Capitellum Osteochondral Allograft Transplantation for Osteochondritis Dissecans of the Elbow.

Reconstruction of unstable osteochondritis dissecans lesions of the capitellum using fresh osteochondral allograft transplantation from the capitellum has the advantages of restoring hyaline cartilage, matching the native radius of curvature, and avoiding the donor-site morbidity encountered with osteochondral autograft transfer. This technical note describes the indications and contraindications, pertinent anatomy, and surgical technique of open osteochondral allograft transplantation using fresh distal humerus allograft for the treatment of unstable osteochondritis dissecans lesions of the capitellum.

Posterior bony Bankart bridge technique results in reliable clinical 2-year outcomes and high return to sports rate for the treatment of posterior bony Bankart lesions.

PURPOSE: To introduce the arthroscopic "posterior bony Bankart bridge" repair technique, and to report clinical outcomes, patient satisfaction, recurrent instability rate, and return to sport rate. METHODS: Patients who were treated for posterior bony Bankart lesions with posterior bony Bankart bridge technique and were at least 2 years out from surgery were included. Clinical outcomes were assessed prospectively by the use of the American Shoulder and Elbow Surgeons (ASES) Score, Single Assessment Numerical Evaluation (SANE) Score, Quick Disabilities of the Arm, Shoulder and Hand (DASH) Score and patient satisfaction. Return to sports rate and complications were reported. RESULTS: Seven patients with a median age of 23.5 (range 17-43) and a median follow-up of 8 years (range 3-10) were included. Median time from injury to surgery was 15 days (range 3 days-2.2 years). Mean glenoid bone defect was 19% (range 11-31%). At final follow-up the median postoperative outcome scores were: ASES score 100 (range 92-100), SANE score 99 points (range 94-99) and QuickDASH 2.2 points (range 0-9). Median satisfaction of all patients was 10/10 (range 9-10). One patient reported subjective recurrent subluxations, which resolved under physical therapy. No patient underwent further surgery. No complications were noticed. At final follow-up, all patients (100%) reported that their sports participation levels were equal to their pre-injury levels. CONCLUSION: The arthroscopic posterior bony Bankart bridge technique leads to reliable postoperative shoulder function and restores shoulder stability with high patient satisfaction and low complication rate in this small patient cohort for the treatment of posterior bony Bankart lesions. Also, no recurrent dislocation was observed at a minimum follow-up of at least 3 years, one patient continued to complain of subjective subluxations which resolved under physical therapy. All patients were able to return to their pre-injury sports level. LEVEL OF EVIDENCE: Case series, Level IV.

A Systematic Review and Meta-analysis of Biceps Tenodesis Fixation Strengths: Fixation Type and Location Are Biomechanically Equivalent.

PURPOSE: The purpose of this meta-analysis and systematic review was to critically evaluate the biomechanical outcomes of different fixation constructs for a variety of biceps tenodesis techniques in cadaveric models based on both type of fixation and location. METHODS: A PROSPERO-registered systematic review (CCRD42018109243) of the current literature was conducted with the terms "long head of biceps" AND "tenodesis" AND "biomechanics" and numerous variations thereof in the PubMed, Embase, and Cochrane databases, yielding 1,460 abstracts. After screening by eligibility criteria, 18 full-text articles were included. The individual biomechanical factors evaluated included ultimate load to failure (in newtons), stiffness (in newtons per millimeter), and cyclic displacement (in millimeters). After reviewing the included literature, we performed a quality analysis of the studies (Quality Appraisal for Cadaveric Studies scale score) and a meta-analysis comparing raw mean differences in data between the suprapectoral and subpectoral fixation location groups, as well as between the fixation construct groups. RESULTS: Among the 18 included studies, 347 cadaveric specimens were evaluated for ultimate load to failure, stiffness, and cyclic displacement when comparing both location (suprapectoral vs subpectoral) and tenodesis fixation type (interference screw vs cortical button, suture anchor, or all-soft-tissue techniques). Interference screw fixation showed significantly greater mean stiffness by 8.0 N/mm (P = .013) compared with the other grouped techniques but did not show significant differences when evaluated for ultimate load to failure and cyclic displacement (P = .28 and P = .18, respectively). Additionally, no difference in construct strength was seen when comparing the fixation strength of suprapectoral versus subpectoral techniques for stiffness, ultimate load to failure, and cyclic loading (P = .47, P = .053, and P = .13, respectively). CONCLUSIONS: In this meta-analysis, no significant biomechanical differences were found when the results were stratified by specific surgical technique (interference screw vs other tenodesis techniques) and location (suprapectoral vs subpectoral biceps tenodesis). CLINICAL RELEVANCE: As a result of this study, when biomechanically evaluating specific tenodesis constructs, the individual clinician has the liberty of choosing the fixation technique based on his or her preference and knowledge of shortcomings of each type of fixation construct.

Clinical and Imaging Outcomes After Arthroscopic Superior Capsule Reconstruction With Human Dermal Allograft for Irreparable Posterosuperior Rotator Cuff Tears: A Minimum 2-Year Follow-Up.

PURPOSE: To report the clinical and structural outcomes for non-pseudoparalytic irreparable posterosuperior rotator cuff tears treated with superior capsule reconstruction (SCR) using dermal allograft (DA). METHODS: Patients who underwent SCR using DA with a mean thickness of 3 mm for irreparable posterosuperior rotator cuff tears and underwent surgery at least 2 years earlier were included. Outcomes were assessed prospectively by the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; patient satisfaction; and visual analog scale for pain. Structurally, acromiohumeral distances (AHDs) were assessed both preoperatively and postoperatively (standard radiographs). Graft integrity was assessed by magnetic resonance imaging. Clinical failures were reported. RESULTS: We included 22 patients with a mean age of 56 years (range, 41-65 years) and a mean follow-up period of 2.1 years (range, 2-3 years). The ASES score improved from 54.0 to 83.9 (P < .001); the Single Assessment Numeric Evaluation score improved from 44.9 to 71.4 (P < .001); and Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH) improved from 37.6 to 16.2 (P = .001). Of the patients, 85% achieved an improvement in the ASES score that exceeded the minimal clinically important difference (11.1 points). The median patient satisfaction rating was 8.5 (range, 1-10). The median preoperative visual analog scale score decreased from 4 to 0 (range, 0-3) postoperatively (P < .001). Complete radiographs of 19 of 22 patients (86%) were obtained at a mean of 5.2 months (range, 1.4-10 months) postoperatively and showed a significant increase in the mean AHD from 7.0 mm preoperatively to 8.3 mm postoperatively (P = .029). Postoperative magnetic resonance imaging scans were obtained in 95% of the patients (21 of 22) at a mean of 2.5 months (range, 0.3-10.2 months) postoperatively and showed graft integrity rates of 100% (21 of 21) on the tuberosity side, 76% (16 of 21) at the midsubstance, and 81% (17 of 21) on the glenoid side. No significant differences in clinical outcome scores (P > 0.930) were found in patients with intact grafts versus those with torn grafts. The number of previous shoulder surgical procedures was a negative predictor of clinical outcome. There was 1 clinical failure. CONCLUSIONS: SCR using DA for irreparable tears improves outcomes with high satisfaction and high graft integrity at short-term follow-up. Graft integrity, although correlated with an increased AHD, had no correlation with clinical outcomes at final follow-up. LEVEL OF EVIDENCE: Level IV, case series.

Complications and implant survivorship following primary reverse total shoulder arthroplasty in patients younger than 65 years: a systematic review.

BACKGROUND: Concerns exist regarding the complication rates and implant survivorship of reverse total shoulder arthroplasty (RTSA) in younger patients. METHODS: A systematic review of the literature regarding the existing evidence on RTSA in patients younger than 65 years was performed using the CENTRAL (Cochrane Central Register of Controlled Trials), PubMed, and Embase databases on June 9, 2019. Articles published between 1995 and 2019 with combinations of the following keywords were identified: "reverse shoulder arthroplasty" and "65," "60," and/or "55." Complications, reoperations, and revisions were recorded. Reoperation-free survival and implant survival rates were grouped at 2, 5, and 10 years. Range of motion and clinical outcomes, along with postoperative radiographic results, were recorded. RESULTS: Data from 7 studies with a total of 286 shoulders were obtained for quantitative analysis. The mean patient age was 58.4 years (mean age range, 48.9-60.4 years), and the mean follow-up period was 4.7 years (mean follow-up range, 3.0-7.8 years). The overall rate of complications was 18.6%; reoperations, 14.4%; and revisions, 11.2%. The reoperation-free survival rate was 97% at 2 years, 88%-90% at 5 years, and 76% at 10 years. The implant survival rate was 99% at 2 years, 91%-98% at 5 years, and 88% at 10 years. Active abduction, forward elevation, and external rotation significantly improved from preoperatively to postoperatively. All clinical outcome measures significantly improved from preoperatively to postoperatively, with no decline seen over time. The overall rate of infrascapular notching was 22.7% at final follow-up. CONCLUSION: RTSA is safe and effective in patients younger than 65 years. Complication, reoperation, and revision rates were similar to those seen in older patient cohorts, without an increase in revisions owing to aseptic loosening. Clinical outcome scores showed significant and lasting improvements.

Minimum 2-year clinical outcomes after superior capsule reconstruction compared with reverse total shoulder arthroplasty for the treatment of irreparable posterosuperior rotator cuff tears in patients younger than 70 years.

BACKGROUND: To compare clinical outcomes following arthroscopic superior capsule reconstruction (SCR) using a dermal allograft (DA) with reverse total shoulder arthroplasty (RTSA) when used to treat irreparable posterosuperior rotator cuff tears without glenohumeral osteoarthritis (GHOA) in patients younger than 70 years. METHODS: In this case-control study, patients who underwent SCR or RTSA for the treatment of irreparable posterosuperior rotator cuff tears, who were younger than 70 years at the time of surgery, and who were at least 2 years out of surgery were included. Clinical outcomes were assessed using the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numerical Evaluation (SANE), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores and the 12-Item Short Form Health Survey (SF-12). Return to sports and patient satisfaction along with clinical failures (recurrent pain or persistent pain or loss of function), revisions, and complications were reported. RESULTS: Two-year follow-up was obtained on 22/22 patients (100%) in the SCR group and 29/33 patients (88%) in the RTSA group. Group differences were significant for age (SCR mean, 57 ± 6.6 years, vs. RTSA mean, 63 ± 4.9 years; P < .001) and follow-up interval (SCR mean, 2.1 years, vs. RTSA mean, 2.9 years; P = .001). Preoperative outcome scores showed no significant differences (all P > .05) between groups. No significant differences in postoperative outcome scores were detected (P > .05) between SCR and RTSA: the mean ASES score was 82.6 ± 15.5 vs. 79.3 ± 21.4, mean SANE score was 71.4 ± 24.5 vs. 75.4 ± 23.3, mean QuickDASH score was 16.2 ± 16.9 vs. 25.3 ± 21.0, and mean SF-12 was 47.7 ± 8.8 vs. 46.9 ± 10.4. No significant differences in return-to-sport responses were noticed between groups at baseline or postoperatively (P = .585, P = .758). One SCR was revised at 1.2 years with revision SCR and 1 RTSA had the glenoid component revised day 1 postoperatively for instability. Both patient groups achieved successful clinical outcomes. CONCLUSION: SCR using DA results in similar postoperative functional outcomes in a younger patient population when compared to RTSA for the treatment of irreparable posterosuperior rotator cuff tears, without GHOA, at short-term follow-up.

The impacts of anxiety and depression on outcomes in orthopaedic trauma surgery: a narrative review.

Introduction: The impact of anxiety and depression on outcomes in orthopaedic trauma surgery is a topic of growing research interest. Patients and methods: Orthopaedic trauma patients often experience high rates of psychiatric disorders, with anxiety and depression being the most prevalent. Mental health disorders have been shown to increase the risk of negative surgical outcomes and morbidity. This narrative review seeks to summarize the current literature surrounding the impacts of anxiety and depression on orthopaedic trauma surgery outcomes. Discussion: There is a bidirectional relationship between chronic pain and mental health disorders, involving overlapping brain regions and neurotransmitter pathways. Anxiety and depression have been identified as predictors of negative surgical outcomes in orthopaedic trauma patients. Screening tools like the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Screener-7 (GAD-7), and Medical Outcomes Study 36-item Short Form (SF-36) can assess mental health status and help tailor interventions. Psychological distress, chronic pain, and traumatic limb amputation are factors that contribute to adverse mental health outcomes in orthopaedic trauma patients. Opioid use for pain management is common in orthopaedic surgery, but it can worsen symptoms of depression and lead to dependency. Non-opioid pain management strategies may improve postoperative outcomes by reducing the impact of opioid-exacerbated depression. Conclusion: Mental health interventions, both preoperative and postoperative, are crucial in optimizing surgical outcomes and improving patient quality of life. Multidisciplinary approaches that address both physical and mental health are recommended for orthopaedic trauma patients. Further research is needed to develop effective interventions for improving mental health outcomes in this patient population.

Imaging Findings of Complications After Lateral Extra-Articular Tenodesis of the Knee: A Current Concepts Review.

Background: Despite successful anterior cruciate ligament (ACL) reconstruction, many patients continue to experience persistent anterolateral rotatory instability. Lateral extra-articular tenodesis (LET) is used to address this instability by harvesting a portion of the iliotibial band, passing it underneath the fibular collateral ligament, and attaching it just proximal and posterior to the lateral femoral epicondyle. Based on the most recent clinical evidence, the addition of LET to ACL reconstruction improves clinical outcomes, which has led to an increase in the use of this technique. Purpose: To provide an overview of the postoperative complications of the LET procedure and their associated imaging findings, with a focus on magnetic resonance imaging (MRI). Study Design: Narrative review. Methods: In this scoping review, the authors reviewed available radiographic, computed tomography, and MRI scans of patients who experienced postoperative complications after ACL reconstruction with LET, in which the complication was determined to be from the LET procedure. Images were reviewed and subsequently described by an on-staff musculoskeletal radiologist. Results: The authors found 9 different complications associated with LET: graft failure, hematoma, infection, chronic pain, tunnel convergence, fixation device migration, muscular hernia, peroneal nerve palsy, and knee stiffness. They supplemented these findings with radiographic evidence from 6 patients. Conclusion: As extra-articular reconstruction techniques including LET become more popular among orthopaedic surgeons, it is important that radiologists and surgeons be adept at recognizing the normal imaging findings of LET and associated complications.

SLAP Repair Versus Subpectoral Biceps Tenodesis for Isolated SLAP Type 2 Lesions in Overhead Athletes Younger Than 35 Years: Comparison of Minimum 2-Year Outcomes.

Background: It remains unclear if young overhead athletes with isolated superior labrum anterior-posterior (SLAP) type 2 lesions benefit more from SLAP repair or subpectoral biceps tenodesis. Purpose: To evaluate clinical outcomes and return to sport in overhead athletes with symptomatic SLAP type 2 lesions who underwent either biceps tenodesis or SLAP repair. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was performed in patients who underwent subpectoral biceps tenodesis (n = 14) or SLAP repair (n = 24) for the treatment of isolated type 2 SLAP lesions. All patients were aged <35 years at time of surgery, participated in overhead sports, and were at least 2 years out from surgery. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numerical Evaluation (SANE) score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; and the 12-Item Short Form (SF-12) physical component score. Return to sport and patient satisfaction were documented. Clinical failures requiring revision surgery and complications were reported. Results: Preoperative baseline scores in both the tenodesis and SLAP repair groups were similar. There were no significant differences between the groups on any postoperative outcome measure: For biceps tenodesis versus SLAP repair, the ASES score was 92.7 ± 10.4 versus 89.1 ± 16.7, the SANE score was 86.2 ± 13.7 versus 83.0 ± 24.1, the QuickDASH score was 10.0 ± 12.7 versus 9.0 ± 14.3, and SF-12 was 51.2 ± 7.5 versus 52.8 ± 7.7. No group difference in return-to-sports rate (85% vs 79%; P = .640) was noted. More patients in the tenodesis group (80%) reported modifying their sporting/recreational activity postoperatively because of weakness compared with patients in the SLAP repair group (15%; P = .022). One patient in each group progressed to surgery for persistent postoperative stiffness, and 1 patient in the tenodesis group had a postoperative complication related to the index surgery. Conclusion: Both subpectoral biceps tenodesis and SLAP repair provided excellent clinical results for the treatment of isolated SLAP type 2 lesions, with a high rate of return to overhead sports and a low failure rate, in a young and high-demanding patient cohort. More patients reported modifying their sporting/recreational activity because of weakness after subpectoral tenodesis.

Concomitant Glenolabral Articular Disruption (GLAD) Lesion is Not Associated With Inferior Clinical Outcomes After Arthroscopic Bankart Repair for Shoulder Instability: A Retrospective Comparative Study.

Purpose: The purpose of this study was to compare outcomes between anterior shoulder instability patients with and without glenolabral articular disruption (GLAD) lesions after undergoing arthroscopic Bankart repair and to evaluate potential risk factors for inferior outcomes and recurrent instability. Methods: Prospectively collected data were retrospectively reviewed for patients who underwent arthroscopic Bankart repair with and without GLAD lesions at a minimum of 2 years follow-up. Consecutive patients were matched by age, sex, and number of anchors. Patient-reported outcomes (PROs) were evaluated before and after surgery, including American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Quick Disabilities of the Arm, Shoulder and Hand, Short Form-12 score, and satisfaction. Recurrent dislocation, subjective instability, and reoperation were analyzed. Additionally, PROs were assessed on the basis of GLAD lesion characteristics. Results: A total of 54 patients (27 GLAD, 27 control) with a mean age of 28.9 ± 11.6 years were analyzed at mean 4.5 ± 1.9 years (range, 2-9 years) follow-up. Thirty-eight (70.3%) of the participants were male. Patients in both groups experienced significant improvements in all PROs (P ≤ .006 for all measures) and reported high median satisfaction (scale 1-10: 10 vs 10, P = .290) at final follow-up. Two patients in the GLAD cohort and 1 in the control cohort underwent reoperation (P = .588). Four (14.8%) patients in each group reported recurrent dislocation (P = 1.0). Additionally, 2 (7.4%) GLAD patients and 1 (3.7%) control patient reported subjective shoulder instability after surgery (P = 1.0). No significant differences in PROs were observed based on anchor/labral advancement or treatment with microfracture, nor were significant correlations observed between GLAD lesion size and PROs (P > .05 for all). Conclusion: Arthroscopic Bankart repair in patients with GLAD lesions resulted in significantly improved outcomes with high satisfaction, which was no different when compared with those without GLAD lesions. Level of Evidence: Level III, retrospective comparative study.

Glenoid retroversion does not impact clinical outcomes or implant survivorship after total shoulder arthroplasty with minimal, noncorrective reaming.

Hypothesis: Both clinical outcomes and early rates of failure will not be associated with glenoid retroversion. Methods: All patients who underwent an anatomic total shoulder arthroplasty with minimal, noncorrective reaming between 2006 and 2016 with minimum 2-year follow-up were reviewed. Measurements for retroversion, inclination, and posterior subluxation were obtained from magnetic resonance imaging or computerized tomography. A regression analysis was performed to assess the association between retroversion, inclination and subluxation, and their effect on patient reported outcomes (PROs). Clinical failures and complications were reported. Results: One hundred fifty-one anatomic total shoulder arthroplasties (90% follow-up) with a mean follow-up of 4.6 years (range, 2-12 years) were assessed. The mean preoperative retroversion was 15.6° (range, 0.2-42.1), the mean posterior subluxation was 15.1% (range, -3.6 to 44.1%), and the mean glenoid inclination was 13.9° (range, -11.3 to 44.3). All median outcome scores improved significantly from pre- to post-operatively (P < .001). The median satisfaction was 10/10 (1st quartile = 7 and 3rd quartile = 10). Linear regression analysis found no significant association between retroversion and any postoperative PRO. A total of 5 (3.3%) failures occurred due to glenoid implant loosening (3 patients) and Cutibacterium acnes infection (2 patients) with no association between failure causation and increased retroversion or inclination. No correlation could be found between the Walch classification and postoperative PROs. Conclusion: Anatomic total shoulder replacement with minimal and noncorrective glenoid reaming demonstrates reliable increases in patient satisfaction and clinical outcomes at a mean of 4.6-year follow-up in patients with up to 40° of native retroversion. Higher values of retroversion were not associated with early deterioration of clinical outcomes, revisions, or failures. Long-term studies are needed to see if survivorship and outcomes hold up over time.

Rehabilitation Following Posterior Shoulder Stabilization.

Posterior shoulder instability has been noted in recent reports to occur at a higher prevalence than originally believed, with many cases occurring in active populations. In most cases, primary surgical treatment for posterior shoulder instability-a posterior labral repair-is indicated for those patients who have failed conservative management and demonstrate persistent functional limitations. In order to optimize surgical success and return to a prior level of function, a comprehensive and focused rehabilitation program is crucial. Currently, there is a limited amount of literature focusing on rehabilitation after surgery for posterior instability. Therefore, the purpose of this clinical commentary is to present a post-surgical rehabilitation program for patients following posterior shoulder labral repair, with recommendations based upon best medical evidence. LEVEL OF EVIDENCE: 5.

Latarjet Procedure for the Treatment of Anterior Glenohumeral Instability in the Athlete - Key Considerations for Rehabilitation.

The Latarjet procedure with transfer of the coracoid process and its attached conjoint tendon is a well-established surgical technique for the treatment of anterior glenohumeral instability in patients with anteroinferior bone loss and/or high risk for recurrence. Biomechanical and clinical studies have shown excellent results and high rates of return to sports. However, there is an absence of standardized, objective criteria to accurately assess an athlete's ability to progress through each phase of rehabilitation. Return to sports rehabilitation, progressed by quantitatively measured functional goals, may improve the athlete's integration back to sports participation. Therefore, the purpose of this clinical commentary is to provide a rehabilitation protocol for the Latarjet procedure, progressing through clearly defined phases, with guidance for safe and effective return to sport. Recommended criteria are highlighted which allows the clinician to progress the patient through each phase appropriately rather than purely following timeframes from surgery. This progression ensures the patient has completed a thorough rehabilitation program that addresses ROM, strength, power, neuromuscular control and a graded return to play. Level of Evidence: 5.

Quantitative T2 mapping of the glenohumeral joint cartilage in asymptomatic shoulders and shoulders with increasing severity of rotator cuff pathology.

PURPOSE: To examine the relationship between glenohumeral cartilage T2 mapping values and rotator cuff pathology. METHOD: Fifty-nine subjects (age 48.2 ±â€¯13.5 years, 15 asymptomatic volunteers and 10 tendinosis, 13 partial-thickness tear, 8 full-thickness tear, and 13 massive tear patients) underwent glenohumeral cartilage T2 mapping. The humeral head cartilage was segmented in the sagittal and coronal planes. The glenoid cartilage was segmented in the coronal plane. Group means for each region were calculated and compared between the groups. RESULTS: Massive tear group T2 values were significantly higher than the asymptomatic group values for the humeral head cartilage included in the sagittal (45 ±â€¯7 versus 32 ±â€¯4 ms, p <  .001) and coronal (44 ± 6 versus 38 ± 1 ms, p =  0.01) plane images. Mean T2 was also significantly higher for massive than full-thickness tears (45 ± 7 versus 38 ± 5 ms, p =  0.02), massive than partial-thickness tears (45 ± 7 versus 34 ± 4 ms, p <  0.001), and massive tears than tendinosis (45 ± 7 versus 35 ± 4 ms, p =  0.001) in the sagittal-images humeral head region and significantly higher for massive tears than asymptomatic shoulders (44 ± 6 versus 38 ± 1 ms, p =  0.01) in the coronal-images humeral head region. CONCLUSION: Humeral head cartilage T2 values were significantly positively correlated with rotator cuff pathology severity. Massive rotator cuff tear patients demonstrated significantly higher superior humeral head cartilage T2 mapping values relative to subjects with no/lesser degrees of rotator cuff pathology.

Anterior Shoulder Instability in the Professional Athlete: Return to Competition, Time to Return, and Career Length.

BACKGROUND: Anterior shoulder instability is a common condition in professional athletes, yet little is known about the success of surgery. Return to competition (RTC) is a metric indicative of a successful outcome for professional athletes who undergo anterior shoulder stabilization surgery. PURPOSE: To determine the rate of RTC, time to RTC, recurrence rate, and length of career after surgery in professional athletes who had undergone surgical treatment for anterior shoulder instability. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We evaluated professional athletes who underwent surgical treatment for anterior shoulder instability by a single surgeon between 2007 and 2018. Data from patients' medical records, a patient data registry, basic search engines, sports websites, and individual team websites were used to determine length of professional play before injury, duration of career after surgery, and RTC level. RESULTS: Overall, 23 professional athletes (25 shoulders from 12 contact and 13 noncontact athletes) were identified. The mean age at the time of surgery was 24.3 ± 4.9 years (range, 16-35 years). Primary procedures included arthroscopic Bankart repair (76%; 19/25), open Latarjet (20%; 5/25), and bony Bankart repair (4%; 1/25). Of the 23 athletes, 22 returned to their previous level of competition (96%; 95% CI, 78%-100%). The mean time between surgery and RTC was 4.5 months (range, 3-8 months). There was no difference in time to RTC between contact and noncontact athletes (4.1 vs 4.4 months). There was no difference in RTC rates and time to return for players who received a Bankart repair versus a Latarjet procedure (4.6 vs 4.2 months). A total of 12 participants were still actively engaged in their respective sport at an average of 4.3 years since surgery, while 11 athletes went on to retire at an average of 4.8 years. Duration of play after surgery was 3.8 years for contact athletes and 5.8 years for noncontact athletes (P > .05). CONCLUSION: In this series, professional athletes who underwent surgical shoulder stabilization for the treatment of anterior glenohumeral instability returned to their presurgical levels of competition at a high rate. No differences in RTC rate or time to RTC were observed for contact versus noncontact athletes or for those who received arthroscopic Bankart repair versus open Latarjet. However, contact athletes had shorter careers after surgery than did noncontact athletes.

Arthroscopic Knotless Modified McLaughlin Procedure for Reverse Hill-Sachs Lesions.

Posterior shoulder dislocations often are associated with an impression fracture involving the anterior humeral head known as a reverse Hill-Sachs lesion. These injuries can result in significant bone defects that require surgical management to prevent them from engaging the posterior glenoid. We present a modified arthroscopic, knotless McLaughlin procedure (tenodesis of the subscapularis tendon into the bone defect) for the treatment of small-to medium-sized, engaging Hill-Sachs lesions. The knotless fashion aims to eliminate potential problems associated with knot tying, such as knot migration, knot impingement, and chondral abrasion.

Comprehensive review of the physical exam for glenohumeral instability.

Glenohumeral instability is a common pathology of the shoulder joint, especially among young athletes. Despite advancements in technology and the widespread use of diagnostic imaging, a careful history and physical examination still remain the cornerstone of diagnosing patients with shoulder instability. Due to the involvement of many static and dynamic stabilizers, proficient physical examination can be challenging. With a systematic approach to clinical evaluation, the clinician can recognize characteristic patterns of relevant signs and symptoms and make an accurate diagnosis.

Minimum 5-Year Clinical Outcomes, Survivorship, and Return to Sports After Hamstring Tendon Autograft Reconstruction for Sternoclavicular Joint Instability.

BACKGROUND: Instability of the sternoclavicular (SC) joint is a rare but potentially devastating pathologic condition, particularly when it occurs in young or active patients, where it can lead to persistent pain and impairment of shoulder function. SC joint reconstruction using a hamstring tendon autograft is a commonly used treatment option, but midterm results are still lacking. PURPOSE/HYPOTHESIS: The purpose of this study was to assess the clinical outcomes, survivorship, and return-to-sports rate after SC joint reconstruction using a hamstring tendon autograft in patients suffering from SC joint instability. We hypothesized that SC joint reconstruction would result in good clinical outcomes, high rate of survivorship, and a high rate of return to sports. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients who underwent SC joint reconstruction with a hamstring tendon autograft for SC joint instability, with a minimum 5-year follow-up, were included. Patient-reported outcomes were assessed prospectively by the use of the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation (SANE) score, short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, 12-Item Short Form Health Survey (SF-12) physical component summary (PCS), and patient satisfaction. Survivorship of reconstruction was defined as no further revision surgery or clinical failure such as recurrent instability or subluxation events. Return to sports and pain were assessed using a customized questionnaire. RESULTS: A total of 22 shoulders that underwent SC joint reconstruction, with a mean patient age of 31.3 years (range, 15.8-57.0 years) at the time of surgery, were included. At the final evaluation, 18 shoulders, with a mean follow-up of 6.0 years (range, 5.0-7.3 years), completed a minimum 5-year follow-up. All clinical outcome scores improved significantly from preoperatively to postoperatively: ASES (50.0 to 91.0; P = .005), SANE (45.9 to 86.0; P = .007), QuickDASH (44.2 to 12.1; P = .003), and SF-12 PCS (39.4 to 50.9; P = .001). Median postoperative satisfaction was 9 (range, 7-10). The construct survivorship was 90% at 5-year follow-up. There were 2 patients with failed treatment at 82 and 336 days postoperatively because of instability or pain who underwent revision SC joint reconstruction and capsulorrhaphy. Another patient had a superficial wound infection, which was debrided once and resulted in a good clinical outcome. Of the patients who answered optional sports activity questions, 15 (17 shoulders, 77%) participated in recreational or professional sports before the injury. At final follow-up, 14 patients (16 of 17 shoulders, 94%) returned to their preinjury level of sports. The visual analog scale score for pain today (P = .004) and pain at its worst (P = .004) improved significantly from preoperatively to postoperatively. CONCLUSION: SC joint reconstruction with a hamstring tendon autograft for SC joint instability resulted in significantly improved clinical outcomes with high patient satisfaction and 90% survivorship at midterm follow-up. Furthermore, 94% of this young and high-demand patient population returned to their previous level of sports. Concerns in terms of advanced postinstability arthritis were not confirmed because a significant decrease in pain was found after a minimum 5-year follow-up.

Biologics to Improve Healing in Large and Massive Rotator Cuff Tears: A Critical Review.

Large and massive rotator cuff tears have the highest risk of retear. Common biologic modalities that can potentially reduce the retear rate and improve healing include platelet-rich plasma (PRP), scaffolds, and mesenchymal stem cells (MSCs). PRP has been studied for its role in improving rotator cuff healing and results of randomized controlled trials and meta-analyses show mixed results. Most studies in large and massivge tears show that PRP decreases the retear rate, but the connection between structural integrity and clinical outcomes is still unknown. Extracellular matrix (ECM) and synthetic scaffolds can increase healing in augmentation and bridging repair. Acellular dermal allografts have shown better healing rates and outcomes than xenografts in meta-analyses. Synthetic scaffolds augmented with bone marrow-derived stem cells have only been studied in vitro but are promising for the combination of mechanical stability and induction of a biological response. Superior capsule reconstruction is an exciting type of interposition graft reconstruction that has shown favorable early clinical outcomes for large and massive tears. Bone marrow-derived stem cells and adipose-derived stem cells improve the biomechanical characteristics of tendon repair and enhance the histological findings of the healing process in animal studies. However, evidence from human studies is lacking, especially in patients with large and massive tears. In summary, there are many biological options to augment rotator cuff repair in patients with large and massive tears. Due to mixed results and a lack of standardization in high-quality studies, we cannot recommend PRP at this time as an adjunct to rotator cuff repair. Both ECM and synthetic scaffolds, as well as SCR, can be used, especially in situations where native tendon is compromised, and additional mechanical augmentation is needed. Stem cells have been the least studied to date, so it is difficult to give recommendations for or against their use at this time.

Posterior Glenoid Augmentation With Extra-articular Iliac Crest Autograft for Recurrent Posterior Shoulder Instability.

Several techniques have been described for bone block augmentation as a treatment for posterior shoulder instability, including intra-articular distal tibial allograft and extra-articular iliac crest autograft. Although indications are not yet well defined, these bone augmentation procedures are considered in patients with glenoid bone loss, increased glenoid retroversion, previous failed posterior soft-tissue repair, and insufficient posterior capsulolabral tissue. In patients with posterior glenoid bone loss, the senior author (P.J.M.) recommends intra-articular glenoid reconstruction with a fresh distal tibial osteoarticular allograft. In patients with insufficient posterior capsulolabral tissue, the senior author prefers an extra-articular iliac crest autograft to buttress the posterior soft-tissue restraints. This technique guide outlines extra-articular iliac crest autograft treatment for recurrent posterior shoulder instability in patients with insufficient posterior soft tissues due to prior failed surgery. After an open capsulolabral repair is performed using suture anchors, the bone block is placed extra-articularly on the posterior glenoid neck.