Primary Monoblock Inset Reverse Shoulder Arthroplasty Resulted in Decreased Pain and Improved Function.

BACKGROUND: The first-generation, lateral-center-of-rotation reverse shoulder arthroplasty (RSA) modular design has demonstrated durable early-, mid-, and long-term outcomes. The second-generation monoblock implant shares a similar design but eliminates the modular junction and facilitates inset placement within the metaphysis to avoid humeral-sided junctional failures and facilitate metaphyseal press-fit. However, no paper has specifically examined the radiographic findings and improvements in pain and function after the use of this next generation design. QUESTIONS/PURPOSES: (1) After second-generation, lateral-center-of-rotation monoblock RSA, what are the improvements in shoulder scores, general health scores, and ROM at a minimum of 2 years of followup? (2) Are the differences in shoulder scores, health scores, and ROM associated with fixation (cemented versus cementless components)? (3) How frequently do complications occur (defined as humeral loosening, dislocation, baseplate failure, scapular notching, acromial fractures, and revision surgery) after inset monoblock RSA? METHODS: We retrospectively studied patients undergoing primary RSA between 2010 and 2015 with preoperative data and a minimum of 2 years of clinical followup. Of the 329 primary RSA performed during this period, 125 were excluded based on the use of a different generation humeral stem of the same design, three based on need for a nickel-free implant, and 39 due to a lack of preoperative shoulder scores. Of the remaining 162 patients, 137 patients (85%) met the inclusion criteria with a mean age of 74 years (range, 46-90 years). The predominant indications were osteoarthritis with a massive rotator cuff tear (74%) and fracture sequelae (16%). During the study, humeral implants were typically inserted using an uncemented press-fit technique (85%), with only 21 patients requiring a cemented humeral stem. The mean clinical and radiographic followup period was 37 months (range, 24-82 months). Patient-reported outcome measures (PROMs) including the Simple Shoulder Test, American Shoulder and Elbow Surgeons Total, VAS for pain, SF-12, Single Assessment Numeric Evaluation, and measured active motion (forward elevation and external and internal rotation) were recorded at pre- and postoperative intervals. Postoperative radiographs were evaluated for baseplate failure, glenoid and humeral loosening, scapular notching, and acromion fractures. Complications were recorded in the longitudinally maintained institutional repository. RESULTS: At the most recent followup examination, there were improvements in measured motion, general health outcomes, and all PROMs. There were no differences between the cemented and press-fit techniques. Complications observed included 17 of 137 patients (12%) with scapular notching, six postoperative acromion fractures (4%), and two revision procedures (1%). No patients experienced gross humeral loosening or baseplate failure. CONCLUSIONS: Primary RSA using a second-generation monoblock inset humeral component resulted in improvements in pain and functional outcomes as well as low rates of acromion fractures, humeral radiolucency, and complications. Future studies are needed to provide a more definitive analysis on the use of an uncemented technique for humeral stem fixation and the effect of an inset stem on postoperative acromion fractures. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Midterm results of anatomic total shoulder arthroplasty with a third-generation implant.

BACKGROUND: Anatomic total shoulder arthroplasty (TSA) provides reliable, reproducible, and durable results; however, outcomes of many modern TSA systems are lacking. The present study reports early to midterm results of a third-generation TSA system using a traditional-length press-fit humeral stem and cemented glenoid. METHODS: A retrospective review was conducted of TSA patients with minimum 2-year clinical follow-up. Patient-reported outcome measures, including Simple Shoulder Test, American Shoulder and Elbow Surgeons Total, visual analog scale for pain, 12-Item Short Form Health Survey, and Single Assessment Numeric Evaluation, as well as measured active motion (forward elevation, external and internal rotation), were recorded at preoperative and postoperative intervals. Preoperative midglenoid axial computed tomography scans were used to evaluate eccentric glenoid wear, humeral head subluxation, and glenoid version. Most recent postoperative radiographs were used to evaluate glenoid loosening, humeral loosening, lesser tuberosity union, and medial calcar resorption. Patient satisfaction at final follow-up was reported as excellent, good, satisfied, or unsatisfied. RESULTS: There were 267 patients who met inclusion criteria, with a mean age of 70.9 years and mean clinical follow-up of 47 months. Average glenoid retroversion was 9.7°, and 27% had eccentric glenoid wear. At final follow-up, measured motion and nearly all patient-reported outcome measures showed significant improvements, with 75.6% of patients rating their satisfaction as excellent. No patient was considered "at risk" for humeral stem loosening. Glenoid radiolucencies were seen in 13.5% of shoulders (7 gross loosening). Five patients were revised to reverse TSA. CONCLUSION: TSA using a third-generation traditional-length press-fit stem and cemented glenoid provides excellent early to midterm outcomes with low rates of loosening and high rates of excellent satisfaction.

Improved outcomes with arthroscopic repair of partial-thickness rotator cuff tears: a systematic review.

PURPOSE: The optimum treatment strategy for the surgical management of partial-thickness rotator cuff tears (PTRCT) is evolving. In this study, two research questions were sought to be answered: "Does the repair technique for PTRCTs involving >50% of the tendon thickness have an effect on structural and functional outcomes of arthroscopic repair?" and "Is there a difference in outcomes of arthroscopically treated articular- and bursal-sided PTRCTs?". METHODS: A systematic review according to the PRISMA statement was conducted to identify all literature published reporting on outcomes of arthroscopic treatment of PTRCTs classified with the Ellman classification with minimum 2-year follow-up. Prospective randomized trials were eligible for quantitative synthesis. A total of 19 studies, published between 1999 and 2015, met the inclusion criteria of this systematic review. Two studies reporting outcomes of articular-sided PTRCTs with prospective randomized study design were included in quantitative synthesis calculations. RESULTS: Arthroscopic repair of PTRCTs >50% thickness results in significant pain relief and good to excellent functional outcomes. When in situ repair was compared with repair of the tendon after completion to full-thickness RCT, there were no significant differences in functional or structural outcomes or complication rates. The best treatment method for low-grade PTRCTs remains unclear. CONCLUSIONS: The repair technique (in situ repair versus repair of the tendon after completion to full-thickness RCT) did not significantly affect the outcomes for arthroscopic repair of PTRCTs >50% thickness. The current literature contains evidence for inferior outcomes and higher failure rates after arthroscopic debridement of bursal-sided compared to articular-sided PTRCTs, and some evidence suggests that repair of lower-grade bursal-sided tears may be beneficial over debridement. LEVEL OF EVIDENCE: IV.

Glenoid Erosion Leading to Contact with Retained Metallic Suture Anchors: Bilateral Metallosis After Bilateral Shoulder Hemiarthroplasty: A Case Report.

CASE: Hemiarthroplasty of the shoulder is commonly indicated for younger patients with osteoarthritis who desire to continue recreational and employment activities. In patients who have undergone prior shoulder surgery, metallic suture anchors may be present in the glenoid. We present a case of bilateral shoulder metallosis following bilateral resurfacing hemiarthroplasty for arthropathy in the setting of previous shoulder instability; the prostheses caused eventual glenoid erosion, leading to contact with the retained metal anchors. CONCLUSION: Because glenoid erosion is a common complication after shoulder hemiarthroplasty, patients with retained metal anchors are at risk for secondary metallosis due to medial protrusion of the prosthesis in the glenoid, with subsequent erosion of the metal anchors.

Isolated Biceps Reflection Pulley Tears Treated With Subpectoral Biceps Tenodesis: Minimum 2-Year Outcomes.

PURPOSE: To investigate if patients younger than 50 years old had improved functional outcomes after subpectoral biceps tenodesis (BT) for the treatment of biceps reflection pulley (BRP) lesions at minimum 2-year postoperative follow-up. METHODS: Patients who had arthroscopically confirmed BRP tears that were treated with subpectoral BT and were at least 2 years out from surgery were included; patients were excluded if they had concomitant reconstructive or reparative procedures at index surgery. Patient-centered outcomes including return to activity, American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Short Form-12 Physical Component Summary (SF-12 PCS) scores, and patient satisfaction were collected. The pre- and postoperative scores were compared with a Wilcoxon test. Failure was defined as revision BT. RESULTS: Between January 2006 and July 2014, of 1,184 patients who underwent open subpectoral BT, 14 patients (6 male, 8 female) with mean age 37 (range, 16-49 years) met the inclusion criteria. Minimum 2-year outcomes data were available for all 14 patients (100% follow-up). The mean follow-up was 3.6 ± 1.3 years. There were significant improvements postoperatively for all outcome scores (P = .017 ASES, P = .002 QuickDASH, P = .003 SF-12 PCS). There was no correlation between age and outcome scores (P > .05). Median patient satisfaction was 9 of 10. Five patients (36%) reported return to recreational activity with no modifications; 9 (64%) indicated a return to activity with modifications. The 5 patients who returned to recreational activity with no modification had significantly less time from initial injury/onset of symptoms until surgery in comparison with the 9 patients who modified their activity (P = .028). No complications or reoperations were reported. CONCLUSIONS: Patients younger than 50 years old with a symptomatic isolated BRP lesion experienced excellent results, high return to recreational activity, little postoperative pain, and high degrees of satisfaction when treated with subpectoral BT. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Concomitant glenohumeral pathologies associated with acute and chronic grade III and grade V acromioclavicular joint injuries.

PURPOSE: The purpose of this study was to identify the risk of concomitant glenohumeral pathologies with acromioclavicular joint injuries grade III and V. METHODS: Patients who underwent arthroscopically-assisted stabilization of acromioclavicular joint injuries grade III or grade V between 01/2007 and 12/2015 were identified in the patient databases of two surgical centres. Gender, age at index surgery, grade of acromioclavicular joint injury (Rockwood III or Rockwood V), and duration between injury and index surgery (classified as acute or chronic) were of interest. Concomitant glenohumeral pathologies were noted and their treatment was classified as debridement or reconstructive procedure. RESULTS: A total of 376 patients (336 male, 40 female) were included. Mean age at time of arthroscopic acromioclavicular joint reconstruction surgery was 42.1 ± 14.0 years. Overall, 201 patients (53%) had one or more concomitant glenohumeral pathologies. Lesions of the biceps tendon complex and rotator cuff were the most common. Forty-five patients (12.0%) had concomitant glenohumeral pathologies that required an additional repair. The remaining 156 patients (41.5%) received a debridement of their concomitant pathologies. Rockwood grade V compared to Rockwood grade III (p = 0.013; odds ratio 1.7), and chronic compared to acute injury were significantly associated with having a concomitant glenohumeral pathology (p = 0.019; odds ratio 1.7). The probability of having a concomitant glenohumeral pathology was also significantly associated with increasing age (p < 0.0001). CONCLUSIONS: Concomitant glenohumeral pathologies were observed in 53% of surgically treated patients with an acute or chronic acromioclavicular joint injury of either grade III or V. Twenty-two percent of these patients with concomitant glenohumeral pathologies received an additional dedicated repair procedure. Although a significant difference in occurrence of concomitant glenohumeral pathologies was seen between Rockwood grades III and V, and between acute and chronic lesions, increasing age was identified as the most dominant predictor. LEVEL OF EVIDENCE: Level IV, case series.

Arthroscopic Acromioclavicular Joint Reconstruction Using Knotless Coracoclavicular Fixation and Soft-Tissue Anatomic Coracoclavicular Ligament Reconstruction.

Acromioclavicular joint injuries are one of the most common shoulder injuries, and there are a variety of treatment options. Recently, there have been newer arthroscopic techniques that have addressed coracoid and clavicle fracture risk by using a knotted suture-button fixation through a single, small bone tunnel with additional looped soft-tissue graft stabilization. Although clinical outcomes have been good to excellent, there have still been instances of knot and hardware irritation. The described technique builds on the latest advances and achieves an anatomic coracoclavicular (CC) reconstruction through a single knotless CC fixation device with additional soft-tissue allograft reconstruction of the CC ligaments. This technique minimizes the risks of coracoid and clavicle fractures and knot and hardware irritation while maintaining excellent stability.

A Cadaveric Model Evaluating the Influence of Bony Anatomy and the Effectiveness of Partial Scapulectomy on Decompression of the Scapulothoracic Space in Snapping Scapula Syndrome.

BACKGROUND: Snapping scapula syndrome (SSS) is caused by bony and/or soft tissue impingement in the scapulothoracic articulation. Surgical resection of the superomedial angle (SMA) plus bursectomy can provide relief in most cases; however, the amount needed to achieve adequate scapulothoracic space decompression (SSD) is unknown. PURPOSE: The aim of this study was to evaluate the effectiveness of partial scapulectomy and the influence of bony anatomy on SSD. It was hypothesized that the anterior offset and costomedial angle would correlate with the amount of bony resection needed to achieve adequate SSD. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty pairs (n = 40) of shoulder specimens (mean age, 58 years [range, 41-64 years]; 10 male and 10 female specimens) were included. The scapula shape, medial scapula corpus angle (MSCA), anterior offset, and costomedial angle were obtained from computed tomography scans. Specimens were dissected, and each bare bony scapula was rigidly mounted. Points were collected using a 3-dimensional measuring arm. An SMA point and theoretical resection points (incremental 1-cm points up to 3 cm) proceeding laterally and medially were collected. The scapular plane was interpolated using points from the posterior scapular body. The horizontal distances of the anterior offset and each resection point to the scapular plane were calculated. The difference between the native anterior offset and the offset after resection represented the SSD. Adequate SSD was set at 5 mm. One-way analyses of variance and Pearson correlations were used with statistical significance set at P < .05. RESULTS: The maximum SSD with 3-cm resection was significantly correlated with the anterior offset ( R = 0.83, P < .001) as well as the costomedial angle ( R = -0.43, P = .006) but not the MSCA ( R = -0.11, P = .495) or scapula shape ( F2,37 = 0.39, P = .681). For the 5 scapulae with an anterior offset of less than 20 mm, a 5-mm SSD was not achieved. For 18 of 30 (60%) scapulae with an anterior offset between 20 mm and 35 mm, 3-cm resection provided at least a 5-mm SSD. For the 5 scapulae with an anterior offset of greater than 35 mm, 2-cm resection resulted in at least a 5-mm SSD in all cases. CONCLUSION: The anterior offset of the scapula appeared to be the most important bony parameter to consider during preoperative planning and the evaluation of SSD with partial scapulectomy. CLINICAL RELEVANCE: The results of this study may help surgeons with preoperative planning of surgical decompression of the scapulothoracic space for patients with symptomatic SSS.

Arthroscopic Repair of Isolated Partial- and Full-Thickness Upper Third Subscapularis Tendon Tears: Minimum 2-Year Outcomes After Single-Anchor Repair and Biceps Tenodesis.

PURPOSE: To investigate outcomes of arthroscopic single-anchor repair and biceps tenodesis of partial- and full-thickness tears of the upper third subscapularis (SSC). METHODS: Thirty-three patients with arthroscopically confirmed isolated SSC tears, Lafosse type I (>50% of the tendon thickness involved), or type II were included. All patients underwent arthroscopic subcoracoid decompression, coracoplasty if the coracohumeral distance was narrowed, biceps tenodesis, and a single-anchor repair of the upper third SSC. No other reconstructive procedures were performed. Subjective evaluations included American Shoulder and Elbow Surgeons, Short-Form 12, Quick Disabilities of the Arm, Shoulder and Hand, Single Assessment Numeric Evaluation, and visual analog scale pain scores preoperatively and at minimum 2 years postoperatively. RESULTS: Thirty-one patients (n = 25 male, n = 6 female) were included in the final collective, because 2 patients refused participation. Minimum 2-year follow-up data were available for 28 of the 31 patients (90.3%). The mean age at the time of surgery was 54.8 (range, 36-71) years. The mean follow-up was 4.1 (range, 2.0-8.0) years. The results of all outcome measures improved significantly postoperatively compared with preoperative scores (P < .05). Patients with single-anchor repair of type II SSC tears (n = 17) had a significantly higher mean postoperative American Shoulder and Elbow Surgeons score (93.7 ± 10.8) than patients with single-anchor repair of type I SSC tears (n = 11; 86.7 ± 10.9; P = .027). CONCLUSIONS: Arthroscopic single-anchor repair of upper third SSC tendon tears led to improved function and decreased pain with high patient satisfaction. Outcomes of full-thickness upper third SSC tears were more favorable compared with outcomes of high grade partial-thickness upper third SSC tears. LEVEL OF EVIDENCE: Level IV, retrospective therapeutic case series.

Anatomic and Biomechanical Comparison of the Classic and Congruent-Arc Techniques of the Latarjet Procedure.

BACKGROUND: The Latarjet procedure is commonly performed using either the classic or the congruent-arc technique. Each technique has potential clinical advantages and disadvantages. However, data on the anatomic and biomechanical effects, benefits, and limitations of each technique are limited. Hypothesis/Purpose: To compare the anatomy and biomechanical fixation strength (failure load) between the 2 techniques. It was hypothesized that the classic technique would have superior initial fixation when compared with the congruent-arc technique and that this would be affected by sex and coracoid size. STUDY DESIGN: Controlled laboratory study. METHODS: A biomechanical cadaver study was performed with 20 pairs of male and female shoulders. One of each pair of shoulders was randomly assigned to receive the classic or congruent-arc technique. Coracoid and glenoid anatomic measurements were collected before biomechanical testing. A tensile force was applied through the conjoined tendon to replicate forces experienced by the coracoid graft in the early postoperative period, and the failure load was determined for each specimen. RESULTS: The mean ± SD surface area available for fixation was 263 ± 63 mm2 in the classic technique compared with 177 ± 63 mm2 in the congruent-arc group ( P < .001). 36% of the glenoid width was recreated in the classic group and 50% in the congruent-arc group ( P < .001). The congruent-arc technique resulted in a significantly lower ( P = .005) mean failure load (239 ± 91 N) compared with the classic technique (303 ± 114 N). Failure load was significantly higher in males ( P = .037); male specimens had a mean failure load of 344 ± 122 N for the classic technique and 289 ± 73 N for the congruent-arc technique, and females had a mean failure load of 266 ± 98 N and 194 ± 84 N, respectively. CONCLUSION: In this biomechanical model, the classic technique of the Latarjet procedure provided a greater surface area for healing to the glenoid and superior initial fixation when compared with the congruent-arc technique. The congruent-arc technique allowed restoration of a larger glenoid defect. CLINICAL RELEVANCE: The classic and congruent-arc techniques of coracoid transfer have anatomic and biomechanical advantages and disadvantages that should be considered when choosing between the 2 techniques.

Subpectoral Biceps Tenodesis for Tenosynovitis of the Long Head of the Biceps in Active Patients Younger Than 45 Years Old.

PURPOSE: The objective of this study was to assess the outcomes after subpectoral biceps tenodesis (BT) for long head of the biceps (LHB) tenosynovitis in active patients <45 years old. METHODS: This was an Institutional Review Board-approved, retrospective outcomes study with prospectively collected data. Patients treated with subpectoral BT were included if they met the following criteria: age <45 years, anterior shoulder pain with arthroscopically confirmed LHB tenosynovitis, no concomitant procedures other than debridement and decompression procedures, and minimum 2 years out from surgery. Patients were excluded from analysis if they refused participation. The American Shoulder and Elbow Surgeons (ASES), Short Form-12, Quick Disabilities of the Arm, Shoulder and Hand, Single Assessment Numeric Evaluation, and pain scores as well as sports participation preoperatively and at a minimum of 2 years postoperatively were obtained. Pre- and postoperative scores were compared using paired samples t-test and Wilcoxon signed-rank test. RESULTS: Thirty patients met the inclusion criteria. Two of these patients refused to participate in follow-up and were excluded from analysis. Of the remaining 28 patients (17 male, 11 female; 37.0 ± 8.0 years), minimum 2-year outcomes were available for 24 (13 males, 11 females: 37.7 ± 8.2 years; 85.7%). Mean follow-up was 3.1 years (range, 2.0 to 7.3 years). There were significant improvements in all outcome measures including ASES score (P < .001), with a postoperative mean of 95.8 ± 7.8, visual analog scale "pain today" (P < .001), and pain affecting activities of daily living (P < .001). Seventeen of 20 (85%) patients who answered the question about postoperative sport participation were able to return to sport. Mean patient satisfaction was 9.2/10 (standard deviation, +1.7). There were no postoperative complications such as Popeye deformity or cramping. There were no clinical failures. CONCLUSIONS: Subpectoral BT is an excellent treatment option for active patients <45 years old with LHB tenosynovitis and chronic anterior shoulder pain, resulting in decreased pain, improved function, high satisfaction, and improved quality of life. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Metals in Spine.

The treatment of spinal disorders requires the consideration of a number of factors and understanding the type of material we are implanting is important. Alloys have different mechanical properties and behave differently under different physiologic conditions. Spinal implants need to have good performance in the characteristics of biofunctionality and biocompatibility. In this review, the alloys titanium, cobalt-chrome, nitinol, and tantalum will be examined closely. Several of the important properties that are considered when selecting an alloy for use in spinal instrumentation are explored and detailed for each. This allows for an assessment and comparison of each alloy and a possible determination of which is the best alloy for specific surgery or the best alloy for use in specific situations.

Cost-Effectiveness of Arthroscopic Rotator Cuff Repair Versus Reverse Total Shoulder Arthroplasty for the Treatment of Massive Rotator Cuff Tears in Patients With Pseudoparalysis and Nonarthritic Shoulders.

PURPOSE: To determine the most cost-effective treatment strategy for patients with massive rotator cuff tears and pseudoparalysis of the shoulder without osteoarthritis of the glenohumeral joint (PP without OA). Specifically, we aimed to compare arthroscopic rotator cuff repair (ARCR) versus reverse total shoulder arthroplasty (RTSA) and investigate the effect of patient age on this decision. METHODS: A Markov decision model was used to compare 3 treatment strategies for addressing PP without OA: (1) ARCR with option to arthroscopically revise once, (2) ARCR with immediate conversion to RTSA on potential failure, and (3) primary RTSA. Hypothetical patients were cycled through the model according to transition probabilities, meanwhile accruing financial costs, utility for time in health states, and disutilities for surgical procedures. Utilities were derived from the Short Form-6D scale and expressed as quality-adjusted life-years. Model parameters were derived from the literature and from expert opinion, and thorough sensitivity analyses were conducted. TreeAge Pro 2015 software was used to construct and assess the Markov model. RESULTS: For the base-case scenario (60-year-old patient), ARCR with conversion to RTSA on potential failure was the most cost-effective strategy when we assumed equal utility for the ARCR and RTSA health states. Primary RTSA became cost-effective when the utility of RTSA exceeded that of ARCR by 0.04 quality-adjusted life-years per year. Age at decision did not substantially change this result. CONCLUSIONS: Primary ARCR with conversion to RTSA on potential failure was found to be the most cost-effective strategy for PP without OA. This result was independent of age. Primary ARCR with revision ARCR on potential failure was a less cost-effective strategy. LEVEL OF EVIDENCE: Level IV, economic and decision analysis.

Arthroscopic Treatment of Snapping Scapula Syndrome: Outcomes at Minimum of 2 Years.

PURPOSE: To investigate clinical outcomes after primary and revision arthroscopic treatment for snapping scapula syndrome (SSS) and identify predictive factors associated with outcomes. METHODS: Patients who underwent arthroscopic treatment for SSS between October 2005 and December 2013 were identified in a prospectively collected database. The inclusion criteria were patients with a diagnosis of symptomatic SSS, in whom extensive nonoperative modalities failed, who underwent arthroscopic surgery for SSS, and who had undergone surgery a minimum of 2 years earlier. Postoperative clinical outcomes were assessed with the American Shoulder and Elbow Surgeons score; short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; and general health Short Form 12 (SF-12) scores, including both physical component summary and mental component summary. Patient satisfaction was recorded on a 10-point visual analog scale. Scapular bony morphology was determined on preoperative magnetic resonance imaging. RESULTS: Ninety-two scapulae underwent arthroscopic treatment for SSS. There were 74 scapulae that met the inclusion criteria, including having undergone surgery a minimum of 2 years earlier. An outcome questionnaire was completed for 60 of 74 (81%). The mean age was 33 years (range, 12-65 years), and the mean duration of symptoms before surgery was 4 years (range, 90 days to 20.4 years). The mean follow-up period was 3.4 years (range, 2-7 years). Eight scapulae failed initial surgical management (10.9%) because of recurrent pain and underwent revision surgery at a mean of 309 days (range, 120-917 days). After surgery, there was a significant improvement in all outcome scores, including SF-12 physical component summary score, from 39.2 to 45.4 (P = .002); SF-12 mental component summary score, from 45.0 to 49.6 (P = .023); American Shoulder and Elbow Surgeons score, from 52.6 to 75.8 (P < .001); and score on the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire, from 40.2 to 24.2 (P = .001). The median patient satisfaction rating was 7 of 10. Greater age, lower preoperative psychological score, and longer duration of symptoms before surgery correlated with lower postoperative outcome scores. CONCLUSIONS: Arthroscopic surgery is an effective treatment for SSS in both primary and revision cases, showing significant improvements in all postoperative outcome scores at a mean of 3.4 years. Lower preoperative mental status score, longer duration of symptoms, and greater age were associated with poorer outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Association of Traumatic and Atraumatic Posterior Shoulder Instability With Glenoid Retroversion and Outcomes After Arthroscopic Capsulolabral Repair.

PURPOSE: To compare glenoid retroversion and functional outcomes between patients with traumatic onset of posterior shoulder instability (PSI) and patients with atraumatic onset of PSI. METHODS: Patients with PSI who underwent arthroscopic posterior capsulolabral anchor repair, were active in sports, and had undergone surgery a minimum of 2 years earlier were included. Traumatic onset was defined as PSI that occurred after a trauma with the shoulder in adduction, flexion, and internal rotation in patients with no history of instability. Subjective evaluations were obtained with the American Shoulder and Elbow Surgeons (ASES); Quick Disabilities of the Arm, Shoulder and Hand; Single Assessment Numeric Evaluation (SANE); and Short Form 12 Physical Component Summary scores preoperatively and after a minimum 2-year follow-up postoperatively. Additional questions assessed return to sport and shoulder stability. Glenoid version was measured with a 2-dimensional glenoid vault method on magnetic resonance imaging. RESULTS: A total of 41 shoulders in 38 patients were eligible for inclusion (3 female and 35 male patients; mean age, 27.6 years; age range, 13 to 66 years). Three patients refused participation, and 2 patients required subsequent surgery for failure. Postoperative outcomes were available for 32 of the remaining 36 shoulders (89%) with a mean follow-up of 4.1 years (range, 2.0 to 7.8 years; 20 atraumatic and 12 traumatic). The ASES score improved significantly in both groups (P < .03), whereas the SANE; Quick Disabilities of the Arm, Shoulder and Hand; and Short Form 12 Physical Component Summary scores only significantly improved for patients with traumatic PSI (P < .02). Baseline score-adjusted comparison between groups showed that the postoperative median ASES scores (atraumatic, 95.8; traumatic, 99.9) and SANE scores (atraumatic, 86.5; traumatic, 98.0) were significantly more improved in patients with traumatic PSI (P = .01 and P = .012, respectively). Atraumatic PSI was associated with significantly higher glenoid retroversion (-21.8° ± 4.2° vs -17.7° ± 5.5°, P = .032). There was no significant difference regarding return to sport (P = .375) or postoperative re-dislocations (P = .99) between the groups. CONCLUSIONS: Atraumatic onset of PSI was associated with higher degrees of glenoid retroversion and less favorable functional outcomes of arthroscopic posterior capsulolabral anchor repair than traumatic PSI. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Minimum 2-year outcomes and return to sport following resection arthroplasty for the treatment of sternoclavicular osteoarthritis.

HYPOTHESIS: The aim of this study was to assess the effect of open resection arthroplasty for osteoarthritis of the sternoclavicular (SC) joint on pain levels, functional outcomes, and return to sport. METHODS: Patients from a single surgeon's practice who underwent open resection arthroplasty (maximum 10-mm resection) for SC osteoarthritis or prearthritic changes between November 2006 and November 2013 were retrospectively reviewed. This was an outcomes study with prospectively collected data. Preoperative and postoperative American Shoulder and Elbow Surgeons score, Quick Disabilities of the Arm, Shoulder, and Hand score, Single Assessment Numeric Evaluation score, several pain scores, and level of sport intensity were assessed. RESULTS: Seventeen SC joints in 16 patients (9 female, 7 male) met inclusion criteria. Mean age at time of surgery way 41.1 years (range, 12-66 years). One patient refused participation in the study. Three SC joint resections (17.7%) required SC joint revision surgery. Minimum 2-year outcomes data were available for 11 of the remaining 13 SC joints (84.6%). The mean time to follow-up was 3.3 years (range, 2.0-8.8 years). Pain at its worst (P = .026), pain at competition (P = .041), the Quick Disabilities of the Arm, Shoulder, and Hand score (P = .034), and the ability to sleep on the affected shoulder (P = .038) showed significant improvement postoperatively. The average postoperative American Shoulder and Elbow Surgeons score was 83.3. The level of sports participation (P = .042) as well as strength and endurance when participating in sport (P = .039) significantly increased postoperatively. CONCLUSION: Resection arthroplasty of the medial end of the clavicle in patients with osteoarthritis of the SC joint without instability results in pain reduction, functional improvement, and a high rate of return to sport at midterm follow-up.

Impact of Arthroscopic Lateral Acromioplasty on the Mechanical and Structural Integrity of the Lateral Deltoid Origin: A Cadaveric Study.

PURPOSE: To determine whether a 5-mm and/or 10-mm arthroscopic lateral acromioplasty (ALA) would weaken the structural and mechanical integrity of the lateral deltoid. METHODS: The acromion and lateral deltoid origin were harvested from 15 pairs (n = 30) of fresh-frozen human cadaveric shoulder specimens. One side of each specimen pair (left or right) was randomly assigned to either a 5-mm (n = 7) or 10-mm (n = 8) ALA group, and the contralateral sides (n = 15) were used as matched controls. Acromion thickness and width were measured pre- and postoperatively. After ALA, specimens were inspected for damage to the lateral deltoid origin. Each specimen was secured within a dynamic testing machine, and the deltoid muscle was pulled to failure. Statistical analysis was performed to determine whether ALA reduced the lateral deltoid's failure load. RESULTS: There was no significant difference in failure load between the 5-mm ALA group (661 ± 207 N) and its matched control group (744 ± 212 N; mean difference = 83 N; 95% confidence interval [CI], -91 to 258; P = .285) nor between the 10-mm ALA group (544 ± 210 N) and its matched control group (598 ± 157 N; mean difference = 54 N; 95% CI, -141 to 250; P = .532). There was no correlation found between the amount of bone resected (measured by percent thickness and width of the acromion after ALA) and the failure load of the deltoid. Visual evaluation of the acromion after ALA revealed the lateral deltoid origin had no damage in any case. CONCLUSIONS: ALA did not weaken the structural or mechanical integrity of the lateral deltoid origin. Neither a 5-mm nor a 10-mm ALA significantly reduced the deltoid's failure load. The lateral deltoid origin was not macroscopically damaged in any case. CLINICAL RELEVANCE: ALA can be performed without the potential risk of macroscopically damaging the lateral deltoid origin or reducing its failure load.

Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 5-Year Follow-up.

BACKGROUND: There are little data on midterm outcomes after the arthroscopic management of glenohumeral osteoarthritis (GHOA) in young active patients. PURPOSE: To report outcomes and survivorship for the comprehensive arthroscopic management (CAM) procedure for the treatment of GHOA at a minimum of 5 years postoperatively. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The CAM procedure was performed on a consecutive series of 46 patients (49 shoulders) with advanced GHOA who met criteria for shoulder arthroplasty but instead opted for a joint-preserving, arthroscopic surgical option. The procedure included glenohumeral chondroplasty, capsular release, synovectomy, humeral osteoplasty, axillary nerve neurolysis, subacromial decompression, loose body removal, microfracture, and biceps tenodesis. Outcome measures included 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 for pain, and satisfaction scores. Kaplan-Meier survivorship analysis was performed with failure defined as progression to total shoulder arthroplasty (TSA). RESULTS: Forty-six consecutive patients (49 shoulders) who underwent a CAM procedure at a minimum of 5 years from surgery were included. Two patients were excluded for refusing to participate before study initiation. The mean age at surgery was 52 years (range, 27-68 years) in 15 women and 29 men. All patients were recreational athletes with 7 former collegiate or professional athletes. Twelve shoulders (26%) progressed to TSA at a mean of 2.6 years (range, 0.5-8.2 years). For survivorship analysis, the status of the shoulder (preservation of the native joint or progression to TSA) at a minimum of 5 years was known for 45 of 47 (96%) shoulders. Survivorship was 95.6% at 1 year, 86.7% at 3 years, and 76.9% at 5 years. For surviving shoulders, minimum 5-year subjective outcome data were available for 28 of 32 (87.5%) shoulders at a mean of 5.7 years (range, 5-8 years). The mean (±SD) ASES score was 84.5 ± 17, the mean SANE score was 82 ± 18, the mean QuickDASH score was 15 ± 13, the mean SF-12 PCS score was 51.0 ± 9.1, and median patient satisfaction was 9 of a possible 10 points. CONCLUSION: This study demonstrates significant improvements in midterm clinical outcomes and high patient satisfaction after the arthroscopic CAM procedure for GHOA, with a 76.9% survivorship rate at a minimum of 5 years postoperatively. For patients looking for an alternative to TSA, the CAM procedure can provide reasonable outcomes and should be considered an effective procedure in appropriately selected, young active patients. Further studies are warranted to evaluate long-term outcomes and durability after this procedure.

The Effects of Arthroscopic Lateral Acromioplasty on the Critical Shoulder Angle and the Anterolateral Deltoid Origin: An Anatomic Cadaveric Study.

PURPOSE: To investigate if (1) an anterolateral acromioplasty and (2) a lateral acromion resection alter the critical shoulder angle (CSA) without affecting the deltoid origin. METHODS: First, the native CSAs of 10 human cadaveric shoulders (6 male and 4 female specimens; mean age, 54.2 years) were determined with the use of fluoroscopy. Setup allowed for consistent repetitive measurements. Next, a standard arthroscopic anterolateral acromioplasty was performed to create a type 1 acromion, and the CSA was reassessed fluoroscopically. Afterward, a lateral acromioplasty was performed with a 5-mm lateral acromion resection using a 5-mm burr, and the CSA was measured again. The native CSA was compared with (1) the CSA after acromioplasty and (2) the CSA after acromioplasty and lateral acromion resection using a paired t test. Finally, the acromial deltoid attachment was evaluated anatomically for damage to the anterolateral origin. RESULTS: The mean native CSA (34.3° ± 2.1°) was reduced significantly by acromioplasty (33.1° ± 2.0°, P < .001) and further reduced by lateral acromion resection (31.5° ± 1.7°, P < .001). Anterolateral acromioplasty reduced the CSA by a mean of 1.4° (95% confidence interval boundaries, 0.8° and 1.9°), and in combination with lateral acromion resection, the CSA was reduced by a mean of 2.8° (95% confidence interval boundaries, 2.1° and 3.5°). In all specimens (5 of 5) with a presurgery CSA of 35° or greater, the CSA was reduced to the range of 30° to 35° by the combination of both techniques. However, in 2 specimens with a CSA of approximately 32°, the CSA was reduced to less than 30°. The acromial deltoid attachment was found to be well preserved in all specimens. CONCLUSIONS: Arthroscopic anterolateral acromioplasty and a 5-mm lateral acromion resection each reduced the CSA significantly and did not damage the deltoid origin. CLINICAL RELEVANCE: The combination of both techniques could potentially be used in clinical practice to reduce a CSA greater than 35° to the desired range of 30° to 35°.

Arthroscopic Remplissage and Open Latarjet Procedure for the Treatment of Anterior Glenohumeral Instability With Severe Bipolar Bone Loss.

Bipolar bone loss in patients with anterior glenohumeral instability is challenging to treat. The goal of the treatment is to restore stability by ensuring that the humeral head remains within the glenoid vault. This can be achieved either with the combination of an arthroscopic Bankart procedure and remplissage (glenoid bone loss <25%), or with a Latarjet procedure (glenoid bone loss >25%). In cases with more severe bipolar bone loss of both the glenoid and the humeral head, the conventional approach has been to lengthen the articular arc of the glenoid and to ignore the Hill-Sachs lesion. However, it has recently been shown that this can still lead to an "off-track" situation with persistent shoulder instability from engagement of the Hill-Sachs on the anterior glenoid. In these cases, the combination of a Hill-Sachs remplissage and the Latarjet procedure can be effective in preventing persistent instability. In this technical note, the surgical technique of an arthroscopic Hill-Sachs remplissage in combination with an open Latarjet procedure is presented.