The Majority of Black Orthopaedic Surgeons Report Experiencing Racial Microaggressions During Their Residency Training.

BACKGROUND: Orthopaedic surgery is the least-diverse surgical specialty based on race and ethnicity. To our knowledge, the impact of this lack of diversity on discriminatory or noninclusive experiences perceived by Black orthopaedic surgeons during their residency training has never been evaluated. Racial microaggressions were first defined in the 1970s as "subtle verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults to the target person or group." Although the term "microaggression" has long been established, more recently, as more workplaces aim to improve diversity, equity, and inclusion, it has entered the medical profession's lexicon as a means of describing the spectrum of racial discrimination, bias, and exclusion in the healthcare environment. QUESTION/PURPOSES: (1) What is the extent of discrimination that is perceived by Black orthopaedic surgeons during residency? (2) What subtypes of racial microaggressions (which encompasses racial discrimination, bias, and exclusion) do Black orthopaedic surgeons experience during residency training, and who are the most common initiators of these microaggressions? (3) What feedback statements could be perceived as racially biased to Black orthopaedic surgeons in residency training? (4) Are there gender differences in the reported types of racial microaggressions recalled by Black respondents during residency training? METHODS: An anonymous survey was administered between July 1, 2020, and September 1, 2020, to practicing orthopaedic surgeons, residents, and fellows in the J. Robert Gladden Orthopaedic Society database who self-identify as Black. There were 455 Black orthopaedic surgeons in practice and 140 Black orthopaedic residents or fellows in the database who met these criteria. Fifty-two percent (310 of 595) of participants responded. Fifty-three percent (243 of 455) were practicing surgeons and 48% (67 of 140) were current residents or fellows. Respondents reported their perception of discrimination in the residency workplace using a modified version of the single-item Perceived Occupational Discrimination Scale and were asked to recall any specific examples of experiences with racial discrimination, bias, or exclusion during their training. Examples were later categorized as different subtypes of racial microaggressions and were quantified through a descriptive analysis and compared by gender. RESULTS: Among survey respondents, 34% (106 of 310) perceived a lot of residency workplace discrimination, 44% (137 of 310) perceived some residency workplace discrimination, 18% (55 of 310) perceived a little residency workplace discrimination, and 4% (12 of 310) perceived no residency workplace discrimination. Categorized examples of racial microaggressions experienced in residency were commonly reported, including being confused for a nonphysician medical staff (nurse or physician's assistant) by 87% (271 of 310) of respondents or nonmedical staff (janitorial or dietary services) by 81% (250 of 310) of respondents. Racially explicit statements received during residency training were reported by 61% (190 of 310) of respondents. Thirty-eight percent (117 of 310) of such statements were reportedly made by patients and 18% (55 of 310) were reportedly made by attending faculty. Fifty percent (155 of 310) of respondents reported receiving at least one of nine potentially exclusionary or devaluing feedback statements during their residency training. Among those respondents, 87% (135 of 155) perceived at least one of the statements to be racially biased in its context. The three feedback statements that, when received, were most frequently perceived as racially biased in their context was that the respondent "matched at their program to fulfill a diversity quota" (94% [34 of 36]), the respondent was unfriendly compared with their peers (92% [24 of 26]), or that the respondent was "intimidating or makes those around him/her uncomfortable" (88% [51 of 58]). When compared by gender, Black women more frequently reported being mistaken for janitors and dietary services at 97% (63 of 65), compared with Black men at 77% (187 of 244; p < 0.01). In addition, Black women more frequently reported being mistaken as nurses or physician assistants (100% [65 of 65]) than Black men did (84% [205 of 244]) during orthopaedic residency training (p < 0.01). Black women also more frequently reported receiving potentially devaluing or exclusionary feedback statements during residency training. CONCLUSION: Perception of workplace discrimination during orthopaedic residency training is high (96%) among Black orthopaedic surgeons in the United States. Most respondents reported experiencing discrimination, bias, and exclusion that could be categorized as specific subtypes of racial microaggressions. Several different examples of racial microaggressions were more commonly reported by Black women. Certain feedback statements were frequently perceived as racially biased by recipients. CLINICAL RELEVANCE: To better understand barriers to the successful recruitment and retention of Black physicians in orthopaedics, the extent of racial discrimination, bias, and exclusion in residency training must be quantified. This study demonstrates that racial discrimination, bias, and exclusion during residency, wholly categorized as racial microaggressions, are frequently recalled by Black orthopaedic surgeons. A better understanding of the context of these experiences of Black trainees is a necessary starting point for the development of a more inclusive workplace training environment in orthopaedic surgery.

Perception of Racial and Intersectional Discrimination in the Workplace Is High Among Black Orthopaedic Surgeons: Results of a Survey of 274 Black Orthopaedic Surgeons in Practice.

INTRODUCTION: There are approximately 573 practicing Black orthopaedic surgeons in the United States, which represents 1.9% overall. The purpose of this study was to describe this underrepresented cohort within the field of orthopaedic surgery and to report their perception of occupational opportunity and workplace discrimination. METHODS: An anonymous survey was administered to 455 practicing orthopaedic surgeons who self-identify as Black. The 38-question electronic survey requested demographic and practice information and solicited perspectives on race and racial discrimination in current orthopaedic practices and general views regarding occupational opportunity and discrimination. RESULTS: The survey was completed by 274 Black orthopaedic surgeons (60%). Over 97% of respondents believe that Black orthopaedic surgeons in the United States face workplace discrimination. Most Black orthopaedic surgeons (94%) agreed that racial discrimination in the workplace is a problem but less than 20% agreed that the leaders of national orthopaedic organizations are trying sincerely to end it. Black female orthopaedic surgeons reported lower occupational opportunity and higher discrimination than Black male orthopaedic surgeons across all survey items. DISCUSSION: This study is the first to report on the workplace environment and the extent of discrimination experienced by Black surgeons, specifically Black orthopaedic surgeons in the United States. Most respondents, particularly female respondents, agreed that racial discrimination and diminished occupational opportunity are pervasive in the workplace and reported experiencing various racial microaggressions in practice.

Safety and efficacy of umbilical cord-derived Wharton's jelly compared to hyaluronic acid and saline for knee osteoarthritis: study protocol for a randomized, controlled, single-blind, multi-center trial.

BACKGROUND: Osteoarthritis (OA) is the most common joint disorder in the United States of America (USA) with a fast-rising prevalence. Current treatment modalities are limited, and total knee replacement surgeries have shown disadvantages, especially for grade II/III OA. The interest in the use of biologics, including umbilical cord (UC)-derived Wharton's jelly (WJ), has grown in recent years. The results from a preliminary study demonstrated the presence of essential components of regenerative medicine, namely growth factors, cytokines, hyaluronic acid (HA), and extracellular vesicles, including exosomes, in WJ. The proposed study aims to evaluate the safety and efficacy of intra-articular injection of UC-derived WJ for the treatment of knee OA symptoms. METHODS: A randomized, controlled, single-blind, multi-center, prospective study will be conducted in which the safety and efficacy of intra-articular administration of UC-derived WJ are compared to HA (control) and saline (placebo control) in patients suffering from grade II/III knee OA. A total of 168 participants with grade II or III knee OA on the KL scale will be recruited across 53 sites in the USA with 56 participants in each arm and followed for 1 year post-injection. Patient satisfaction, Numeric Pain Rating Scale, Knee Injury and Osteoarthritis Outcome Score, 36-Item Short Form Survey (SF-36), and 7-point Likert Scale will be used to assess the participants. Physical exams, X-rays, and MRI with Magnetic Resonance Observation of Cartilage Repair Tissue score will be used to assess improvement in associated anatomy. DISCUSSION: The study results will provide valuable information into the safety and efficacy of intra-articular administration of Wharton's jelly for grade II/III knee osteoarthritis. The results of this study will also add to the treatment options available for grade II/III OA as well as help facilitate the development of a more focused treatment strategy for patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04711304 . Registered on January 15, 2021.

The Timing of Corticosteroid Injections Following Simple Knee Arthroscopy Is Associated With Infection Risk.

PURPOSE: To examine any association between the timing of ipsilateral postoperative corticosteroid injection following simple knee arthroscopy and infection. METHODS: Private payer (PP) and Medicare (MC) national insurance databases were queried for patients who underwent simple arthroscopic knee procedures. Patients undergoing concomitant open or more complex procedures with grafts were excluded. Patients who underwent ipsilateral corticosteroid injections within 2, 4, 6, and 8 weeks postoperatively were then identified. Postoperative infection within 90 days after the injection was assessed using International Classification of Diseases, 9th Revision, and Current Procedural Terminology coding and compared using a multivariate binomial logistic regression analysis. RESULTS: A total of 5,533 patients were identified, including 725 that received an injection within 2 weeks; 1,236 patients within 4 weeks; 1,716 patients within 6 weeks; and 1,856 patients that received an injection within 8 weeks postoperatively. In both the PP and MC datasets, the rate of infection was significantly higher in the 2-week group compared with the 6- (PP: odds ratio [OR] 3.81, P = .012; MC: OR 9.36, P = .001) and 8-week (PP: OR 8.59, P = .003; MC: OR 7.80, P = .001) groups. The rate of infection was also higher in the 4-week group compared with the 6- (PP: OR 2.54, P = .024; MC: OR 8.91, P = .001) and 8-week (PP: OR 5.64, P = .009; MC: OR 7.80, P = .001) groups. There was no difference in infection rates between the 2- and 4-week groups in either dataset (PP: P = .278; MC: P = .861). CONCLUSIONS: There is a significant association between intra-articular knee corticosteroid injections within 4 weeks of surgery and an increased incidence of postoperative infection in both MC and PP patients after knee arthroscopy compared with patients with steroid injections more than 4 weeks postoperatively and matched controls who did not receive injections. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Risk Factors for Infection After Shoulder Arthroscopy in a Large Medicare Population.

BACKGROUND: Shoulder arthroscopy is well established as a highly effective and safe procedure for the treatment for several shoulder disorders and is associated with an exceedingly low risk of infectious complications. Few data exist regarding risk factors for infection after shoulder arthroscopy, as previous studies were not adequately powered to evaluate for infection. PURPOSE: To determine patient-related risk factors for infection after shoulder arthroscopy by using a large insurance database. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: The PearlDiver patient records database was used to query the 100% Medicare Standard Analytic Files from 2005 to 2014 for patients undergoing shoulder arthroscopy. Patients undergoing shoulder arthroscopy for a diagnosis of infection or with a history of prior infection were excluded. Postoperative infection within 90 days postoperatively was then assessed with International Classification of Diseases, Ninth Revision codes for a diagnosis of postoperative infection or septic shoulder arthritis or a procedure for these indications. A multivariate binomial logistic regression analysis was then utilized to evaluate the use of an intraoperative steroid injection, as well as numerous patient-related risk factors for postoperative infection. Adjusted odds ratios (ORs) and 95% CIs were calculated for each risk factor, with P < .05 considered statistically significant. RESULTS: A total of 530,754 patients met all inclusion and exclusion criteria. There were 1409 infections within 90 days postoperatively (0.26%). Revision shoulder arthroscopy was the most significant risk factor for infection (OR, 3.25; 95% CI, 2.7-4.0; P < .0001). Intraoperative steroid injection was also an independent risk factor for postoperative infection (OR, 1.46; 95% CI, 1.2-1.9; P = .002). There were also numerous independent patient-related risk factors for infection, the most significant of which were chronic anemia (OR, 1.58; 95% CI, 1.4-1.8; P < .0001), malnutrition (OR, 1.42; 95% CI, 1.2-1.7; P = .001), male sex (OR, 2.71; 95% CI, 2.4-3.1; P < .0001), morbid obesity (OR, 1.41; 95% CI, 1.2-1.6; P < .0001), and depression (OR, 1.36; 95% CI, 1.2-1.5; P < .0001). CONCLUSION: Intraoperative steroid injection was a significant independent risk factor for postoperative infection after shoulder arthroscopy. There were also numerous significant patient-related risk factors for postoperative infection, including revision surgery, obesity, male sex, chronic anemia, malnutrition, depression, and alcohol use, among others.

Operative Fixation of an Anterior Inferior Iliac Spine Apophyseal Avulsion Fracture Nonunion in an Adolescent Soccer Player: A Case Report.

CASE: A 14-year-old male competitive soccer player presented with a history of recurrent right hip pain for 18 months. He was diagnosed with an anterior inferior iliac spine (AIIS) apophyseal avulsion fracture nonunion with subspinal impingement, which was confirmed by radiographs, computed tomography, and magnetic resonance imaging. The patient underwent surgical fixation and subspinal decompression. He returned to competitive soccer 5 months postoperatively. CONCLUSION: AIIS apophyseal avulsion fractures occur in adolescent athletes and generally respond to nonoperative treatment. When such management is unsuccessful, surgical fixation can lead to resolution of pain with return of full function.

Traumatic Avulsion of the Serratus Anterior Muscle in a Collegiate Rower: A Case Report.

A 19-year-old female collegiate rower presented with a new, painful mass along her right anterolateral chest wall after competition. The patient was diagnosed with a rupture of the serratus anterior muscle from its costal attachments, as confirmed by magnetic resonance imaging. The patient fully recovered after a period of rest followed by a graduated 2-month physical therapy regimen consisting of stretching and scapulothoracic and core strengthening. A traumatic rupture of the serratus anterior muscle should be suspected in athletes who present with a painful chest wall mass after exertion of large forces through the scapulothoracic region. Athletes can return to play after nonoperative management.

Increased Failure Rates After Anterior Cruciate Ligament Reconstruction With Soft-Tissue Autograft-Allograft Hybrid Grafts.

PURPOSE: To compare the rate of failure between a group of patients who underwent anterior cruciate ligament (ACL) reconstruction with an autograft-allograft hybrid soft-tissue graft and a matched group of patients who underwent ACL reconstruction with hamstring autograft. METHODS: From 2007 to 2012, 29 patients underwent hybrid ACL reconstruction performed by 4 fellowship-trained sports medicine surgeons at a single institution. Patients who underwent ACL reconstruction with hamstring autograft comprised the control group and were matched to patients in the hybrid group by sex, age, date of surgery, reconstruction technique, and method of femoral fixation. Graft failure was defined as revision ACL reconstruction or complete graft rupture on magnetic resonance imaging. Graft compromise was defined as magnetic resonance imaging evidence of partial graft rupture or arthroscopically identified partial graft rupture. Lysholm Knee Scoring Scale and International Knee Documentation Committee scores were obtained. RESULTS: Both groups included 10 men and 19 women, with a mean postoperative follow-up period of 44.4 ± 16.9 months in the hybrid group and 48.0 ± 15.2 months in the control group. Follow-up was obtained in 25 of 29 patients (86.2%) in the hybrid group, and each was matched to 1 patient who received hamstring autograft. The failure rate was 13.8% (4 of 29 patients) in the hybrid group compared with 3.4% (1 of 29) in the control group (P = .160). An additional 27.6% of hybrid group patients (7 of 29) had compromised grafts as defined earlier, as compared with 1 (3.4%) of the control patients (P = .022). Thus the overall hybrid graft failure/compromise rate was 37.9% (11 of 29) compared with 6.9% (2 of 29) for the hamstring autograft group (P = .005). In the hybrid group, the Lysholm score (80.2 ± 12.1) was significantly lower than that in the control autograft ACL group (89.9 ± 11.8) (P = .030). The International Knee Documentation Committee score for the hybrid ACL group (71.26 ± 19.5) was significantly worse than that for the autograft ACL group (85.7 ± 13.0) (P = .012). CONCLUSIONS: Allograft-autograft hybrid hamstring ACL grafts fail or become structurally compromised at a higher rate than matched autograft hamstring controls. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Platelet-rich plasma in meniscal repair: does augmentation improve surgical outcomes?

BACKGROUND: Increased contact stresses after meniscectomy have led to an increased focus on meniscal preservation strategies to prevent articular cartilage degeneration. Platelet-rich plasma (PRP) has received attention as a promising strategy to help induce healing and has been shown to do so both in vitro and in vivo. Although PRP has been used in clinical practice for some time, to date, few clinical studies support its use in meniscal repair. QUESTIONS/PURPOSES: We sought to (1) evaluate whether PRP augmentation at the time of index meniscal repair decreases the likelihood that subsequent meniscectomy will be performed; (2) determine if PRP augmentation in arthroscopic meniscus repair influenced functional outcome measures; and (3) examine whether PRP augmentation altered clinical and patient-reported outcomes. METHODS: Between 2008 and 2011, three surgeons performed 35 isolated arthroscopic meniscus repairs. Of those, 15 (43%) were augmented with PRP, and 20 (57%) were performed without PRP augmentation. During the study period, PRP was used for patients with meniscus tears in the setting of no ACL reconstruction. Complete followup at a minimum of 2 years (mean, 4 years; range, 2-6 years) was available on 11 (73%) of the PRP-augmented knees and 15 (75%) of the nonaugmented knees. Clinical outcome measures including the International Knee Documentation Committee (IKDC) score, Tegner Lysholm Knee Scoring Scale, and return to work and sports/activities survey tools were completed in person, over the phone, or through the mail. Range of motion data were collected from electronic patient charts in chart review. With the numbers available, a post hoc power calculation demonstrated that we would have expected to be able to discern a difference using IKDC if we treated 153 patients with PRP and 219 without PRP assuming an alpha rate of 5% and power exceeding 80%. Using the Lysholm score as an outcome measure, post hoc power estimate was 0.523 and effect size was -1.1 (-2.1 to -0.05) requiring 12 patients treated with PRP and 17 without to find statistically significant differences at p = 0.05 and power = 80%. RESULTS: There was no difference in the proportion of patients who underwent reoperation in the PRP group (27% [four of 15]) compared with the non-PRP group (25% [five of 20]; p = 0.89). Functional outcome measures were not different between the two groups based on the measures used (mean IKDC score, 69; SD, 26 with PRP and 76; SD, 17 without PRP; p = 0.288; mean, Tegner Lysholm Knee Scoring Scale, 66, SD, 32 with PRP and 89; SD, 10 without PRP; p = 0.065). With the numbers available there was no difference in the proportion of patients who returned to work in the PRP group (100% [six of six]) compared with the non-PRP group (100% [nine of nine]) or in the patients who returned to their regular sports/activities in the PRP group (71% [five of seven]) compared with the non-PRP group (78% [seven of nine]; p = 0.75). CONCLUSIONS: Patients who sustain meniscus injuries should be counseled at the time of injury about the outcomes after meniscus repair. With our limited study group, outcomes after meniscus repair with and without PRP appear similar in terms of reoperation rate. However, given the lack of power and nature of the study, modest size differences in outcome may not have been detected. Future larger prospective studies are needed to definitively determine whether PRP should be used with meniscal repair. Additionally, studies are needed to determine if PRP and other biologics may benefit complex tear types. LEVEL OF EVIDENCE: Level III, therapeutic study.

Chronic leg pain in athletes.

Chronic leg pain is commonly treated by orthopaedic surgeons who take care of athletes. The sources are varied and include the more commonly encountered medial tibial stress syndrome, chronic exertional compartment syndrome, stress fracture, popliteal artery entrapment syndrome, nerve entrapment, Achilles tightness, deep vein thrombosis, and complex regional pain syndrome. Owing to overlapping physical examination findings, an assortment of imaging and other diagnostic modalities are employed to distinguish among the diagnoses to guide the appropriate management. Although most of these chronic problems are treated nonsurgically, some patients require operative intervention. For each condition listed above, the pathophysiology, diagnosis, management option, and outcomes are discussed in turn.

Arthroscopic suprapectoral and open subpectoral biceps tenodesis: a comparison of minimum 2-year clinical outcomes.

BACKGROUND: While a vast body of literature exists describing biceps tenodesis techniques and evaluating the biomechanical aspects of tenodesis locations or various implants, little literature presents useful clinical outcomes to guide surgeons in their decision to perform a particular method of tenodesis. PURPOSE/HYPOTHESIS: To compare the clinical outcomes of open subpectoral biceps tenodesis (OSPBT) and arthroscopic suprapectoral biceps tenodesis (ASPBT). Our null hypothesis was that both methods would yield satisfactory results with regard to shoulder and biceps function, postoperative shoulder scores, pain relief, and complications. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent either ASPBT or OSPBT for isolated superior labrum or long head of the biceps lesions with a minimum follow-up of 2 years were evaluated with several validated clinical outcome measures and physical examinations including range of motion and strength. RESULTS: Between 2007 and 2011, a total of 82 patients met all inclusion and exclusion criteria, which included 32 patients with ASPBT and 50 patients with OSPBT; 27 of 32 (84.4%) patients with ASPBT and 35 of 50 (70.0%) patients with OSPBT completed clinical follow-up. Overall outcomes for both procedures were satisfactory. No significant differences were noted in postoperative Constant-Murley (ASPBT: 90.7; OSPBT: 91.8; P = .755), American Shoulder and Elbow Surgeons (ASPBT: 90.1; OSPBT: 88.4; P = .735), Single Assessment Numeric Evaluation (ASPBT: 87.4; OSPBT: 86.8; P = .901), Simple Shoulder Test (ASPBT: 10.4; OSPBT: 10.6; P = .762), long head of the biceps (ASPBT: 91.6; OSPBT: 93.6; P = .481), or Veterans RAND 36-Item Health Survey (ASPBT: 81.0; OSPBT: 80.1; P = .789) scores. No significant range of motion or strength differences was noted between the procedures. CONCLUSION: Both ASPBT and OSPBT yield excellent clinical and functional results for the management of isolated superior labrum or long head of the biceps lesions. No significant differences in clinical outcomes as determined by several validated outcome measures were found between the 2 tenodesis methods, nor were any significant range of motion or strength deficits noted at a minimum 2 years postoperatively.

Increased incidence of postoperative stiffness after arthroscopic compared with open biceps tenodesis.

PURPOSE: To determine the incidence of postoperative stiffness after open and arthroscopic biceps tenodesis, compare the incidence between each method, and determine relevant risk factors for its occurrence. METHODS: A consecutive series of patients who underwent biceps tenodesis during a 3-year period were retrospectively reviewed. RESULTS: We evaluated 249 patients, which included 143 who underwent open subpectoral tenodesis and 106 who underwent arthroscopic suprapectoral tenodesis. The mean overall follow-up period for the arthroscopic group was 9.9 months (range, 5.1 to 33.5 months). The mean overall follow-up period for the open group was 9.5 months (range, 4.7 to 49.2 months). There was no significant difference in overall follow-up duration between groups (P = .627). A significantly increased incidence of postoperative stiffness was found in the arthroscopic group compared with the open group (17.9% v 5.6%, P = .002). Within the arthroscopic group, patients with postoperative stiffness were more frequently female patients than those without stiffness (63.2% v 33.3%, P = .016) and were more likely to be smokers than those without stiffness (36.8% v 16.1%, P = .040). The tenodesis site was located significantly more proximal in the arthroscopic group of patients with postoperative stiffness compared with patients without postoperative stiffness (32.44 ± 7.8 mm from the top of the humeral head v 50.34 ± 7.8 mm, P < .0001). CONCLUSIONS: Our results show a notably increased incidence of postoperative stiffness after arthroscopic suprapectoral biceps tenodesis compared with open subpectoral biceps tenodesis. This appears to occur more commonly in female patients and smokers and may have a relation to the position of the tenodesis, with a more superiorly placed tenodesis site being a potential influencing factor. On the basis of this series, this complication most commonly will improve over time and with symptom-based management. LEVEL OF EVIDENCE: Level III, therapeutic case-control study.

Biceps tenodesis is a viable option for salvage of failed SLAP repair.

BACKGROUND: Outcomes of arthroscopic superior labral anterior-posterior (SLAP) repairs have been well reported with generally favorable outcomes. Unfortunately, a percentage of patients remain dissatisfied or suffer further injury after SLAP repair and may seek additional treatment. The purpose of this study was to evaluate the surgical outcomes of biceps tenodesis for failed SLAP repairs. METHODS: A retrospective review of all patients undergoing biceps tenodesis was completed. Inclusion criteria were previous SLAP repair and subsequent revision biceps tenodesis. Exclusion criteria were additional shoulder procedures including rotator cuff repair, instability procedures, and preoperative frozen shoulder. Objective outcomes were postoperative assessments with Constant score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Veterans RAND 36-Item Health Survey. Physical examination was conducted to determine postoperative range of motion and strength compared with the nonoperative shoulder. RESULTS: A cohort of 24 patients was identified, and of these, 17 patients (71%) completed the study at 2 years' follow-up. The average postoperative Constant score was 84.4; American Shoulder and Elbow Surgeons score, 75.5; Single Assessment Numeric Evaluation score, 73.1%; Simple Shoulder Test score, 9.2; and Veterans RAND 36-Item Health Survey score, 76.1. Postoperative range of motion of the operative shoulder returned to near that of the asymptomatic nonoperative shoulder. Workers' compensation status led to inferior results. CONCLUSIONS: Options for patients with a failed prior SLAP repair are limited. As a salvage operation for failed SLAP repair, biceps tenodesis serves the majority of patients well, with favorable outcomes by validated measures and excellent shoulder range of motion and elbow strength at 2 years' follow-up. Workers' compensation status may predispose patients to poorer outcomes.

Anatomic and radiographic comparison of arthroscopic suprapectoral and open subpectoral biceps tenodesis sites.

BACKGROUND: Arthroscopic suprapectoral and open subpectoral surgical techniques are both commonly utilized approaches for proximal biceps tenodesis of the long head of the biceps brachii. A central limitation to the widespread use of an arthroscopic approach for biceps tenodesis is that the tendon may be tenodesed too proximally in the bicipital groove, leading to persistent pain and tendinopathy. Purpose/ HYPOTHESIS: The purpose of this study was to determine the in vivo tenodesis location using arthroscopic suprapectoral and open subpectoral techniques for proximal biceps tenodesis in relation to clinically pertinent anatomic and radiographic landmarks. The null hypothesis was that arthroscopic suprapectoral biceps tenodesis would not be significantly different in terms of the location from open subpectoral biceps tenodesis. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 20 matched pairs of cadaveric shoulder specimens were randomized such that within each pair, 1 shoulder underwent a standard open subpectoral biceps tenodesis and the other underwent an arthroscopic suprapectoral tenodesis. Limited dissection and exposure of the surgical tunnel site and reference landmarks were subsequently performed, and anteroposterior and lateral radiographs were obtained. Direct measurements were performed anatomically using a digital caliper and radiographically using picture archiving and communication system (PACS) software from the proximal lip of the humeral tunnel to regional landmarks. RESULTS: Both techniques were able to place the humeral tunnel distal to the bicipital groove in all specimens. On average, the open subpectoral approach placed the tunnel 2.2 cm distal to the arthroscopic suprapectoral approach. CONCLUSION: The arthroscopic suprapectoral biceps tenodesis technique used in this study consistently placed the tenodesis tunnel distal to the bicipital groove, which may allay concerns about the bicipital groove as a pain source after this procedure. CLINICAL RELEVANCE: This anatomic study provides new information on tunnel placement in 2 biceps tenodesis techniques. In addition, it provides clinically relevant anatomic and radiographic guidelines using clinically pertinent landmarks. This information may be useful in preoperative planning, intraoperative technique, and postoperative assessment of both open subpectoral and arthroscopic suprapectoral biceps tenodesis.

Femoral tunnel length in primary anterior cruciate ligament reconstruction using an accessory medial portal.

PURPOSE: The purpose of this study was to evaluate tunnel length during independent femoral tunnel drilling using an accessory medial portal with the knee in maximal hyperflexion, and correlate the tunnel length and flexion angle with anthropometric data. METHODS: During a 1-year period, 106 consecutive patients undergoing primary anterior cruciate ligament (ACL) reconstruction were included in the study. All patients underwent independent femoral tunnel drilling using an accessory medial portal with maximal knee hyperflexion. Tunnel length and maximal intraoperative knee flexion angles were measured. Additionally, height, weight, and body mass index (BMI), plus the width and depth of the lateral femoral condyle (LFC), were recorded to correlate with tunnel length and knee flexion angles. RESULTS: Average tunnel length was 37.0 ± 3.3 mm (range, 26 to 45), with all but one tunnel greater than 30 mm. Average knee flexion angle was 134.4 ± 5.0° (range, 122° to 147°). Height (r = 0.5, P < .001) and weight (r = 0.33, P = .001), but not BMI (r = 0.14, P = .17), correlated positively with tunnel length. Width (r = 0.46, P < .001) and depth (r = 0.38, P < .001) of the LFC also correlated positively with tunnel length. Knee flexion angle was not correlated with tunnel length (r = -0.09, P = .39) or width (r = -0.04, P = .7) and depth (r = -0.01, P = .91) of the LFC. Knee flexion angle was negatively correlated with weight (r = -0.44, P < .001) and BMI (r = -0.46, P < .001). CONCLUSIONS: Using an accessory medial portal for independent femoral tunnel drilling, with maximal knee hyperflexion, in ACL reconstruction consistently produced tunnel lengths greater than 30 mm with no posterior wall fractures. Tunnel lengths tend to be longer with increasing patient height, mass, and larger LFC dimensions. Maximum knee flexion angle achieved intraoperatively tends to be less for patients with increasing weight and BMI. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Complications related to anatomic reconstruction of the coracoclavicular ligaments.

BACKGROUND: Anatomic reconstruction of the coracoclavicular (CC) ligaments has become a popular surgical treatment for high-grade acromioclavicular (AC) dislocations, but little has been reported about complications related to these newer surgical techniques. PURPOSE: We sought to review the complications related to several new techniques for the anatomic reconstruction of the CC ligaments for the treatment of AC separations. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We conducted a retrospective review of the operative treatment of AC separation utilizing anatomic reconstruction of the CC ligaments by reviewing the case logs of 3 fellowship-trained orthopaedic surgeons at a single academic sports medicine center for the past 5 years using appropriate current procedural terminology codes. The medical records and postoperative radiographs were assessed for complications. RESULTS: Twenty-seven cases of anatomic reconstruction of the CC ligaments were reviewed. All patients had an autograft or allograft ligament reconstruction utilizing either a coracoid tunnel (10 cases) or a loop around the coracoid base (17 cases). Eight complications (80%) were noted in the coracoid tunnel group including 2 coracoid fractures (20%), 5 patients with some loss of reduction (more than 5-mm increased CC interval displacement on subsequent postoperative radiographs) (50%), and 1 patient with an intraoperative failure of the coracoid button fixation (10%). Six patients developed complications in the coracoid loop group (35%) including 3 clavicle fractures (18% within group, 11% overall), 1 patient with loss of reduction (6%), 1 patient with loss of reduction and an infection (6% within group, 4% overall), and 1 patient with adhesive capsulitis postoperatively (6% within group, 4% overall). CONCLUSION: Newer techniques for the anatomic reconstruction of the CC ligaments may have steep learning curves associated with complications such as coracoid and clavicle fractures. Loss of reduction continues to be associated with the operative treatment of high-grade AC separations. Further refinement of surgical technique and experience with the operative treatment of AC separation is warranted.