Intraobserver and Interobserver Reliability of the Snyder and Expanded SLAP Classification System: A Video Study.

Background: Superior labral anterior and posterior (SLAP) tears are a common finding in overhead athletes. The original classification system produced by Snyder in 1990 contained 4 types of SLAP tears and was later expanded to 10 types. The classification has been challenging because of inconsistencies between surgeons making diagnoses and treatments based on the diagnosis. Furthermore, patient factors-such as age and sports played-affect the treatment algorithms, even across similarly classified SLAP tears. Purpose: To (1) assess the interobserver and intraobserver reliability of the Snyder and expanded SLAP (ESLAP) classification systems and (2) determine the consistency of treatment for a given SLAP tear depending on different clinical scenarios. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 20 arthroscopic surgical videos and magnetic resonance imaging scans of patients with SLAP tears were sent to 20 orthopaedic sports medicine surgeons at various stages of training. Surgeons were asked to identify the type of SLAP tear using the Snyder and ESLAP classifications. Surgeons were then asked to determine the treatment for a SLAP tear using 4 clinical scenarios: (1) in the throwing arm of an 18-year-old pitcher; (2) in the dominant arm of an 18-year-old overhead athlete; (3) a 35-year-old overhead athlete; (4) or a 50-year-old overhead athlete. Responses were recorded, and the cases were shuffled and sent back 6 weeks after the initial responses. Results were then analyzed using the Fleiss kappa coefficient (κ) to determine interobserver and intraobserver degrees of agreement. Results: There was moderate intraobserver reliability in both the Snyder and ESLAP classifications (κ = 0.52) and fair interobserver reliability for both classification systems (Snyder, κ = 0.31; ESLAP, κ = 0.30; P < .0001) among all surgeons. Additionally, there was only fair agreement (κ = 0.30; P < .0001) for the treatment modalities chosen by the reviewers for each case. Conclusion: This study demonstrated that SLAP tears remain a challenging problem for orthopaedic surgeons in diagnostics and treatment plans. Therefore, care should be taken in the preoperative discussion with the patient to consider all the possible treatment options because this may affect the postoperative recovery period and patient expectations.

Clinical Evaluation of an Arthroscopic Knotless Suprapectoral Biceps Tenodesis Technique: Loop 'n' Tack Tenodesis.

BACKGROUND: Pathology of the long head of the biceps tendon is a well-known cause of shoulder pain that is commonly managed with arthroscopic suprapectoral biceps tenodesis when conservative treatment fails. PURPOSE: To present an arthroscopic knotless suprapectoral biceps tenodesis technique known as "Loop 'n' Tack" tenodesis and to report the clinical outcomes of patients with a minimum 2 years of follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of all patients who had undergone Loop 'n' Tack tenodesis between January 2009 and May 2014 was completed. Charts were reviewed, and patients were contacted for demographic data, time from surgery, concomitant procedures, and workers' compensation status, as well as visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and University of California, Los Angeles (UCLA) scores. RESULTS: Complete follow-up evaluations were performed for 59 of 68 patients (87%). Mean follow-up was 43 months. A majority (88%) of patients had at least 1 additional procedure performed at the time of biceps tenodesis. The mean ASES shoulder score improved from 42.6 preoperatively to 91.0 postoperatively (P < .001), and 54 of 59 patients (91.5%) had a good/excellent outcome, with a UCLA shoulder score >27 and ASES shoulder score >70. Three patients (5%) reported biceps cramping pain with overuse, and 2 (3.3%) reported intermittent anterior shoulder pain. No patients had developed a "Popeye" deformity at final clinical examination, and 97% reported that they were overall satisfied with the procedure. CONCLUSION: The Loop 'n' Tack tenodesis technique results in a high rate of patient satisfaction, significant improvement in shoulder outcome scores, and a low incidence of postoperative pain, with no reoperations for biceps-related pathology.

Biomechanical Comparison of Fixed-Loop and Adjustable-Loop Cortical Suspensory Devices for Metaphyseal Femoral-Sided Soft Tissue Graft Fixation in Anatomic Anterior Cruciate Ligament Reconstruction Using a Porcine Model.

PURPOSE: To compare the displacement, stiffness, and ultimate failure load of a fixed-loop cortical suspensory device with 2 adjustable-loop devices when positioned on metaphyseal bone. METHODS: Thirty devices (10 of each device) were positioned on the metaphyseal cortex of 30 porcine femora simulating anatomic anterior cruciate ligament femoral tunnel placement. Bovine tendons were used for soft tissue grafts, and the constructs were then cycled 1,000 times and pulled to failure, measuring displacement, stiffness, and failure load. RESULTS: Initial displacement, cyclic displacement, and total displacement were 2.98 mm, 2.09 mm, and 5.08 mm for the Endobutton CL (ECL), 2.82 mm, 2.27 mm, and 5.09 mm for the Tightrope (TRT), and 4.25 mm, 3.19 mm, and 7.44 mm for the adjustable-loop ToggleLoc Inline with Ziploop (TLZ), respectively. There was no difference between the ECL and the TRT on any measured outcome. Differences between the TLZ and ECL were statistically significant (initial displacement P = .024, cyclic displacement P < .001, and total displacement P < .001), as were those between the TLZ and TRT (initial displacement P = .010, cyclic displacement P = .001, and total displacement P < .001). Failure loads were 804 N, 801 N, and 682 N for the TRT, ECL, and TLZ, respectively, with no statistically significant difference. CONCLUSIONS: When positioned on the metaphyseal cortex, there was no difference in the biomechanical performance of the fixed-loop ECL and adjustable-loop TRT, and no lengthening of the TRTs was observed during cycling. However, the TLZ showed statistically significantly lower stiffness and more displacement during cycling with lengthening of the adjustable loop, the clinical significance of which is unknown. CLINICAL RELEVANCE: When used for femoral-sided soft tissue graft fixation in an anatomically placed femoral tunnel, the adjustable-loop TRT was biomechanically equivalent to the fixed-loop ECL. However, the adjustable-loop TLZ showed displacement during biomechanical testing that could potentially contribute to clinical failure after anterior cruciate ligament reconstruction. However, the clinical significance was not directly tested.

Outcomes of Bankart Repairs Using Modern Arthroscopic Technique in an Athletic Population.

PURPOSE: To report a large number of highly active patients who underwent arthroscopic Bankart repair at our institution over the last decade. METHODS: A retrospective analysis of patients who underwent primary and revision arthroscopic Bankart repairs using bioabsorbable anchors was performed. Outcome measures included recurrence of dislocation, American Shoulder and Elbow Scores (ASES), Rowe, visual analog scale (VAS), return to sports, and satisfaction scores. RESULTS: A total of 94 shoulders met the inclusion criteria. The recurrence rate was 6/94 (6.4%) at a mean follow-up of 5 years (range, 3 to 8.3). The mean postoperative scores were as follows: ASES = 91.5/100; Rowe = 84.3/100; VAS = 0.8/10; satisfaction = 8.8/10. In those who attempted to return to sports, 82.5% were able to return to the same level of competition. Statistical analyses revealed a significant increase in risk of recurrence among high school and recreational athletes. No recurrences were observed among professional or college-level athletes. No significant difference in recurrence rates was observed in regards to age, time to surgery, type of athlete (collision v limited contact), repair of SLAP lesion, number of anchors, or revision surgery. CONCLUSIONS: Although several repair techniques exist for traumatic anterior shoulder instability, arthroscopic repair remains a viable option even in a highly active patient population. This study uniquely identified high school and recreational athletes at higher risk for recurrence. This is perhaps due to inferior shoulder development and technique as well as to limited access to postoperative physical therapy. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Hypertension attenuates cell-to-cell communication in hamster retractor muscle feed arteries.

This study examined whether hypertension attenuated cell-to-cell communication in skeletal muscle resistance arteries. Briefly, arteries feeding the retractor muscle of normotensive and hypertensive hamsters were cannulated, pressurized, and superfused with a physiological saline solution. Cell-to-cell communication was functionally assessed by application of vasoactive stimuli (via micropipette) to a small portion of a feed artery while diameter at sites distal to the point of agent application was monitored. In keeping with past observations, discrete application of a smooth muscle depolarizing agent (phenylephrine or KCl) elicited a localized vasoconstriction that conducted poorly along feed arteries from normotensive hamsters. In contrast, acetylcholine, an agent known to hyperpolarize endothelial cells, elicited a vasodilation in normotensive feed arteries that conducted with little decay. Whereas smooth muscle depolarizing agents continued to elicit a localized response, conduction of endothelium-dependent vasodilation was attenuated in hypertensive hamsters. This decrease occurred in the absence of changes in vessel reactivity to intravascular pressure or to global application of phenylephrine, U-46619, or acetylcholine. We propose, on the basis of these physiological observations, quantitative mRNA measurements of connexins 37, 40, 43, and 45, and analysis of the literature, that an increase in endothelial-to-endothelial or smooth muscle-to-endothelial coupling resistance is likely responsible for hypertension-induced impairment in vascular communication. We hypothesize that this attenuation could contribute to the rise in total peripheral resistance characteristically observed in hypertension.