Lateral ulnar collateral ligament reconstruction using an autologous triceps tendon graft for subclinical posterolateral rotatory instability in recalcitrant lateral epicondylitis.

PURPOSE: To evaluate midterm outcome of lateral ulnar collateral ligament (LUCL) repair with triceps autograft in patients with PLRI under recalcitrant lateral epicondylitis. METHODS: In total, 25 elbows (23 patients) with recalcitrant epicondylitis longer than 12 months were included into this retrospective study. All patients underwent arthroscopic instability examination. In 18 elbows (16 patients, mean age 47.4 years, range 25-60), PLRI was verified, and an LUCL repair using an autologous triceps tendon graft was performed. Clinical outcome was evaluated before and at least 3 years after surgery using the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form-Elbow Score (ASES-E), Liverpool Elbow Score (LES), Mayo Elbow Performance Index (MEPI), Patient-Rated Elbow Evaluation score (PREE), Subjective Elbow Value (SEV), quick Disabilities of the Arm, Shoulder, and Hand score (qDASH), and the visual analog scale (VAS) for pain. Postoperative satisfaction with the procedure and complications were recorded. RESULTS: Seventeen patients were available at a mean follow-up of 66.4 months (range 48-81). Patient satisfaction postoperatively was reported in 15 elbows as excellent (90%-100%) and 2 as moderate, with 93.1% overall. All scores of the 3 female and 12 male patients significantly increased from pre- to the postoperative follow-up (ASES: 28.3 ± 10.7 to 54.6 ± 12.1, P < .001; MEPI: 49.2 ± 8.3 to 90.5 ± 15.4, P < .001; PREE: 66.1 ± 14.9 to 11.3 ± 23.5, P < .001; qDASH: 63.2 ± 21.1 to 11.5 ± 22.6, P < .001; VAS: 8.75 ± 1.0 to 1.5 ± 2.0, P < .001). All patients suffered from high extension pain preoperatively, which was reported to be relieved after surgery. No recurrent instability or major complication occurred. CONCLUSION: The repair and augmentation of the LUCL with a triceps tendon autograft reached significant improvements; hence, it seems to be a good treatment option for posterolateral elbow rotatory instability with promising midterm results under a low rate of recurrent instability.

Treatment of non-arthritic pseudoparetic shoulders with irreparable massive rotator cuff tears: arthroscopic procedures yield comparable midterm results to reverse arthroplasty.

BACKGROUND: Irreparable massive rotator cuff tears (IMRCTs) are a well-known cause for functional limitation and difficult to treat. Although several joint-preserving as well as joint-replacing procedures were found to provide pain relief and gain of function, midterm results are scarce, particularly in pseudoparetic shoulder joints unaccompanied by severe osteoarthritis. The purpose of this study was to compare the midterm functional outcomes of arthroscopic procedures to those of reverse total shoulder arthroplasty (RTSA) in pseudoparetic shoulders with IMRCTs unaccompanied by severe osteoarthritis. METHODS: All patients who underwent either joint-preserving (group A) or joint-replacing (group B) procedures for IMRCT unaccompanied by severe osteoarthritis with a pseudoparetic shoulder function were retrospectively included. Clinical assessment included the Constant Score (CS), the Subjective Shoulder Value (SSV) and the Visual Analog Score (VAS) at baseline and at latest follow-up. Furthermore, the complication and revision rates were assessed. RESULTS: Overall, a total 56 patients were included of whom each 28 patients formed group A (male, 36%) and B (male, 53%) with a mean patient age at time of surgery of 70 ± 7 years and 72 ± 7 years, respectively. The mean follow-up period was 56 ± 17 months. At final follow-up, the total CS (group A: 66 ± 14 points; group B 54 ± 15 points) was significantly increased after arthroscopic treatment when compared to RTSA (p=0.011). However, no significant differences were detected with SSV (p=0.583) and VAS (p=0.536). Although complication rate (11% versus 18%) was not significantly different (p=0.705), number of revision surgeries was significantly higher in group B when compared to group A (p=0.041). CONCLUSIONS: In non-arthritic pseudoparetic shoulders, both joint-preserving and joint-replacing procedures yielded good clinical midterm outcomes for the treatment of degenerative IMRCTs. Despite of comparable functional and satisfactory functional improvement, increased complication rates and surgical invasiveness outweigh the benefits of primary RTSA and therefore reserve this procedure to a second-line treatment in pseudoparetic patients without any signs of severe cuff arthropathy.

Cutibacterium Acnes (Formerly Propionibacterium Acnes) Contamination of the Surgical Field During Shoulder Arthroscopy.

PURPOSE: To evaluate the prevalence of Cutibacterium acnes in the shoulder region and to analyze changes in C acnes contamination during shoulder arthroscopy, as well as to investigate the influence of sex and type of arthroscopic surgery on those parameters. METHODS: Forty-eight consecutive patients undergoing reconstructive or non-reconstructive shoulder arthroscopy, after hair removal with a medical clipper, routine antibiotic prophylaxis, and skin preparation with an alcohol-based skin disinfectant, were prospectively enrolled in this study. The shoulder was divided into 4 regions of interest (anterior, medial, posterior, and axilla). Skin swabs were taken from each region at 3 time points (preoperatively before and after skin preparation, and at the conclusion of surgery), cultured for 21 days, and analyzed for the prevalence of C acnes. RESULTS: The rate of C acnes-positive skin cultures was significantly increased at the end of surgery compared with preoperatively before (44.3% vs 27.6%, P < .001) and after (44.3% vs 31.3%, P = .001) skin preparation. No reduction in C acnes was observed with preoperative skin preparation (27.6% vs 31.3%, P = .401). At the end of shoulder arthroscopy, 64.6% of patients showed at least 1 culture positive for C acnes. The C acnes prevalence was significantly higher in male patients (48.3%) than female patients (20.1%, P < .001), at all time points (P < .016), and in all regions of interest (P < .001) except the axilla. No differences in the prevalence of C acnes were found between non-reconstructive and reconstructive procedures. CONCLUSIONS: Skin contamination with C acnes around the shoulder increased significantly from before and after skin preparation to the conclusion of surgery in patients undergoing shoulder arthroscopy despite perioperative preventive measures. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The knotless cinch-bridge technique for delaminated rotator cuff tears leads to a high healing rate and a more favorable short-term clinical outcome than suture-bridge repair.

PURPOSE: To compare functional outcomes and magnetic resonance image (MRI) tendon integrity following either the suture bridge or the knotless cinch-bridge technique used for arthroscopic double-layer rotator cuff repair. METHODS: 37 prospectively enrolled patients (46-76 years), who were treated with arthroscopic double-layer rotator cuff repair (group 1: suture bridge n = 20, group 2: cinch bridge n = 17) were clinically and radiographically assessed before and at an average of 24.0 ± 4.7 months after the procedure. Shoulder function was evaluated by the constant score (CS), range of motion, and various patient-related scores. Repaired tendon integrity was evaluated by MRI. Peri- and postoperative complications were recorded. RESULTS: All functional and patient-related scores significantly improved from pre- to postoperative. Significantly better postoperative CS (P = 0.037), flexion (P < 0.001), and abduction (P = 0.009) were detected after arthroscopic cinch compared to suture-bridge repair. The mean CS improvements from baseline to follow-up were not significantly different between the groups (n.s.). Patient-related scores did not show any statistical significant differences. The MRI healing rate following arthroscopic double-layer repair with the suture- and cinch-bridge technique was 95% and 94%, respectively. Fatty infiltration regarding the supraspinatus and infraspinatus increased in 55% and 35% (group 1) and in 53% and 48% (group 2), respectively. Muscle hypotrophy remained stable in all patients. Overall, 92% of the patients were very satisfied or satisfied with the procedure. No complications were detected. CONCLUSIONS: Arthroscopic knotless double-layer rotator cuff repair with the cinch-bridge technique showed higher CS, forward flexion, and abduction values, as well as similar patient-related short-term outcome and MRI integrity compared to the suture-bridge technique. These results highlight the potential importance of less tendon strangulation for better clinical short-term outcome. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Glenoid morphology is associated with the development of instability arthropathy.

BACKGROUND: Instability arthropathy (IA) is a major long-term concern in patients with anterior shoulder instability. This study investigated the association of glenoid morphology with the development of IA. METHODS: The study included 118 patients with unilateral anterior shoulder instability and available bilateral computed tomography scans. Instability-specific information was obtained from all patients. The glenoid morphology of the affected shoulder was compared with the nonaffected contralateral side resembling the constitutional preinjury glenoid shape. Both shoulders were evaluated independently by 3 observers to assess the grade of IA according to a Comprehensive Arthropathy Rating (CAR) system. Associations between IA and the glenoid morphology parameters were investigated. RESULTS: The average glenoid retroversion (P < .001), glenoid depth (P < .001), glenoid diameter (P < .001), and the bony shoulder stability ratio (P < .001) of the affected shoulder were significantly reduced compared with the contralateral side due to bony defects in 79.6% of the patients. The CAR of the affected side was significantly higher (P < .001), with more osteophytes (P = .001) and more sclerosis and cysts (P < .001). Differences in CAR (Δ-CAR) correlated positively with the age at the time of the computed tomography scan (P < .001), age at the initial dislocation (P = .001), size of the glenoid defect (P = .005), and the contralateral glenoid depth (P = .011), glenoid diameter (P = .016), and bony shoulder stability (P = .029), and negatively with glenoid retroversion of the affected side (P = .027). CONCLUSION: Development of IA arthropathy is associated not only with the age of the patients but also with morphologic parameters of the glenoid, including glenoid defect size and the constitutional glenoid concavity shape.

Radiological changes do not influence clinical mid-term outcome in stemless humeral head replacements with hollow screw fixation: a prospective radiological and clinical evaluation.

BACKGROUND: Stemless shoulder arthroplasty is a fairly new concept. Clinical and radiological follow-up is essential to prove implant safety and concept. This prospective single-centre study was performed to evaluate the influence of radiological changes on clinical mid-term outcome following stemless humeral head replacement with hollow screw fixation. METHODS: Short- and mid-term radiological and clinical evaluations were performed in 73 consecutive shoulders treated mainly for idiopathic and posttraumatic osteoarthritis with stemless humeral head arthroplasty including 40 hemi- (HSA) and 33 total shoulder arthroplasties (TSA). Operating times of stemless implantations were compared to 110 stemmed anatomical shoulder prostheses. Appearances of humeral radiolucencies or radiological signs of osteolysis or stress shielding were assessed on standardized radiographs. Patients' clinical outcome was evaluated using the Constant score and patients' satisfaction was documented. RESULTS: Radiological changes, detected in 37.0%, did not affect clinical outcome. Constant scores significantly improved from baseline to short and mid-term follow-up (p < 0.001). The majority of patients (96.2%) were satisfied with the procedure. No loosening of the humeral head component was detected during a mean follow-up of 58 months. Operating times were significantly shorter with stemless compared to stemmed implants (p < 0.001). CONCLUSIONS: Clinical mid-term outcome after stemless humeral head replacement was not affected by radiological changes. TRIAL REGISTRATION: The institutional review board (St. Vincent Hospital Vienna; 201212_EK01; date of issue: 11.12.2012) approved the study. The trial was registered at ClinicalTrials.gov ( NCT02754024 ). Retrospective registration.

Arthroscopic Versus Open Iliac Crest Bone Grafting in Recurrent Anterior Shoulder Instability With Glenoid Bone Loss: A Computed Tomography-Based Quantitative Assessment.

PURPOSE: To assess the iliac crest bone graft (ICBG) position in the en-face view and axial plane comparing arthroscopic with open procedures. METHODS: A total of 40 consecutive patients with recurrent anterior shoulder instability and glenoid bone loss over 10% treated by 2 independent orthopaedic departments were included. Two independent observers analyzed preoperative and immediate postoperative computed tomography scans of 20 open (group O) and 20 arthroscopic (group A) procedures. Defect and ICBG characteristics of the J-shaped graft in the en-face view and axial plane were manually assessed by multiplanar reconstructed computed tomography scans. Variances in terms of graft positioning were analyzed. RESULTS: No significant variances in arthroscopic graft positioning were observed. The graft position in the en-face view was comparable in both groups, with the superior extent of the arthroscopic graft (40° ± 9° [inferior extent, 139° ± 16°]) lying significantly higher than the superior extent in group O (50° ± 13°, P = .005 [inferior extent, 147° ± 21°; P = .178]). The covered glenoid defect size was above 95% (98% ± 1% in group O vs 95% ± 2% in group A, P = .001). The arthroscopic graft in the axial plane showed a significantly steeper impaction angle (34.8° ± 7.8° vs 26.9° ± 9.9°, P = .010), with a significantly increased medial offset compared with group O (6.6 ± 1.7 mm vs 5.4 ± 1.3 mm, P = .024). The mediolateral step formation, however, was not significantly different (2.9 ± 1.1 mm in group A vs 3.2 ± 0.8 mm in group O, P = .289). The interobserver reliability was very good for all measurements (R = 0.969; 95% confidence interval, 0.965-0.972). CONCLUSIONS: Positioning of the arthroscopic ICBG in the en-face view and axial plane is comparable to that of the open technique. Good glenoid defect coverage and glenoid concavity reconstruction can be achieved with the arthroscopic technique. The main difference compared with the open procedure is the significantly steeper impaction angle. LEVEL OF EVIDENCE: Level III, case-control study.

Critical shoulder angle combined with age predict five shoulder pathologies: a retrospective analysis of 1000 cases.

BACKGROUND: Acromial morphology has previously been defined as a risk factor for some shoulder pathologies. Yet, study results are inconclusive and not all major shoulder diseases have been sufficiently investigated. Thus, the aim of the present study was to analyze predictive value of three radiological parameters including the critical shoulder angle, acromion index, and lateral acromion angle in relationship to symptomatic patients with either cuff tear arthropathy, glenohumeral osteoarthritis, rotator cuff tear, impingement, and tendinitis calcarea. METHODS: A total of 1000 patients' standardized true-anteroposterior radiographs were retrospectively assessed. Receiver-operating curve analyses and multinomial logistic regression were used to examine the association between shoulder pathologies and acromion morphology. The prediction model was derived from a development cohort and applied to a validation cohort. Prediction model's performance was statistically evaluated. RESULTS: The majority of radiological measurements were significantly different between shoulder pathologies, but the critical shoulder angle was an overall better parameter to predict and distinguish between the different pathologies than the acromion index or lateral acromion angle. Typical critical shoulder angle-age patterns for the different shoulder pathologies could be detected. Patients diagnosed with rotator cuff tears had the highest, whereas patients with osteoarthritis had the lowest critical shoulder angle. The youngest patients were in the tendinitis calcarea and the oldest in the cuff tear arthropathy group. CONCLUSIONS: The present study showed that critical shoulder angle and age, two easily assessable variables, adequately predict different shoulder pathologies in patients with shoulder complaints.

Infections following arthroscopic rotator cuff repair: incidence, risk factors, and prophylaxis.

PURPOSE: The primary aim of the present study was to determine the incidence of infections following arthroscopic rotator cuff repair in a single department over a 10-year period. Secondary goals included the evaluation of potential risk factors for infections and to investigate the efficacy of perioperative antibiotic prophylaxis in the reduction of infectious complications. METHODS: A retrospective evaluation of 3294 all-arthroscopic rotator cuff repairs performed between 2004 and 2014 at a single institution was conducted to determine the rate of infection in all-arthroscopic rotator cuff repairs. Detailed data including demographics, co-morbidities, initial surgical procedure, time from index surgery to infection, clinical presentation, isolated pathogens, and subsequent treatment were recorded of patients with infections. Univariate logistic regression was performed, and a multivariate model was developed to identify variables that were predictive of infections following arthroscopic rotator cuff repair. RESULTS: The rate of infection was 8.5/1000 in whom rotator cuff repairs were performed (95 % CI 0.58-1.23 %) during the study period. The most commonly identified pathogen was Staphylococcus epidermidis (n = 11, 39.3 %), followed by Propionibacterium acnes (n = 8, 28.6 %) and Staphylococcus aureus (n = 2, 7.1 %). Patients presented at our institution with signs of infection an average of 28.9 ± 14.7 days after the index surgery. The leading symptom that was present in all patients was diffuse or localized shoulder pain, followed by local signs of infection in 19 (67.9 %), secretion in 14 (50 %), and fever in 9 (32.1 %) patients, respectively. Univariate and multivariate analyses identified the male gender, age over 60, and duration of surgery over 90 min as predictive factors for infection. Administration of perioperative antibiotic prophylaxis was an independent mitigating factor for postoperative infection and reduced the infection rate from 1.54 % (95 % CI 0.98-2.30 %) to 0.28 % (95 % CI 0.10-0.67 %). CONCLUSIONS: The overall incidence of infection was 8.5/1000 arthroscopic rotator cuff repairs over a 10-year period. Gender, age, and length of surgery were identified as predictive factors for infection. The administration of perioperative antibiotic prophylaxis significantly reduced the overall risk of infection and is therefore recommended in all-arthroscopic rotator cuff repairs. However, current prophylactic treatment strategies were not equally efficient for all types of pathogens. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Patient-specific instrumentation improved mechanical alignment, while early clinical outcome was comparable to conventional instrumentation in TKA.

PURPOSE: The aim of this prospective study was to compare early clinical outcome, radiological limb alignment, and three-dimensional (3D)-component positioning between conventional and computed tomography (CT)-based patient-specific instrumentation (PSI) in primary mobile-bearing total knee arthroplasty (TKA). METHODS: Two hundred ninety consecutive patients (300 knees) with severe, debilitating osteoarthritis scheduled for TKA were included in this study using either conventional instrumentation (CVI, n = 150) or PSI (n = 150). Patients were clinically assessed before and 2 years after surgery according to the Knee-Society-Score (KSS) and the visual-analog-scale for pain (VAS). Additionally, the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and the Oxford-Knee-Score (OKS) were collected at follow-up. To evaluate accuracy of CVI and PSI, hip-knee-ankle angle (HKA) and 3D-component positioning were assessed on postoperative radiographs and CT. RESULTS: Data of 222 knees (CVI: n = 108, PSI: n = 114) were available for analysis after a mean follow-up of 28.6 ± 5.2 months. At the early follow-up, clinical outcome (KSS, VAS, WOMAC, OKS) was comparable between the two groups. Mean HKA-deviation from the targeted neutral mechanical axis (CVI: 2.2° ± 1.7°; PSI: 1.5° ± 1.4°; p < 0.001), rates of outliers (CVI: 22.2%; PSI: 9.6%; p = 0.016), and 3D-component positioning outliers were significantly lower in the PSI group. Non-outliers (HKA: 180° ± 3°) showed better clinical results than outliers at the 2-year follow-up. CONCLUSIONS: CT-based PSI compared with CVI improves accuracy of mechanical alignment restoration and 3D-component positioning in primary TKA. While clinical outcome was comparable between the two instrumentation groups at early follow-up, significantly inferior outcome was detected in the subgroup of HKA-outliers. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

Arthroscopic management of massive rotator cuff tears: an evaluation of debridement, complete, and partial repair with and without force couple restoration.

PURPOSE: To evaluate the effectiveness of arthroscopic debridement (DB), partial (PR), and complete repair (CR) for massive rotator cuff tears (mRCT) in terms of functional and subjective parameters, and repair integrity. METHODS: For this single-centre study, 68 consecutive shoulders with mRCT involving at least three tendons and treated with arthroscopic DB (n = 23), PR (n = 22), and CR (n = 23) were included. All patients (52-81 years) were prospectively assessed before and at a mean of 45 months after surgery using functional and subjective parameters. Preoperative tendon rupture pattern and post-operative repair integrity were assessed by MRI. A coding system describing accurately rotator cuff rupture, treatment, and integrity was established. RESULTS: All treatment groups improved significantly from pre- to post-operative (P < 0.01), while preoperative parameters, except fatty degeneration, were not significantly different. However, post-operative comparisons revealed similar scores with DB (constant score, CS 65.8 ± 14.7, qDASH 24.1 ± 20.6) and PR (CS 67.5 ± 9.9, P = n.s.; qDASH 20.5 ± 14.4, P = n.s.), while CR were significantly better (CS 80.3 ± 8.9; qDASH 7.0 ± 8.7; P ≤ 0.001). Force couple restoration of PR did not significantly influence outcome. Re-tear rates with CR (29 %) were lower compared to PR (53 %). Intact CR compared to intact PR showed better CS (83.4 ± 7.3 vs. 68.5 ± 10.6, P = 0.009) and qDASH (5.4 ± 8.3 vs. 21.2 ± 9.5, P = 0.006). The vast majority of patients were satisfied with their arthroscopic procedure (DB 87 %; PR 86 %; CR 91 %). CONCLUSION: Arthroscopic DB, PR, and CR were effective in treating mRCT involving at least three tendons. Reparability of mRCT was influenced by fatty degeneration of the muscles. However, CR showed the most favourable short-term improvements. LEVEL OF EVIDENCE: IV.

Arthroscopic partial shoulder resurfacing.

PURPOSE: The purpose of this study was to report patients' clinical and subjective outcomes 2 years after arthroscopic-assisted partial resurfacing of the humeral head. METHODS: In this prospective case series, 11 patients (4 females, 7 males; median age, 59 years; range 47-72) underwent arthroscopic-assisted partial shoulder resurfacing between April 2010 and March 2011. Clinical conditions and subjective assessments were evaluated before surgery and at 6 weeks, 3 and 6 months, and then annually after surgery using the Constant score (CS), active range of motion (ROM), the visual analogue scale (VAS) for pain, the American Shoulder and Elbow Surgeons scale (ASES), and the subjective shoulder value (SSV). Radiological outcomes and major complications were monitored. RESULTS: The mean CS improved significantly from 54.6 ± 13.6 preoperatively to 72.9 ± 17.2 points 6 weeks postoperatively (P = 0.009). At the 2-year follow-up, the mean CS had further increased to 86.5 ± 14.3 points (P < 0.001). Trends towards increasing ROMs were detected. VAS, ASES, and SSV significantly improved from baseline to the first follow-up and maintained improvement after 2 years. One patient required revision surgery owing to a technical failure and two patients because of rapidly progressive osteoarthritis. Ten of 11 patients (91 %) claimed that they would undergo arthroscopic partial shoulder resurfacing again. CONCLUSION: Arthroscopic-assisted partial humeral head resurfacing, which has the advantages of bone stock preservation and the maintenance of an intact subscapularis tendon, allowed immediate postoperative mobilization and provided significant improvements in subjective outcomes, especially for pain relief in active patients without severe glenoid cartilage wear. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

Electromyographic analysis: shoulder muscle activity revisited.

INTRODUCTION: Restoring optimal strength and biomechanics of a pathologic shoulder knowledge of activity patterns of healthy glenohumeral muscles is mandatory. Yet, data on normal shoulder muscle activity are not always conclusive. The study was undertaken (a) to evaluate muscle activity patterns in the healthy shoulder using surface and fine-wire electromyography (EMG), and (b) to assess method's suitability in the clinical setting especially regarding painfulness and practicability. MATERIALS AND METHODS: Surface and fine-wire EMG was performed on 11 healthy subjects (2f/9 m, Ø age 28 years) to assess 14 muscles including rotator cuff muscles during 8 planar standardised shoulder movements (abduction, forward flexion, internal and external rotation in neutral, 45° and 90° abduction). Pain was assessed using the visual analogue scale before testing, after inserting the fine-wire electrodes, after maximal voluntary contraction, before and after exercises, and after electrode removal. RESULTS: The most important finding regarding EMG activity patterns in the healthy shoulder was that the subscapularis activity was found to play a major role in abduction and forward flexion. Furthermore, this study was able to show that EMG measurements, especially fine-wire EMG, is prone to high failure rates (up to 32%); however, pain was not a limiting factor. CONCLUSION: The present study (1) revealed a new insight, especially finding the subscapularis activity playing a major role in abduction and forward flexion of the healthy shoulder; and (2) motion analysis system and the use of fine-wire electrodes were prone to failure; however, pain was not a limiting factor. LEVEL OF EVIDENCE: Basic Science, Electrodiagnostic Study.

Bony Regrowth and New Spur Formation as Possible Causes of Failed Distal Clavicle Excision-Mid-Term Outcomes after Revision Surgery in a Matched-Pair Analysis.

BACKGROUND: Despite high rates of successful outcomes after open and arthroscopic distal clavicle excision (DCE) for symptomatic acromioclavicular joint (ACJ) degeneration, some patients present with persistent symptoms and disabilities after surgical intervention. This study aims to compare radiological, functional, and subjective outcomes of open revision surgery after failed arthroscopic DCE to primary successful arthroscopic DCE. METHODS: In this retrospective case-control study, 10 patients who underwent open DCE revision were age- and gender-matched with 10 patients who did not require revision surgery after DCE. Radiographic evaluation included presence of acromioclavicular spurs and acromioclavicular joint distance. Functional and subjective outcomes were assessed using the CS, SSV, SST, VAS for pain, patient's satisfaction, ASES and quick DASH score. RESULTS: At the latest postoperative follow-up (case: 57.3 ± 19.2 months; control: 63.5 ± 16.3 months), spur formation was detected in twice as many cases in the revision group, while acromioclavicular distance showed no significant difference. However, a significant bony regrowth was noticed in the revision group between revision surgery and latest follow-up, with a decrease of the acromioclavicular distance from 9.2 ± 1.6 mm to 5.9 ± 4.6 mm (p = 0.026) and a development of new spur formations in 30% of cases. There were no significant differences in overall CS between the revision and control group (p = 0.174) at final follow-up, but the control group scored significantly higher in the CS subgroups pain (p = 0.012) and internal rotation (p = 0.016). Mean SSV was significantly lower in the revision (65.5 ± 22.3%) compared to the control group (85.9 ± 16.4%; p = 0.031). CONCLUSIONS: Bony regrowth at the distal clavicle presenting as postoperative AC-distance narrowing and new spur formation was observed more distinctly in the revision group. Despite a slight increase in postoperative outcomes after revision surgery, subjective satisfaction and recalcitrant pain remain a concern. LEVEL OF EVIDENCE: Therapeutic Level III, retrospective case-control study.

Comparison of Outcomes After Arthroscopic Superior Capsule Reconstruction Versus Arthroscopic Partial Repair or Arthroscopic Debridement for Irreparable Rotator Cuff Tears.

Background: Arthroscopic superior capsule reconstruction (SCR), arthroscopic partial repair (PR), and arthroscopic debridement (DB) are valid treatment options for irreparable rotator cuff (RC) tears. Purpose/Hypothesis: The purpose of this study was to compare clinical, functional, and radiological outcomes of arthroscopic SCR with arthroscopic PR and arthroscopic DB in patients with irreparable posterosuperior RC tears. It was hypothesized that SCR would lead to superior clinical and functional outcomes compared with PR or DB. Study Design: Cohort study; Level of evidence, 3. Methods: Clinical and functional outcomes of this single-center retrospective study included range of motion, strength, and the age- and sex-adjusted Constant-Murley score. Patient-reported outcome measures (PROMs) involved the quick Disabilities of the Arm, Shoulder and Hand score, the Subjective Shoulder Value, and the visual analog scale for pain. Graft and repaired tendon integrity was evaluated by magnetic resonance imaging (MRI) at 12 months of follow-up. Results: In total, 57 patients treated with SCR (n = 20), PR (n = 17), and DB (n = 20) were included. The mean clinical follow-up was 33.8 ± 17.9 months. Preoperative clinical and functional characteristics were comparable among the 3 groups. The range of motion and clinical and functional scores of all 3 groups significantly improved from pre- to postoperatively. Postoperative PROMs showed no differences among all 3 study groups. SCR revealed significantly higher postoperative strength compared with PR (P = .001) and DB (P = .004). Postoperative MRI revealed a rerupture in 4 patients with SCR (20%). Postoperative MRI showed a rerupture in 9 patients with PR ( 53%). Fatty muscle infiltration of the supraspinatus and infraspinatus significantly progressed within all 3 study groups in postoperative MRI scans. No clinical and functional differences were observed between intact and reruptured PR. Conclusion: Patients who underwent SCR had better postoperative strength recovery than patients who underwent PR or DB.

All-arthroscopic implant-free iliac crest bone grafting: new technique and case report.

Glenoid bone loss is a recognized risk for recurrent instability. Open J-graft augmentation has been reported as a well-established procedure for anterior shoulder instability. Few data are available on arthroscopic techniques for the repair of bony Bankart lesions. We describe an all-arthroscopic implant-free iliac crest bone grafting technique and present the case of a 32-year-old hockey player who underwent glenoid reconstruction using this novel arthroscopic repair technique after 2 failed soft-tissue procedures. After 13 months, the patient reached nearly full range of motion with a slight loss of external rotation. The computed tomography scan showed a restoration of the glenoid cavity and complete healing of the graft.

Superiority of bridging techniques with medial fixation on initial strength.

PURPOSE: The purpose of our study was to evaluate the initial fixation strength of bridging techniques compared to other suture techniques for rotator cuff repair using a biomechanical animal model, which incorporated pretesting of intact tendons. METHODS: Seventy-six fresh bovine shoulders were used for testing seven suture configurations including simple suture (SS), mattress suture (MS), Mason-Allen (MA), modified double row (mDR), SpeedBridge (SpB), SpeedBridge with medial fixation (mSpB), and double-mattress SutureBridge (dmSuB) techniques. Cyclic loading was performed with all intact bone-tendon complex before (pretest) and after repair of the tendon (main test) at the level of 10 and 180 N at 100 Hz with displacement-controlled ramps of ± 33 mm/s. The pretest was stopped after 200 cycles. For the main test, the loading scheme was continued for a maximum of 500 cycles or until failure. RESULTS: The mean elongation of all 76 intact tendons measured at the pretest was 3.8 ± 0.6 mm (2.4-5.4 mm). No differences of gap formations at the 1st cycle were detected between SS, MS, MA, and mDR. SpB showed significant higher gap formations compared to all other suture techniques (p = 0.001). No significant differences were detected between mSpB and dmSuB, whereas both techniques were significant different when compared to the other groups (p < 0.05). CONCLUSIONS: In this study, results showed that bridging techniques with medial fixations have superior initial repair strength compared to other suture techniques. Knowledge of initial fixation strength of rotator cuff repair techniques may be of informative value to the surgeon.

Arthroscopic, Implant-Free Bone-Grafting for Shoulder Instability with Glenoid Bone Loss.

Anterior shoulder instability is commonly associated with injuries to the labrocapsular structures of the glenohumeral joint and with osseous glenoid defects of varying degree. If the bone defect exceeds a clinically relevant threshold, mere soft-tissue repairs result in high rates of recurrent instability and the glenoid needs to be reconstructed with osseous augmentation. The most popular techniques for glenoid reconstruction include variations of coracoid transfer or bone-block procedures; however, these procedures are not free from risks and complications, which are often related to the method of fixation1. An alternative to the widely used coracoid transfer variations or bone-block procedures is anatomic implant-free glenoid reconstruction with a J-shaped iliac-crest bone graft. After press-fit fixation, the graft undergoes a physiological remodeling process resulting in the restoration of native scapular neck morphology. Although not as widely known, the open J-bone-graft procedure has been successfully used for the treatment of glenoid bone loss for nearly 3 decades2-4. The arthroscopic J-bone-graft technique represents an innovative advancement of the open procedure. Early to midterm follow-up of the arthroscopic J-bone-graft technique has revealed excellent clinical results1. DESCRIPTION: The major steps of the procedure, which are demonstrated in the present video article, include (1) detachment of the labrocapsular ligamentous complex and preparation of the anterior aspect of the glenoid, (2) establishment of a deep anterior-inferior portal and splitting of the subscapularis tendon, (3) introduction of the "waterslide," (4) osteotomy at the scapular neck 30° relative to the glenoid surface and trial impaction, (5 and 6) harvesting and preparation of a J-shaped bicortical iliac-crest bone graft, (7) press-fit impaction of the bone graft in the prepared osteotomy over the "waterslide", and (8) capsuloligamentous repair over the graft. ALTERNATIVES: Coracoid transfer (Latarjet-Bristow), iliac-crest bone-grafting, and distal tibial allograft. RATIONALE: Although widely in use, nonanatomic coracoid transfer procedures or bone-block techniques relying on hardware fixation are associated with specific complications, including nonunion, osteolysis, coracoid fractures, hardware complications, and difficult revision1. Many of these disadvantages can be avoided by the use of anatomic implant-free glenoid reconstruction with a J-shaped iliac-crest bone graft. After press-fit fixation, the graft undergoes a physiological remodeling process that follows the law of bone adaptation to mechanical stresses described by Wolff, which ultimately results in the restoration of a nearly native anterior scapular neck morphology4. The open version of this technique has been successfully used for over 3 decades. The arthroscopic, minimally invasive variation of the J-bone-graft technique presented in this video article represents a further advancement of the anatomic nature of the procedure. EXPECTED OUTCOMES: The arthroscopic implant-free J-bone-graft technique is an alternative to other procedures widely used for the treatment of anterior glenoid bone defects. The main advantage of this technique is the avoidance of severe complications that arise from the nonanatomic reconstruction and fixation methods found with other procedures1. Early to midterm follow-up of the arthroscopic J-bone-graft technique has revealed excellent clinical results, and the traditional open technique has been in use successfully for over 3 decades2-5. Previous patients have been able to return to a variety of occupational and athletic activities including overhead, throwing, and contact sports. Return to daily living and to moderate athletic activities is usually possible within 3 months. Return to competition is allowed after 6 months2-5. IMPORTANT TIPS: •Avoid intraoperative graft fractures by applying strictly axial force during impaction.•Reduce the risk of glenoid fractures by performing an oblique osteotomy at an angle of 20° to 30° and 5 mm medial to the glenoid surface.•The postoperative physiological remodeling process determines ultimate graft fixation and glenohumeral stability. Keep this in mind when allowing return to activities.