Establishing the Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient Acceptable Symptomatic State After Arthroscopic Posterior Labral Repair for Posterior Glenohumeral Instability.

BACKGROUND: Posterior glenohumeral instability is an increasingly recognized cause of shoulder pain and dysfunction among young, active populations. Outcomes after posterior stabilization procedures are commonly assessed using patient-reported outcome measures including the Single Assessment Numeric Evaluation (SANE), the Rowe instability score, the American Shoulder and Elbow Surgeons (ASES) score, and the visual analog scale (VAS) for pain. The clinical significance thresholds for these measures after arthroscopic posterior labral repair (aPLR), however, remain undefined. PURPOSE: We aimed to define the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for the SANE, Rowe score, and ASES score as well as the VAS pain after aPLR. Additionally, we sought to determine preoperative factors predictive of reaching, as well as failing to reach, clinical significance. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This study was a retrospective analysis of patient-reported outcome scores collected from patients who underwent aPLR between January 2011 and December 2018. To determine the clinically significant threshold that corresponded to achieving a meaningful outcome, the MCID, SCB, and PASS were calculated for the SANE, Rowe score, ASES score, and VAS pain utilizing either an anchor- or distribution-based method. Additionally, univariate and multivariate logistic regression analyses were performed to determine the factors associated with achieving, or not achieving, the MCID, SCB, and PASS. RESULTS: A total of 73 patients with a mean follow-up of 82.55 ± 24.20 months were available for final analysis. MCID, SCB, and PASS values for the VAS pain were 1.10, 6, and 3, respectively; for the ASES score were 7.8, 34, and 80, respectively; for the SANE were 10.15, 33, and 85, respectively; and for the Rowe score were 11.3, 60, and 90, respectively. To meet the MCID, male sex (odds ratio [OR], 1.1639; P = .0293) was found to be a positive predictor for the VAS pain, and a lower preoperative SANE score (OR, 0.9939; P = .0003) was found to be a negative predictor for the SANE. Dominant arm involvement was associated with lower odds of achieving the PASS for the ASES score (OR, 0.7834; P = .0259) and VAS pain (OR, 0.7887; P = .0436). Patients who reported a history of shoulder trauma were more likely to reach the PASS for the SANE (OR, 1.3501; P = .0089), Rowe score (OR, 1.3938; P = .0052), and VAS pain (OR, 1.3507; P = .0104) as well as the SCB for the ASES score (OR, 1.2642; P = .0469) and SANE (OR, 1.2554; P = .0444). A higher preoperative VAS pain score was associated with higher odds of achieving the SCB for both the VAS pain (OR, 1.1653; P = .0110) and Rowe score (OR, 1.1282; P = .0175). Lastly, concomitant biceps tenodesis was associated with greater odds of achieving the SCB for the ASES score (OR, 1.3490; P = .0130) and reaching the PASS for the SANE (OR, 1.3825; P = .0038) and Rowe score (OR, 1.4040; P = .0035). CONCLUSION: To our knowledge, this study is the first to define the MCID, SCB, and PASS for the ASES score, Rowe score, SANE, and VAS pain in patients undergoing aPLR. Furthermore, we found that patients who reported a history of shoulder trauma and those who underwent concomitant biceps tenodesis demonstrated a greater likelihood of achieving clinical significance. Dominant arm involvement was associated with lower odds of achieving clinical significance.

Recovery of Shoulder, Elbow, and Forearm Movement After Nerve Reconstruction for Neonatal Brachial Plexus Palsy.

BACKGROUND AND OBJECTIVES: There is a relative dearth of published data with respect to recovery of upper extremity movement after nerve reconstruction for neonatal brachial plexus palsy (NBPP). This study aimed to demonstrate long-term recovery of active range of motion (AROM) at the shoulder, elbow, and forearm after nerve reconstruction for NBPP and to compare that with patients managed nonoperatively. METHODS: We interrogated a prospectively collected database of all patients evaluated for NBPP at a single institution from 2005 to 2020. AROM measurements for shoulder, elbow, and forearm movements were collected at every visit up to 5 years of follow-up and normalized between 0 and 1. We used generalized estimated equations to predict AROM for each movement within local age windows over 5 years and compared the operative and nonoperative cohorts at each age interval. RESULTS: In total, >13 000 collected datapoints representing 425 conservatively and 99 operatively managed children were included for analysis. At 5 years, absolute recovery of AROM after nerve reconstruction was ∼50% for shoulder abduction and forward flexion, ∼65% for shoulder external rotation, and ∼75% for elbow flexion and forearm supination, with ∼20% loss of elbow extension AROM. Despite more limited AROM on presentation for the operative cohort, at 5 years, there was no significant difference between the groups in AROM for shoulder external rotation, elbow extension, or forearm supination, and, in Narakas grade 1-2 injury, shoulder abduction and forward flexion. CONCLUSION: We demonstrate recovery of upper extremity AROM after nerve surgery for NBPP. Despite more severe presenting injury, operative patients had similar recovery of AROM when compared with nonoperative patients for shoulder external rotation, elbow extension, forearm supination, and, for Narakas grade 1-2 injury, shoulder abduction and forward flexion.

Long-term results of arthroscopic repair of type II SLAP lesions in sports: assessment of return to pre-injury playing level and critical risk factors for complication.

PURPOSE: The management of isolated SLAP lesions is still debated especially in athletes. Aims of the study were: 1. to analyse our algorithm to treat SLAP lesions starting from the selection of patients for surgery and 2. to correlate the familiarity for diabetes and hypothyroid disorders with post-operative results. METHODS: Seventy-eight patients with isolated SLAP lesion were arthroscopically treated using knotless anchors and microfractures. All patients had a pre-operative and post-operative clinical examination according to Walch-Duplay, Constant, Rowe and Dash scores and interviewed for familiarity to diabetes and hypothyroid disorders. RESULTS: About 68.8% of patients solved pain with rehabilitation. About 29% of patients returned to the sports activities. About 32% of patients were no responder to physiotherapy and were arthroscopically treated. About 53.9% of patients responded excellent, 34.7% good, 3.8% medium and 7.6% poor results according to Walch-Duplay score. The Constant score increased from 64 to 95, the Rowe score from 48 to 96. The outcomes were significantly worse in patients with familiarity for diabetes. CONCLUSIONS: Microfractures and knotless anchor give long-term good results for the treatment of SLAP lesions in athletes. The familiarity for diabetes is an important risk factor that can lead to decreased outcomes.

Similar outcomes between biceps tenodesis and SLAP repair for SLAP tears in younger patients - A meta-analysis.

OBJECTIVES: The purpose of this study is to systematically review the comparative studies in the literature to ascertain if biceps tenodesis or superior-labrum anterior to posterior (SLAP) repair results in superior clinical outcomes in the treatment of type II SLAP tears in patients under 40. METHODS: A systematic search of articles in Pubmed, EMBASE and The Cochrane Library databases was carried out according to the PRISMA guidelines. Cohort studies comparing biceps tenodesis to repair in type II SLAP tears in patients under 40 were included. Clinical outcomes were extracted including return to play, reoperations, ASES, and VAS for pain. All statistical analysis was performed using Review Manager. A p-value of <0.05 was considered to be statistically significant. RESULTS: Five studies were included. Biceps tenodesis resulted in comparable rates of return to play compared to SLAP repair (78.5% vs 67.7%, p â€‹= â€‹0.33), and there was no significant difference in return to play in overhead athletes (83.6% vs 74%, p â€‹= â€‹0.82). There was no significant difference in ASES score (87.2 vs 86.2, p â€‹= â€‹0.27) or VAS score for pain (1.8 vs 2.1, p â€‹= â€‹0.48). There was no significant difference in re-operation rates (2.9% vs 10.8%, p â€‹= â€‹0.22). CONCLUSION: This study found that biceps tenodesis has no significant difference in rates of return to play in athletes, as well as in functional outcome scores and rates of revision surgery in younger patients compared to SLAP repair. LEVEL OF EVIDENCE: Level III, Systematic review of Level III studies.

Occult, Incomplete, and Complete Posterior Labral Tears Without Glenohumeral Instability on Imaging Underestimate Labral Detachment.

PURPOSE: To introduce a classification of posterior labral tear and describe clinical characteristics, magnetic resonance imaging (MRI)/magnetic resonance arthrography (MRA) findings, arthroscopic findings, and outcomes after arthroscopic repair for patients with posterior labral tears without glenohumeral instability. METHODS: Sixty patients with posterior labral tear who underwent arthroscopic repair were analyzed retrospectively. Patients with shoulder instability were excluded. Tear patterns were classified into 3 types; occult (type 1), incomplete (type 2), and complete (type 3) based on MRI/MRA studies. A visual analog scale score for pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score for satisfaction, and return to sports were evaluated at a minimum follow-up of 2 years. Computed tomography arthrography was performed at a year follow-up for assess labral healing. The diagnosis was confirmed in arthroscopy, and arthroscopic labral repair without capsular plication was performed. RESULTS: The mean patient age was 30.4 ± 6.9 years, and all patients were male. Forty-four patients (73.3%) were participating in sports. MRI/MRA studies identified 10 patients with type 1, 18 with type 2, and 32 with type 3 tears. Type 1 tear patients showed a significantly longer symptom duration than those with type 3 (32.5 ± 17.2 vs 18.2 ± 17.1 months; P = .015). In arthroscopic findings, 70% of type 1 tear was confirmed as incomplete or complete tears. The American Shoulder and Elbow Surgeons score improved from 79.6 ± 10.3 to 98.1 ± 3.7, and pain was relieved from 2.4 ± 0.7 to 0.2 ± 0.5 at the last follow-up visit with high labral healing rate (95%). Thirty-nine (88.6%) patients returned to sports at preinjury levels. CONCLUSIONS: In active young men with shoulder pain during daily activities or sports despite programmed conservative treatment, posterior labral tears should be considered even when MRI/MRA findings are ambiguous. Arthroscopic posterior labral repair without capsular plication provided satisfactory clinical outcomes and a high labral healing rate. LEVEL OF EVIDENCE: Level Ⅳ, case series.

Editorial Commentary: Patients May Have Posterior Glenoid Labral Tears in the Absence of Instability or Magnetic Resonance Imaging Findings.

Posterior labral tears occur more often than imagined 25 years ago. Although such tears are generally identified in patients with posterior shoulder instability, the spectrum of labral tears in patients without instability creates a challenging diagnosis. Both physical examination and magnetic resonance imaging interpretation are difficult. Pathology encompassing posterior labral tears without instability notably reveals differences compared with throwers with posterior labral tears and patients with posterior instability. Recent research has identified 3 tear types: occult (type 1), incomplete (type 2), and complete (type 3). Attention to diagnosis deserves critical attention, in addition to tailoring of repair techniques to address the appropriate conditions in the shoulder. Even in patients without posterior instability and with ambiguous magnetic resonance imaging or magnetic resonance arthrography findings, posterior shoulder pain during daily activities or sports may indicate a posterior labral tear. Arthroscopic posterior labral repair without capsular plication provides good clinical outcomes and high rates of return to sport and labral healing.

Preparing for and Executing the Ideal Posterior Labral Repair.

Posterior labral tears are a source of pain and instability of the shoulder. Despite being relatively uncommon (reported in approximately 10% of instability cases), the incidence of posterior labral tear is increasingly recognized as underestimated in highly active populations. Posterior labral tears can result from a traumatic posterior dislocation or repetitive microtrauma, leading to posterior chondral/labral attrition. Patients often present with vague, deep-seated shoulder discomfort rather than the sensation of instability. Unfavorable results with nonsurgical management will indicate which patients will most benefit from surgery. Arthroscopic stabilization has proven to be an effective and reliable treatment, and many techniques for posterior labral repair have been described. It is important to highlight the evaluation, preparation, and execution of arthroscopic stabilization of an isolated posterior labral repair using high-strength knotless all-suture anchors to allow for a stable, efficient, reproducible, and reliable repair while maintaining a low-profile construct that minimizes damage to the surrounding tissue.

Concomitant Biceps Tenodesis Does Not Portend Inferior Outcomes After Anterior Glenohumeral Stabilization.

BACKGROUND: Military patients are known to suffer disproportionately high rates of glenohumeral instability as well as superior labrum anterior to posterior (SLAP) tears. Additionally, a concomitant SLAP tear is frequently observed in patients with anterior shoulder instability. Even though biceps tenodesis has been demonstrated to produce superior outcomes to SLAP repair in military patients with isolated SLAP lesions, no existing studies have reported on outcomes after simultaneous tenodesis and anterior labral repair in patients with co-existing abnormalities. PURPOSE: To evaluate outcomes after simultaneous arthroscopic-assisted subpectoral biceps tenodesis and anterior labral repair in military patients younger than 40 years. We also sought to compare these outcomes with those after repair of an isolated anterior labral tear. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study is a retrospective analysis of all military patients younger than 40 years from a single base who underwent arthroscopic anterior glenohumeral stabilization with or without concomitant biceps tenodesis between January 2010 and December 2019. Patients with glenoid bone loss of >13.5% were not eligible for inclusion. Outcome measures including the visual analog scale (VAS) for pain, the Single Assessment Numeric Evaluation (SANE), the American Shoulder and Elbow Surgeons (ASES) shoulder score, the Rowe instability score, and range of motion were administered preoperatively and postoperatively, and scores were compared between groups. RESULTS: A total of 82 patients met inclusion criteria for the study. All patients were active-duty service members at the time of surgery. The mean follow-up was 87.75 ± 27.05 months in the repair + tenodesis group and 94.07 ± 28.72 months in the isolated repair group (P = .3085). Patients who underwent repair + tenodesis had significantly worse preoperative VAS pain (6.85 ± 1.86 vs 5.02 ± 2.07, respectively; P < .001), ASES (51.78 ± 11.89 vs 62.43 ± 12.35, respectively; P = .0002), and Rowe (26.75 ± 7.81 vs 37.26 ± 14.91, respectively; P = .0002) scores than patients who underwent isolated repair. Both groups experienced significant improvements in outcome scores postoperatively (P < .0001 for all), and there were no statistically significant differences in postoperative outcome scores or range of motion between groups. There were no differences in the percentage of patients who achieved the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state for the VAS pain, SANE, ASES, and Rowe scores between groups. Overall, 37 of the 40 (92.50%) patients in the repair + tenodesis group and 40 of the 42 (95.24%) patients in the isolated repair group returned to unrestricted active-duty military service (P = .6045). In addition, 38 (95.00%) patients in the repair + tenodesis group and 40 (95.24%) patients in the isolated repair group returned to preinjury levels of sporting activity (P = .9600). There were no significant differences in the number of failures, revision surgical procedures, or patients discharged from the military between groups (P = .9421, P = .9400, and P = .6045, respectively). CONCLUSION: The findings of this study indicate that simultaneous biceps tenodesis and labral repair was a viable treatment option for the management of concomitant SLAP and anterior labral lesions in young, active military patients younger than 40 years.

Arthroscopic Repair and Reconstruction of Coracoclavicular Ligament.

Acromioclavicular joint separations are common shoulder injuries that require prompt recognition, diagnosis, and treatment. Deciding on a treatment algorithm relies on a detailed knowledge of anatomy and a thorough understanding of the specific functional demands of the patient in question. When a repair or reconstruction is indicated, arthroscopic assistance can be a helpful tool to ensure a safe, anatomic reconstruction that minimizes morbidity and maximizes the potential return to high-level function.

Outcomes Following Combined Posterior Labral and SLAP Repair in Military Patients Younger Than 35 Years.

BACKGROUND: Members of the military are known to experience disproportionately high rates of both glenohumeral instability and superior labrum anterior-posterior (SLAP) tears when compared with civilian populations. Although the outcomes after simultaneous repair of Bankart and SLAP lesions have been well described, there is a paucity of literature available regarding the operative management of posterior instability with concomitant superior labral pathology. PURPOSE: To compare outcomes of combined arthroscopic posterior labral and SLAP repair with those of isolated posterior labral repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All consecutive patients younger than 35 years who underwent arthroscopic posterior labral repair from January 2011 to December 2016 with a minimum follow-up of 5 years were identified. From this cohort of eligible patients, all individuals who had undergone combined SLAP and posterior labral repair (SLAP cohort) versus posterior labral repair alone (instability cohort) were then identified. Outcome measures including the visual analog scale score, Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) score, Rowe instability score, and range of motion were collected pre- and postoperatively and scores were compared between groups. RESULTS: In total, 83 patients met the inclusion criteria for the study. All patients were active-duty military at the time of surgery. The mean follow-up was 93.79 ± 18.06 months in the instability group and 91.24 ± 18.02 months in the SLAP group (P = .5228). Preoperative SANE and ASES scores were significantly worse in the SLAP group. Both groups experienced statistically significant improvements in outcome scores postoperatively (P < .0001 for all), and there were no significant differences in any outcome scores or range of motion between groups. In total, 39 patients in the instability cohort and 37 in the SLAP cohort returned to preinjury levels of work (92.86% vs 90.24%, respectively; P = .7126), and 38 instability patients and 35 SLAP patients returned to preinjury levels of sporting activity (90.48% vs 85.37%, respectively; P = .5195). Two patients in the instability group and 4 patients in the SLAP group were medically discharged from the military (4.76% vs 9.76%; P = .4326), and 2 patients in each cohort had experienced treatment failure at the final follow-up (4.76% vs 4.88%; P > .9999). CONCLUSION: Combined posterior labral and SLAP repair led to statistically and clinically significant increases in outcome scores and high rates of return to active-duty military service that did not differ significantly from the results after isolated posterior labral repair. The results of this study indicate that simultaneous repair is a viable treatment option for the management of combined lesions in active-duty military patients <35 years of age.

Is fixation of both clavicle and scapula better than clavicle alone in surgical treatment of floating shoulder injury? A retrospective study.

BACKGROUND & OBJECTIVE: Little research was available to explore which surgical fixation was better between fixation of both clavicle and scapula and clavicle alone in management of floating shoulder injury. METHODS: Total 69 patients with floating shoulder injury receiving surgery from February 2005 to July 2020 participated in the study. 49 patients underwent fixation of the clavicle alone (Group C) while 20 patients underwent fixation of both clavicle and scapula (Group C + S). They were further divided into subgroups according to age: Group C1, Group C + S1 (age ≤ 55 years old) and Group C2, Group C + S2 (age>55 years old). The radiological parameter (glenopolar angle (GPA)) and clinical outcomes (Herscovici score, Constant-Murley shoulder outcome score (CSS score), and Visual Analogue Scale score (VAS score)) were collected and compared between these groups. The correlation between age and radiological parameter and clinical outcomes was calculated by the Spearman correlation analysis. RESULTS: All people were followed up for at least 1 year. The degree of change in GPA before and after surgery in Group C + S is significantly better than that in Group C. The Herscovici and CSS score in Group C + S2 were significantly higher than those in Group C2 at 1 month, 3 months and 1 year after surgery. However, no significant difference in Herscovici and CSS score was found at final follow-up (1 year after surgery) between Group C + S1 and Group C1. The VAS score in Group C + S2 at final follow-up was significantly lower than that in Group C2. No significant difference in VAS score at final follow-up was found between Group C + S1 and Group C1. In addition, the VAS score was negatively correlated with Herscovici and CSS score. No correlation was found between VAS score and GPA. CONCLUSIONS: Both types of surgical fixation are effective in management of floating shoulder injury. For young people with floating shoulder injury, both types of surgical fixation are equally effective. However, for older people with floating shoulder injury, fixation of both clavicle and scapula is better in prognosis than fixation of clavicle alone.

Suprascapular nerve injury after reverse total shoulder arthroplasty: correlation with screw out of vault penetration and functional situation: prospective study.

BACKGROUND: Baseplate screws have been suggested as a possible cause of suprascapular neuropathy after reverse total shoulder arthroplasty. This study aims to investigate the association between screw penetration out of the vault, electromyographic study, and the clinical outcomes. METHODS: A total of 31 patients who underwent reverse total shoulder arthroplasty for cuff tear arthropathy were prospectively enrolled. They were followed up for a minimum of 24 months. All patients underwent computed tomography 6 months postoperatively to determine the extraosseous position of the screws (perforation of the second bone cortex and protrusion into the supra- or infraspinatus fossa). Electrodiagnostic evaluation was performed preoperatively and postoperatively to stablish any relation between cortex perforation of the screw and suprascapular nerve (SSN) injury. Clinical outcomes pre- and postoperatively (Constant score, ranges of motion, and visual analog scale) of patients with and without documented injury were recorded. RESULTS: A total of 14 patients (45.2%) had an abnormal preoperative SSN electrodiagnostic study (chronic or disuse injuries), and 6 patients (19.4%) had an abnormal postoperative study (acute injury). Of the 6 patients, 2 cases appeared over the pre-existing lesion and 4 appeared over an intact preoperative nerve, all of them affecting the infraspinatus branch of the SSN. Perforation of the second cortex was detected for 60% of superior screws and 40% of posterior screws. The mean lengths of the superior and posterior screws were 30 and 18.2 mm, respectively. Patients with screw perforation of the second cortex were assessed as having a high risk of nerve injury (40% vs. 9.5%). CONCLUSIONS: Preoperative SSN injuries do not have a significant clinical impact and do not predispose to an acute postoperative SSN lesion. The Constant score and visual analog scale score for patients with acute SSN injuries were not statistically different from those without SSN injury. The extraosseous position of the screw increases the probability of an SSN injury to 31%. This risk is higher with the posterior screw, which leads us to question whether it is really necessary to use it.

Midterm Outcomes Following Combined Biceps Tenodesis and Anterior Labral Repair in Active Duty Military Patients Younger Than 35 Years.

BACKGROUND: Superior labrum anterior-posterior (SLAP) lesions and anterior instability are common causes of shoulder pain and dysfunction among active-duty members of the United States military. However, little data have been published regarding the surgical management of type V SLAP lesions. PURPOSE: To compare the outcomes of arthroscopic-assisted subpectoral biceps tenodesis and anterior labral repair with those of arthroscopic SLAP repair (defined as contiguous repair spanning from the superior labrum to the anteroinferior labrum) for type V SLAP tears in active-duty military patients younger than 35 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All consecutive patients from January 2010 to December 2015 who underwent arthroscopic SLAP repair or combined biceps tenodesis and anterior labral repair for a type V SLAP lesion with a minimum 5-year follow-up were identified. The decision to perform type V SLAP repair versus combined biceps tenodesis and anterior labral repair was based on the condition of the long head of the biceps tendon (LHBT). Labral repair was performed in patients who had a type V SLAP tear with an otherwise clinically and anatomically healthy LHBT. Combined tenodesis and repair was performed in patients with evidence of LHBT abnormalities. Outcomes including the visual analog scale (VAS) score, the Single Assessment Numeric Evaluation (SANE) score, the American Shoulder and Elbow Surgeons (ASES) shoulder score, the Rowe instability score, and range of motion were collected preoperatively and postoperatively, and scores were compared between the groups. RESULTS: A total of 84 patients met the inclusion criteria for the study. All patients were active-duty service members at the time of surgery. A total of 44 patients underwent arthroscopic type V SLAP repair, and 40 patients underwent anterior labral repair with biceps tenodesis. The mean follow-up was 102.59 ± 20.98 months in the repair group and 94.50 ± 27.11 months in the tenodesis group (P = .1281). There were no significant differences in preoperative range of motion or outcome scores between the groups. Both groups experienced statistically significant improvements in outcome scores postoperatively (P < .0001 for all); however, compared with the repair group, the tenodesis group reported significantly better postoperative VAS (2.52 ± 2.36 vs 1.50 ± 1.91, respectively; P = .0328), SANE (86.82 ± 11.00 vs 93.43 ± 8.81, respectively; P = .0034), and ASES (83.32 ± 15.31 vs 89.90 ± 13.31, respectively; P = .0394) scores. There were no differences in the percentage of patients who achieved the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state for the SANE and ASES between the groups. Overall, 34 patients in each group returned to preinjury levels of work (77.3% vs 85.0%, respectively; P = .3677), and 32 patients (72.7%) in the repair group and 33 patients (82.5%) in the tenodesis group returned to preinjury levels of sporting activity (P = .2850). There were no significant differences in the number of failures, revision surgical procedures, or patients discharged from the military between the groups (P = .0923, P = .1602, and P = .2919, respectively). CONCLUSION: Both arthroscopic-assisted subpectoral biceps tenodesis combined with anterior labral repair and arthroscopic SLAP repair led to statistically and clinically significant increases in outcome scores, marked improvements in pain, and high rates of return to unrestricted active duty in military patients with type V SLAP lesions. The results of this study suggest that biceps tenodesis combined with anterior labral repair produces comparable outcomes to arthroscopic type V SLAP repair in active-duty military patients younger than 35 years.

Minimum 10-Year Clinical Outcomes After Arthroscopic Capsulolabral Repair for Isolated Posterior Shoulder Instability.

BACKGROUND: Arthroscopic capsulolabral repair for posterior shoulder instability has been shown to improve patient-reported outcomes and return to sport at short-term and midterm follow-up, but long-term outcomes are unknown. PURPOSE: To determine the objective and subjective clinical outcomes of shoulder function after arthroscopic posterior shoulder stabilization at a minimum 10-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 53 patients (55 shoulders) with unidirectional recurrent posterior shoulder instability who underwent arthroscopic capsulolabral repair were evaluated at a mean follow-up of 15.4 years. Outcomes such as the American Shoulder and Elbow Surgeons (ASES) shoulder score, Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score, and subjective strength, stability, range of motion, and pain were evaluated preoperatively and postoperatively at a minimum 10-year follow-up. Outcomes from the same patient cohort were previously collected at 3.0-year follow-up and were evaluated for longitudinal analysis. Subgroup analyses for sport type (contact vs noncontact), position (thrower vs nonthrower), and revision versus nonrevision were performed. Risk factors for revision surgery based on magnetic resonance imaging findings, patient characteristics, and surgical findings were investigated. RESULTS: Arthroscopic capsulolabral repair for posterior shoulder instability led to a statistically significant improvement on all outcome measures, with similar values at short-term (3.0-year) and long-term (15.4-year) follow-up. Across the total population, patients with 19 of 55 shoulders (35%) returned to sport at the same preinjury level, and patients with 33 of 55 shoulders (60%) returned to sport at some level. At long-term follow-up, patients with only 22% of shoulders were involved in the primary sport in which the injury was sustained, with patients with 28% of shoulders discontinuing sporting participation because of ongoing shoulder issues. Throwers trended toward lower Kerlan-Jobe Orthopaedic Clinic scores than nonthrowers both preoperatively (36.5 ± 22.8 vs 48.7 ± 22.9, respectively; P = .10) and postoperatively (57.4 ± 27.0 vs 73.5 ± 26.8, respectively; P = .09) but had similar improvements. Contact and noncontact athletes had similar preoperative and postoperative values, with equal improvements after surgery. With failure defined as revision surgery, an ASES score <60, or a stability value >5, 19 of 55 shoulders (35%) met failure criteria at final follow-up. Overall, 7 of 55 shoulders (13%) underwent revision surgery. At long-term follow-up, patients who underwent revision surgery had worse outcomes than those who did not undergo revision (ASES score: 53.1 ± 25.9 vs 81.8 ± 19.4, respectively; P < .001). An acute injury in the postoperative period (P < .001) and a smaller glenoid bone width on magnetic resonance imaging (P = .02) were the only identified risk factors for revision surgery. CONCLUSION: Arthroscopic capsulolabral repair for posterior shoulder instability was a durable treatment option that improved long-term shoulder pain and function and facilitated return to sport in the majority of patients at a mean follow-up of 15.4 years, although a notable proportion of patients met various criteria for failure.

SLAP lesion type IX: case series and a review of literature.

PURPOSE: A type IX SLAP (superior labrum anterior to posterior) lesion involves 360° of the glenohumeral labrum. Only rare reports have been published analyzing the risk factors of this lesion and the success of its arthroscopic management. The aim of our study is to evaluate predisposing factors that lead to SLAP IX and to assess the clinical outcome after arthroscopic treatment. Our treatment algorithm is also presented. METHODS: We report on a series of six patients treated in our institution between January 2014 and January 2019 who underwent shoulder arthroscopy and were intraoperatively found to have a SLAP lesion type IX. Arthroscopic labral repair and biceps tenodesis were indicated in all patients. American Shoulder and Elbow Surgeons (ASES) Shoulder Score, Rowe Score and Constant Murley Shoulder Score (CS) were used for clinical evaluation. Patients were evaluated preoperatively and at 12 weeks, 1 year and 2 years postoperatively. RESULTS: We analyzed six patients of which 83% were males (5/6 patients). The average age at the time of surgery was 37.16 (range 30-42 years). The dominant arm was affected in 50% of patients (3/6 patients). A significant postoperative improvement was seen in all six patients. 83% (5/6) of patients returned to their pre-injury activity level. Average values of all three measured scores show a significant increase comparing preoperative to postoperative period (P-value < 0.05). All patients were able to return to work. CONCLUSIONS: The final diagnosis was established intraoperatively as 83% (5/6) of radiology reports differed from subsequent arthroscopic findings. The mechanism of injury in all our cases was high energy trauma with traction, arm in abduction or anteflexion. We observed great success with arthroscopic treatment as high percentage of our patients returned back to work and sports.

Postoperative Rehabilitation After Superior Labrum Anterior Posterior Repair.

The 4-phase rehabilitation protocol outlined in this article provides a comprehensive 26-week program to return patients with superior labrum anterior posterior repairs to their preinjury states. It is guided by the principle of gradual return to preinjury function while preserving the integrity of the surgical repair. Objective criteria are present at the conclusion of each phase to ensure patients are progressing appropriately. The goal is to allow patients to return to their previous functional ability in their sport-specific or occupational-specific training.

Intra-articular soft arthroscopic Latarjet technique as a Bankart-plus procedure for type V superior labrum anterior-posterior lesion: lower rate of instability recurrence and better functional outcomes of a prospective cohort study.

BACKGROUND: Intra-articular soft arthroscopic Latarjet technique (in-SALT) involves augmentation of arthroscopic Bankart repair (ABR) with soft tissue tenodesis of long head of biceps to upper subscapularis. This study was conducted to investigate superiority of outcomes of in-SALT-augmented ABR over those of concurrent ABR and anterosuperior labral repair (ASL-R) in management of type V superior labrum anterior-posterior (SLAP) lesion. METHODS: This prospective cohort study (conducted between January 2015 and January 2022) included 53 patients with arthroscopic diagnosis of type V SLAP lesion. Patients were allocated into 2 consecutive groups: group A of 19 patients managed with concurrent ABR/ASL-R and group B of 34 patients managed with in-SALT-augmented ABR. Outcome measurements included 2-year postoperative pain, range of motion, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Rowe instability scores. Failure was defined as frank/subtle postoperative recurrence of glenohumeral instability or objective diagnosis of Popeye deformity. RESULTS: The statistically matched studied groups showed significant postoperative improvement in outcome measurements. However, group B demonstrated significantly better 3-month postoperative visual analog scale score (3.6 vs. 2.6, P = .006) and 24-month postoperative external rotation at 0° abduction (44° vs. 50°, P = .020) and ASES (84 vs. 92, P < .001) and Rowe (83 vs. 88, P = .032) scores. Rate of postoperative recurrence of glenohumeral instability was relatively lower in group B (10.5% vs. 2.9%, P = .290). No Popeye deformity was reported. CONCLUSION: For management of type V SLAP lesion, in-SALT-augmented ABR yielded a relatively lower rate of postoperative recurrence of glenohumeral instability and significantly better functional outcomes compared with concurrent ABR/ASL-R. However, currently reported favorable outcomes of in-SALT should be validated via further biomechanical and clinical studies.

A Surgical Framework for the Management of Incomplete Axillary Nerve Injuries.

BACKGROUND: Axillary nerve injury is the most common nerve injury affecting shoulder function. Nerve repair, grafting, and/or end-to-end nerve transfers are used to reconstruct complete neurotmetic axillary nerve injuries. While many incomplete axillary nerve injuries self-resolve, axonotmetic injuries are unpredictable, and incomplete recovery occurs. Similarly, recovery may be further inhibited by superimposed compression neuropathy at the quadrangular space. The current framework for managing incomplete axillary injuries typically does not include surgery. METHODS: This study is a retrospective analysis of 23 consecutive patients with incomplete axillary nerve palsy who underwent quadrangular space decompression with additional selective medial triceps to axillary end-to-side nerve transfers in 7 patients between 2015 and 2019. Primary outcome variables included the proportion of patients with shoulder abduction M3 or greater as measured on the Medical Research Council (MRC) scale, and shoulder pain measured on a Visual Analogue Scale (VAS). Secondary outcome variables included pre- and postoperative Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores. RESULTS: A total of 23 patients met the inclusion criteria and underwent nerve surgery a mean 10.7 months after injury. Nineteen (83%) patients achieved MRC grade 3 shoulder abduction or greater after intervention, compared with only 4 (17%) patients preoperatively (p = 0.001). There was a significant decrease in VAS shoulder pain scores of 4.2 ± 2.5 preoperatively to 1.9 ± 2.4 postoperatively (p < 0.001). The DASH scores also decreased significantly from 48.8 ± 19.0 preoperatively to 30.7 ± 20.4 postoperatively (p < 0.001). Total follow-up was 17.3 ± 4.3 months. CONCLUSION: A surgical framework is presented for the appropriate diagnosis and surgical management of incomplete axillary nerve injury. Quadrangular space decompression with or without selective medial triceps to axillary end-to-side nerve transfers is associated with improvement in shoulder abduction strength, pain, and DASH scores in patients with incomplete axillary nerve palsy.

Surgical Treatment of Superior Labral/Biceps Pathology in the Overhead Thrower.

Symptomatic superior labral anterior and posterior (SLAP) tears have become an increasingly common diagnosis, particularly within the competitive overhead athlete population. Type II SLAP tears are the most encountered variant in overhead throwing athletes. Given the high incidence of false positives on advanced imaging, corroborating the history and physical examination with imaging is paramount to accurately establish a SLAP lesion diagnosis. Previous studies have reported conflicting success rates with conservative management, but the number of pitching athletes able to return to prior level of performance with nonsurgical management strategies has been unsatisfactory. Although there has historically been a notable disconnect between the incidence of SLAP tears in the literature and the number of SLAP repairs in recent investigations, high-grade or unstable tears may be candidates for débridement, labral repair, biceps tenodesis, or less frequently, biceps tenotomy. Biceps tenodesis has been increasingly used for the management of these lesions, with recent studies reporting high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes in carefully selected athletes.

[Progress in arthroscopic surgery for injury of superior labrum anterior posterior of shoulder joint].

Superior labrum anterior posterior (SLAP) injury is a major challenge for orthopedic surgeons, due to the poor healing ability of the injured labrum. Although arthroscopic surgery is the gold standard for the treatment of SLAP injury, there are still disputes about the adaptation of different surgical techniques, the choice of anchors during operation, knotted or knotless anchors, and fixation methods. The authors believe that arthroscopic repair of SLAP lesions is effective for young patients with intact glenoid labrum(<35 years old) or with extensive activity, where single and knotless anchor is preferred. For the older patients(≥35 years old) with degeneration and wear of glenoid labrum, biceps tenodesis is more preferable, and interference screw fixation technique is recommended. As for patients with failed SLAP repair, biceps tenodesis can achieve a high success rate as a revision surgery. By review of the relevant literature in recent years, this paper summarizes the adaptation of different surgical methods of arthroscopic treatment of SLAP injury, intraoperative anchoring techniques, fixation methods and other improved surgical techniques.