Promising Outcomes of Suture Tape Augmentation in Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction.

The management of anterior cruciate ligament (ACL) injuries continually evolves with new interest in all-sort tissue quadriceps tendon autograft, and new interest in suture tape augmentation of the graft, particularly in high-risk patients with young age; female sex; lower limb alignment, tibial, or femoral abnormalities; hyperlaxity; concomitant meniscal and/or additional ligamentous injuries; or participation in high-risk sports. Load sharing suture tape enhances biomechanical stability of the reconstructed ACL, especially during the initial ingrowth and ligamentization phase, and biomechanical evidence highlights reduced risk of graft elongation and failure under the loads encountered during daily physical activities and sport. Optimal tape tensioning could be in knee hyperextension, when the ACL is at maximal length, to avoid overconstraint. Two-year published outcomes of this technique are excellent. Current comparative studies, however, have not shown superiority. Additional controlled studies, and studies with longer term follow-up are needed, as well as comparison to extra-articular tenodesis augmentation.

Minimum 5-Year Clinical and Return-to-Sport Outcomes After Primary Arthroscopic Scapulothoracic Bursectomy and Partial Scapulectomy for Snapping Scapula Syndrome.

BACKGROUND: Snapping scapula syndrome (SSS) is a rare condition that is oftentimes debilitating. For patients whose symptoms are resistant to nonoperative treatment, arthroscopic surgery may offer relief. Because of the rarity of SSS, reports of clinical outcomes after arthroscopic SSS surgery are primarily limited to small case series and short-term follow-up studies. PURPOSE: To report minimum 5-year clinical and sport-specific outcomes after arthroscopic bursectomy and partial scapulectomy for SSS and to identify demographic and clinical factors at baseline associated with clinical outcomes at minimum 5-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent arthroscopic bursectomy and partial scapulectomy for SSS between October 2005 and February 2016 with a minimum of 5 years of postoperative follow-up were enrolled in this single-center study. Clinical outcome scores, including the 12-Item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) score for pain, were collected at a minimum 5-year follow-up. Additionally, it was determined which patients reached the minimal clinically important difference. Bivariate analysis was used to determine whether baseline demographic and clinical factors had any association with the outcome scores. RESULTS: Of 81 patients eligible for inclusion in the study, follow-up was obtained for 66 patients (age 33.6 ± 13.3 years; 31 female). At a mean follow-up of 8.9 ± 2.5 years (range, 5.0-15.4 years), all of the outcome scores significantly improved compared with baseline. These included the ASES (from 56.7 ± 14.5 at baseline to 87.2 ± 13.9 at follow-up; P < .001), QuickDASH (from 38.7 ± 17.6 to 13.1 ± 14.6; P < .001), SANE (from 52.4 ± 21.2 to 82.7 ± 19.9; P < .001), SF-12 Physical Component Summary (from 39.7 ± 8.3 to 50.3 ± 8.2; P < .001), SF-12 Mental Component Summary (from 48.2 ± 11.7 to 52.0 ± 9.0; P = 0.014) and VAS pain (from 5.2 ± 2.1 to 1.4 ± 2.0; P < .001). The minimal clinically important difference in the ASES score was reached by 77.6% of the patients. Median postoperative satisfaction was 8 out of 10. It was found that 90.5% of the patients returned to sport, with 73.8% of the patients able to return to their preinjury level. At the time of final follow-up, 8 (12.1%) patients had undergone revision surgery for recurrent SSS symptoms. Older age at surgery (P = .044), lower preoperative SF-12 Mental Component Summary score (P = .008), lower preoperative ASES score (P = .019), and increased preoperative VAS pain score (P = .016) were significantly associated with not achieving a Patient Acceptable Symptom State on the ASES score. CONCLUSION: Patients undergoing arthroscopic bursectomy and partial scapulectomy for SSS experienced clinically significant improvements in functional scores, pain, and quality of life, which were sustained at a minimum of 5 years and a mean follow-up of 8.9 years postoperatively. Higher patient age, inferior mental health status, increased shoulder pain, and lower ASES scores at baseline were significantly associated with worse postoperative outcomes.

Malrotated lateral knee radiographs do not allow for a proper assessment of medial or lateral posterior tibial slope.

PURPOSE: The aim of this study was to investigate whether malrotation of lateral knee radiographs influences posterior tibial slope (PTS) measurements. METHODS: Lateral knee radiographs of all patients who underwent knee surgery at a single institution between June 2022 and January 2023 and received multiple lateral knee radiographs were included. Radiographs were categorised as malrotated lateral knee radiographs or lateral knee radiographs based on the radiographic distance between the medial and lateral posterior femoral condyles. Medial PTS (MPTS) and lateral PTS (LPTS) were evaluated on malrotated lateral knee radiographs and lateral knee radiographs and compared using the paired t test. Intra- and interrater reliability between four raters were assessed for MPTS and LPTS measurements. RESULTS: A total of 92 lateral knee radiographs (46 pairs of malrotated lateral knee radiographs and lateral knee radiographs; 50.0% right side) from 46 patients (33.2 ± 12.4 years, 69.6% male) were included. Mean posterior femoral condyle distance in malrotated lateral knee radiographs was 8.1 ± 4.4 mm. Overall, MPTS and LPTS were significantly higher on malrotated lateral knee radiographs versus lateral knee radiographs (medial: 10.5 ± 3.2° vs. 9.7 ± 3.5°, p < 0.05; lateral: 10.6 ± 3.4° vs. 9.7 ± 3.3°, p < 0.05). Mean absolute difference between MPTS and LPTS on malrotated lateral knee radiographs versus lateral knee radiographs were |1.9| ± |1.5|° and |2.0| ± |1.8|°, respectively. Intrarater reliability was 'moderate' and interrater reliability was 'good' for both MPTS and LPTS. CONCLUSION: Malrotation of lateral knee radiographs led to a significant distortion of both the MPTS and LPTS. In clinical practice, attention should be placed on the (mal)rotation of lateral knee radiographs, especially in patients for whom a slope-correcting osteotomy is being discussed. LEVEL OF EVIDENCE: Level IV.

Tibiofemoral Subluxation on Radiograph as a Predictor of Location and Size of Osteochondritis Dissecans Lesions of the Knee.

Background: Lower limb malalignment has been associated with osteochondritis dissecans (OCD). However, the location of the OCD lesion often is not concordant with the mechanical leg axis. Other potentially modifiable alignment parameters may influence the propensity for impingement of the femoral condyles. Purpose: To assess differences in lower limb alignment (LLA) and relative tibiofemoral position between patients with medial (MFC-OCD) or lateral OCD (LFC-OCD) of the femoral condyle. Study Design: Cohort study; Level of evidence, 3. Methods: Patients ≤30 years old who were diagnosed with unicondylar OCD between January 2010 and January 2020 were eligible for this study. Included were 55 patients (age, 20.8 ± 4.5 years)-46 with MFC-OCD and 9 with LFC-OCD. Preoperative standing long-leg radiographs were studied to obtain primary outcomes-including LLA and mechanical alignment analyses-and secondary outcomes-including knee joint obliquity angle; rotation angle; medial, central (c-subluxation), and lateral subluxation (L-subluxation) of the tibia relative to the femur in the coronal plane; and tibiofemoral joint line center distance (TFJCD). Results: With regard to primary outcomes, LLA was significantly different between MFC-OCD (1.7°± 3.1° varus) and LFC-OCD (2.7 ± 3.1° valgus) (P < .001), and 78% (36/46) of patients with MFC-OCD had varus alignment, whereas 78% (7/9) of patients with LFC-OCD had valgus alignment (P < 0.002). With regard to secondary outcomes, patients with MFC-OCD had a more medial tibial position in relation to the femur, with a significantly smaller rotation angle (5.6°± 2.4° vs 9.6°± 3.6°; P < .001), a smaller C-subluxation (7.2 ± 6.6 vs 14.9 ± 8.8 mm; P < .01), a smaller L-subluxation (2.3 ± 2.6 vs 4.4 ± 2.7 mm; P < .05), and reduced TFJCD (3.5 ± 1.7 vs 6.6 ± 1.8 mm; P < .001) compared with the LFC-OCD group. For patients with MFC-OCD, the size of the OCD was significantly correlated with C-subluxation (r = 0.412; P = .006). Conclusion: LLA was significantly different according to OCD location. In patients with MFC-OCD, the tibia was subluxated medially, resulting in a change of joint geometry by approximation of the medial tibial eminence toward the medial femoral condyle, potentially causing excessive pressure overload and microtrauma of the cartilage. Interestingly, the extent of subluxation was correlated with OCD size.

Multicentric development and validation of a multi-scale and multi-task deep learning model for comprehensive lower extremity alignment analysis.

Osteoarthritis of the knee, a widespread cause of knee disability, is commonly treated in orthopedics due to its rising prevalence. Lower extremity misalignment, pivotal in knee injury etiology and management, necessitates comprehensive mechanical alignment evaluation via frequently-requested weight-bearing long leg radiographs (LLR). Despite LLR's routine use, current analysis techniques are error-prone and time-consuming. To address this, we conducted a multicentric study to develop and validate a deep learning (DL) model for fully automated leg alignment assessment on anterior-posterior LLR, targeting enhanced reliability and efficiency. The DL model, developed using 594 patients' LLR and a 60%/10%/30% data split for training, validation, and testing, executed alignment analyses via a multi-step process, employing a detection network and nine specialized networks. It was designed to assess all vital anatomical and mechanical parameters for standard clinical leg deformity analysis and preoperative planning. Accuracy, reliability, and assessment duration were compared with three specialized orthopedic surgeons across two distinct institutional datasets (136 and 143 radiographs). The algorithm exhibited equivalent performance to the surgeons in terms of alignment accuracy (DL: 0.21 ± 0.18°to 1.06 ± 1.3°vs. OS: 0.21 ± 0.16°to 1.72 ± 1.96°), interrater reliability (ICC DL: 0.90 ± 0.05 to 1.0 ± 0.0 vs. ICC OS: 0.90 ± 0.03 to 1.0 ± 0.0), and clinically acceptable accuracy (DL: 53.9%-100% vs OS 30.8%-100%). Further, automated analysis significantly reduced analysis time compared to manual annotation (DL: 22 ± 0.6 s vs. OS; 101.7 ± 7 s, p ≤ 0.01). By demonstrating that our algorithm not only matches the precision of expert surgeons but also significantly outpaces them in both speed and consistency of measurements, our research underscores a pivotal advancement in harnessing AI to enhance clinical efficiency and decision-making in orthopaedics.

The Effect of Concomitant Biceps Tenodesis on Revision Surgery Rates After Primary Rotator Cuff Repair.

INTRODUCTION: We aimed to use a national database to compare the 4-year revision surgery rates after rotator cuff repair (RCR) in patients with concomitant biceps tenodesis (BT) versus those without BT. METHODS: A retrospective cohort analysis was conducted using the PearlDiver database from 2015 to 2017. Patients undergoing primary open and arthroscopic RCR with and without BT were identified. Demographic variables, 90-day complications, and 2- and 4-year revision surgery rates were analyzed, and a multivariable logistic regression was conducted. RESULTS: Of the 131,155 patients undergoing RCR, 24,487 (18.7%) underwent concomitant BT and 106,668 (81.3%) did not. After controlling for comorbidities and demographics, patients with concomitant BT were associated with lower odds of all-cause revision (OR; P-value [0.77; P < 0.001]), revision BT (0.65; P < 0.001), revision RCR (0.72; P < 0.001), and shoulder arthroplasty (0.81; P = 0.001) within 4 years when compared with those without concomitant BT. DISCUSSION: In our analysis, patients undergoing primary RCR with concomitant BT had 35% reduced odds of revision BT and 23% reduced odds of any all-cause revision within 4 years when compared with those without concomitant BT. This suggests that tenodesis at the time of primary RCR may be associated with a reduction in the utilization of ipsilateral shoulder revision surgery rates.

Long-Term Functional Outcomes and Athletic Ability in Shoulder Sports After Anatomic Coracoclavicular Ligament Reconstruction for Chronic Type 3 and 5 Acromioclavicular Joint Injuries.

Background: Promising short- and midterm outcomes have been seen after anatomic coracoclavicular ligament reconstruction (ACCR) for chronic acromioclavicular joint (ACJ) injuries. Purpose/Hypothesis: To evaluate long-term outcomes and shoulder-related athletic ability in patients after ACCR for chronic type 3 and 5 ACJ injuries. It was hypothesized that these patients would maintain significant functional improvement and sufficient shoulder-sport ability at a long-term follow-up. Study Design: Case series; Level of evidence, 4. Methods: Included were 19 patients (mean age, 45.9 ± 11.2 years) who underwent ACCR for type 3 or 5 ACJ injuries between January 2003 and August 2014. Functional outcome measures included the American Shoulder and Elbow Surgeons (ASES), Rowe, Constant-Murley, Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE) scores as well as the visual analog scale (VAS) for pain, which were collected preoperatively and at the final follow-up. Postoperative shoulder-dependent athletic ability was assessed using the Athletic Shoulder Outcome Scoring System (ASOSS). Shoulder activity level was evaluated using the Shoulder Activity Scale (SAS), while the Subjective Patient Outcome for Return to Sports (SPORTS) score was collected to assess the patients' ability to return to their preinjury sporting activity. Results: The mean follow-up time was 10.1 ± 3.8 years (range, 6.1-18.8 years). Patients achieved significant pre- to postoperative improvements on the ASES (from 54.2 ± 22.6 to 83.5 ± 23.1), Rowe (from 66.6 ± 18.1 to 85.3 ± 19), Constant-Murley (from 64.6 ± 20.9 to 80.2 ± 22.7), SST (from 7.2 ± 3.4 to 10.5 ± 2.7), SANE (from 30.1 ± 23.2 to 83.6 ± 26.3), and VAS pain scores (from 4.7 ± 2.7 to 1.8 ± 2.8) (P < .001 for all), with no significant differences between type 3 and 5 injuries. At the final follow-up, patients achieved an ASOSS of 80.6 ± 32, SAS level of 11.6 ± 5.1, and SPORTS score of 7.3 ± 4.1, with no significant differences between type 3 and 5 injuries. Four patients (21.1%) had postoperative complications. Conclusion: Patients undergoing ACCR using free tendon allografts for chronic type 3 and 5 ACJ injuries maintained significant improvements in functional outcomes at the long-term follow-up and achieved favorable postoperative shoulder-sport ability, activity, and return to preinjury sports participation.

Mid-term outcomes of microfracture for the treatment of focal, full-thickness cartilage defects isolated to the humeral head.

BACKGROUND: While microfracture has been shown to be an effective treatment for chondral lesions in the knee, evidence to support its use for chondral defects in the shoulder is limited to short-term outcomes studies. The purpose of this study is to determine if microfracture provides pain relief and improved shoulder function in patients with isolated focal chondral defects of the humeral head at a minimum 5-year follow-up. METHODS: Patients who underwent microfracture procedure for isolated focal chondral defects of the humeral head with a minimum follow-up of 5 years between 02/2006 and 08/2016 were included. At minimum 5-year follow-up, pre- and postoperative patient-reported outcome (PRO) measures were collected, including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Short Form-12 (SF-12) Physical Component Summary (PCS), Visual Analog Scale (VAS) for pain, and patient satisfaction level (1 = unsatisfied, 10 = very satisfied). Demographic, injury, and surgical data were retrospectively reviewed. Surgical failure was defined as revision surgery for humeral chondral defects or conversion to arthroplasty. Kaplan-Meier analysis was performed to determine survivorship at 5 years. RESULTS: A total of 17 patients met inclusion/exclusion criteria. There were 15 men and 2 women with an average age of 51 years (range 36-69) and an average follow-up of 9.4 years (range 5.0-15.8). The median ASES score improved from 62 (range: 22-88) preoperatively to 90 (range: 50-100) postoperatively (P = .011). Median satisfaction was 8 out of 10 (range: 2-10). There was no correlation between patient age or defect size and PROs. Postoperatively, patients reported significant improvements in recreational and sporting activity as well as the ability to sleep on the affected shoulder (P ≤ .05). Three patients failed and required revision surgery. The Kaplan-Meier analysis determined an overall survivorship rate of 80% at 5 years. CONCLUSION: The presented study illustrates significant improvements for PROs, improved ability to perform recreational and sporting activities, and a survival rate of 80% at a mean of 9.4 years after microfracture for focal chondral humeral head defects.

Preoperative patient factors that predict achieving the minimal clinically important difference following arthroscopic treatment of snapping scapula syndrome.

BACKGROUND: The aim of this study was to define the minimal clinically important difference (MCID) values for patient-reported outcomes (PROs) after arthroscopic treatment of snapping scapula syndrome (SSS) using a distribution-based method, and to identify demographic, clinical, and intraoperative factors significantly associated with the achievement of MCID. It was hypothesized that subjective satisfaction scores after the procedure would be strongly associated with the achievement of MCID thresholds for the PROs and that pain, preoperative response to injection, and a scapulectomy in addition to bursal resection would be predictive of clinically relevant improvement. METHODS: Patients who underwent arthroscopic treatment of SSS between October 2005 and September 2020 with a minimum of 2-year short-term postoperative follow-up were enrolled in this retrospective single-center study. The MCID was calculated using a distribution-based approach for the following PROs: 12-Item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) pain "today" and "at worst." The association between achievement of the MCID and postoperative subjective satisfaction was investigated, and factors associated with achievement of MCID were determined using bivariate analysis. RESULTS: Of a total of 190 patients assessed for eligibility, 77 patients (38.1 ± 14.3 years; 36 females) were included. Within the study population, statistically significant improvements in postoperative SF-12 physical component summary (PCS) (P < .001) and mental component summary (MCS) (P < 0.034), ASES (P < .001), QuickDASH (P < .001), SANE (P < .001), and VAS pain (P < .001) scores were observed at the minimum 2-year follow-up. The calculated MCID threshold values based on the study population were 5.0 for SF-12 PCS, 5.8 for SF-12 MCS, 11.3 for ASES, -10.5 for QuickDASH, 14.7 for SANE, 1.5 for VAS pain, and 1.7 for VAS pain at worst. Reaching the MCID was strongly associated with postoperative satisfaction (rated on a scale of 1-10). Across the PROs, younger age, favorable preoperative response to injection, partial scapuloplasty or scapulectomy, no prior surgery, and pain and function at baseline were significantly associated with attaining MCID. CONCLUSIONS: Patients who underwent arthroscopic treatment for SSS experienced clinically significant improvements in functional scores, pain, and quality of life. This study demonstrated predictive roles for certain patient-specific factors and diagnostic variables for achieving MCID in PROs, which may help surgeons preoperatively assess the probability of success and manage patient expectations.

The Association of Tobacco Smoking and Level of Apoptosis in the Long Head of the Biceps Chronic Tendinopathy-An Immunohistochemical Study.

BACKGROUND: The substances present in cigarette smoke have a negative impact on cellular integrity and metabolism, can reduce blood flow to tissues, and can disrupt collagen synthesis. Ultimately this can lead to cell death, which clinically may result in impaired tendon healing and the onset of chronic tendinopathy. Within the shoulder, the exact association between the extent of apoptosis in the long head of the biceps (LHB) tendon and harmful factors like cigarette smoke remains unclear. OBJECTIVES: The purpose of this study was to investigate the connection between smoking, the degree of apoptosis in LHB tendinopathy, and the long-term outcomes of surgical treatment. DESIGN: Observational, retrospective study. METHODS: This study included 22 consecutive patients who had undergone arthroscopic biceps tenodesis or tenotomy for symptomatic LHB tendinopathy with or without concomitant rotator cuff tears (RCT). The intra-articular LHB tendon remnants were histologically examined by measuring the level of expression of apoptotic cell markers such as BCL2, cleaved caspase 3, and p53. Pre- and postoperative clinical outcomes were analyzed by collecting patient report outcome measures such as the American Shoulder and Elbow Surgeons (ASES) score and the Visual Analogue Scale (VAS) for pain. RESULTS: The smokers group had a mean pack-year history of 13.12 (SD = 9.94), mean number of cigarettes per day of 14.77 (SD = 4.64), and a mean smoking duration of 16.38 (SD = 10.1) years. Among the smoking indexes, the number of cigarettes per day showed a positive correlation with Snyder classification (p = 0.0459, rho = 0.3682). Non-smokers and smokers did not show a statistically significant difference in the expression indexes of BCL2, cleaved caspase 3, or p53 (p = 0.4216, p = 0.5449, p = 0.5613, respectively). However, the cleaved caspase 3 expression index showed a negative correlation with the severity of rotator cuff lesions in the total population (p = 0.0193, rho = -0.4651). CONCLUSIONS: While apoptotic processes in the LHB tendon were observed, no significant association was found between tobacco smoking, the extent of apoptosis, and clinical outcomes. However, the expression of the apoptotic marker cleaved caspase 3 correlated with the severity of rotator cuff pathology. Furthermore, active smoker status was associated with worse clinical outcomes in terms of pain following LHB tenodesis or tenotomy.

Anterior Latissimus Dorsi Transfer for Irreparable Subscapularis Tears Improves Shoulder Kinematics in a Dynamic Biomechanical Cadaveric Shoulder Model.

BACKGROUND: In young patients with irreparable subscapularis deficiency (SSC-D) and absence of severe osteoarthritis, anterior latissimus dorsi transfer (aLDT) has been proposed as a treatment option to restore the anteroposterior muscular force couple to regain sufficient shoulder function. However, evidence regarding the biomechanical effect of an aLDT on glenohumeral kinematics remains sparse. PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the effects of an aLDT on range of glenohumeral abduction motion, superior migration of the humeral head (SM), and cumulative deltoid force (cDF) in a simulated SSC-D model using a dynamic shoulder model. It was hypothesized that an aLDT would restore native shoulder kinematics by reestablishing the insufficient anteroposterior force couple. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen cadaveric shoulders were tested using a validated shoulder simulator. Glenohumeral abduction angle (gAA), SM, and cDF were compared across 3 conditions: (1) native, (2) SSC-D, and (3) aLDT. gAA and SM were measured using 3-dimensional motion tracking, while cDF was recorded in real time during dynamic abduction motion by load cells connected to actuators. RESULTS: The SSC-D significantly decreased gAA (Δ-9.8°; 95% CI, -14.1° to -5.5°; P < .001) and showed a significant increase in SM (Δ2.0 mm; 95% CI, 0.9 to 3.1 mm; P = .003), while cDF was similar (Δ7.8 N; 95% CI, -9.2 to 24.7 N; P = .586) when compared with the native state. Performing an aLDT resulted in a significantly increased gAA (Δ3.8°; 95% CI, 1.8° to 5.7°; P < .001), while cDF (Δ-36.1 N; 95% CI, -48.7 to -23.7 N; P < .001) was significantly reduced compared with the SSC-D. For the aLDT, no anterior subluxation was observed. However, the aLDT was not able to restore native gAA (Δ-6.1°; 95% CI, -8.9° to -3.2°; P < .001). CONCLUSION: In this cadaveric study, performing an aLDT for an irreparable subscapularis insufficiency restored the anteroposterior force couple and prevented superior and anterior humeral head migration, thus improving glenohumeral kinematics. Furthermore, compensatory deltoid forces were reduced by performing an aLDT. CLINICAL RELEVANCE: Given the favorable effect of the aLDT on shoulder kinematics in this dynamic shoulder model, performing an aLDT may be considered as a treatment option in patients with irreparable SSC-D.

Patient-reported outcomes of arthroscopic repair for partial or full-thickness upper third subscapularis tendon tears with open sub-pectoral biceps tenodesis: minimum 10-year outcomes.

BACKGROUND: Although short-term results are promising, there are limited data for long-term results of arthroscopic subscapularis (SSC) repair. The purpose of this study is to report minimum 10-year outcomes of primary arthroscopic repair of isolated partial or full-thickness tears of the upper third of the SSC tendon. METHODS: Patients who underwent arthroscopic repair of isolated upper third SSC tears, Lafosse type I (>50% of tendon thickness) or type II were included. Surgeries were performed by a single surgeon between November 2005 and August 2011. Patient-reported outcome measures were prospectively collected and retrospectively reviewed at minimum follow-up of 10 years. Patient-reported outcomes utilized included the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (SANE), Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), the Short Form 12 physical component summary, return to activity, and patient satisfaction. A subanalysis of patient age and outcomes was performed. Retears, revision surgeries, and surgical complications were recorded. RESULTS: In total, 29 patients with isolated upper third SSC repairs were identified. After application of exclusion criteria, 14 patients were included in the final analysis. Follow-up could be obtained from 11 patients. The mean age at surgery was 52.7 years (range: 36-72) and the mean follow-up was 12 years (range 10-15 years). The American Shoulder and Elbow Surgeons score improved from 52.9 ± 21.8 preoperatively to 92.2 ± 13.7 postoperatively (P < .001). Regarding the SANE and QuickDASH scores, only postoperative data were available. Mean postoperative SANE, QuickDASH, and Short Form 12 physical component summary scores were 90.27 ± 10.5, 14.6 ± 15.5, and 49.2 ± 6.6, respectively. Median patient satisfaction was 10 (range 6-10). Patients reported improvements in sleep, activities of daily living, and sports. There was no correlation between patient age and clinical outcome (P > .05). No patients underwent revision surgery for a SSC retear. CONCLUSION: Arthroscopic repair of upper third SSC tendon tears leads to improved clinical scores and high patient satisfaction at minimum 10-year follow-up. The procedure is durable, with no failures in the presented cohort.

Biomechanical Evaluation of the 2 Different Levels of Coracoid Graft Positions in the Latarjet Procedure for Anterior Shoulder Instability.

Background: In the Latarjet procedure, the ideal placement of the coracoid graft in the medial-lateral position is flush with the anterior glenoid rim. However, the ideal position of the graft in the superior-inferior position (sagittal plane) for restoring glenohumeral joint stability is still controversial. Purpose: To compare coracoid graft clockface positions between the traditional 3 to 5 o'clock and a more inferior (for the right shoulder) 4 to 6 o'clock with regard to glenohumeral joint stability in the Latarjet procedure. Study Design: Controlled laboratory study. Methods: A total of 10 fresh-frozen cadaveric shoulders were tested in a dynamic, custom-built robotic shoulder model. Each shoulder was loaded with a 50-N compressive load while an 80-N force was applied in the anteroinferior axes at 90° of abduction and 60° of shoulder external rotation. Four conditions were tested: (1) intact, (2) 6-mm glenoid bone loss (GBL), (3) Latarjet procedure fixed at 3- to 5-o'clock position, and (4) Latarjet procedure fixed at 4- to 6-o'clock position. The stability ratio (SR) and degree of lateral humeral displacement (LHD) were recorded. A 1-factor random-intercepts linear mixed-effects model and Tukey method were used for statistical analysis. Results: Compared with the intact state (1.77 ± 0.11), the SR was significantly lower after creating a 6-mm GBL (1.14 ± 0.61, P = .009), with no significant difference in SR after Latarjet 3 to 5 o'clock (1.51 ± 0.70, P = .51) or 4 to 6 o'clock (1.55 ± 0.68, P = .52). Compared with the intact state (6.48 ± 2.24 mm), LHD decreased significantly after GBL (3.16 ± 1.56 mm, P < .001) and Latarjet 4 to 6 o'clock (5.48 ± 3.39 mm, P < .001). Displacement decreased significantly after Latarjet 3 to 5 o'clock (4.78 ± 2.50 mm, P = .04) compared with the intact state but not after Latarjet 4 to 6 o'clock (P = .71). Conclusion: The Latarjet procedure in both coracoid graft positions (3-5 and 4-6 o'clock) restored the SR to the values measured in the intact state. A more inferior graft position (fixed at 4-6 o'clock) may improve shoulder biomechanics, but additional work is needed to establish clinical relevance. Clinical Relevance: An inferior coracoid graft fixation, the 4- to 6-o'clock position, may benefit in restoring normal shoulder biomechanics after the Latarjet procedure.

Does glenoid version and its correction affect outcomes in anatomic shoulder arthroplasty? A systematic review.

BACKGROUND: Correction of glenoid retroversion is commonly performed in anatomic total shoulder arthroplasty (TSA) to increase component contact area and decrease eccentric loading of the glenoid component. Despite demonstrated biomechanical advantages, limited information exists on the clinical benefit of correcting glenoid retroversion. The purpose of this systematic review is to critically evaluate the existing literature on the effect of preoperative and postoperative glenoid retroversion on clinical functional and radiologic outcomes in patients who underwent anatomic TSA. METHODS: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using PubMed, Embase, and Cochrane Library evaluating the impact of glenoid retroversion on clinical and radiologic outcomes of TSA. English-language studies of level I through IV evidence were included. Blinded reviewers conducted multiple screens and methodological quality was appraised using the Modified Coleman Methodology Score. RESULTS: Sixteen studies, including 3 level III and 13 level IV studies (1211 shoulders), satisfied all inclusion criteria. To address glenoid retroversion, 9 studies used corrective reaming techniques, and 4 studies used posteriorly augmented glenoids. Two studies used noncorrective reaming techniques. Mean preoperative retroversion ranged from 12.7° to 24° across studies. Eleven studies analyzed the effect of glenoid retroversion on clinical outcomes, including patient-reported outcome scores (PROs), range of motion (ROM), or clinical failure or revision rates. Most studies (8 of 11) did not report any significant association of pre- or postoperative glenoid retroversion on any clinical outcome. Of the 3 studies that reported significant effects, 1 study reported a negative association between preoperative glenoid retroversion and PROs, 1 study reported inferior postoperative abduction in patients with postoperative glenoid retroversion greater than 15°, and 1 study found an increased clinical failure rate in patients with higher postoperative retroversion. Ten studies reported radiographic results (medial calcar resorption, Central Peg Lucency [CPL] grade, Lazarus lucency grade) at follow-up. Only 1 study reported a significant effect of pre- and postoperative retroversion greater than 15° on CPL grade. CONCLUSION: There is currently insufficient evidence that pre- or postoperative glenoid version influences postoperative outcomes independent of other morphologic factors such as joint line medialization. Given that noncorrective reaming demonstrated favorable postoperative outcomes, and postoperative glenoid version was not significantly and consistently found to impact outcomes, there is inconclusive evidence that correcting glenoid retroversion is routinely required.

Increased risk of reoperation and failure to attain clinically relevant improvement following autologous chondrocyte implantation of the knee in female patients and individuals with previous surgeries: a time-to-event analysis based on the German cartilage registry (KnorpelRegister DGOU).

PURPOSE: This study aimed to analyze the risk of reoperation following autologous chondrocyte implantation (ACI) of the knee utilizing third-generation ACI products in a time-to-event analysis and report on the associated patient-reported outcome measures (PROM) in case of reoperation. METHODS: Patients undergoing ACI were included from a longitudinal database. Patient age, sex, body mass index (BMI), number of previous surgeries, lesion localization, lesion size, symptom duration, as well as time and type of reoperation was extracted. A cox proportional-hazards model was applied to investigate the influence of baseline variables on risk of reoperation. Reoperation was defined as any type of subsequent ipsilateral knee surgery, excluding hardware removal. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was utilized to compare PROM between patients with and without reoperation. RESULTS: A total of 2039 patients were included with 1359 (66.7%) having a minimum follow-up of 24 months. There were overall 243 reoperations (prevalence 17.9%). Minor arthroscopic procedures (n = 96, 39.5%) and revision cartilage repair procedures (n = 78, 32.1%) were the most common reoperations. Nineteen patients (0.9%) reported conversion arthroplasty at 17.7 (10.4) months after ACI. Female sex (HR 1.5, 95% CI [1.2, 2.0], p = 0.002) and the presence of 1-2 previous surgeries (HR 1.5, 95% CI [1.1, 2.0], p = 0.010), or more than 2 previous surgeries (HR 1.9, 95% CI [1.2, 2.9], p = 0.004) were significantly associated with increased risk of reoperation following ACI. Significantly less patients surpassed the minimal clinically important difference (MCID) in the reoperation group at 24 months regarding the KOOS subscores pain (OR 1.6, 95% CI [1.1, 2.2]), quality of life (OR 2.2, 95% CI [1.6, 3.2]), symptoms (OR 2.0 [1.4, 2.9]), and sports (OR 2.0 [1.4, 2.8]). CONCLUSION: Female patients and individuals with a history of previous surgeries face an elevated risk of requiring reoperation after undergoing ACI, which is associated with failure to attain clinically relevant improvements. A thorough evaluation of the indications for ACI is paramount, particularly when patients have a history of previous surgeries. LEVEL OF EVIDENCE: Level III.

The effect of augmenting suture material with magnesium and platelet-rich plasma on the in vitro adhesion and proliferation potential of subacromial bursa-derived progenitor cells.

Background: Connective tissue subacromial bursa-derived progenitor cells (SBDCs) have been suggested as a potent biologic augment to promote healing of the repaired rotator cuff tendon. Maximizing the amount of retained progenitor cells at the tendon repair site is essential for ensuring an optimal healing environment, warranting a search for proadhesive and proliferative adjuvants. The purpose was to evaluate the effect of magnesium (Mg), platelet-rich plasma (PRP), and a combination of both adjuvants on the in vitro cellular adhesion and proliferation potential of SBDCs on suture material commonly used in rotator cuff surgery. Methods: SBDCs were isolated from subacromial bursa samples harvested during rotator cuff repair and cultured in growth media. Commercially available collagen-coated nonabsorbable flat-braided suture was cut into 1-inch pieces, placed into 48-well culture dishes, and sterilized under ultraviolet light. Either a one-time dose of 5 mM sterile Mg, 0.2 mL of PRP, or a combination of both adjuvants was added, while a group without treatment served as a negative control. Cellular proliferation and adhesion assays on suture material were performed for each treatment condition. Results: Augmenting the suture with Mg resulted in a significantly increased cellular adhesion (total number of attached cells) of SBDCs compared to PRP alone (31,527 ± 19,884 vs. 13,619 ± 8808; P < .001), no treatment (31,527 ± 19,884 vs. 21,643 ± 8194; P = .016), and combination of both adjuvants (31,527 ± 19,884 vs. 17,121 ± 11,935; P < .001). Further, augmentation with Mg achieved a significant increase in cellular proliferation (absorbance) of SBDCs on suture material when compared to the PRP (0.516 ± 0.207 vs. 0.424 ± 0.131; P = .001) and no treatment (0.516 ± 0.207 vs. 0.383 ± 0.094; P < .001) group. The combination of Mg and PRP showed a significantly higher proliferation potential compared to PRP alone (0.512 ± 0.194 vs. 0.424 ± 0.131; P = .001) and no treatment (0.512 ± 0.194 vs. 0.383 ± 0.094; P < .001). There were no significant differences in the remaining intergroup comparisons (P > .05, respectively). Conclusion: Augmenting suture material with Mg resulted in a significantly increased cellular adhesion of SBDCs compared to untreated suture material, as well as augmentation with PRP alone or a combination of both adjuvants. Further, Mg with or without PRP augmentation achieved a significant increase in the cellular proliferation of SBDCs on suture material compared to untreated sutures and augmentation with PRP alone. Application of Mg may be a clinically feasible approach to optimizing the use of SBDCs as a biological augment in rotator cuff repair, while combined augmentation with PRP may harness the full potential for optimized tissue recovery due to the high concentration of PRP-derived growth factors.

Arthroscopic Labral Repair and Pancapsular Shift With Knotless All-Suture Anchors in the Setting of Multidirectional Instability of the Shoulder.

In the management of multidirectional type of shoulder instability (MDI), arthroscopic surgical stabilization is a preferred treatment option after failed conservative therapy regimens because of the ability to easily access all aspects of the capsule with one surgical procedure. As arthroscopic techniques have evolved, factors critical to postoperative success have been elucidated. Currently, optimal arthroscopic treatment of MDI involves circumferentially restoring labral integrity, a tailored, patient-specific surgical reduction of capsular volume, and adequately managing potential lesions of the biceps anchor. The purpose of this article and accompanying video is to present our technique for arthroscopic circumferential labral repair and pancapsular shift using knotless all-suture anchors in the setting of MDI with a concurrent type II SLAP lesion.

Contact Mechanics of Elliptical and Spherical Head Implants during Axial Rotation in Anatomic Total Shoulder Arthroplasty: A Biomechanical Comparison.

BACKGROUND: Elliptical humeral head implants have been proposed to result in more anatomic kinematics following total shoulder arthroplasty (aTSA). The purpose of this study was to compare glenohumeral contact mechanics during axial rotation using spherical and elliptical humeral head implants in the setting of aTSA. METHODS: Seven fresh-frozen cadaveric shoulders were utilized for biomechanical testing in neutral (NR), internal (IR), and external (ER) rotation at various levels of abduction (0°, 15°, 30°, 45°, 60°) with lines of pull along each of the rotator cuff muscles. Each specimen underwent the following three conditions: (1) native, and TSA using (2) an elliptical and (3) spherical humeral head implant. Glenohumeral contact mechanics, including contact pressure (CP; kPa), peak contact pressure (PCP; kPa), and contact area (CA; mm2), were measured in neutral rotation as well as external and internal rotation using a pressure mapping sensor. RESULTS: Elliptical head implants showed a significantly lower PCP in ER compared to spherical implants at 0° (Δ-712.0 kPa; p = 0.034), 15° (Δ-894.9 kPa; p = 0.004), 30° (Δ-897.7 kPa; p = 0.004), and 45° (Δ-796.9 kPa; p = 0.010) of abduction, while no significant difference was observed in ER at 60° of abduction or at all angles in NR and IR. Both implant designs had similar CA in NR, ER, and IR at all tested angles of abduction (p > 0.05, respectively). CONCLUSIONS: In the setting of aTSA, elliptical heads showed significantly lower PCP during ER at 0° to 45° of abduction, when compared to spherical head implants. However, in NR and IR, PCP was similar between implant designs. Both designs showed similar CA during NR, ER, and IR at all abduction angles. LEVEL OF EVIDENCE: basic science; controlled laboratory study.

Establishing the Minimal Clinically Important Difference and Patient Acceptable Symptomatic State following Patellofemoral Inlay Arthroplasty for Visual Analog Scale Pain, Western Ontario and McMaster Universities Arthritis Index, and Lysholm Scores.

BACKGROUND: The purposes of the study were to define the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after patello-femoral inlay arthroplasty (PFA) and to identify factors predictive for the achievement of clinically important outcomes (CIOs). METHODS: A total of 99 patients who underwent PFA between 2009 and 2019 and had a minimum of 2-year postoperative follow-up were enrolled in this retrospective monocentric study. Included patients had a mean age of 44 years (range, 21 to 79). The MCID and PASS were calculated using an anchor-based approach for the visual analog scale (VAS) pain, Western Ontario and McMaster Universities Arthritis Index (WOMAC), and Lysholm patient-reported outcome measures. Factors associated with CIO achievement were determined using multivariable logistic regression analyses. RESULTS: The established MCID thresholds for clinical improvement were -2.46 for the VAS pain score, -8.5 for the WOMAC score, and + 25.4 for the Lysholm score. Postoperative scores corresponding to the PASS were <2.55 for the VAS pain score, <14.6 for the WOMAC score, and >52.5 points for the Lysholm score. Preoperative patellar instability and concomitant medial patello-femoral ligament reconstruction were independent positive predictors of reaching both MCID and PASS. Additionally, inferior baseline scores and age were predictive of achieving MCID, whereas superior baseline scores and body mass index were predictive of achieving PASS. CONCLUSION: This study determined the thresholds of MCID and PASS for the VAS pain, WOMAC, and Lysholm scores following PFA implantation at 2-year follow-up. The study demonstrated a predictive role of patient age, body mass index, preoperative patient-reported outcome measure scores, preoperative patellar instability, and concomitant medial patello-femoral ligament reconstruction in the achievement of CIOs. LEVEL OF EVIDENCE: Prognostic Level IV.

Physiological Tensioning During Lower Trapezius Transfer for Irreparable Posterosuperior Rotator Cuff Tears May Be Important for Improvement in Shoulder Kinematics.

BACKGROUND: Lower trapezius transfer (LTT) has been proposed for restoring the anteroposterior muscular force couple in the setting of an irreparable posterosuperior rotator cuff tear (PSRCT). Adequate graft tensioning during surgery may be a factor critical for sufficient restoration of shoulder kinematics and functional improvement. PURPOSE/HYPOTHESIS: The purpose was to evaluate the effect of tensioning during LTT on glenohumeral kinematics using a dynamic shoulder model. It was hypothesized that LTT, while maintaining physiological tension on the lower trapezius muscle, would improve glenohumeral kinematics more effectively than undertensioned or overtensioned LTT. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 10 fresh-frozen cadaveric shoulders were tested using a validated shoulder simulator. Glenohumeral abduction angle, superior migration of the humeral head, and cumulative deltoid force were compared across 5 conditions: (1) native, (2) irreparable PSRCT, (3) LTT with a 12-N load (undertensioned), (4) LTT with a 24-N load (physiologically tensioned according to the cross-sectional area ratio of the lower trapezius muscle), and (5) LTT with a 36-N load (overtensioned). Glenohumeral abduction angle and superior migration of the humeral head were measured using 3-dimensional motion tracking. Cumulative deltoid force was recorded in real time throughout dynamic abduction motion by load cells connected to actuators. RESULTS: Physiologically tensioned (Δ13.1°), undertensioned (Δ7.3°), and overtensioned (Δ9.9°) LTT each significantly increased the glenohumeral abduction angle compared with the irreparable PSRCT (P < .001 for all). Physiologically tensioned LTT achieved a significantly greater glenohumeral abduction angle than undertensioned LTT (Δ5.9°; P < .001) or overtensioned LTT (Δ3.2°; P = .038). Superior migration of the humeral head was significantly decreased with LTT compared with the PSRCT, regardless of tensioning. Physiologically tensioned LTT resulted in significantly less superior migration of the humeral head compared with undertensioned LTT (Δ5.3 mm; P = .004). A significant decrease in cumulative deltoid force was only observed with physiologically tensioned LTT compared with the PSRCT (Δ-19.2 N; P = .044). However, compared with the native state, LTT did not completely restore glenohumeral kinematics, regardless of tensioning. CONCLUSION: LTT was most effective in improving glenohumeral kinematics after an irreparable PSRCT when maintaining physiological tension on the lower trapezius muscle at time zero. However, LTT did not completely restore native glenohumeral kinematics, regardless of tensioning. CLINICAL RELEVANCE: Tensioning during LTT for an irreparable PSRCT may be important to sufficiently improve glenohumeral kinematics and may be an intraoperatively modifiable key variable to ensure postoperative functional success.