Prevalence of Rotator Cuff Repairs with and Without Concomitant Subacromial Decompressions Has Not Changed.

BACKGROUND: Recent research from the American Board of Orthopaedic Surgery database indicates a decreasing rate of subacromial decompression (SAD) performed with rotator cuff repair (RCR) by younger orthopedic surgeons. QUESTIONS/PURPOSES: The purpose of this study was to determine the rate of RCR with and without SAD and whether the rate of RCR with SAD decreased over time. Further, we set out to determine if there was significant variation in the rate of RCR with SAD by state. METHODS: Rates of RCR with and without open or arthroscopic SAD from 2010 to 2012 were determined based upon de-identified data from a national health insurance carrier. Data were normalized per 10,000 insured patients for comparative analysis. RESULTS: Rates of RCR with concomitant SAD were higher than RCR without SAD in each year analyzed. In patients 50 years old and older, this same significant difference was also seen for each year. The rate of RCR with or without SAD did not decrease over the 3-year time period. The rate of RCR performed concomitantly with SAD was significantly higher than RCR performed without SAD in all patient age groups combined. There was wide variation in the rate of RCR with or without concurrent SAD across states. CONCLUSION: Disproving our hypothesis, the overall rate of RCR with or without SAD did not decrease over the period from 2010 to 2012. There was wide variation in the rate of RCR by state; however, this variation was not seen in the incidence of SAD performed concomitant with the RCR.

Posterior Distal Clavicle Beveling for Chronic Nonincarcerated Type IV Acromioclavicular Separations: Surgical Technique and Early Clinical Outcomes.

PURPOSE: To describe the arthroscopic partial posterior distal clavicle beveling technique for treatment of chronic nonincarcerated type IV acromioclavicular (AC) separations and report clinical outcomes and return to sport. METHODS: All patients who underwent the arthroscopic partial distal clavicle beveling technique and met eligibility criteria were identified and retrospectively reviewed. Inclusion criteria included the clinical diagnosis of a chronic nonincarcerated type IV AC separation and a minimum follow-up period of 24 months. Subjects completed the American Shoulder Elbow Surgeons shoulder assessment and a study-designed questionnaire. Radiographic images and clinical charts were also reviewed. RESULTS: This study identified 15 consecutive patients with 2 lost to follow-up, resulting in inclusion of 13 subjects (9 males and 4 females). Dominant arm was involved in 77% of cases. Mean age at operation was 33.2 years (range, 19-56 years). The mean period between injury and operation was 12.5 months (range, 3-37 months), and follow-up was 48.5 months (range, 24-126 months). The mean preoperative ASES score was 46.6 ± 16.9 (range, 33-68), and the mean postoperative ASES score was 87.3 ± 17.4 (range, 50-100) (P < .0001). All 9 athletes in the study returned to competition with a mean recovery period of 2.3 months (range, 2 weeks to 4 months). Mean timeframe for return to work was 2 weeks (range, 1 day to 2 months). One subject underwent a subsequent coracoclavicular ligament reconstruction for continued pain. The mean satisfaction level was 4.3 out of 5, and 91% would choose to have the surgery again. One subject indicated dissatisfaction with shoulder appearance. CONCLUSIONS: The arthroscopic partial distal clavicle beveling procedure for nonincarcerated type IV AC separations resulted in a significant reduction in pain, improved daily function, and early return to sport. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic posterior-inferior capsular release in the treatment of overhead athletes.

In this article, we present our technique for arthroscopic posterior-inferior capsular release and report the results of applying this technique in a population of athletes with symptomatic glenohumeral internal rotation deficit (GIRD) that was unresponsive to nonoperative treatment and was preventing them from returning to sport. Fifteen overhead athletes met the inclusion criteria. Two were lost to follow-up. Of the 13 remaining, 6 underwent isolated posterior-inferior capsular releases, and 7 had concomitant procedures. Before and after surgery, patients completed an activity questionnaire, which included the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form. Passive internal rotation in the scapular plane was measured with a bubble goniometer. Mean age was 21 years (range, 16-33 years). Mean follow-up was 31.1 months (range, 24-59 months). Mean ASES score improved significantly (P<.01) from before surgery (71.5) to after surgery (86.9). Mean GIRD improved from 43.1° to 9.7° (P<.05). Three athletes (23%) did not return to their preoperative level of play; the other 10 (77%) returned to their same level of play or a higher level. Selective arthroscopic posterior-inferior capsular release may be a reasonable solution for overhead athletes with symptomatic GIRD unresponsive to conservative management.

Complications observed following labral or rotator cuff repair with use of poly-L-lactic acid implants.

BACKGROUND: A variety of complications associated with the use of poly-L-lactic acid (PLLA) implants, including anchor failure, osteolysis, glenohumeral synovitis, and chondrolysis, have been reported in patients in whom these implants were utilized for labral applications. We report on a large series of patients with complications observed following utilization of PLLA implants to treat either labral or rotator cuff pathology. METHODS: Patients who had undergone arthroscopic debridement to address pain and loss of shoulder motion following index labral or rotator cuff repair with PLLA implants were identified retrospectively with use of our research database. A total of forty-four patients in whom macroscopic anchor debris had been observed and/or biopsy samples had been obtained during the debridement were included in the study. Synovial biopsy samples taken at the time of the arthroscopic debridement were available for thirty-eight of the forty-four patients and were analyzed by a board-certified pathologist. Magnetic resonance imaging (MRI) scans acquired after the index procedure and data from the arthroscopic debridement were available for all patients. RESULTS: Macroscopic intra-articular anchor debris was observed in >50% of the cases. Giant cell reaction was observed in 84%; the presence of polarizing crystalline material, in 100%; papillary synovitis, in 79%; and arthroscopically documented Outerbridge grade-III or IV chondral damage, in 70%. A significant correlation (rho = 0.36, p = 0.018) was observed between the time elapsed since the index procedure and the degree of chondral damage. A recurrent rotator cuff tear that was larger than the tear documented at the index procedure was observed in all patients whose index procedure included a rotator cuff repair. CONCLUSIONS: Clinically important gross, histologic, and MRI-visualized pathology was observed in a large cohort of patients in whom PLLA implants had been utilized to repair lesions of the labrum or rotator cuff.

Typical and atypical shoulder impingement syndrome: diagnosis, treatment, and pitfalls.

The cause of shoulder impingement syndrome usually is considered to be compression of the rotator cuff and subacromial bursa against the anterolateral aspect of the acromion. The typical symptom is anterolateral shoulder pain that worsens at night and with overhead activity. However, the pain may be caused by factors other than a hooked acromion. Atypical impingement syndrome most commonly results from an os acromiale, a subcoracoid disorder, acromioclavicular joint undersurface hypertrophy, a deconditioned rotator cuff, or scapular dyskinesis. The correct diagnosis is made through the patient history and physical examination, with appropriate diagnostic imaging. Nonsurgical treatment is successful for most types of impingement syndrome; if it is not successful, all structural causes of mechanical impingement must be corrected.

Computed tomography analysis of the coracoid process and anatomic structures of the shoulder after arthroscopic coracoid decompression: a cadaveric study.

The purpose of this anatomic study is to define the morphologic changes of the coracoid and surrounding soft tissue after arthroscopic coracoid decompression. We obtained 5 fresh-frozen forequarter cadaveric specimens, 3 female and 2 male, with a mean age of 86.2 years. Arthroscopic coracoid decompression was performed, and intraarticular pathology was documented. Preoperative and postoperative measures of coracoid overlap, coracoid index, and coracohumeral distance were made on limited-cut axial computed tomography scans. Dissection was performed to assess anatomic relationships after coracoid decompression. Arthroscopic findings revealed subscapularis pathology and glenohumeral arthritis in all specimens, long head of biceps pathology in 3, and supraspinatus pathology in 2. Gross dissection confirmed the pathologic findings. Arthroscopic coracoid decompression effectively improves coracoid overlap, coracoid index, and coracohumeral distance. The adjacent major neurovascular structures are at a safe distance from the decompression site.

Accuracy of office-based ultrasonography of the shoulder for the diagnosis of rotator cuff tears.

BACKGROUND: This prospective multi-institutional study was designed to define the accuracy of ultrasonography, when performed in an orthopaedic surgeon's office, for the diagnosis of rotator cuff tears. METHODS: An anatomic diagnosis and a treatment plan were made on the basis of office-based shoulder ultrasonography, physical examination, and radiographs for ninety-eight patients (ninety-nine shoulders) with a clinical diagnosis of a rotator-cuff-related problem. The results of the ultrasonographic studies were then compared with the results of magnetic resonance imaging and the operative findings. RESULTS: Office-based ultrasonography led to the correct diagnosis for thirty-seven (88%) of forty-two shoulders with a full-thickness rotator cuff tear or both full and partial-thickness tears, twenty-six (70%) of thirty-seven shoulders with a partial-thickness rotator cuff tear only, and sixteen (80%) of twenty shoulders with normal tendons. In no case was the surgical approach (open or arthroscopic) that had been planned on the basis of the ultrasonography altered by the operative findings, but the operative finding of a full-thickness tear resulted in an arthroscopic cuff repair in four shoulders. Magnetic resonance imaging led to the correct diagnosis for forty (95%) of forty-two shoulders with a full-thickness rotator cuff tear or both full and partial-thickness rotator cuff tears, twenty-seven (73%) of thirty-seven shoulders with only a partial-thickness tear, and fifteen (75%) of twenty shoulders with normal tendons. There were no significant differences between magnetic resonance imaging and ultrasonography with regard to the correct identification of a full-thickness tear or its size. The sensitivity of ultrasonography for detecting tear size in the anterior-posterior dimension was 86% (95% confidence interval, 71% to 95%), and that of magnetic resonance imaging was 93% (95% confidence interval, 81% to 99%) (p = 0.26). The sensitivity of ultrasonography for detecting tear size in the medial-lateral dimension was 83% (95% confidence interval, 69% to 93%), and that of magnetic resonance imaging was 88% (95% confidence interval, 74% to 96%) (p = 0.41). CONCLUSIONS: A well-trained office staff and an experienced orthopaedic surgeon can effectively utilize ultrasonography, in conjunction with clinical examination and a review of shoulder radiographs, to accurately diagnose the extent of rotator cuff tears in patients suspected of having such tears. Errors in diagnosis made on the basis of ultrasonography most often consist of an inability to distinguish between partial and full-thickness tears that are approximately 1 cm in size. In this study, such errors did not significantly affect the planned surgical approach.

Nonoperative management for in-season athletes with anterior shoulder instability.

BACKGROUND: Acute or recurrent anterior shoulder instability is a frequent injury for in-season athletes. Treatment options for this injury include shoulder immobilization, rehabilitation, and shoulder stabilization surgery. PURPOSE: To determine if in-season athletes can be returned to their sports quickly and effectively after nonoperative treatment for an anterior instability episode. METHODS: Over a 2-year period, 30 athletes matched the inclusion criteria for this study. Nineteen athletes had experienced anterior dislocations, and 11 had experienced subluxations. All were treated with physical therapy and fitted, if appropriate, with a brace. These athletes were followed for the number of recurrent instability episodes, additional injuries, subjective ability to compete, and ability to complete their season or seasons of choice. RESULTS: Twenty-six of 30 athletes were able to return to their sports for the complete season at an average time missed of 10.2 days (range, 0-30 years). Ten athletes suffered sport-related recurrent instability episodes (range, 0-8 years). An average of 1.4 recurrent instability episodes per season per athlete occurred. There were no further injuries attributable to the shoulder instability. Sixteen athletes underwent surgical stabilization for their shoulders during the subsequent off-season. CONCLUSIONS: Most of the athletes were able to return to their sport and complete their seasons after an episode of anterior shoulder instability, although 37% experienced at least 1 additional episode of instability during the season.

Poly-L-lactic acid tack synovitis after arthroscopic stabilization of the shoulder.

BACKGROUND: Progress has been made in the design of bioabsorbable implants, with reduced complication rates and slower degradation times. PURPOSE: To report on complications related to use of poly-L-lactic acid implants after arthroscopic shoulder stabilization procedures. STUDY DESIGN: Retrospective cohort study. METHODS: Between 1997 and 1999, 52 patients underwent arthroscopic stabilization at one institution with an average of 2.2 poly-L-lactic acid tacks. Ten patients (19%), with an average age of 30 years, developed delayed onset of symptoms at an average of 8 months after surgery, including pain in all 10 and progressive stiffness in 6. The patients underwent magnetic resonance imaging and arthroscopic evaluation and debridement. RESULTS: Nine patients had gross implant debris. Evidence of glenohumeral synovitis was seen arthroscopically in all 10 patients. Three patients had significant full-thickness chondral damage on the humeral head. All preexisting labral lesions were healed. One year after arthroscopic debridement, loose body removal, and synovectomy, seven patients reported no or minimal pain and full return of motion. Two patients continued to have persistent pain and stiffness, and one patient reported discomfort with overhand throwing; all three had chondral lesions. CONCLUSIONS: Patients with symptoms of delayed pain and progressive stiffness after arthroscopic stabilization with poly-L-lactic acid implants should be evaluated for synovitis and chondral injury. Arthroscopic treatment provides a significant decrease in symptoms and increased range of motion.

Acromioclavicular injuries in the throwing athlete.

Acromioclavicular injuries in the overhead or throwing athlete are frequently encountered by team physicians. Treatment regimens vary greatly, depending on dominant versus nondominant arm, injury in-season or out-of-season, and the athlete's goals for future seasons. This article focuses on each of these unique issues with regards to acromioclavicular separations and fractures, acromioclavicular arthritis, and acromioclavicular osteolysis.

Surgical management of the symptomatic os acromiale.

Os acromiale is an uncommon cause of shoulder pain with symptoms often resulting from an unstable meso-acromion. The associated pain may be due to impingement from the unfused fragment, a concomitant rotator cuff tear, or gross motion at the os acromiale site. Currently, initial treatment includes physical therapy, nonsteroidal anti-inflammatory agents, and subacromial corticosteroid injections. Surgical intervention is reserved for patients who do not respond to nonoperative treatment. Treatment options include open fragment excision, open reduction and internal fixation, and arthroscopic decompression. Open fragment excision can lead to persistent deltoid dysfunction and should be reserved for small fragments or after failed internal fixation. Open reduction and internal fixation allows for both preservation of large fragments and anterior deltoid function. Internal fixation is technically difficult, has led to frequent nonunion rates and often requires hardware removal as a result of postoperative irritation. Arthroscopic subacromial decompression with complete or nearly complete resection of the unstable meso-acromion can be performed without the aforementioned complications. The surgical technique requires no special instrumentation and may be performed reproducibly by those familiar with arthroscopic techniques of the shoulder. Advantages include more rapid rehabilitation, better range of motion, and shorter surgical times. Satisfactory short-term results have shown this to be an effective treatment option for the unstable meso-acromion.