACKGROUND: Surgical treatment of rotator cuff tears has consistently demonstrated good clinical and functional outcomes. However, in some cases, the rotator cuff fails to heal. While improvements in rotator cuff constructs and biomechanics have been made, the role of biologics to aid healing is currently being investigated. METHODS: A selective literature search was performed and personal surgical experiences are reported. RESULTS: Biologic augmentation of rotator cuff repairs can for example be performed wtableith platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs). Clinical results on PRP application have been controversial. Application of MSCs has shown promise in animal studies, but clinical data on its effectiveness is presently lacking. The role of Matrix Metalloproteinase (MMP) inhibitors is another interesting field for potential targeted drug therapy after rotator cuff repair. CONCLUSIONS: Large randomized clinical studies need to confirm the benefit of these approaches, in order to eventually lower retear rates and improve clinical outcomes after rotator cuff repair.

Irreparable Rotator Cuff Tears: Restoring Joint Kinematics by Tendon Transfers.

BACKGROUND: Tendon transfers can be a surgical treatment option in managing younger, active patients with massive irreparable rotator cuff tears. The purpose of this article is to provide an overview of the use of tendon transfers to treat massive irreparable rotator cuff tears and to summarize clinical outcomes. METHODS: A selective literature search was performed and personal surgical experiences are reported. RESULTS: Latissimus dorsi transfers have been used for many years in the management of posterosuperior rotator cuff tears with good reported clinical outcomes. It can be transferred without or with the teres major (L'Episcopo technique). Many surgical techniques have been described for latissimus dorsi transfer including single incision, double incision, and arthroscopically assisted transfer. Transfer of the pectoralis major tendon is the most common tendon transfer procedure performed for anterosuperior rotator cuff deficiencies. Several surgical techniques have been described, however transfer of the pectoralis major beneath the coracoid process has been found to most closely replicate the force vector that is normally provided by the intact subscapularis. CONCLUSION: Tendon transfers can be used successfully in the management of younger patients with massive irreparable rotator cuff tears and minimal glenohumeral arthritis. Improvements in clinical outcomes scores and range of motion have been demonstrated. This can delay arthroplasty, which is of particular importance for younger patients with high functional demands.

Outcomes After Arthroscopic Pancapsular Capsulorrhaphy With Suture Anchors for the Treatment of Multidirectional Glenohumeral Instability in Athletes.

BACKGROUND: Outcomes after arthroscopic pancapsular capsulorrhaphy (APC) with suture anchors for multidirectional instability (MDI) of the shoulder are not widely reported. PURPOSE: To compare intraoperative findings and midterm outcomes of APC with suture anchors for MDI between female and male athletes and between a classic, atraumatic onset versus clinical onset of MDI after a traumatic event. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent APC with suture anchors for MDI and were at least 2 years out from surgery were included. Data were prospectively collected and retrospectively reviewed and included the onset of MDI, intraoperative pathoanatomic findings, level of sports participation, and patient satisfaction as well as the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Short Form-12 Physical Component Summary (SF-12 PCS) scores. Information regarding shoulder instability and return to sport was collected, and Kaplan-Meier survivorship analysis was performed. RESULTS: Forty-one patients (45 shoulders; 25 male, 20 female), consecutively treated between October 2006 and January 2013, were included. The onset of MDI was atraumatic in 22 shoulders and traumatic in 23 shoulders. At surgery, 29 of 45 (64.4%) had labral detachment. Seven shoulders (16.7%) experienced instability episodes postoperatively, and 3 of these underwent revision surgery. The mean follow-up was 3.3 years (range, 2.0-6.6 years). All subjective outcome scores improved significantly from preoperative levels (P < .005). At final follow-up, the mean ASES score was 92.0, and 76.7% (23/30) indicated that they had returned to sports participation equal to or slightly below their preinjury level. Kaplan-Meier analysis showed a survivorship rate of 87% at 3 years. Male patients were 2.3 times more likely to have a traumatic onset of instability (68% vs 30%, respectively; P = .017) and were 2.1 times more likely to have concomitant lesions (84% vs 40%, respectively; P = .004) than female patients. Furthermore, male patients demonstrated a higher mean postoperative ASES score than female patients (97.0 ± 4.7 vs 85.5 ± 16.4, respectively; P = .023). Female patients were 6.9 times more likely to undergo an additional rotator interval closure (RIC) procedure (58% vs 4.7%, respectively; P < .001) and to experience postoperative subluxations (40% vs 22%, respectively; P = .035) than male patients. A traumatic onset of MDI was associated with a higher mean postoperative ASES score (96.4 ± 6.9 vs 87.0 ± 15.7, respectively; P = .048), higher median satisfaction score (10 vs 9, respectively; P = .029), and higher return-to-sport rate (83% vs 44%, respectively; P = .030) than an atraumatic onset. CONCLUSION: APC with suture anchors can be an effective and safe treatment for patients with MDI. Labral tears were commonly found, even in patients with a classic, atraumatic onset. Male patients and patients with a traumatic onset of MDI had more favorable outcomes. Female patients may be more challenging to treat as they were more likely to undergo an additional RIC procedure and experience postoperative subluxations.

Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 5-Year Follow-up.

BACKGROUND: There are little data on midterm outcomes after the arthroscopic management of glenohumeral osteoarthritis (GHOA) in young active patients. PURPOSE: To report outcomes and survivorship for the comprehensive arthroscopic management (CAM) procedure for the treatment of GHOA at a minimum of 5 years postoperatively. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The CAM procedure was performed on a consecutive series of 46 patients (49 shoulders) with advanced GHOA who met criteria for shoulder arthroplasty but instead opted for a joint-preserving, arthroscopic surgical option. The procedure included glenohumeral chondroplasty, capsular release, synovectomy, humeral osteoplasty, axillary nerve neurolysis, subacromial decompression, loose body removal, microfracture, and biceps tenodesis. Outcome measures included the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Short Form-12 (SF-12) Physical Component Summary (PCS), visual analog scale for pain, and satisfaction scores. Kaplan-Meier survivorship analysis was performed with failure defined as progression to total shoulder arthroplasty (TSA). RESULTS: Forty-six consecutive patients (49 shoulders) who underwent a CAM procedure at a minimum of 5 years from surgery were included. Two patients were excluded for refusing to participate before study initiation. The mean age at surgery was 52 years (range, 27-68 years) in 15 women and 29 men. All patients were recreational athletes with 7 former collegiate or professional athletes. Twelve shoulders (26%) progressed to TSA at a mean of 2.6 years (range, 0.5-8.2 years). For survivorship analysis, the status of the shoulder (preservation of the native joint or progression to TSA) at a minimum of 5 years was known for 45 of 47 (96%) shoulders. Survivorship was 95.6% at 1 year, 86.7% at 3 years, and 76.9% at 5 years. For surviving shoulders, minimum 5-year subjective outcome data were available for 28 of 32 (87.5%) shoulders at a mean of 5.7 years (range, 5-8 years). The mean (±SD) ASES score was 84.5 ± 17, the mean SANE score was 82 ± 18, the mean QuickDASH score was 15 ± 13, the mean SF-12 PCS score was 51.0 ± 9.1, and median patient satisfaction was 9 of a possible 10 points. CONCLUSION: This study demonstrates significant improvements in midterm clinical outcomes and high patient satisfaction after the arthroscopic CAM procedure for GHOA, with a 76.9% survivorship rate at a minimum of 5 years postoperatively. For patients looking for an alternative to TSA, the CAM procedure can provide reasonable outcomes and should be considered an effective procedure in appropriately selected, young active patients. Further studies are warranted to evaluate long-term outcomes and durability after this procedure.

Arthroscopic Knotless, Double-Row, Extended Linked Repair for Massive Rotator Cuff Tears.

The management of massive rotator cuff tears remains a challenge for physicians, with failure rates being higher when compared with smaller tears. Many surgical treatment options exist including debridement with biceps tenodesis, complete repair, partial repair, repair with augmentation devices, superior capsule reconstruction, tendon transfer, and reverse total shoulder arthroplasty. The purpose of this article is to describe our preferred surgical technique for a complete arthroscopic repair using an extended linked, knotless, double-row construct.

Clinical and Anatomic Predictors of Outcomes After the Latarjet Procedure for the Treatment of Anterior Glenohumeral Instability With Combined Glenoid and Humeral Bone Defects.

BACKGROUND: The Latarjet procedure for the treatment of recurrent anterior shoulder instability is highly successful, but reasons for failure are often unclear. Measurements of the "glenoid track" have not previously been evaluated as potential predictors of postoperative stability. HYPOTHESIS: There are clinical and anatomic characteristics, including the glenoid track, that are predictive of outcomes after the Latarjet procedure. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent the Latarjet procedure for anterior shoulder instability with glenoid bone loss before October 2012 were assessed for eligibility. Patient-reported subjective data that were prospectively collected and retrospectively reviewed included demographic information, patient satisfaction, pain measured on a visual analog scale (VAS), questions regarding instability, Single Assessment Numeric Evaluation (SANE) scores, American Shoulder and Elbow Surgeons (ASES) scores, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores, and Short Form-12 Physical Component Summary (SF-12 PCS) scores. Anatomic measurements were performed of the coracoid size (surface area and width), width of the conjoined tendon and subscapularis tendon, estimated glenoid defect surface area, Hill-Sachs interval (HSI), and projected postoperative glenoid track engagement. Failure was defined as the necessity for revision stabilization or continued instability (dislocation or subjective subluxation) at a minimum of 2 years postoperatively. RESULTS: A total of 38 shoulders in 38 patients (33 men, 5 women) with a mean age of 26 years (range, 16-43 years) were included. The mean follow-up for 35 of 38 patients (92%) was 3.2 years (range, 2.0-7.9 years); 25 of 38 had undergone prior stabilization surgery, and 6 had workers' compensation claims. All mean subjective outcome scores significantly improved (P < .05), with a high median satisfaction score of 9 of 10. Eight patients had failures because of continued instability. Patients with moderate or higher preoperative pain scores (VAS ≥3) had a negative correlation with postoperative SF-12 PCS scores (ρ = 0.474, P = .022). Patients with outside-and-engaged (Out-E) or "off-track" lesions were 4.0 times more likely to experience postoperative instability (relative risk, 4.0; 95% CI, 1.32-12.2; P = .33). The width of patients' coracoid processes was also directly associated with postoperative stability (P = .014). Moreover, 50% (4/8) of failures demonstrated Out-E glenoid tracks (off-track lesions) versus 16% (4/25) of those without recurrent instability (P = .033). Five of 8 failures were considered as such because of subjective subluxation events, not frank dislocations. Four of the 6 patients with workers' compensation claims had failed results (P = .016). CONCLUSION: Workers' compensation claims were associated with continued instability, and patients with higher preoperative pain levels demonstrated lower SF-12 PCS scores postoperatively. The concept of the glenoid track may be predictive of stability after the Latarjet procedure and may be helpful in surgical decision making regarding the treatment of Hill-Sachs lesions at risk for persistent engagement. Although stability and patient satisfaction are high after the Latarjet procedure, subjective complaints of subluxation may be more common than previously estimated.

Outcomes After Open Revision Repair of Massive Rotator Cuff Tears With Biologic Patch Augmentation.

PURPOSE: To assess minimum 2-year clinical outcomes after open revision biologic patch augmentation in patients with massive rotator cuff retears who had deficient rotator cuff tendons with healthy rotator cuff muscles. METHODS: Patients with massive posterosuperior rotator cuff retears who underwent open revision rotator cuff repair with patch augmentation were identified from a surgical registry. Outcomes data collected included American Shoulder and Elbow Surgeons; Quick Disabilities of the Arm, Shoulder and Hand; Single Assessment Numeric Evaluation; and Short Form-12 Physical Component Summary scores along with postoperative patient satisfaction, and activity modification. RESULTS: There were 10 men and 2 women (13 shoulders, 1 bilateral) with a mean age of 57 years (range, 26 to 68 years). All patients had at least one prior arthroscopic rotator cuff repair. After patch augmentation, there were no complications, no adverse reactions to the patch, and no patients required further surgery. One patient (7.7%) with 4 prior cuff repairs had a documented posterosuperior retear on magnetic resonance imaging 2 months after repair. Minimum 2-year outcome scores were available for 12 of 13 (92.3%) shoulders after a mean follow-up period of 2.5 years (range, 2.0 to 4.0 years). The ASES score improved by 21.5 points. Although the pain component of the ASES score and the total ASES score did not improve significantly, the function component of the ASES score improved significantly when compared with their preoperative baselines (P < .05). Median patient satisfaction at final follow-up was 9/10 (range, 2 to 10). CONCLUSIONS: Biologic patch augmentation with human acellular dermal allograft was a safe and effective treatment method for patients with massive rotator cuff retears with deficient posterosuperior rotator cuff tendons in the presence of healthy rotator cuff muscles. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Predictors for satisfaction after anatomic total shoulder arthroplasty for idiopathic glenohumeral osteoarthritis.

INTRODUCTION: The use of total shoulder arthroplasty (TSA) to treat primary glenohumeral osteoarthritis (GHOA) is increasing. Factors influencing patient satisfaction after surgery have not been well documented. The aim of this study was to determine demographic, radiologic, and surgical, factors predictive for satisfaction after TSA for GHOA. MATERIALS AND METHODS: Between 2005 and 2012, 95 shoulders undergoing TSA for GHOA by a single surgeon were eligible for inclusion in the study. Age, gender, previous surgeries, American Society of Anesthesiologists (ASA) score, and Walch glenoid morphology were analyzed as satisfaction predictors. Patients with Walch glenoid type C were excluded. RESULTS: Data on 80/92(87 %) shoulders were available at a mean of 3 years (range 2-9). Three complications (3 %) and 2 failures (2 %) occurred. The outcome scores collected significantly improved from preoperative values (p < 0.05). Median patient satisfaction was 10/10. Gender, age, previous surgery, ASA score, and Walch morphology were not associated with patient satisfaction. CONCLUSIONS: TSA provided excellent results for patients with idiopathic GHOA with low complication and failure rates. Outcomes after TSA for type B glenoid morphology with posterior subluxation were similar to outcomes after TSA for centered type A morphology. Overall patient satisfaction was high and was not influenced by the demographic, anatomic, and surgical variables investigated. LEVEL OF EVIDENCE: III, Therapeutic study, Retrospective Cohort Study.

Clinical Results After Conservative Management for Grade III Acromioclavicular Joint Injuries: Does Eventual Surgery Affect Overall Outcomes?

PURPOSE: To compare the clinical outcomes in patients with grade III acromioclavicular (AC) joint injuries in whom nonoperative therapy was successfully completed and those who had nonoperative therapy failure and who proceeded to undergo surgical reconstruction. METHODS: Forty-nine patients were initially treated nonoperatively for grade III AC joint injuries with physical therapy. Patients completed questionnaires at initial presentation and after a follow-up period of 2 years. Outcome measures included the Short Form 12 Physical Component Score; American Shoulder and Elbow Surgeons score; Quick Disabilities of the Arm, Shoulder and Hand score; and Single Assessment Numeric Evaluation score. Failure of nonoperative treatment occurred when a patient underwent AC reconstruction before final follow-up. RESULTS: Forty-one patients with a mean age of 39 years (range, 18 to 79 years) were included. In this cohort, 29 of 41 patients (71%) successfully completed nonoperative therapy whereas 12 of 41 (30%) had nonoperative therapy failure at a median of 42 days (range, 6 days to 17.0 months). Of the 41 patients, 39 (95.3%) were contacted to determine treatment success. Of the 12 patients who had nonoperative therapy failure, 11 (92%) had sought treatment more than 30 days after the injury. Subjective follow-up data were available for 10 of 12 patients (83.3%) who had nonoperative therapy failure and for 23 of 29 patients (79.3%) who were successfully treated nonoperatively. The mean length of follow-up was 3.3 years (range, 1.8 to 5.9 years). Although there were no statistically significant differences in outcome scores between groups, those who sought treatment more than 30 days after their injury showed decreased postoperative Single Assessment Numeric Evaluation scores (P = .002) and Short Form 12 Physical Component Scores (P = .037). CONCLUSIONS: According to our results, (1) a trial of nonoperative treatment is warranted because successful outcomes can be expected even in patients who eventually opt for surgery and (2) patients who presented more than 30 days after their injury were less likely to complete nonoperative treatment successfully. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Chronic rupture of the long head of the biceps tendon: comparison of 2-year results following primary versus revision open subpectoral biceps tenodesis.

INTRODUCTION: The purpose of this study was to evaluate the clinical results of surgical repair for proximal long head of the biceps (LHB) tendon ruptures comparing chronic primary and postsurgical revision LHB tendon ruptures. MATERIALS AND METHODS: Patients who underwent subpectoral LHB tenodesis for chronic ruptures with a minimum of 2 years from surgery were identified. ASES and SF-12 PCS scores and surgical and demographic data were collected prospectively. At final follow-up, patients were interviewed regarding symptoms related to their biceps. Symptoms were converted into a Subjective Proximal Biceps Score (SPBS). RESULTS: Twenty-seven patients (22 males, 5 females) with a mean age of 61 years (range 40-76 years) underwent LHB tenodeses. Twenty patients (74.1 %) were primary repairs for chronic ruptures and seven patients (25.9 %) were revision repairs after failed prior LHB tenodesis. Twenty-five patients (92.6 %; n = 18 primary; n = 7 revision) were available for follow-up a mean of 3.8 years (range 2-6.1). The overall median postoperative SPBS showed significant improvement over the preoperative baseline (p < 0.001). Individual components of the SPBS showed substantial improvements. The SPBS significantly correlated with the postoperative ASES score (r = -0.478; p = 0.038). There were no differences in postoperative SPBSs between the primary and revision tenodesis groups. The mean postoperative ASES score was 90.3 and SF-12 PCS was 52.6. CONCLUSIONS: Open subpectoral LHB tenodesis was a safe and effective method for the treatment of chronic LHB tendon ruptures and for the revision of failed post-surgical LHB ruptures. Patients had less pain, cramping, and deformity after LHB tenodesis. The SPBS, ASES, and SF-12 PCS scores significantly improved among this group of patients. LEVEL OF EVIDENCE: Level III; Retrospective comparative study.

Alterations in Glenohumeral Kinematics in Patients With Rotator Cuff Tears Measured With Biplane Fluoroscopy.

PURPOSE: To quantitatively measure the 3-dimensional (3D) glenohumeral translations during dynamic shoulder abduction in the scapular plane, using a biplane fluoroscopy system, in patients with supraspinatus rotator cuff tears. METHODS: A custom biplane fluoroscopy system was used to measure the 3D position and orientation of the scapula and humerus of 14 patients with full-thickness supraspinatus or supraspinatus and infraspinatus rotator cuff tears and 10 controls as they performed shoulder abduction over their full range of motion. The 3D geometries of the scapula and humerus were extracted from a computed tomography scan of each shoulder. For each frame, the 3D bone position and orientation were estimated using a contour-based matching algorithm, and the 3D position of the humeral head center was determined relative to the glenoid. For each subject the superior-inferior and anterior-posterior translation curves were determined from 20° through 150° of arm elevation. RESULTS: The humeral head in shoulders with rotator cuff tears was positioned significantly inferior compared with controls for higher elevation angles of 80° to 140° (P < .05). For both groups the humeral head translated inferiorly during shoulder abduction from 80° (P = .044; rotator cuff tear v controls: -0.2 ± 1.3 v 1.2 ± 1.4 mm) up to 140° (P = .047; rotator cuff tear v controls: -1.3 ± 2.2 v 0.44 ± 1.4 mm). There was no significant translation in the anterior- posterior direction. CONCLUSIONS: Patients with well-compensated single or 2-tendon rotator cuff tears show no dynamic superior humeral head migration but unexpectedly show an inferior shift during active elevation. It is unclear whether the size of the translational differences found in this study, while statistically significant, are also of clinical significance. LEVEL OF EVIDENCE: Level III, comparative study.

Clinical outcomes after autograft reconstruction for sternoclavicular joint instability.

BACKGROUND: Instability of the sternoclavicular (SC) joint is a rare condition. However, in some cases, SC joint instability may lead to persistent pain and impairment of shoulder function that requires surgical management. This study evaluated clinical outcomes after SC joint reconstruction with hamstring tendon autograft in patients with SC joint instability. METHODS: From December 2010 to January 2014, 21 reconstructions of the SC joint with hamstring tendon autograft were performed. Outcomes data were prospectively collected and retrospectively reviewed. Data analyzed included American Shoulder and Elbow Surgeons score, Quick Disability of the Arm, Shoulder and Hand, physical component of the Short Form 12, and Single Assessment Numeric Evaluation scores. Pain with activities of daily living, work, and sleep were separately analyzed along with painless use of arm for activities. Patients were also questioned regarding postoperative satisfaction. RESULTS: Nine women and 10 men (2 bilaterals), with a mean age of 30 years (range, 15-56 years), were monitored for a mean of 2 years (range, 12-36 months) postoperatively. Mean American Shoulder and Elbow Surgeons, Quick Disability of the Arm, Shoulder and Hand, and Single Assessment Numeric Evaluation scores significantly improved (P < .001). Pain scores also improved over preoperative baselines, including pain with activities of daily living, work, and sleep (P < .001). Median satisfaction at final follow-up was 8.5 (range, 7-10). There were no intraoperative or postoperative complications and no cases of recurrent instability. CONCLUSION: Free hamstring tendon autograft reconstruction for SC joint instability resulted in significantly improved clinical outcomes with high patient satisfaction and no intraoperative or postoperative complications.

The Comprehensive Arthroscopic Management Procedure for Treatment of Glenohumeral Osteoarthritis.

Younger, high-demand patients who are less suitable for joint replacement procedures are often affected by advanced glenohumeral osteoarthritis. There are several alternatives to total joint arthroplasty for the treatment of these patients. However, the outcomes of these procedures are less predictable and have limited durability. The comprehensive arthroscopic management procedure, which includes a combination of arthroscopic glenohumeral debridement, chondroplasty, synovectomy, loose body removal, humeral osteoplasty with excision of the goat's beard osteophyte, capsular releases, subacromial and subcoracoid decompressions, axillary nerve decompression, and biceps tenodesis, has been shown to reduce pain, improve function, and provide a predictable short-term joint-preserving option for patients with advanced glenohumeral osteoarthritis. A unique feature of the comprehensive arthroscopic management procedure is the indirect and direct decompression of the axillary nerve, which may explain the difference in outcomes with this technique compared with other approaches. Furthermore, the technique is technically demanding and associated with several notable pitfalls that are preventable when using the meticulous surgical technique detailed in this article and accompanying video.