Beyond guesswork: how accurate are surgeons at determining the degree of glenoid bone loss in instability surgery?

Background: Accurate measurement of glenoid bone loss (GBL) is critical to preoperative planning in cases of recurrent shoulder instability. The concept of critical bone loss has been established with a value of GBL >13.5% being associated with higher failure rate following arthroscopic Bankart Repair. Advanced imaging, such as magnetic resonance imaging (MRI) scans, can be used to quantify GBL prior to surgery using the best-fit circle technique. Surgeons have traditionally relied on visual inspection of the MRI scan preoperatively or on visual inspection of the glenoid at the time of arthroscopy to determine whether GBL is present. The purpose of this study is to determine if 3 fellowship-trained shoulder surgeons could adequately quantify GBL without using best-fit circle measurements on MRI. Methods: A retrospective review was performed which included 122 patients over an 8-year period that had an arthroscopic Bankart repair performed by 3 fellowship-trained surgeons. In all patients, preoperative MRI scans were retrospectively measured using best-fit circle technique to determine true GBL and compare that to the surgeons' preoperative and intraoperative estimation of GBL. Results: GBL was correctly identified in only 36% (18/50) of patients when the preoperative best-fit circle measurements were not made. Critical bone loss was missed in 9.8% (12/122) of patients in the study group. The estimated mean bone loss in that group by visual inspection was 11.3% compared to 16% true bone loss measured on MRI. Even in the 18 patients with some identified bone loss prior to surgery, critical bone loss was missed in 6 patients when using visual inspection of the MRI or intraoperative inspection alone. Conclusion: Simple visual inspection of glenoid images on MRI scan and visual inspection of the glenoid at the time of surgery are inaccurate in determining the true extent of GBL especially in cases of subtle bone deficiency. Preoperative planning is dependent on the exact degree of bone deficiency and measurement on the MRI scan using the best-fit circle technique is recommended in all cases of instability surgery.

Consensus statement on the treatment of massive irreparable rotator cuff tears: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons.

BACKGROUND: Management of massive irreparable rotator cuff tears (MIRCTs) remains controversial owing to variability in patient features and outcomes contributing to a lack of unanimity in treatment recommendations. The purpose of this study was to implement the Delphi process using experts from the Neer Circle of the American Shoulder and Elbow Surgeons to determine areas of consensus regarding treatment options for a variety of MIRCTs. METHODS: A panel of 120 shoulder surgeons were sent a survey regarding MIRCT treatments including arthroscopic débridement and partial cuff repair, graft augmentation, reverse shoulder arthroplasty (RSA), superior capsular reconstruction (SCR), and tendon transfer. An iterative Delphi process was then conducted with a first-round questionnaire consisting of 13 patient factors with the option for open-ended responses to identify important features influencing the treatment of MIRCTs. The second-round survey sought to determine the importance of patient factors related to the 6 included treatment options. A third-round survey asked participants to classify treatment options for 60 MIRCT patient scenarios as either preferred treatment, acceptable treatment, not acceptable/contraindicated, or unsure/no opinion. Patient scenarios were declared to achieve consensus for the preferred and not acceptable/contraindicated categories when at least 80% of the survey respondents agreed on a response, and a 90% threshold was required for the acceptable treatment category, defined by an acceptable treatment or preferred treatment response. RESULTS: Seventy-two members agreed to participate and were deemed to have the requisite expertise to contribute based on their survey responses regarding clinical practice and patient volume. There were 20 clinical scenarios that reached 90% consensus as an acceptable treatment, with RSA selected for 18 scenarios and arthroscopic débridement and/or partial repair selected for 2. RSA was selected as the singular preferred treatment option in 8 scenarios. Not acceptable/contraindicated treatment options reached consensus in 8 scenarios, of which, 4 related to SCR, 3 related to RSA, and 1 related to partial repair with graft augmentation. CONCLUSION: This Delphi process exhibited significant consensus regarding RSA as a preferred treatment strategy in older patients with pseudoparesis, an irreparable subscapularis, and dynamic instability. In addition, the process identified certain unacceptable treatments for MIRCTs such as SCR in older patients with pseudoparesis and an irreparable subscapularis or RSA in young patients with an intact or reparable subscapularis without pseudoparesis or dynamic instability. The publication of these scenarios and areas of consensus may serve as a useful guide for practitioners in the management of MIRCTs.

Variability of glenoid labral tear patterns: a study of 280 sequential surgical cases.

BACKGROUND: Glenoid labrum tears are a common cause of shoulder pain and instability and tear patterns have historically been ascribed into categorical descriptions such as anterior, posterior, and superior labral tears (SLAP [superior labrum anterior and posterior]) with multiple subtypes. Although often quoted as representing no more than 10% of instabilities, posterior shoulder instability may be more common than previously recognized. The purpose of this study was to review observed labral tear patterns and compare incidence and morphologies to historical descriptions. METHODS: All patients undergoing arthroscopic or open labral repair (Current Procedural Terminology codes 29806, 29807, 23455, 23460, 23462, 23465) by 2 fellowship-trained shoulder surgeons from July 2012 to May 2019 were retrospectively reviewed. Labral tears were categorized into 3 groups: exclusively anterior to the midline of the glenoid, exclusively posterior, and those crossing the midline of the glenoid. Chief complaint, mechanism of injury, hand dominance, preoperative MRI interpretation by surgeon, and independent radiologist were analyzed for each tear type. RESULTS: During the 7-year period, 280 patients underwent arthroscopic or open labral repair. Sixty percent of tears were traumatic, with dislocation being the most common traumatic mechanism at 31.4%. Ten distinct tear patterns were identified: 3 types of 90° tears (anteroinferior, posteroinferior, and posterosuperior), 4 types of 180° tears (anterior, posterior, inferior, and SLAP), 2 types of 270° tears (anteroinferior and anterosuperior), and 360° labral tears. A total of 134 tears (47.9%) were classified as posterior, and 72 tears (25.7%) were anterior. Seventy-four tears (26.4%) were combined anterior-posterior tears. Labral tears involving some portion of the posterior labrum constituted 74% of tears. A significant association between tear location and primary complaint (P < .001) was noted. Patients with anterior tears complained of only instability in 62.5% of cases, and only pain in 22%. Patients with posterior labral tears complained primarily of pain in 68% of cases, and instability in 21%. There was an accurate preoperative diagnosis given by both radiologists and surgeons on 30% (n = 63) of the tears. CONCLUSION: There is a wide variety of labral tear patterns identified at the time of surgery, and the incidence of posterior labral tears is higher than previously described. Isolated Bankart lesions are relatively rare and are often associated with more extensive labral lesions. Patients with posterior labral pathology more often complain of pain rather than instability, whereas patients with anterior labral tears more often complain of instability.

Decision making in treatment after a first-time anterior glenohumeral dislocation: A Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons.

BACKGROUND: The treatment of patients who sustain a first-time anterior glenohumeral dislocation (FTAGD) is controversial. The purpose of this study was to find consensus among experts using a validated iterative process in the treatment of patients after an FTAGD. METHODS: The Neer Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons. Consensus among 72 identified experts from this group was sought with a series of surveys using the Delphi process. The first survey used open-ended questions designed to identify patient-related features that influence treatment decisions after an FTAGD. The second survey used a Likert scale to rank each feature's impact on treatment decisions. The third survey used highly impactful features to construct 162 clinical scenarios. For each scenario, experts recommended surgery or not and reported how strongly they made their recommendation. These data were analyzed to find clinical scenarios that had >90% consensus for recommending treatment. These data were also used in univariate and multivariate mixed-effects models to identify odds ratios (ORs) for different features and to assess how combining these features influenced the probability of surgery for specific populations. RESULTS: Of the 162 scenarios, 8 (5%) achieved >90% consensus for recommending surgery. All of these scenarios treated athletes with meaningful bone loss at the end of their season. In particular, for contact athletes aged > 14 years who were at the end of the season and had apprehension and meaningful bone loss, there was >90% consensus for recommending surgery after an FTAGD, with surgeons feeling very strongly about this recommendation. Of the scenarios, 22 (14%) reached >90% consensus for recommending nonoperative treatment. All of these scenarios lacked meaningful bone loss. In particular, surgeons felt very strongly about recommending nonoperative treatment after an FTAGD for non-athletes lacking apprehension without meaningful bone loss. The presence of meaningful bone loss (OR, 6.85; 95% confidence interval, 6.24-7.52) and apprehension (OR, 5.60; 95% confidence interval, 5.03-6.25) were the strongest predictors of surgery. When these 2 features were combined, profound effects increasing the probability of surgery for different populations (active-duty military, non-athletes, noncontact athletes, and contact athletes) were noted, particularly non-athletes. CONCLUSION: Consensus for recommending treatment of the FTAGD patient was not easily achieved. Certain combinations of patient-specific factors, such as the presence of meaningful bone loss and apprehension, increased the probability of surgery after an FTAGD in all populations. Over 90% of shoulder instability experts recommend surgery after an FTAGD for contact athletes aged > 14 years at the end of the season with both apprehension and meaningful bone loss. Over 90% of experts would not perform surgery after a first dislocation in patients who are not athletes and who lack apprehension without meaningful bone loss.

Successful Performance After Ulnar Collateral Ligament Reconstruction: An Analysis of 88 Drafted Professional Baseball Pitchers With a Matched Comparison Cohort.

BACKGROUND: Analysis of pitchers entering the Major League Baseball (MLB) draft after ulnar collateral ligament reconstruction (UCLR) is challenging for team physicians. PURPOSE: (1) To define the characteristics of pitchers drafted after UCLR associated with placement in AAA and MLB professional levels and completion of a career of at least 3 years, (2) to define characteristics placing pitchers at risk for reinjury after surgery, (3) to compare the professional-level placement and career duration of the UCLR cohort with a matched control group, and (4) to evaluate the accuracy of team physician predraft risk assessments to predict elbow reinjury in pitchers with a history of UCLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We analyzed pitchers from a single professional baseball team database who were drafted after UCLR from 2010 to 2013. A matched control group based on position and draft year was selected with the MLB database. The following pitcher characteristics were analyzed: age at the time of UCLR, time from UCLR to the MLB draft, pitching role (starter vs reliever), highest level of play attained, body mass index (BMI), throwing-side dominance, and predraft physician risk assessment. Physician assessments to predict risk for elbow reinjury were derived from operative and clinical history and evaluated for accuracy during the follow-up period. Pitcher characteristics were evaluated for correlation with successful AAA or MLB placement with a career duration of at least 3 years and as risk factors for elbow reinjury. The professional-level achievement and career duration of the UCLR cohort were compared with the matched cohort. RESULTS: A total of 88 pitchers matched the selection criteria and had at least 5 years of follow-up (range, 5-8 years). Pitcher age at the time of UCLR (P = .55), throwing-side dominance (P = .41), and BMI (P = .86) did not correlate with AAA- or MLB-level placement. Relief pitchers (P = .03) and pitchers with a longer time from surgery to final follow-up (P = .02) were more likely to reach the AAA or MLB level. Similarly, pitcher age at the time of UCLR (P = .56), throwing-side dominance (P = .27), and BMI (P = .69) did not correlate with a duration of play of at least 3 years. Relief pitchers (P = .03) and pitchers with a longer time from UCLR to the final follow-up (P = .005) were more likely to achieve at least 3 years of play. There was no difference in AAA or MLB placement between the UCLR and matched cohorts (P = .22). The UCLR cohort achieved a higher duration of play than the matched cohort (P = .002). Pitchers with a BMI >25 kg/m2 had a lower risk of elbow reinjury versus players with a BMI ≤25 kg/m2 (P = .012). Patient age at time of UCLR (P = .92), time from UCLR to the MLB draft (P = .18), pitching role (P = .74), and throwing-side dominance (P = .77) did not correlate with elbow reinjury. Physician risk assessment did not accurately predict reinjury (P = .27). Of the 88 patients, 4 (4.5%) required revision UCLR. CONCLUSION: Pitcher age at the time of UCLR, throwing-side dominance, and BMI did not correlate with performance. Relief pitchers and players with a longer time from surgery to final follow-up were more likely to reach AAA and MLB levels and achieve at least a 3-year duration of play. Pitchers with a greater BMI had a lower risk of reinjury. After UCLR, pitchers were able to perform at least as well as the matched nonsurgical cohort. Physician risk assessment at the time of the draft was not accurate at predicting reinjury.

Posterior Labral Repairs of the Shoulder Among Baseball Players: Results and Outcomes With Minimum 2-Year Follow-up.

BACKGROUND: There is a paucity of information regarding the treatment of posterior labral tears of the shoulder for baseball players. Reports regarding treatment and postoperative outcomes are more limited than its anterior and superior counterparts. PURPOSE: To evaluate the clinical presentation, surgical findings, postoperative outcomes, and rate of return to sport after arthroscopic repair of posterior labral injuries of the shoulder among baseball players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Retrospective review was performed of baseball players who underwent arthroscopic posterior labral repair between 2009 and 2015 by a single surgeon, with a minimum 2-year follow-up. The group was composed of 32 male patients involved in recreational (6.3%), high school (43.8%), college (31.3%), and professional (18.8%) baseball, with a mean age of 20.5 years. Patients were categorized by chief complaint, clinical findings, surgical findings, and concomitant procedures performed. Pre- and postoperative measures included pain scale, range of motion, American Shoulder and Elbow Surgeons shoulder score, return to play, and patient satisfaction. RESULTS: A variety of tear patterns were identified; 32% involved 90° of the posterior superior labrum; 35% involved the posterior 180°; and 32% involved 90° of the posterior inferior labrum. The dominant mechanism of injury was throwing (34.4%). The most common chief complaint was pain (n = 25, 78%), followed by pain and instability symptoms (n = 6, 18.8%), with only 3% citing isolated sensation of instability. Magnetic resonance imaging clearly identified tear patterns in 75% of cases. American Shoulder and Elbow Surgeons scores significantly improved ( P < .0001), increasing on average 30.9 points from the preoperative mean of 65.4 to a postoperative mean of 96.3. No significant range of motion deficits were noted. Tear size and number of anchors utilized did not influence outcomes. Ninety-four percent of athletes returned to play, 61% at previous levels, and 6% did not return. Pitchers had a lower return to previous level of play than position players (41% vs 86%, P = .0113). CONCLUSION: Arthroscopic treatment of posterior labral tears of baseball players was effective in improving pain and function, resulting in 94% patient satisfaction and 94% return to sport, with 61% returning to previous level of play. Patient presentation is variable, with a majority of patients citing pain rather than instability.

Elbow Injuries in the Adolescent Thrower.

PURPOSE OF REVIEW: With an increasing rate of adolescent elbow injuries, especially in throwing athletes, the purpose of this review is to investigate the current literature regarding the diagnosis, treatment, and non-operative and operative outcomes of medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures. RECENT FINDINGS: Acceptable outcomes with both non-operative and operative treatments of medial epicondyle fractures have been reported, with surgical indications continuing to evolve. Unstable osteochondritis dissecans lesions, especially in patients with closed growth plates, require operative fixation, and emerging open and arthroscopic techniques including lesion debridement, marrow stimulation, autograft transfer, and allograft transplantation are described with good outcomes. Ulnar collateral repair has emerged as an exciting treatment option for an avulsion of either end of the ligament in young throwing athletes, with faster rehabilitation times than traditional ulnar collateral ligament reconstruction. Olecranon stress fractures are increasing in prevalence, and when a non-operative treatment course is unsuccessful, athletes have a high return-to-play rate after percutaneous cannulated screw placement. With proper indications, non-operative and operative treatment modalities are reported with a high return-to-play and acceptable clinical outcomes for common elbow injuries, including medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures, in adolescent throwing athletes. Further research is needed to better define treatment algorithms, surgical indications, and outcomes.

Interfragmentary suture fixation for displaced acute type II distal clavicle fractures.

OBJECTIVES: Stable fixation of displaced type II distal clavicle fractures presents a challenge to the surgeon because of distal fragment comminution and the large deforming forces created by the weight of the arm. We hypothesized that suture fixation around the coracoid and interfragmentary suture fixation would adequately counteract these forces and lead to a high rate of union and restoration of function. DESIGN: This is a retrospective study of 20 sequential patients treated between 1997 and 2009. SETTING: In-patient operating room followed by the clinic. PATIENTS/PARTICIPANTS: All patients presenting with acute displaced distal clavicle fractures to 2 surgeons were included. All patients completed the study without loss to follow-up. INTERVENTION: Open repair was performed by placing two #5 Fiberwire sutures around the coracoid and through drill holes in the clavicular shaft. Interfragmentary fixation was performed with figure-of-eight #2 Fiberwire sutures. MAIN OUTCOME MEASURES: Patients evaluation included the American Shoulder and Elbow Surgeons scale, range of motion, radiographic evaluation, and patient satisfaction. RESULTS: All fractures healed without loss of reduction at an average of 2.6 months, and all patients were satisfied. American Shoulder and Elbow Surgeons score was 98.5 out of 100. Average follow-up was 7.1 years (range, 3.1-14.3 years). One postoperative wound hematoma and one superficial wound infection were treated nonoperatively. CONCLUSIONS: Interfragmentary and coracoclavicular suture fixation for displaced acute distal clavicle fractures is a safe and effective treatment with an excellent union rate, low complication rate, and high patient satisfaction. LEVEL OF EVIDENCE: Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

Scapula fractures: interobserver reliability of classification and treatment.

OBJECTIVES: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. DESIGN: Web-based reliability study. SETTING: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS: Fleiss kappa (κ) was used to assess the reliability of agreement between the surgeons. RESULTS: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), κ = 0.79) was substantial and the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA. CONCLUSIONS: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

Humeral head resurfacing for glenohumeral arthritis associated with dysplasia.

Humeral head resurfacing is indicated for the treatment of glenohumeral arthrosis in a variety of well-described situations, including humeral shaft abnormalities and obstructing hardware. This report of 2 cases emphasizes the benefit of this stemless device in situations in which dislocation of the humeral head and access to the humeral canal is not possible. In these 2 patients with developmental dysplasia and secondary glenohumeral arthrosis, humeral head resurfacing arthroplasty resulted in successful improvement of severe preoperative pain. In cases in which the humeral head cannot be dislocated due to severe dysplastic changes and joint line medialization, humeral resurfacing arthroplasty allows prosthetic placement through nontraditional exposures and results in high patient satisfaction and excellent pain relief.

The clinical results of arthroscopic transtendinous repair of grade III partial articular-sided supraspinatus tendon tears.

PURPOSE: The purpose of this study was to evaluate the clinical results of arthroscopic transtendinous repair of deep partial articular-sided rotator cuff tears. METHODS: We retrospectively evaluated the results of 53 patients who underwent arthroscopic transtendinous repair for Ellman grade III articular-sided rotator cuff tears (>50% of the thickness of the rotator cuff). The intact bursal side of the cuff was not detached, and all associated pathology was treated. Fifty patients available for follow-up were evaluated with the American Shoulder and Elbow Surgeons (ASES) questionnaire. RESULTS: American Shoulder and Elbow Surgeons scores improved from a mean of 48.0 to 89.4 (+41.4) (P < .0001). Pain scores on a visual analog scale improved from 5.7 to 1.0 (P < .0001). Ninety-eight percent of patients were satisfied with the results of surgery. Results for the 50 patients available for follow-up were excellent in 32 (64%), good in 6 (12%), fair in 6 (12%), and poor in 6 (12%). Articular-sided rotator cuff tears rarely occurred in isolation but were typically found in association with coexisting pathology suggestive of the tears' etiology. Most common were impingement lesions, seen in 94% of patients, and instability lesions such as labral tears, seen in 30% of patients. Associated procedures included acromioplasty in 47, distal clavicle resection in 29, treatment of biceps pathology in 7, and instability repair in 15. One patient sustained a postoperative pulmonary embolism, which represented the only complication. Tears varied in size from 50% to 90% of the thickness of the cuff insertion. Significant differences were identified in the results of Workers' Compensation patients. Preoperative magnetic resonance imaging and magnetic resonance arthrography were accurate in identifying a partial-thickness rotator cuff tear in less than 40% of cases. CONCLUSIONS: Arthroscopic transtendinous repair of partial articular-sided rotator cuff tears is a safe and effective treatment that allows identification of commonly associated pathology and reliable improvement in pain and function. LEVEL OF EVIDENCE: Level IV, therapeutic case series.