Injections for Knee Osteoarthritis: Corticosteroids, Viscosupplementation, Platelet-Rich Plasma, and Autologous Stem Cells.

This article reviews the benefits of corticosteroid, viscosupplementation, platelet-rich plasma, and autologous mesenchymal stem cell injections for the treatment of patients with knee osteoarthritis. Integrating injections into both clinical and surgical practices is complicated given existing health insurance reimbursement policies. This review describes the outcomes associated with these interventions and appropriate methods of navigating the existing reimbursement pathways to help providers implement these treatments into their practices.

Can Competitive Athletes Return to High-Level Play After Osteochondral Allograft Transplantation of the Knee?

PURPOSE: To investigate functional outcomes among competitive athletes undergoing osteochondral allograft (OCA) transplantation of the knee, including rates of return to play (RTP), and factors preventing RTP. METHODS: A retrospective review identified all competitive athletes (high school, intercollegiate, professional) undergoing isolated femoral condyle OCA from 2004 to 2013. Patient-reported outcome (PRO) questionnaires (Lysholm, International Knee Documentation Committee [IKDC], Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMasters Universities Arthritis Index [WOMAC], 12-Item Short Form Health Survey [SF-12], Tegner, and Marx) and custom RTP surveys were administered. All subsequent reoperations were documented. RESULTS: Thirteen athletes (4 intercollegiate, 9 high-school) were identified with an average follow-up of 5.9 ± 2.5 years. Seven athletes (54%) returned to competitive sport at an average of 7.9 ± 3.5 months, 5 of whom returned to preinjury functional levels. Of the 8 athletes who either did not return to competitive sport or failed to sustain their high level of play, the most common reasons cited were graduation from high school or college (4 patients, 50%) or fear of reinjury (3 patients, 38%). All 4 patients citing graduation as the primary factor preventing return to preinjury level of competitive sport resumed recreational sport without limitations, yielding an adjusted RTP rate of 10 patients (77%) who either returned to competitive play or believed they could return if they had not graduated. At final follow-up, athletes reported significant improvements in all PRO scores except for KOOS-Sport, WOMAC-Stiffness, and SF-12 Mental subscales. There were 3 reoperations at an average of 3.8 ± 3.3 years after the index OCA. There were no instances of graft failure. CONCLUSIONS: OCAs provide an adjusted RTP rate of 77% for high-level adolescent athletes. Social factors may be more likely than persistent pain to prevent return to sport. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Hip Arthroscopy Outcomes With Respect to Patient Acceptable Symptomatic State and Minimal Clinically Important Difference.

PURPOSE: To determine whether the hip arthroscopy literature to date has shown outcomes consistent with published patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) estimates. METHODS: All clinical investigations of hip arthroscopy using modified Harris Hip Score (mHHS) and/or Hip Outcome Score (HOS) outcomes with at least 1 year of follow-up were reviewed. Ninety-one studies (9,746 hips) were included for review. Eighty-one studies (9,317 hips) contained only primary hip arthroscopies and were the primary focus of this review. The remaining studies (429 hips) did not exclude patients with prior surgical history and were thus considered separately. Mean mHHS, HOS-ADL (Activities of Daily Living) and HOS-SS (Sports-Specific) scores were compared with previously published PASS and MCID values. RESULTS: After 31 ± 20 months, 5.8% of study populations required revision arthroscopy and 5.5% total hip arthroplasty. A total of 88%, 25%, and 30% of study populations met PASS for mHHS, HOS-ADL, and HOS-SS, respectively, and 97%, 90%, and 93% met MCID. On bivariate analysis, increasing age was associated with significantly worse postoperative mHHS (P < .01, R(2) = 0.14), HOS-SS (P = .05, R(2) = 0.12), and rates of reoperation (P = .02, R(2) = 0.08). Increasing body mass index was associated with significantly worse HOS-ADL (P = .02, R(2) = 0.35) and HOS-SS (P = .03, R(2) = 0.30). CONCLUSIONS: In this meta-analysis of 81 studies of primary hip arthroscopy, we have found that more than 90% of study populations meet MCID standards for the most commonly used patient-reported outcomes measures in hip arthroscopy literature, mHHS and HOS. Eighty-eight percent meet PASS standards for the mHHS, but PASS standards are far more difficult to achieve for HOS-ADL (25%) and HOS-SS (30%) subscales. Differences in psychometric properties of the mHHS and HOS likely account for the discrepancies in PASS. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Hip Arthroscopy Surgical Volume Trends and 30-Day Postoperative Complications.

PURPOSE: To determine hip arthroscopy surgical volume trends from 2006 to 2013 using the National Surgical Quality Improvement Program (NSQIP) database, the incidence of 30-day complications of hip arthroscopy, and patient and surgical risk factors for complications. METHODS: Patients who underwent hip arthroscopy from 2006 to 2013 were identified in the NSQIP database for the over 400 NSQIP participating hospitals from the United States using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. Trends in number of hip arthroscopy procedures per year were analyzed. Complications in the 30-day period after hip arthroscopy were identified. Univariate and multivariate regression analyses were performed to identify risk factors for complications. RESULTS: We identified 1,338 patients who underwent hip arthroscopy, with a mean age of 39.5 ± 13.0 years. Female patients comprised 59.6%. Hip arthroscopy procedures became 25 times more common in 2013 than 2006 (P < .001). Major complications occurred in 8 patients (0.6%), and minor complications occurred in 11 patients (0.8%); overall complications occurred in 18 patients (1.3%) (1 patient had 2 complications). The most common complications were bleeding requiring a transfusion (5, 0.4%), return to the operating room (4, 0.3%), superficial infection not requiring return to the operating room (3, 0.2%), deep venous thrombosis (2, 0.1%), and death (2, 0.1%). Multivariate analysis showed that regional/monitored anesthesia care as opposed to general anesthesia (P = .005; odds ratio, 0.102) and a history of patient steroid use (P = .05; odds ratio, 8.346) were independent predictors of minor complications in the 30 days after hip arthroscopy. CONCLUSIONS: Hip arthroscopy is an increasingly common procedure, with a 25-fold increase from 2006 to 2013. There is a low incidence of 30-day postoperative complications (1.3%), most commonly bleeding requiring a transfusion, return to the operating room, and superficial infection. Regional/monitored anesthesia care and steroid use were independent risk factors for minor complications. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

History of surgical intervention of anterior shoulder instability.

BACKGROUND: Anterior glenohumeral instability most commonly affects younger patients and has shown high recurrence rates with nonoperative management. The treatment of anterior glenohumeral instability has undergone significant evolution over the 20th and 21 centuries. METHODS: This article presents a retrospective comprehensive review of the history of different operative techniques for shoulder stabilization. RESULTS: Bankart first described an anatomic suture repair of the inferior glenohumeral ligament and anteroinferior labrum in 1923. Multiple surgeons have since described anatomic and nonanatomic repairs, and many of the early principles of shoulder stabilization have remained even as the techniques have changed. Some methods, such as the Magnusson-Stack procedure, Putti-Platt procedure, arthroscopic stapling, and transosseous suture fixation, have been almost completely abandoned. Other strategies, such as the Bankart repair, capsular shift, and remplissage, have persisted for decades and have been adapted for arthroscopic use. DISCUSSION: The future of anterior shoulder stabilization will continue to evolve with even newer practices, such as the arthroscopic Latarjet transfer. Further research and clinical experience will dictate which future innovations are ultimately embraced.

Treatment of Unicameral Bone Cysts of the Calcaneus: A Systematic Review.

The calcaneus is the most common tarsal affected by unicameral bone cysts (UBCs); however, the treatment of calcaneal UBCs remains controversial. The purpose of the present systematic review was to evaluate the treatment modalities for calcaneal UBCs. A systematic review was performed using clinical studies of calcaneal UBCs with a minimum of 1 year of follow-up and level I to IV evidence. Ten studies with 171 patients (181 cysts) were selected. Heel pain and radiographic cyst consolidation were the primary outcomes. A series of Z tests were used to compare the outcomes in the nonoperative and operative groups, cannulated screw and bone augmentation groups, and autografting and allografting groups. All patients treated with open curettage and bone augmentation had significant improvements in heel pain (p < .001). Only 1.1% ± 1.0% of the cysts treated conservatively had healed on radiographs compared with 93.0% ± 13.0% of the cysts after surgery (p < .001). A greater percentage of patients treated with bone augmentation had preoperative heel pain and resolution of that pain than did patients treated with cannulated screws (p < .001). Autografting had a significantly greater percentage of radiographic cyst consolidation than did allografting (97.4% ± 11.1% versus 85.1% ± 15.8%, p < .001, Z = 3.5). Objective outcomes data on calcaneal UBCs are relatively sparse. The results of the present review suggest that open curettage with autograft bone augmentation is the most effective procedure. We would encourage future comparative clinical studies to elucidate differences in UBC treatment modalities.

Blastomyces Tenosynovitis of the Foot and Ankle: A Case Report and Review of the Literature.

Deep fungal infection localized to the foot is not common, and when it occurs it often affects immunocompromised individuals. In this report, we describe the case of an adult diabetic patient who suffered with with Blastomycosis infection of the flexor digitorum longus and peroneal tendon sheaths. The condition was treated with systemic antifungal therapy and surgical debridement.

Rotator cuff repair augmentation with local autogenous bone marrow via humeral cannulation in a rat model.

BACKGROUND: Growth factors have been shown to improve healing after rotator cuff repair. Bone marrow is a potential vehicle for growth factor augmentation, yet methods of delivering marrow to cuff repair sites are still under-researched. We hypothesized that a cannulated humeral implant would deliver local bone marrow and thereby improve healing in a rat model. METHODS: Twenty-eight rats underwent bilateral rotator cuff injury and repair. Each rat acted as its own control, randomized to a cannulated humeral implant in one shoulder and a solid implant in the other. Rats were euthanized at 4 and 8 weeks to create 4 time-treatment cohorts. Tendon healing was evaluated by dimensional measurements, biomechanical testing, and histology. RESULTS: Tendon thickness, all biomechanical measures, and semi-quantitative histologic scores improved over time (P < .05) but not with treatment. The most common site of biomechanical tendon failure was midsubstance in the 8-week cannulated cohort and at the tendon footprint in the other 3 cohorts. Intraluminal bone growth was evident in all cannulated implants. CONCLUSIONS: Humeral cannulation did not quantifiably improve tendon-to-bone healing in a rat model. The diminutive size of implants in rats, however, may have prevented sufficient delivery of local autogenous bone marrow; hence, further study in a larger animal is recommended.

Rapid sequence induction in obstetrics revisited.

PURPOSE OF REVIEW: The regimen of thiopental, succinylcholine (SCh) and unsupplemented nitrous oxide/oxygen for Caesarean section was first introduced 50 years ago. This review examines which elements have endured, what has changed, and how practice might alter in the very near future. RECENT FINDINGS: Sugammadex, a cyclodextrin, is capable of rapid reversal of profound rocuronium neuromuscular blockade. SUMMARY: It is now feasible that SCh might be replaced with a high-dose rocuronium-sugammadex combination.

A Novel Traction Frame for Femur Fracture Management in Developing Countries: Technique and Outcomes.

Fractures of the femur have long been a major cause of morbidity and mortality in developing countries and are most frequently caused by road traffic accidents. Intramedullary nail fixation has become the gold standard of care for diaphyseal fractures of the femur. However, modern techniques require proper implants, access to imaging, and accessible operating room facilities, all of which have limited availability in the developing world. We describe a new technique for assembly of a polyvinyl chloride traction frame for treatment of femur fractures in resource-poor settings. Our report includes a retrospective review of patients treated with polyvinyl chloride traction frames in the Dominican Republic and Haiti.

A T-capsulotomy provides increased hip joint visualization compared with an extended interportal capsulotomy.

The purpose of this study was to compare the cross-sectional area (CSA) of joint visualization between extended interportal and T-capsulotomies. Twenty fresh-frozen cadaveric hips were dissected to their capsuloligamentous complexes and fixed in a custom apparatus in neutral hip position. Ten hips underwent sequential interportal capsulotomies at lengths of 2, 4, 6, and 8 cm. Ten hips underwent sequential T-capsulotomies starting from a 4 cm interportal capsulotomy, creating a 2 cm T-capsulotomy (Half-T), and finally a 4 cm T-capsulotomy (Full-T). Following each sequential capsule change in both groups, a high-resolution digital photograph was taken to measure the visualized intra-articular cross-sectional area (CSA). Independent t-test was used to compare CSA interportal and T-capsulotomy groups. Analysis demonstrated a statistically significant increase in CSA visualization with each sequential increase in interportal capsulotomy length up to 6 cm (2cm: 0.6 ± 0.2 cm2; 4cm: 2.1 ± 0.5 cm2 (p<0.001); 6cm: 3.6 ± 1.0 cm2 (p=0.001)), and no difference at 8cm (4.2 ± 1.2 cm2 (p=0.20)). For the T-capsulotomy group the average CSA visualization significantly increased from 3.2 ± 0.9 cm2 for the Half-T to 7.1 ± 1.0 cm2 for the Full-T (p<0.001). The Half-T CSA visualization was not statistically different from the 6 cm capsulotomy (p=0.4) and the 8cm capsulotomy (p=0.05). The Full-T had significantly superior CSA visualization area as compared to the 6 cm and 8 cm interportal capsulotomies (p<0.001 for both). In conclusion, T-capsulotomy resulted in improved cross-sectional area of joint visualization compared to an extended (8cm) interportal capsulotomy in a cadaveric model. Surgeons must weigh the benefits of greater visualization from T-capsulotomy that may help to avoid residual FAI while ensuring to completely repair the capsulotomy to avoid iatrogenic instability.

Sympathetic bias.

We wish to deal with investigator bias in a statistical context. We sketch how a textbook solution to the problem of "outliers" which avoids one sort of investigator bias, creates the temptation for another sort. We write down a model of the approbation seeking statistician who is tempted by sympathy for client to violate the disciplinary standards. We give a simple account of one context in which we might expect investigator bias to flourish. Finally, we offer tentative suggestions to deal with the problem of investigator bias which follow from our account. As we have given a very sparse and stylized account of investigator bias, we ask what might be done to overcome this limitation.

Have Residents Produced More Research Since the Inception of the 80-Hour Workweek?

BACKGROUND: This study hypothesizes that resident involvement in research has increased since institution of the maximum 80-hour workweek in 2002. METHODS: All 571 papers published in the Journal of Bone and Joint Surgery (JBJS) in 1997 and 2007 (five years before and after the start of the 80-hour workweek) were reviewed. To identify resident authors, a search was performed in the American Board of Orthopaedic Surgery (ABOS) database for any U.S. author with a medical doctorate (MD). Any authors who were board-certified more than two years after the publication date were identified as "residents." Two-tailed Fisher's exact tests were used to assess proportional changes over time. RESULTS: Between 1997 and 2007, the percentage of U.S. MD authors who were orthopaedic residents increased significantly from 12% to 18% (p = 0.01). U.S. publications with a resident first-author increased from 17% to 27% (p = 0.02), and contributions from foreign nations also increased significantly (p < 0.001). The number of total authors per paper increased (p < 0.001), but linear regression showed that this had no particular association with the proportion of residents (p = 0.20). The relative proportions of MD and non-MD authors did not change between years. The LOE of resident-authored papers improved significantly over time (p = 0.005), while that of international papers did not. CONCLUSIONS: Proportional resident authorship has increased significantly in one of the highest-impact, peer-reviewed orthopaedic journals. LOE of resident-authored papers has improved, and basic science papers are more likely to have a resident first author. LEVEL OF EVIDENCE: III, retrospective cohort study.

Hip Arthroscopy for Atypical Posterior Hip Pain: A Comparative Matched-Pair Analysis.

BACKGROUND: Femoroacetabular impingement (FAI) most commonly manifests as anterior groin pain. Patients occasionally have posterior pain but otherwise have clinical and radiographic evidence of FAI. PURPOSE: To compare outcomes of hip arthroscopy for FAI in patients with atypical posterior pain versus a matched group with the typical anterior pain presentation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing primary hip arthroscopy for FAI were identified from a clinical repository between January 2012 and 2014. Of 503 patients during the study period, 31 (6.2%) had posterior hip or buttock pain reproduced with flexion, adduction, and internal rotation (FADDIR) and were classified as "atypical," while those with anterior hip or groin pain were classified as "typical." Atypical patients were matched in a 1:2 cohort to the typical group based on sex, age, and body mass index (BMI). Postoperative patient-reported outcomes included visual analog scale (VAS) for pain, modified Harris Hip Score (mHHS), and Hip Outcome Scores with Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales. RESULTS: Of the 31 atypical patients, 28 (90.3%) were available for a minimum 2-year follow-up (mean ± SD, 2.6 ± 0.6 years). These patients were matched with 56 typical patients. No differences were noted between typical and atypical cohorts in preoperative demographic or radiographic parameters. Postoperatively, both groups demonstrated significant improvements in mHHS (atypical 60.1 ± 12.4 to 78.8 ± 12.9; typical 60.0 ± 12.3 to 76.9 ± 13.6; P < .001), HOS-ADL (atypical 68.5 ± 17.0 to 88.6 ± 11.0; typical 69.2 ± 17.1 to 86.8 ± 14.7; P < .001), and HOS-SS (atypical 42.0 ± 25.5 to 71.0 ± 26.2; typical 44.4 ± 24.9 to 71.3 ± 27.3; P < .001). No differences were found in 2-year score improvements between the atypical and typical cohorts (mHHS 18.7 ± 13.4 vs 16.9 ± 13.1, P = .48; HOS-ADL 20.1 ± 16.8 vs 17.6 ± 14.6, P = .19; HOS-SS 29.0 ± 30.2 vs 26.9 ± 27.3, P = .93). Also, no significant differences were found in VAS pain improvement (5.0 ± 3.2 vs 5.6 ± 2.8, P = .56) or postoperative satisfaction (79.5 ± 5.5 vs 77.5 ± 4.1, P = .78). CONCLUSION: Atypical posterior hip pain is an uncommon presentation of FAI. Patients demonstrate similar significant improvements after hip arthroscopy in outcome scores, postoperative pain, and satisfaction compared with patients who have classic anterior groin pain.

Subscapularis Tenotomy Versus Lesser Tuberosity Osteotomy for Total Shoulder Arthroplasty: A Systematic Review.

Subscapularis tenotomy (ST) has been the standard method of mobilizing the subscapularis during the approach to a total shoulder arthroplasty (TSA). Recently, lesser tuberosity osteotomy (LTO), which avoids subscapularis complications, has gained in popularity. We performed a systematic review to elucidate any differences in clinical or radiographic outcomes between ST and LTO. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we identified clinical and/or radiographic TSA studies with minimum mean 2-year follow-up and level I to IV evidence. Twenty studies (1420 shoulders, 1392 patients) were included in the study. The ST group had significantly more patients with osteoarthritis (P = .03) and fewer patients with posttraumatic arthritis (P = .04). At final follow-up, mean (SD) forward elevation improvements were significantly (P < .01) larger for the ST group, +50.9° (17.5°) than for the LTO group, +31.3° (0.9°). Complication rates were almost identical, but the ST group showed a trend (P = .31) toward fewer revisions (10.0% vs 16.2%). There were no differences in Constant scores, pain scores, or radiolucencies. Both approaches (ST, LTO) produced excellent outcomes. ST may result in wider range of motion and fewer revisions, but more studies are needed to further evaluate these results.

Effects of Platelet-Rich Plasma and Indomethacin on Biomechanics of Rotator Cuff Repair.

We conducted a study to determine if platelet-rich plasma (PRP) enhances the strength of rotator cuff repair (RCR) and if concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs) affects PRP efficacy. We also wanted to determine the optimal centrifugation protocol for making PRP from rats. This study used 48 rats, 14 in a centrifugation protocol and 34 in an operative protocol. Six syngeneic rats from the operative group were used as PRP blood donors; the other 28 operative rats underwent bilateral RCRs. The Autologous Conditioned Plasma system (Arthrex) was used to prepare leukocyte-poor PRP. One shoulder was randomized to an intratendinous PRP injection, and the other received normal saline. Each rat was also randomly placed on a postoperative diet, either a regular diet or an indomethacin-enhanced diet. After rats were euthanized at 3 weeks, specimens were dissected to isolate the supraspinatus tendon at its humeral attachment, which was subjected to biomechanical testing. PRP prepared with a protocol of 5 minutes × 1300 revolutions per minute had the highest platelet index. Mean (SD) energy to failure was significantly higher (P = .03) in tendons treated with PRP, 11.7 (7.3) N-mm, than in tendons treated with saline, 8.7 (4.6) N-mm. Both groups (PRP, saline) showed no significant differences between tendons treated with NSAIDs and those not treated with NSAIDs. Intraoperative application of PRP enhances energy to failure after RCR in rats. There were no differences in biomechanical strength with NSAID use and no interactions between PRP and NSAID use.

Clinical and Radiographic Outcomes of Total Shoulder Arthroplasty With a Hybrid Dual-Radii Glenoid Component.

In total shoulder arthroplasty (TSA), glenoid prostheses have conforming or nonconforming designs. A hybrid glenoid was designed with dual radii of curvature: a central conforming region surrounded by an outer nonconforming region. We retrospectively reviewed the cases of 169 patients who underwent 196 hybrid glenoid prosthesis TSAs for primary glenohumeral arthritis. Clinical data, retrieved for 178 shoulders at a mean follow-up of 4.8 years, included physical examination, 36-Item Short Form Health Survey (SF-36), American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), subjective Neer criteria, and postoperative complication data. Radiographic data were retrieved for 136 shoulders at a mean of 3.7 years. Kaplan-Meier survivorship analysis was performed with glenoid or humeral revision as the endpoint. All range of motion and survey measures improved in a statistically significant manner (P < .001). Of 139 respondents, 130 (93.5%) stated they were satisfied or very satisfied with their TSA. Of 178 patients, only 3 (1.7%) required revision for component loosening: 2 glenoid and 1 humeral. Of 136 shoulders, 86 (63.2%) had no glenoid lucencies, and 91 (66.9%) had no humeral stem lucencies. Use of a hybrid-congruency glenoid prosthesis had excellent intermediate clinical and radiographic outcomes in the treatment of primary glenohumeral osteoarthritis.

Management of Isolated Greater Tuberosity Fractures: A Systematic Review.

As isolated fractures of the greater tuberosity present a therapeutic challenge, we systematically reviewed all studies of greater tuberosity fracture management. Inclusion criteria were level I to IV evidence and 2-year follow-up. Thirteen studies and 429 shoulders were included in our analyses, which compared 3 paired groups: treatment type (nonoperative vs operative), fracture displacement amount (<5 mm vs >5 mm), and surgery type (open vs arthroscopic). Concomitant anterior glenohumeral instability was documented in 28.1% of patients and was significantly more common in displaced vs nondisplaced fractures (44.3% vs 14.5%; P < .01). Compared with nonoperative patients, operative patients had significantly fewer radiographic losses of reduction (48.6% vs 5.2%; P < .01) but increased shoulder stiffness (0.0% vs 5.7%; P < .01). Heterotopic ossification was more common in displaced vs nondisplaced fractures (7.5% vs 0.0%; P < .01). There were no significant differences in outcome between arthroscopic and open surgery, but with screw fixation (vs suture constructs) there were significantly fewer cases of stiffness (0% vs 12.0%; P < .01) and reoperation (0% vs 8.0%; P = .051). Surgery for displaced fractures is associated with high patient satisfaction and low rates of complications and reoperations, regardless of technique and fixation mode.

Patient Preference Before and After Arthroscopic Rotator Cuff Repair: Which Is More Important, Pain Relief or Strength Return?

Our understanding of patients' desired outcomes and expectations of arthroscopic rotator cuff repair (ARCR) is limited, particularly regarding the importance of pain relief and strength return relative to each other. We conducted a study of patient's ratings of the importance of pain relief and strength return after ARCR. Before undergoing surgery, 60 patients completed a shoulder questionnaire on which they assessed severity of symptoms and rated, on a 10-point scale, the importance of postoperative improvements in pain relief and strength return. After surgery, they completed the same questionnaire, again rating the importance of pain relief and strength return. About 50% of the patients valued pain relief and strength return equally before and after ARCR. However, overall patient ratings were higher for strength return over pain relief, both before surgery, mean (SD), 9.2 (2.1) vs 8.6 (2.3) (P = .02), and afterward, at a follow-up of 5.2 (0.2) years, 8.9 (1.9) vs 8.2 (3.1) (P = .03). This significant preference for strength return held irrespective of sex, age, active sports involvement, preoperative self-assessed pain score, and subjective shoulder weakness. Before surgery, increasing age was associated with a stronger preference for pain relief (r = 0.33, P = .01), and retirees preferred pain relief over strength return. These results show the patterns of patient preference for pain relief and strength return after ARCR. Improved understanding of these patients' expectations will allow meaningful changes in patient satisfaction.