Reverse shoulder arthroplasty for massive rotator cuff tears without glenohumeral arthritis can improve clinical outcomes despite history of prior rotator cuff repair: A systematic review.

IMPORTANCE: Reverse shoulder arthroplasty (RSA) is often used to surgically address massive irreparable rotator cuff tears (MIRCT) without arthritis. The impact of prior attempted rotator cuff repair (RCR) on outcomes is unclear. OBJECTIVE: The purpose of this systematic review was to compare functional outcomes, range of motion, and complications in patients with a MIRCT without arthritis who underwent RSA as a primary procedure versus after prior RCR. EVIDENCE REVIEW: A systematic review was performed on RSA for a MIRCT. The search was conducted from February to March of 2022 using the MEDLINE database. Patient-reported outcome measures (PROs), range of motion (ROM), and complications were extracted. These outcomes were weighted and analysed based on whether the reverse was performed as the primary procedure or following a prior RCR. FINDINGS: Seven studies were included in the analysis, consisting of 343 cases in the primary RSA group and 95 cases in the prior RCR group, with a mean follow-up of 40.8 months. There were no demographic differences between cohorts. Postoperative PROs and ROM were comparable between groups, although the prior RCR group had a higher maximal percentage of improvement (MPI%) for the Constant-Murley Score and Simple Shoulder Test. There was a higher risk for complications (relative risk [RR] 6.26) and revisions (RR 3.91) in the prior RCR group. The most common complications were acromial stress fractures and prosthetic dislocation. CONCLUSION AND RELEVANCE: Patients undergoing RSA for MIRCT following a prior RCR have functional outcomes that are largely comparable to those who have a primary RSA, but they may be at higher risk of complications and revision. LEVEL OF EVIDENCE: IV.

Rip-Stop Fixation Constructs for Rotator Cuff Repair.

In arthroscopic rotator cuff repair, poor tendon quality, medially based tears, lateral tendon loss, or limited tendon mobility can all preclude the use of double-row suture constructs, presenting a challenge in achieving secure fixation and tendon-to-bone healing. Rip-stop suture configurations can be used in these settings to improve resistance to tissue cutout and provide enhanced biomechanical characteristics compared with standard single-row repairs. The load-sharing rip-stop technique uses 2 double-loaded medial suture anchors, which are placed adjacent to the articular margin, and 1 rip-stop suture tape, which is independently secured to bone with 2 lateral knotless anchors. The load-sharing rip-stop technique has been shown to improve ultimate load to failure by 1.7 times compared with a single-row repair. Clinically, this technique has been associated with a 53% healing rate of large and massive rotator cuff tears, compared with only 11% healing when using single-row repair. A completely knotless variation rip-stop configuration also has been described and shown to be biomechanically equivalent to a single-row repair with triple-loaded anchors. For surgeons desiring a single-row repair only, the knotless rip-stop therefore presents an advantage by eliminating the need for knot-tying and decreasing operative time.

A Step-by-Step Approach to Arthroscopic Repair of Massive Rotator Cuff Tears.

Arthroscopic repair of massive rotator cuff tears can be technically challenging but is achievable in many cases. Performing adequate releases are important for successful tendon mobility and avoiding excessive tension in the final repair, thus restoring the native anatomy and biomechanics. This Technical Note provides a step-by-step approach to release and mobilize massive rotator cuff tears to or near anatomical tendon footprints.

Arthroscopically Assisted Tensionable Cerclage Reconstruction of an Acromioclavicular Separation With Combined Fixation of the Coracoclavicular and Acromioclavicular Ligaments.

A variety of surgical techniques are currently available to manage high-grade acromioclavicular (AC) separations, including hook plates/wires, nonanatomic ligament reconstruction, and anatomic cerclage with or without biological augmentation. Traditional reconstructions focused on the coracoclavicular ligaments alone and often were associated with high rates of recurrent deformity. Biomechanical and clinical data have suggested that additional fixation of the AC ligaments is beneficial. This Technical Note describes an arthroscopically assisted approach for combined reconstruction of the coracoclavicular and AC ligaments with a tensionable cerclage.

Short-term functional outcomes of reverse shoulder arthroplasty following three-dimensional planning is similar whether placed with a standard guide or patient-specific instrumentation.

BACKGROUND: Preoperative assessment of the glenoid and surgical placement of the initial guidewire are important in implant positioning during reverse total shoulder arthroplasty (rTSA). Three-dimensional (3D) computed tomography and patient-specific instrumentation (PSI) have improved the placement of the glenoid component, but the impact on clinical outcomes remains unclear. The purpose of this study was to compare short-term clinical outcomes after rTSA based on an intraoperative technique for central guidewire placement in a cohort of patients who had preoperative 3D planning. METHODS: A retrospective matched analysis was performed from a multicenter prospective cohort of patients who underwent rTSA with preoperative 3D planning and a minimum of 2-year clinical follow-up. Patients were divided into 2 cohorts based on the technique used for glenoid guide pin placement: (1) standard manufacture guide (SG) that was not customized or (2) PSI. Patient-reported outcomes (PROs), active range of motion, and strength measures were compared between the groups. The American Shoulder and Elbow Surgeons score was used to assess the minimum clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state. RESULTS: One hundred seventy-eight patients met the study criteria: 56 underwent SGs and 122 underwent PSI. There was no difference in PROs between cohorts. There were no significant differences in the percentage of patients who achieved an American Shoulder and Elbow Surgeons minimum clinically important difference, substantial clinical benefit, or patient acceptable symptomatic state. Improvements in internal rotation to the nearest spinal level (P < .001) and at 90° (P = .002) were higher in the SG group, but likely explained by differences in glenoid lateralization used. Improvements in abduction strength (P < .001) and external rotation strength (P = .010) were higher in the PSI group. CONCLUSION: rTSA performed after preoperative 3D planning leads to similar improvement in PROs regardless of whether an SG or PSI is used intraoperatively for central glenoid wire placement. Greater improvement in postoperative strength was observed with the use of PSI, but the clinical significance of this finding is unclear.

Lesser Tuberosity Osteotomy Healing in Stemmed and Stemless Anatomic Shoulder Arthroplasty Is Higher with a Tensionable Construct and Affected by Body Mass Index and Tobacco Use.

BACKGROUND: This study compared the healing rates of lesser tuberosity osteotomy (LTO) for anatomic total shoulder arthroplasty (TSA), repaired with either standard knot tying or a tensionable construct. Second, we evaluated LTO healing in stemmed and stemless prostheses and identified the patient characteristics associated with healing. METHODS: An analysis of consecutive primary TSAs approached with an LTO performed by a single surgeon between 2016 and 2020 was conducted. In the first two years of the study period, the LTOs were repaired with four #2 polyblend sutures passed through drill tunnels and around a short press-fit stem, followed by manual knot tying. Subsequently, a tensionable construct with suture tapes (TCB) was universally adopted. The radiographic appearance of the LTO was evaluated at a minimum of six months postoperatively. RESULTS: A total of 340 patients met the study criteria, including 168 with manual knot tying, 84 TCB repairs with a stemmed implant, and 88 TCB repairs with a stemless implant. There was no difference in the baseline demographics between the groups. The LTO healing rate of the manual knot tying group (85%) was lower than that of the stemmed (95%) and stemless (98%) TCB groups (p < 0.001). When directly comparing the LTO healing between the stemmed and stemless TCB groups, the differences were not significant (p = 0.44). Across all constructs, the body mass index (BMI) was higher in the displaced nonunion group (p = 0.04), with a failure rate of 9.4% for a BMI between 30 and 40, 12.5% for a BMI between 40 and 50, and 28.6% for a BMI > 50. The rate of tobacco use was higher in the displaced nonunion group (p = 0.037). CONCLUSION: A tensionable construct improves LTO healing compared to manual knot tying, irrespective of the implant type. In addition to the surgical technique, the patient factors that influence tuberosity healing include a greater BMI and tobacco use. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Arthroscopic Rotator Cuff Repair: A Review of Surgical Techniques and Outcomes.

Arthroscopic rotator cuff repair (ARCR) has become the gold standard management for rotator cuff repair. Double-row repairs have shown increased biomechanical strength and enhanced anatomic footprint coverage. The advancement of knotless techniques has led to decreased operating room time and reduced overall costs. We prefer a suture-bridging double-row repair for most rotator cuff repairs and incorporate a knotless medial mattress sutures (double-pulley technique) for additional support as needed.

Arthroscopic Bankart Repair With Remplissage as an Alternative to Latarjet for Anterior Glenohumeral Instability With More Than 15% Glenoid Bone Loss.

Background: Surgical management of anterior shoulder instability continues to evolve. The clinical effectiveness of arthroscopic Bankart repair with remplissage (REMP) in patients with increasing glenoid bone loss (GBL) has not been thoroughly compared with Latarjet. Purpose/Hypothesis: The purpose of this study was to compare 2-year outcomes of REMP versus open Latarjet in patients with >15% GBL. We hypothesized that there would be no difference. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter, retrospective study was performed on a consecutive series of patients who underwent primary REMP or Latarjet by 4 shoulder specialists between August 2013 and December 2019 for >15% GBL. Procedure performance was based on shared decision making between the surgeon and patient. Baseline and 2-year postoperative range of motion (ROM) and the following patient-reported outcomes (PROs) were collected: Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation, and visual analog scale for pain. Return to sport, satisfaction, complications, recurrence, and revisions were reviewed. Results: A total of 47 patients were available for study, including 22 who underwent REMP and 25 who underwent Latarjet. Baseline demographic characteristics, ROM, and PROs were similar between the groups. Mean preoperative GBL (REMP 25.8% ± 7.8% vs Latarjet 25.1% ± 9.0%; P = .800) and off-track lesions (REMP 59.1% vs Latarjet 44.0%; P = .302) were similar. Postoperative change in external rotation favored Latarjet (10° ± 22° vs -4° ± 13°; P = .017). Postoperative PROs, return to the sports (86.4% vs 87.5%; P = .99), and satisfaction (95.5% vs 95.8%; P = .99) were similar between groups. There were no recurrent dislocations in either group. One infected hematoma was encountered in the Latarjet cohort. Conclusion: At short-term follow-up, the hypothesis was upheld. REMP and Latarjet provided similar outcomes for patients with >15% GBL, although REMP patients experienced slightly decreased external rotation. Although larger series and longer-term follow-ups are required, remplissage may be considered in patients with >15% glenoid bone loss.

Arthroscopic Remplissage for the Treatment of Anterior Shoulder Instability: Current and Evolving Concepts.

➢: A Hill-Sachs lesion (HSL) is a compression fracture on the posterolateral humeral head that can increase the risk of recurrent shoulder instability after isolated arthroscopic Bankart repair. ➢: Remplissage involves capsulotenodesis of the infraspinatus tendon and posterior capsule into the HSL to prevent its engagement with the glenoid rim through extra-articular conversion and restraint against humeral head anterior translation. ➢: The glenoid track concept can be applied preoperatively and intraoperatively to evaluate risk of recurrence and help direct clinical management options for recurrent shoulder instability. ➢: Recent literature supports expanding indications for remplissage to include patients with on-track HSLs who are at increased risk of recurrence including collision athletes, military personal, and patients with joint hyperlaxity. ➢: New techniques and suture constructs have demonstrated improved biomechanical strength while avoiding the need to access the subacromial space.

Consideration May Be Given to Lowering the Threshold for the Addition of Remplissage in Patients With Subcritical Glenoid Bone Loss Undergoing Arthroscopic Bankart Repair.

Purpose: Treatment for patients with anterior glenohumeral instability with subcritical bone loss is evolving. The purpose of this study was to compare 2-year outcomes of arthroscopic Bankart repair with and without Hill-Sachs remplissage in patients with <15% glenoid bone loss. Methods: A multicenter retrospective study was performed on a consecutive series of patients who underwent primary isolated arthroscopic Bankart repair (IBR) or arthroscopic Bankart repair with remplissage (REMP) by 4 shoulder specialists between 2013 and 2019. Range of motion (ROM) and patient-reported outcomes (PROs) were collected at baseline and 2 years postoperative: Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation, and visual analog scale for pain. Recurrence, return to sport, satisfaction, complications, and revisions also were reviewed. Results: A total of 123 patients were available, including 75 IBR and 48 REMP. Baseline demographics, activity, ROM, and PROs were similar. Mean glenoid bone loss (2.5% vs 6.1%: P < .001) was greater in REMP, although the number of on-track lesions was similar (98.7% vs 93.8%: P = .298). WOSI scores were improved for REMP (196.5 vs 42.7: P = .004), but otherwise no difference in postoperative PROs or ROM. Differences between cohorts did not reach significance in return to sport (73% vs 83%: P = .203), recurrence (9.3% vs 2.1%: P = .148), or revisions (6.8% vs 2.1%: P = .403). For on-track lesions there were 6 recurrences in IBR (6 of 74; 8.1%) and 1 recurrence in REMP (1 of 45; 2.2%). Conclusions: Despite slightly worse pathology, patients with subcritical bone loss who undergo REMP experience similar short-term postoperative function to isolated IBR. Recurrence, revision, and return to sport favored REMP but this study was underpowered to show statistical significance. Recurrence was common following IBR, despite subcritical glenoid bone loss and primarily on-track lesions, suggesting that REMP can be considered in on-track lesions. Level of Evidence: III, retrospective comparative study.

Remplissage Yields Similar 2-Year Outcomes, Fewer Complications, and Low Recurrence Compared to Latarjet Across a Wide Range of Preoperative Glenoid Bone Loss.

PURPOSE: The purpose of this study was to compare functional outcome, return to sport, satisfaction, postoperative recurrence, and complications in patients undergoing primary arthroscopic Bankart repair with remplissage (ABR) to primary Latarjet. METHODS: A multicenter retrospective study was performed on patients undergoing primary ABR or open Latarjet between 2013 and 2019 who had a minimum 2-year follow-up. Baseline and two-year range of motion (ROM), patient-reported outcomes (PROs: Western Ontario Shoulder Instability Index [WOSI], Single Assessment Numeric Evaluation [SANE], and visual analog scale [VAS] for pain) recurrence, return to sport, satisfaction, and complications were reviewed. RESULTS: This study included 258 patients, including 70 ABRs and 188 Latarjet procedures. Baseline demographics, ROM, and PROs were similar. Mean preop glenoid bone loss (GBL) (12.3% ± 10.9% vs 7.6% ± 9%; P < .001) and off-track lesions (23% vs 13%; P = .046) were higher in the ABR group, while preoperative GBL range was similar (0-42% vs 0-47%). Changes in the VAS (1.9 vs 0.9; P = .019) and WOSI (1096 vs 805; P < .001) were improved in ABR. The percentage of patients who achieved a minimal clinically important difference was improved in WOSI for ABR and PASS for ABR in SANE, VAS, and WOSI scores. The ABR cohort reported worse changes in external rotation (ER) (-4° vs +19°; P < .001). Return to sport among overhead and contact athletes favored ABR (91.5% vs 72.7%; P = .007). Satisfaction and recurrent dislocation were similar. Surgical complications were observed in 0% of ABR cases, compared to 5.9% in the Latarjet group. CONCLUSION: Primary ABR resulted in 2-year functional outcomes that were as good or superior to primary Latarjet, with higher return to sport for overhead and contact activities, fewer complications, and comparably low recurrence rates, even despite greater bipolar bone loss in the ABR cohort. However, this comes at the expense of decreased external rotation, which may be considered in individual patients. LEVEL OF EVIDENCE: III, retrospective comparative study.

Suprapatellar versus infrapatellar approach for intramedullary nail fixation of tibial shaft fractures: a review of the literature.

Semi-extended suprapatellar intramedullary nail fixation of tibial fractures has recently been gaining popularity. Several recent studies and meta-analyses compare the outcomes of the suprapatellar approach with the traditional infrapatellar approach. Despite concerns with intra-articular placement of instruments, studies show the suprapatellar approach to be a safe alternative. Several articles conclude that the suprapatellar approach may be superior to the infrapatellar approach. This review discusses recent findings comparing suprapatellar and infrapatellar approaches for nail insertion.

Compressed autograft biceps tendon augmentation of subscapularis repair following shoulder arthroplasty.

Subscapularis integrity is correlated with function following shoulder arthroplasty. Failure of healing, particularly following anatomic total shoulder arthroplasty, is associated with poor outcomes and the need for revision. Graft augmentation has been used to increase healing following rotator cuff repair but has not been commonly advocated for augmenting the subscapularis following shoulder arthroplasty. The long head biceps tendon is typically tenodesed and discarded during shoulder arthroplasty. Rather than discarding the tendon, the tendon may be compressed and applied to the subscapularis as a biologic scaffold to potentially improve subscapularis healing following shoulder arthroplasty.