Pseudoparalysis and Pseudoparesis of the Shoulder: Definitions, Management, and Outcomes.

Loss of shoulder function can be a complex condition to manage. Specifically, the definition between the terms pseudoparalysis and pseudoparesis remains inconsistent in the literature based on various factors including chronicity, present pathology, and the role of pain in the loss of function. There is also debate as to the optimal management strategies for these challenging conditions. In the setting of advanced glenohumeral arthritis or arthropathy in the correct patient, arthroplasty provides consistent and reliable results. However, in younger patients or the patient without arthritis, arthroplasty may not be the best option. In some cases, addressing pain with biceps procedures, balloon spacer placement, débridement, or others may be appropriate. However, other instances may require attempts at improving shoulder kinematics with procedures such as rotator cuff repair, superior capsular reconstruction, and tendon transfer. In this review, we discuss current definitions for pseudoparalysis and pseudoparesis, in addition to reviewing the indications for the various treatment options and their respective outcomes.

The Impact of Three-Dimensional Humeral Planning and Standard Transfer Instrumentation on Reconstruction of Native Humeral Anatomy for Anatomic Total Shoulder Arthroplasty.

BACKGROUND: Preoperative three-dimensional CT-based planning for anatomic total shoulder arthroplasty (TSA) has grown in popularity in the past decade with the primary focus on the glenoid. Little research has evaluated if humeral planning has any effect on the surgical execution of the humeral cut or the positioning of the prosthesis. METHODS: Three surgeons performed a prospective study utilizing 3D-printed humeri printed from CTs of existing patients, which were chosen to be -3, -1, 0, 1 and 3 standard deviations of all patients in a large database. A novel 3D printing process was utilized to 3D print not only the humerus, but also all four rotator cuff tendons. For each surgical procedure, the printed humerus was mounted inside a silicon shoulder, with printed musculature and skin, and with tensions similar to human tissue requiring standard retraction and instruments to expose the humerus. Three phases of the study were designed: Phase 1: Humeral neck cuts were performed on all specimens without any preoperative humeral planning, Phase 2: 3D planning was performed, and the cuts and implant selection were repeated, Phase 3: A neck shaft angle guide and digital calipers were used to measure humeral osteotomy thickness to aid in the desired humeral cut. All humeri were digitized. The difference between the prosthetic center of rotation (COR) and ideal COR was calculated. The percentage of patients with a varus neck shaft angle (NSA) was calculated for each phase. The difference in planned and actual cut thickness was also compared. RESULTS: For both 3D change in COR and medial to lateral change in COR, use of preoperative planning alone and with standard transfer instrumentation resulted in a significantly more anatomic restoration of ideal COR. The deviations from planned cut thickness decreased with each phase: Phase 1: 2.6±1.9 mm, Phase 2: 2.0±1.3 mm, Phase 3: 1.4±0.9 mm (p = 0.041 for Phase 3 vs Phase 1). For NSA, in Phase 1: 7/15 (47%) cases were in varus, in Phase 2: 5/15 (33%) were in varus and Phase 3: 1/15 (7%) were in varus (p =0.013 for Phase 3 vs Phase 1). CONCLUSIONS: Use of preoperative 3-D humeral planning for stemless anatomic TSA improved prosthetic humeral center of rotation, whether performed with or without standard transfer instrumentation. The use of a neck-shaft angle cut guide and calipers to measure cut thickness significantly reduced the percentage of varus humeral cuts and deviation from planned cut thickness.

Regional Differences in Reimbursement, Volume, and Patient Characteristics Exist for Rotator Cuff Repairs: A Temporal Analysis from 2013 to 2021.

BACKGROUND: Prior studies have demonstrated declining reimbursement and changing procedural utilization across multiple orthopedic subspecialties, yet a comprehensive examination of this has not been performed for rotator cuff repair, particularly at a geographic level. The purpose of this study was to evaluate changes in reimbursement, utilization, and patient populations for open and arthroscopic rotator cuff repairs (RCR) from 2013 to 2021 at a national and regional level. METHODS: The Medicare Physician and Other Practitioners database from years 2013 to 2021 were queried to extract all episodes of open chronic RCR, open acute RCR, and arthroscopic RCR. Utilization was measured as procedural volume per 10,000 Medicare beneficiaries. Inflation-adjusted reimbursement, utilization, surgeon information, and patient characteristics were extracted for each procedure for each year. Data was stratified geographically based on US Census regions and rural-urban commuting codes. Kruskal-Wallis tests and linear regressions were performed to compare geographical areas. RESULTS: Between 2013 and 2021, arthroscopic RCR utilization increased by 9.4% (11.0/10,000 to 12.0/10,000), while open chronic RCR utilization decreased by 58.8% (2.0/10,000 to 0.8/10,000). During that time, average inflation-adjusted reimbursement declined by 10.0% and 11.3% for arthroscopic and open chronic RCR, respectively. The increase in utilization and decrease in reimbursement was greatest in the Midwest. In 2021, arthroscopic RCR utilization was 12.0/10,000, while average reimbursement for was $846.87, nationally. Utilization was highest in the South (14.5/10,000) and lowest in the Northeast (8.1/10,000) (p<0.001). Alternatively, reimbursement was highest in the Northeast ($904.60) and lowest in the South ($830.80) (p<0.001). The proportion of patients who were male, Medicaid eligible, or non-White was highest in the West (p<0.001). Patients in the West also had the fewest comorbidities. Increased patient comorbidities, when controlling patient demographics, was associated with lower reimbursement nationally and within the Northeast (p<0.001). CONCLUSION: Geographical discrepancies in rotator cuff repair utilization and reimbursement exist. The South consistently demonstrates the highest utilization of RCR, while also having the lowest reimbursement. Alternatively, the Northeast has the lowest utilization but the highest reimbursement. Increased patient population comorbidities were associated with reduced RCR reimbursement for surgeons in the Northeast, but not in other regions.

Total Shoulder Arthroplasty Versus Reverse Shoulder Arthroplasty in Primary Glenohumeral Osteoarthritis With Intact Rotator Cuffs: A Meta-Analyses.

Traditional practice favors total shoulder arthroplasty (TSA) for the treatment of primary glenohumeral osteoarthritis (PGHO) with an intact rotator cuff; however, the indications for reverse shoulder arthroplasty (RSA) have expanded to include PGHO. The purpose of this systematic review is to compare the mean differences in the range of motion and patient-reported outcomes between the TSA and RSA with an intact rotator cuff and to analyze the subgroup of the Walch type B2 glenoid. This IRB-exempt, PROSPERO-registered systematic review strictly followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines. A literature search of five databases revealed 493 articles, of which 10 were included for quantitative synthesis. Level III evidence studies with the diagnosis of PGHO and ≥2 years of follow-up were included. Studies without preoperative and postoperative data were excluded. The Newcastle-Ottawa scale was used to evaluate the methodologic quality of the included studies. Preoperative and postoperative range of motion and patient-reported outcomes were collected. The random-effects model was employed, and p < 0.05 was considered statistically significant. There were a total of 544 and 329 studies in the TSA group and RSA group, respectively. The mean age in the TSA group and RSA groups were 65.36 ± 7.06 and 73.12 ± 2.40, respectively (p = 0.008). The percentages of males in the TSA and RSA groups were 73.2% and 51.1%, respectively (p = 0.02). The mean differences in forward elevation, external rotation in adduction, internal rotation scale, visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and Single Assessment Numeric Evaluation (SANE) scores were improved for both groups with no significant differences between the two. There were 9.6 times the revisions in the TSA group (8.8% vs. 0.91%; p = 0.014) and 1.5 times the complications in the TSA group (3.68% vs. 2.4%; p = 0.0096). Two hundred and forty-two glenoids were identified as Walch type B2 (126 in the TSA group and 116 in the RSA group). The mean ages in the B2 subgroup were 68.20 ± 3.25 and 73.03 ± 1.49 for the TSA and RSA, respectively (p = 0.25). The percentages of males in the B2 subgroup were 74.6% and 46.5% for the TSA and RSA groups, respectively (p = 0.0003). The ASES, SANE, forward elevation, and external rotation in the adduction results were descriptively summarized for this subgroup, with average mean differences of 49.0 and 51.2, 45.7 and 66.1, 77.6° and 58.6°, and 38.6° and 34.1° for the TSA and RSA groups, respectively. In the setting of primary glenohumeral osteoarthritis with an intact rotator cuff, the RSA has a similar range of motion and clinical outcomes but lower complication and revision rates as compared to the TSA. This may hold true in the setting of the B2 glenoid, although a high-powered study on this subgroup is required. Anatomic shoulder arthroplasty maintains an important role in select patients. Further studies are required to better elucidate the role of glenoid bone loss and posterior humeral head subluxation with regard to implant choice.

Regional Variation from 2013 to 2021 in Primary Total Shoulder Arthroplasty Utilization, Reimbursement, and Patient Populations.

BACKGROUND: Total shoulder arthroplasty (TSA), encompassing both anatomical and reverse total shoulder arthroplasty, has increased in popularity worldwide. The purpose of this study was to assess how TSA utilization, reimbursement, surgeon practices, and patient populations have evolved within the Medicare population from 2013 to 2021 at a national and regional level. METHODS: The Medicare Physician and Other Practitioners dataset was queried for all episodes of primary TSA (CPT-23472), both anatomic and reverse, between years 2013 and 2021. TSA utilization was assessed as volume per 10,000 Medicare beneficiaries. Average inflation-adjusted reimbursement, physician practice styles, and patient demographics of each TSA surgeon were extracted each year. Data was stratified geographically based on US census classifications and rural-urban commuting codes. Kruskal-Wallis and multivariate regressions were utilized to determine differences between regions. RESULTS: Between 2013 and 2021, TSA utilization increased by 121.8% nationally. The increase was greatest in the Northeast (+147.2%) and least in the Midwest (+115.5%). Average TSA reimbursement declined by 8.8% nationally, with the least decline in the Northeast (6.4%) and the greatest decline in the Midwest (-11.9%). In 2021, the Midwest had the highest TSA utilization (18.1/10,000), while having the lowest average reimbursement ($1,108.59; p<0.001). The Northeast had the lowest utilization (11.5/10,000) and highest reimbursement ($1,223.44; p<0.001) in 2021. Nationally, the number of Medicare beneficiaries per surgeon performing shoulder arthroplasty declined by 5.9%, while the average number of TSAs per surgeon (+8.5%) and average number of billable services per beneficiary (+16.6%) both increased. Surgeons in the South performed the most services per beneficiary in 2021 (9.0; p<0.001). The average comorbidity burden of patients decreased by 4.8% between 2013 and 2021, with the West having the healthiest patients in 2021. Higher patient comorbidities were associated with lower physician reimbursement nationally (p<0.001). CONCLUSION: This study demonstrates that TSA utilization in the Medicare population has more than doubled between 2013 and 2021, while average inflation-adjusted reimbursement has declined by nearly 10%. The Midwest has the highest per-capita TSA utilization, while simultaneously having the lowest average reimbursement per TSA. Over time, TSA surgeons are seeing fewer and healthier beneficiaries but performing more services per beneficiary. Additionally, increased patient complexity may be associated with lower reimbursement. Together, these findings are concerning for long-term equitable access to care within shoulder surgery.

All-Arthroscopic Falciform Portal Biceps Tenodesis.

Biceps tenodesis has been proven to be an effective treatment for biceps tendon and superior labral pathology. Many techniques including both open and arthroscopic approaches have been reported. Open techniques afford management of the entire proximal biceps tendon but are limited by wound healing issues, increased bleeding, and increased surgical time. Arthroscopic tenodesis offers benefits in terms of surgical efficiency, cosmesis, and bleeding risk. However, standard arthroscopic tenodesis only addresses intra-articular biceps pathology. In this report we describe an all-arthroscopic biceps tenodesis technique at the suprapectoral region of the humerus using knotless suture anchor fixation.

The latissimus dorsi creates a dynamic track for the inferior angle of the scapula during arm abduction in humans.

BACKGROUND: The importance of several scapulothoracic muscles, including trapezius and serratus anterior, in maintaining physiological scapula kinematics has been highlighted in the past. However, the relationship between the scapula and the latissimus dorsi muscle remains unclear. Our clinical surgical observation is that the latissimus dorsi does not directly attach but rather runs superficial to the inferior angle of the scapula. Based on this observation, we hypothesise that the latissimus dorsi creates a dynamic track on which the scapula glides under the muscle belly during elevation of the arm, creating the latissimus-scapula overlap (LSO). METHODS: All consecutive patients who had a whole-body computed tomography scan (CT) in case of polytrauma evaluation between 2018 and 2021, with complete depiction of the scapula and latissimus dorsi muscle, were analysed. 150 shoulders in 90 patients with arms up were matched according to their age (within five years), gender, and affected side with 150 shoulders in 88 patients with arms down. Patients with pathologies of the upper extremities or thorax that potentially could alter LSO measurements were excluded. LSO was calculated as a ratio of the measured area of the latissimus dorsi projection on the scapula and the total scapula area. RESULTS: The mean age of the 178 patients (48 females; 13 males) was 60 years. The arms-up group showed a significantly higher LSO than the arms-down group (19.9 ± 6.3% vs. 2.7 ± 2.2%; p < 0.0001). In the arms-up group, approximately one fifth of the scapula was overlapped inferiorly by the muscle belly of the latissimus dorsi, contrary to the almost non-existing LSO in the arms-down group. CONCLUSION: With arms up, humans show a significantly higher LSO in comparison to arms down indicating that the latissimus dorsi indeed creates a dynamic track on which the scapula is forced to travel during abduction of the arm. This finding of increased LSO during the elevation of the arm warrants further consideration of the role of the latissimus dorsi in scapula kinematics and potentially scapular dyskinesis. LEVEL OF EVIDENCE: Level two diagnostic study.

Hamstring Tendon Autograft Is Associated With Increased Knee Valgus Moment After Anterior Cruciate Ligament Reconstruction: A Biomechanical Analysis.

BACKGROUND: There is limited evidence related to the effects of autograft type on functional performance after anterior cruciate ligament reconstruction (ACLR). PURPOSE/HYPOTHESIS: This study aimed to compare biomechanical outcomes during a drop vertical jump (DVJ) between patients with a hamstring tendon (HT) autograft, quadriceps tendon (QT) autograft with bone block, QT autograft without bone block, and bone-patellar tendon-bone autograft at 6 months postoperatively in an adolescent population. The authors' hypothesized there would be differences in DVJ biomechanics between athletes depending on the type of autograft used. STUDY DESIGN: Controlled laboratory study. METHODS: Patients aged 8 to 18 years who underwent primary ACLR were included for analysis. Kinematic and kinetic data collected during a DVJ using a 3-dimensional computerized marker system were assessed at 6 months after ACLR and compared with the uninjured contralateral limb. RESULTS: A total of 155 participants were included. There were no significant differences in terms of age, sex, or affected leg (P≥ .1973) between groups. The HT group was significantly associated with a larger knee valgus moment at initial contact compared with the QT group (28 × 10-2 vs -35 × 10-2 N·m/kg, respectively; P = .0254) and a significantly larger maximum hip adduction moment compared with the QT with bone block group (30 × 10-2 vs -4 × 10-2 N·m/kg, respectively; P = .0426). Both the QT with bone block (-12 × 10-2 vs -3 × 10-2 N·m/kg, respectively; P = .0265) and QT (-13 × 10-2 vs -3 × 10-2 N·m/kg, respectively; P = .0459) groups demonstrated significantly decreased mean knee extension moments compared with the HT group. CONCLUSION: The findings of this study suggest that utilizing an HT autograft resulted in a significantly increased knee valgus moment at initial contact compared with a QT autograft without bone block at 6 months after ACLR in adolescent patients performing a DVJ. A QT autograft was found to be associated with significantly decreased extensor mechanism function compared with an HT autograft. CLINICAL RELEVANCE: This study adds unique kinematic and kinetic information regarding various ACLR autograft options and highlights the biomechanical deficits that should be taken into consideration in rehabilitation.

Surgical Management of Massive Irreparable Cuff Tears: Superior Capsule Reconstruction and Rotator Cable Reconstruction.

PURPOSE OF REVIEW: Massive irreparable rotator cuff tears (MIRCTs) present treatment challenges. Recently, superior capsule reconstruction (SCR) and anterior cable reconstruction have emerged as surgical options, but no single approach is superior. This review provides an overview of SCR and cable reconstruction techniques, including biomechanical studies, clinical outcomes, and surgical considerations. RECENT FINDINGS: Biomechanical studies show SCR with autografts or allografts improves glenohumeral stability and mechanics. Clinical outcomes of SCR demonstrate improved range of motion, function scores, and pain relief in short-term studies. Anterior cable reconstruction reduces superior humeral head translation and subacromial pressures in biomechanical models. Early clinical studies report improved rotator cuff healing and outcomes for cable reconstruction in specific irreparable tear patterns. SCR and cable reconstruction are viable surgical options for MIRCTs based on early encouraging results. However, higher-level comparative studies with long-term follow-up are still needed. Careful consideration of tear pattern, patient factors, and surgical goals is required to optimize treatment of MIRCTs. Further research is necessary to determine the optimal role for these procedures.

Initial versus Subsequent Injury and Illness and Temporal Trends Among Professional Hockey Players.

Background: Research is limited investigating injuries/illness incidence among National Hockey League (NHL) players. This study sought to establish injury/illness incidence, initial versus subsequent injury risk among NHL players, and determine temporal trends of injury and illness incidence. Hypothesis: Variations in injury incidence by body region, and initial versus subsequent injury would be observed among positions. Study Design: Retrospective cohort study. Methods: Publicly available data were utilized. NHL players 18 years or older between 2007-2008 to 2018-2019 were included. Injury and illness was stratified by position and body segment. Incidence rate (IR), and initial versus subsequent injury and illness risk ratios were calculated. Temporal trends were reported. Results: Nine thousand, seven-hundred and thirty four injuries and illnesses were recorded. Centers had the highest overall IR at 15.14 per 1000 athlete game exposures (AGEs) (95%CI:15.12-15.15) and were 1.4 times more likely to sustain a subsequent injury compared to other positions. The groin/hip/thigh was the most commonly injured body region with an IR of 1.14 per 1000 AGEs (95%CI:1.06-1.21), followed by the head/neck (0.72 per 1000 AGEs, 95%CI:0.66-0.78). Combined injury and illness IR peaked in 2009-2010 season at 12.01 (95%CI: 11.22-12.79). The groin/hip/thigh demonstrated peak incidence during the 2007-2008 season (2.53, 95%CI:2.17-2.90); head/neck demonstrated a peak incidence in 2010-2011 season (Overall: 1.03, 95%CI:0.81-1.26). Injuries reported as 'lower body' increased over time. Conclusions: Positional differences were observed; centers demonstrated the highest overall IR, and subsequent injury risk. Injury by body region was similar to previous literature. Head/neck and concussion decreased over time supporting rule changes in body checking and visor wear. Clinicians should be aware that 'lower body' injuries increased over time; therefore, injuries to the groin/hip/thigh or knee are likely underreported. Level of Evidence: Level 3.

Functional Return-to-Sport Testing Demonstrates Inconsistency in Predicting Short-Term Outcomes Following Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To systematically review the relationship between functional testing at the time of return to sport (RTS) and short-term outcomes, such as second anterior cruciate ligament (ACL) tear and return to a preinjury level of sport, among athletes who underwent anterior cruciate ligament reconstruction (ACLR). METHODS: A systematic literature search was performed in MEDLINE, EMBASE, Scopus, and Web of Science to identify studies examining athletes who underwent functional RTS testing and were followed for at least 12 months following ACLR. Studies were screened by 2 reviewers. A standardized template was used to extract information regarding study characteristics, ACLR information, functional test results, and risk factors associated with retear or reduced RTS. RESULTS: Of the 937 studies identified, 22 met the inclusion criteria. The average time between ACLR and RTS testing was 8.5 months. Single leg hop for distance performance had no association with retear risk in any study and no association with RTS rates in most studies. Quadriceps strength had conflicting results in relation to retear risk, whereas it had no relationship with RTS rates. Rates of reinjury and RTS were similar between patients who passed and did not pass combined hop and strength batteries. Asymmetric knee extension and hip moments, along with increased knee valgus and knee flexion angles, demonstrated increased risk of retear. CONCLUSIONS: Individual hop and strength tests that are often used in RTS protocols following ACLR may have limited and inconsistent value in predicting ACL reinjury and reduced RTS when used in isolation. Combined hop and strength test batteries also demonstrate low sensitivity and negative predictive value, highlighting conflicting evidence to suggest RTS testing algorithm superiority. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Magnetic Resonance Imaging Analysis Demonstrates Improved Reliability in Measuring Shoulder Glenoid Bone Loss Using a Two-Thirds Glenoid Height Technique Compared to the "Best-fit Circle".

PURPOSE: To evaluate the superior to inferior glenoid height as a reliable reference in best-fit circle creation for glenoid anatomy. METHODS: The morphology of the native glenoid was evaluated using magnetic resonance imaging (MRI) in patients without shoulder instability. Using T1 sagittal MRI images, 2 reviewers independently estimated glenoid size using the two-thirds technique and the "best-fit circle" technique at 2 different times. A Student t-test was used to determine significant difference between the two methodologies. Inter- and intra-rater reliability were calculated using interclass and intraclass coefficients. RESULTS: This study included 112 patients. Using the results of glenoid height and "best-fit circle" diameter, the diameter of the "best-fit circle" was found to intersect the glenoid line at 67.8% of the glenoid height on average. We found no significant difference between the 2 measures of glenoid diameter (27.6 vs 27.9, P = .456). The interclass and intraclass coefficients for the two-third method were 0.85 and 0.88, respectively. The interclass and intraclass coefficients for the perfect circle methods were 0.84 and 0.73, respectively. CONCLUSIONS: We determined that the diameter of a circle placed on the inferior glenoid using the "best-fit circle" technique corresponds to 67.8% of the glenoid height. Additionally, we found that constructing a perfect circle using a diameter equal to two-thirds the height of the glenoid may improve intraclass reliability. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Sex-related differences in PROMs prior to the outcome: comparison of preoperative PROMIS physical function scores in female vs. male patients undergoing shoulder arthroplasty.

Background: Patient-reported outcome measures (PROMs) are increasingly used to evaluate outcomes in patients undergoing shoulder arthroplasty. The Patient-Reported Outcome Measures Information System (PROMIS) is popular due to low cost and question burden. Females have been reported to have lower postoperative PROMIS scores after shoulder surgery, but studies have not focused on a dedicated cohort of shoulder arthroplasty patients or examined upstream differences in preoperative scores. This study aimed to characterize sex differences in baseline PROMIS scores among anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (rTSA) patients. Methods: Data were collected over a 9-month period. Demographics, Charlson Comorbidity Index (CCI), smoking status, BMI, American Shoulder and Elbow Surgeons (ASES) scores, PROMIS Pain, Physical Function (PF), Upper Extremity, Depression, and Anxiety scores, as well as Single Assessment Numeric Evaluation (SANE) scores were collected. Student t-tests were performed to determine correlation with baseline PROMs. A minimal clinically important difference (MCID) of 4 was used to determine if a PROMIS score difference between groups was clinically important. Significance was set as P < .05. Results: A total of 88 females (34 TSAs 54 rTSA) and 99 males (35 TSA, 64 rTSA) were enrolled. Only sex showed a correlation with preoperative PROMIS score. In rTSA patients, females had significantly lower preoperative PROMIS PF scores (P < .05). Among females undergoing TSA vs. rTSA, lower preoperative PROMIS PF scores were found in rTSA (P < .05). These differences exceeded the MCID of 4. The same difference was not found in men undergoing TSA vs. rTSA. Conclusion: Preoperative sex-based differences in PROMIS scores are underappreciated in the shoulder arthroplasty literature. This is the largest study to date focusing on sex-based differences among a dedicated cohort of TSA and rTSA patients, showing a difference in baseline PROMIS scores between males and females above the MCID. These findings suggest that PROMIS scores are affected by sex-based baseline differences in rTSA patients. Further study should investigate sex-based differences in baseline scores to determine their effects on ultimate outcome.

Rotator Cuff Repair with Knotless All-Suture Medial Row Anchors and Biceps Autograft Augmentation.

Incomplete healing and/or functional failure following rotator cuff tear repair remains a challenging problem for both patients and surgeons. Augmentation strategies are growing to increase healing through biologic and mechanical mechanisms to improve functional results after arthroscopic rotator cuff repair. The majority of currently described augmentation techniques use allograft tissue. An alternative, low-cost, autograft option for augmentation is the use of the long head of biceps tendon autograft as a free functional graft. Here, we describe the use of autograft biceps tendon as a viable option for augmentation of double-row rotator cuff repair with knotless all-suture suture anchors.

Performance-Enhancing Drugs in Healthy Athletes: An Umbrella Review of Systematic Reviews and Meta-analyses.

CONTEXT: Many clinicians, trainers, and athletes do not have a true understanding of the effects of commonly used performance-enhancing drugs (PEDs) on performance and health. OBJECTIVE: To provide an evidence-based review of 7 commonly used pharmacological interventions for performance enhancement in athletes. DATA SOURCES: PubMed and Scopus databases were searched on April 8, 2022. STUDY SELECTION: Systematic reviews (SRs) and meta-analyses (MAs) assessing the performance-enhancing effects of the following interventions were included: androgenic anabolic steroids (AAS), growth hormone (GH), selective androgen receptor modulators (SARMs), creatine, angiotensin-converting enzyme (ACE)-inhibitors, recombinant human erythropoietin (rHuEPO), and cannabis. STUDY DESIGN: Umbrella review of SRs and MAs. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Primary outcomes collected were (1) body mass, (2) muscle strength, (3) performance, and (4) recovery. Adverse effects were also noted. RESULTS: A total of 27 papers evaluating 5 pharmacological interventions met inclusion criteria. No studies evaluating SARMs or ACE-inhibitors were included. AAS lead to a 5% to 52% increase in strength and a 0.62 standard mean difference in lean body mass with subsequent lipid derangements. GH alters body composition, without providing a strength or performance benefit, but potential risks include soft tissue edema, fatigue, arthralgias, and carpel tunnel syndrome. Creatine use during resistance training can safely increase total and lean body mass, strength, and performance in high-intensity, short-duration, repetitive tasks. Limited evidence supports rHuEPO benefit on performance despite increases in both VO2max and maximal power output, and severe cardiovascular risks are documented. Cannabis provides no performance benefit and may even impair athletic performance. CONCLUSION: In young healthy persons and athletes, creatine can safely provide a performance-enhancing benefit when taken in controlled doses. AAS, GH, and rHuEPO are associated with severe adverse events and do not support a performance benefit, despite showing the ability to change bodily composition, strength, and/or physiologic measures. Cannabis may have an ergolytic, instead of ergogenic, effect.

The influence of posterior acromial morphology on outcomes and return to pushups in young patients undergoing arthroscopic posterior capsulolabral repair.

Background: Prior evidence has identified specific posterior acromial morphology as significantly associated with unidirectional posterior shoulder instability. The purpose of this study is to determine the influence of posterior acromial morphology on the outcomes of arthroscopic posterior capsulolabral repair (APCLR) for unidirectional posterior shoulder instability. Additionally, we sought to determine the influence of posterior acromial morphology on the rate and time to return to pushups following APCLR. Methods: We performed a retrospective review of prospectively collected data. The study included consecutive patients undergoing APCLR. Data collected included demographics, radiographic measurements including posterior acromial height (PAH) and posterior acromial tilt on preoperative scapular-Y radiographs, and patient-reported outcome measures at the preoperative and postoperative visits. In addition, starting at 6 months postoperative, patients were asked if they could perform pushups defined as at least 10 repetitions. At the final follow-up, we collected the number of pushups patients were able to perform. Results: Thirty-two consecutive patients underwent APCLR with a mean follow-up of 26 months (range, 12-41). Significant improvement from preoperative to 2 years postoperative was demonstrated in Subjective Shoulder Value (50-85), VAS (6-2.5), American Shoulder and Elbow Surgeons (48 to 83), and Western Ontario Shoulder Instability (WOSI) (1437-777), P = .001. The recurrent instability rate was 3/32 (9%). Patients with PAH > 23 (N = 17) had a recurrent instability rate of 18% (3/17) versus PAH ≤ 23 (N = 15) 0% (0/15), worse WOSI scores (P = .41), and a lower number of pushups (P = .48). The percentage of patients reporting the ability to perform pushups was (6 months/1 year/2 years) (50%/78%/95%). The mean number of pushups reported at the final follow-up was 33 (range, 1-60). Discussion: Following APCLR, approximately 50% of patients resume pushups at 6 months postoperatively, and 80% return at 1 year. Patients reported performing a mean of 33 pushups following APCLR at the final follow-up. Patients with a PAH greater than 23 on preoperative scapular-Y radiographs had a higher rate of recurrent posterior instability, worse WOSI scores, and lower return to pushups; however, the results did not meet statistical significance. Therefore, future larger studies are needed to determine if posterior acromial morphology is independently associated with worse outcomes and increased recurrent instability rates following APCLR.

Radius of curvature of the radial head matches the capitellum: a magnetic resonance imaging analysis.

Background: The purpose of this study is to utilize elbow magnetic resonance imaging (MRI) to compare the radius of curvature (ROC) of the radial head peripheral cartilaginous rim and the cartilage contour of the capitellum to evaluate if the radial head could be a suitable osteochondral autograft for capitellar pathology. Methods: All patients who underwent an MRI of the elbow over a three-year period were reviewed. Patients with the following diagnoses were excluded: osteochondritis dissecans, osteomyelitis, tumor, and osteoarthritis. The radius of curvature of the radial head (RhROC) was measured on the axial oblique MRI sequence. The radius of curvature of the capitellum (CapROC) was measured on sagittal oblique MRI sequences, the width of the articular surface of the capitellum on coronal MRI sequences and the radial head height (RhH) and capitellar vertical height on sagittal oblique sequences. All measurements were obtained at the midpoint of the radiocapitellar joint. Spearman's coefficient was used to assess the correlation between ROC measurements. Results: Eighty-three patients were included with a mean age of 43 +/- 17 years (57 males and 26 females, 51 right and 32 left elbows). The median RhROC and CapROC measurements were 12.3 mm (interquartile range [IQR] 1.6) and 11.9 mm (IQR 1.7), respectively. The median difference was 0.3 mm (IQR = 0.6; CI 95% = [0.24, 0.46]; P < .001). A strong positive correlation was found between RhROC and CapROC (ρ = 0.89; r2 = 0.819; P < .001). Ninety-four percent (78/83) of patients had a median difference between the RhROC and CapROC of less than or equal to 1 mm, and 63% (52/83) were within 0.5 mm. The inter-rater and intra-rater reliability for RhROC and CapROC was good, intraclass correlation coefficient (ICC) = 0.89, ICC = 0.87, and ICC = 0.96, ICC = 0.97, respectively. RhH was 10.6 ± 1.3 mm, and the width of the articular surface of the capitellum was found to be 13.8 ± 1.6 mm. Conclusion: The ROC of the convex peripheral cartilaginous rim of the radial head is similar to the ROC of the capitellum. In addition, the RhH was approximately 78% of the capitellar articular width. Based on this imaging analysis, the radial head could prove to be a robust local osteochondral autograft with a similar cartilage contour in the reconstruction of the capitellum in complex intra-articular distal humerus fractures with associated radial head fractures and in the setting of "kissing lesions" of the radiocapitellar joint. Furthermore, an osteochondral plug harvested from the "safe zone" of the peripheral cartilaginous rim of the radial head could be utilized to treat isolated osteochondral lesions of the capitellum.

Free Bone Block Procedures for Glenoid Reconstruction in Anterior Shoulder Instability.

Advances in the understanding and management of bone loss in shoulder instability have led to the development of free bone block techniques as an alternative to the Latarjet procedure. These techniques have been proposed as a theoretically safer option to Latarjet, and there is growing clinical enthusiasm in their use. The purpose of this article was to contextualize the utilization of free bone block procedures in the current treatment paradigm of anterior shoulder instability and to review the history and common types of bone autograft (eg, iliac crest, distal clavicle, scapular spine) and allograft (eg, distal tibia, preshaped blocks) techniques and approaches, as well as their clinical effectiveness and safety.

Public Interest in Shoulder Platelet-Rich Plasma Injections Is Increasing: A 10-Year Google Trends Analysis.

Purpose: To quantify and analyze public interest trends in platelet-rich plasma (PRP) therapy for shoulder pathology between 2011 and 2020 using Google Trends data. Methods: Google Trends data were queried for online search data ranging from January 2011 to December 2020. Various combinations of terms related to PRP and shoulder pathology were queried. Terms related to corticosteroid therapy in association with shoulder pathology were also generated for comparative analysis. Analyses were performed regarding trends in online search volumes. Results: Linear models were generated to evaluated trends in the volume of online searches for PRP and corticosteroid therapy for shoulder pathology. For both the PRP and steroid groups, linear models showed a statistically significant increase in search volume for the period studied (P < .001). The PRP group showed a significantly greater growth rate than the steroid group (P < .001). There were no statistically significant differences in online search volume when compared between different geographic and socioeconomic locations. Conclusions: This study indicates consistently increasing public interest in PRP injections in the shoulder. The rate of online search volume growth of PRP is significantly greater than that of corticosteroid injections for the period studied. Clinical Relevance: Awareness of patient perceptions has value in informing shared decision making, aligning patient expectations, and guiding areas of future research. Each of these has an impact on patient care. Being aware of patient interest and expectations is particularly important in areas with controversial or emerging research.