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Background: There is no consensus concerning the rehabilitation protocol following reverse shoulder arthroplasty. Several patients are expecting to be able to use their arms for sports or recreation shortly after their operation., Methods: This review was designed as an intervention systematic review with narrative analysis. Authors searched English literature in PubMed and Embase databases from 1/1/1989 until July 2022. Controlled studies comparing rehabilitation protocols for patients undergoing reverse shoulder arthroplasty were included. Data quality was examined with the Cochrane risk of a bias assessment tool for randomized trials, the Methodological Index for Non-Randomized studies (MINORS) tool, as well as the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach., Results: Three studies were finally analyzed. At 3 months post-op, forward flexion was found to be significantly higher in the early rehabilitation group (140.5, 95% confidence intervals (CIs): 135.10-145.89; the delayed rehabilitation group mean was 131.24, 95% CI: 125.73-136.74; p  = 0.019). Twelve months post-op, no significant difference in any clinical or patient-reported outcome was shown. More complications were reported in the 6 weeks-delayed rehabilitation group., Discussion: Newer regimes permit immediate shoulder mobilization but may not be applied to every patient. The lack of strong evidence warrants the need for future controlled studies; subsequently, postoperative rehabilitation should be individualized., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Background: Acromioclavicular joint (ACJ) stabilizations are associated with a high overall failure rate with 9.5% of these patients requiring subsequent revision surgery. Consequently, understanding the specific cause of primary ACJ stabilization failure is paramount to improving surgical decision-making in this challenging patient cohort., Purpose: To (1) identify risk factors and mechanisms for failure following primary arthroscopically-assisted ACJ stabilization to highlight the importance of conducting a detailed failure analysis and to (2) establish revision strategies based on real-life cases of primary failed ACJ stabilization., Study Design: Level of evidence IV., Methods: A survey was shared internationally among members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) shoulder committee. The survey contained failure analysis of 11 real-life cases of failed primary arthroscopically-assisted ACJ stabilization. For each case, a thorough patient history, standardized radiographs, and CT scans were provided. Participants were asked to give their opinion on bone tunnel placement, cause of failure (biological, technical, traumatic, or combined), the stabilization technique used, as well as give a recommendation for revision., Results: Seventeen members of the ISAKOS shoulder committee completed the survey. Biological failure was considered the most common cause of failure (47.1%), followed by technical (35.3%) and traumatic (17.6%) failure. The majority deemed two modifiable factors (i.e., patient's profession and sport) as well as non-modifiable factors (i.e., patient's age and time from trauma to initial surgery) to be risk factors for failure. In 10 of 11 cases, the correct fixation device was used in the primary setting (90.9%; 52.8-82.4% agreement); however, in eight of those cases, the technique was not performed correctly (80.0%; 58.8-100% agreement). In 8 of all 11 cases, the majority recommended an arthroscopically assisted technique with graft augmentation for revision (52.9-58.8% agreement)., Conclusion: Biological failure and technical failure are the most common reason for failure in primary ACJ stabilization followed by traumatic failure. Besides, biological failure can be triggered by technical errors such as clavicular or coracoidal tunnel misplacement. Consequently, a detailed failure analysis including preoperative CT should be conducted on the causes of primary ACJ failure, and, if possible, an arthroscopically-assisted technique with graft augmentation should be prioritized in revision ACJ surgery., Clinical Relevance: ACJ stabilizations are associated with a high overall failure rate - potentially due to biological and technical properties. When encountering failed arthroscopically-assisted ACJ stabilization, a detailed failure analysis should be conducted on the causes of primary ACJ failure. Furthermore, an arthroscopically-assisted revision stabilization is feasible in most cases., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Case: A 54-year-old patient had lateral ligament insufficiency due to cubitus varus from a childhood supracondylar fracture. Arthrolysis/synovectomy and at a later stage double-row extensor origin refixation and lateral ulnar collateral ligament bracing with nonabsorbent tape and anchors were performed. Follow-up at 3, 6, 12, and 24 months showed excellent Mayo Elbow Performance and Disabilities of Arm, Shoulder, and Hand Scores (24-month follow-up = 100 and 2.5, respectively)., Conclusion: Suture tape augmentation and double-row extensor refixation in cases of lateral collateral ligament complex insufficiency due to cubitus varus may provide improved short-term functional outcomes, from the third postoperative month., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C243)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Acromioclavicular (AC) joint injuries are a common cause of shoulder pain, especially among athletes. Surgical reconstruction of the AC joint can lead to complications such as fracture of the coracoid process, clavicle or acromion, which can negatively affect the patient's outcome. The purpose of this review is to discuss the risk factors for fractures associated with AC joint reconstruction, as well as the strategies that can be used to mitigate this risk. Risk factors for fractures include low mineral density, coracoid/clavicle drilling, larger holes in the coracoid, and the number of tunnels used for reconstruction., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effect of an irreparable posterosuperior rotator cuff tear (PSRCT) on glenohumeral joint loads and to quantify improvement after superior capsular reconstruction (SCR) using an acellular dermal allograft., Methods: Ten fresh-frozen cadaveric shoulders were tested using a validated dynamic shoulder simulator. A pressure mapping sensor was placed between the humeral head and glenoid surface. Each specimen underwent the following conditions: (1) native, (2) irreparable PSRCT, and (3) SCR using a 3-mm-thick acellular dermal allograft. Glenohumeral abduction angle (gAA) and superior humeral head migration (SM) were measured using 3-dimensional motion-tracking software. Cumulative deltoid force (cDF) and glenohumeral contact mechanics, including glenohumeral contact area and glenohumeral contact pressure (gCP), were assessed at rest, 15°, 30°, 45°, and maximum angle of glenohumeral abduction., Results: The PSRCT resulted in a significant decrease of gAA along with an increase in SM, cDF, and gCP (P < .001, respectively). SCR did not restore native gAA (P < .001); however, SM was significantly reduced (P < .001). Further, SCR significantly reduced deltoid forces at 30° (P = .007) and 45° of abduction (P = .007) when compared with the PSRCT. SCR did not restore native cDF at 30° (P = .015), 45° (P < .001), and maximum angle (P < .001) of glenohumeral abduction. Compared with the PSRCT, SCR resulted in a significant decrease of gCP at 15° (P = .008), 30° (P = .002), and 45° (P = .006). However, SCR did not completely restore native gCP at 45° (P = .038) and maximum abduction angle (P = .014)., Conclusions: In this dynamic shoulder model, SCR only partially restored native glenohumeral joint loads. However, SCR significantly decreased glenohumeral contact pressure, cumulative deltoid forces, and superior migration, while increasing abduction motion, when compared with the posterosuperior rotator cuff tear., Clinical Relevance: These observations raise concerns regarding the true joint-preserving potential of SCR for an irreparable posterosuperior rotator cuff tear, along with its ability to delay progression of cuff tear arthropathy and eventual conversion to reverse shoulder arthroplasty., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The extent of fatty infiltration and rotator cuff (RC) atrophy is crucial for the clinical results after rotator cuff repair (RCR). The purpose of this study was to evaluate changes in fatty infiltration and RC atrophy after revision RCR and to correlate them with functional outcome parameters., Methods: Patients who underwent arthroscopic revision RCR for symptomatic recurrent full-thickness tear of the supraspinatus tendon between 2008 and 2014 and were retrospectively reviewed with a minimum follow up of 2 years. Magnetic resonance imaging (MRI) was performed pre- and postoperatively to assess 1) tendon integrity after revision RCR according to Sugaya classification, (2) RC atrophy according to Thomazeau classification, and (3) fatty infiltration according to Fuchs MRI classification. Constant score (CS) and the American Shoulder and Elbow Surgeon (ASES) score were used to correlate functional outcome, tendon integrity, and muscle degeneration., Results: 19 patients (17 males and 2 females) with a mean age of 57.5 years (range, 34 to 72) were included into the study at a mean follow-up of 50.3 months (range, 24 - 101). At final evaluation, 9 patients (47%) presented with intact RCR and 10 patients (53%) suffered a re-tear after revision repair. No progress of fatty infiltration was observed postoperatively in the group with intact RC, atrophy progressed in only 1 out of 9 patient (11%). Fatty infiltration progressed in 5/10 patients (50%) and RC atrophy increased in 2/10 patients (20%) within the re-tear group. CS (42.7 ± 17.7 preop, 65.2 ± 20.1 postop) and ASES (47.7 ± 17.2 preop, 75.4 ± 23.7 postop) improved significantly from pre- to postoperatively (p < 0.001). A positive correlation between fatty infiltration and RC integrity was detected (r = 0.77, p < 0.01). No correlation between clinical outcome and tendon integrity or RC atrophy was observed., Conclusion: Arthroscopic revision RCR leads to reliable functional outcomes even in case of a recurrent RC retear. An intact RCR maintains the preoperative state of fatty infiltration and muscle atrophy but does not lead to muscle regeneration., Level of Evidence: Level IV; Therapeutic study., (© 2023. The Author(s).)

When the lateral collateral ligament (LCL) complex fails to support the radiocapitellar and ulnohumeral joints in advanced stages of insufficiency, the patient experiences posterolateral rotatory instability (PLRI). Open lateral ulnar collateral ligament repair with a ligamentous graft has been the standard treatment for PLRI. Despite producing good clinical stability rates, this method is associated with significant lateral soft-tissue dissection and a lengthy recovery period. By fastening the LCL to its humeral insertion, arthroscopic imbrication of the LCL can increase stability. The senior author modified this technique. With the aid of a passer, the LCL complex, lateral capsule, and anconeus may be weaved with a single (doubled) suture, secured with a Nice knot. LCL complex imbrication may be used to restore stability and improve pain and function in patients with grade I and II PLRI., (© 2023 The Authors.)

Background: There exists a vast number of surgical treatment options for acromioclavicular (AC) joint injuries, and the current literature has yet to determine an equivocally superior treatment. AC joint repair has a long history and dates back to the beginning of the twentieth century., Main Body: Since then, over 150 different techniques have been described, covering open and closed techniques. Low grade injuries such as Type I-II according to the modified Rockwood classification should be treated conservatively, while high-grade injuries (types IV-VI) may be indicated for operative treatment. However, controversy exists if operative treatment is superior to nonoperative treatment, especially in grade III injuries, as functional impairment due to scapular dyskinesia or chronic pain remains concerning following non-operative treatment. Patients with a stable AC joint without overriding of the clavicle and without significant scapular dysfunction (Type IIIA) may benefit from non-interventional approaches, in contrast to patients with overriding of the clavicle and therapy-resistant scapular dysfunction (Type IIIB). If these patients are considered non-responders to a conservative approach, an anatomic AC joint reconstruction using a hybrid technique should be considered. In chronic AC joint injuries, surgery is indicated after failed nonoperative treatment of 3 to 6 months. Anatomic AC joint reconstruction techniques along with biologic augmentation (e.g. Hybrid techniques, suture fixation) should be considered for chronic high-grade instabilities, accounting for the lack of intrinsic healing and scar-forming potential of the ligamentous tissue in the chronic setting. However, complication and clinical failure rates remain high, which may be a result of technical failures or persistent horizontal and rotational instability., Conclusion: Future research should focus on addressing horizontal and rotational instability, to restore native physiological and biomechanical properties of the AC joint., (© 2022. The Author(s).)

Background: In the setting of irreparable posterosuperior rotator cuff tears (PSRCTs), lower trapezius transfer (LTT) may be anatomically better positioned for restoring the muscular force couple compared with latissimus dorsi transfer (LDT). The purpose of the study was to evaluate the effect of LTT and LDT on glenohumeral kinematics using a dynamic shoulder model., Methods: Ten fresh-frozen cadaveric shoulders (mean age: 56.5 ± 17.2 years) were tested using a dynamic shoulder simulator. The maximum abduction angle (MAA), superior humeral head migration (SHM), and cumulative deltoid forces (CDFs) were compared across 4 conditions: (1) native; (2) irreparable PSRCT; (3) LTT using an Achilles tendon allograft; and (4) LDT. MAA and SHM were measured using 3-dimensional motion tracking. CDF was recorded in real time throughout the dynamic abduction motion by load cells connected to actuators., Results: Compared to the native state, the PSRCT resulted in a significant decrease (Δ-24.1°; P < .001) in MAA, with a subsequent significant increase after LTT (Δ13.1°; P < .001) and LDT (Δ8.9°; P < .001). LTT achieved a significantly greater MAA than LDT (Δ4.2°; P = .004). Regarding SHM, both LTT (Δ-9.4 mm; P < .001) and LDT (Δ-5.0 mm; P = .008) demonstrated a significant decrease compared with the PSRCT state. LTT also achieved significantly less SHM compared with the LDT (Δ-4.4 mm; P = .011). Further, only the LTT resulted in a significant decrease in CDF compared with the PSRCT state (Δ-21.3 N; P = .048), whereas LTT and LDT showed similar CDF (Δ-11.3 N; P = .346). However, no technique was able to restore the MAA, SHM, and CDF of the native shoulder (P < .001, respectively)., Conclusion: LTT and LDT both achieved a significant increase in MAA along with significantly less SHM compared with the PSRCT state. Although LTT required significantly less compensatory deltoid forces compared with the PSRCT state, this was not observed for the LDT. Further, the LTT prevented loss of abduction motion and SHM more sufficiently. In the challenging treatment of irreparable PSRCTs, LTT may restore native glenohumeral kinematics more sufficiently, potentially leading to improved postoperative functional outcomes., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this systematic review was to update the knowledge on risk factors and prevention strategies for shoulder injuries in overhead sports with special emphasis on methodological quality., Methods: All methodological procedures were performed in line with a previous systematic review by Asker et al. (2018). The literature search was conducted in the PubMed, Google Scholar, Cochrane, and SPORT-Discuss databases. Due to the risk of bias assessment, only studies with at least an acceptable methodological quality were included. A best-evidence synthesis was performed to clarify the evidence and direction of the risk factors and prevention strategies., Results: A total of nine studies were included in the data extraction process. One study had a high and eight studies had an acceptable methodological quality. Seven cohort studies investigated risk factors and two randomised controlled trails evaluated prevention strategies. Moderate evidence was found for two non-modifiable (playing position, gender) and three modifiable factors (shoulder rotational strength, scapular dyskinesia, shoulder prevention programme) that were associated with the shoulder injury risk. All further risk factors had moderate and no association with risk (shoulder rotational ROM, joint position sense) or limited (history of shoulder/elbow pain, age, training experience, training volume, school grade, playing level), and conflicting evidence (setting)., Conclusions: There is moderate evidence for two non-modifiable (playing position, gender) and three modifiable factors (shoulder rotational strength, scapular dyskinesia, shoulder prevention programme) being associated with the shoulder injury risk in overhead sports., (© 2022. The Author(s).)

Purpose: To determine the sensorimotor and clinical function of patients with confirmed successful outcome after either undergoing acromioclavicular joint (ACJ) stabilization, Bankart repair (BR), or rotator cuff repair (RC), and to compare these measures to the contralateral, healthy side without history of previous injuries or surgeries of the upper extremity. It was hypothesized that patients of each interventional group would have inferior sensorimotor function of the shoulder joint compared to the contralateral, healthy side, while presenting with successful clinical and functional outcomes., Methods: Three intervention groups including ten patients who had confirmed successful clinical and functional outcomes after either undergoing ACJ stabilization, BR, or RC were evaluated postoperatively at an average follow-up of 31.7 ± 11.6 months. Additionally, a healthy control group (CG) of ten patients was included. Clinical outcomes were assessed using the Constant-Murley (CM) and American Shoulder and Elbow Surgeons (ASES) Score. Pain was evaluated using the visual analogue scale (VAS). Sensorimotor function was assessed by determining the center of pressure (COP) of the shoulder joint in a one-handed support task in supine position on a validated pressure plate., Results: Each interventional group demonstrated excellent clinical outcome scores including the CM Score (ACJ 83.3 ± 11.8; BR 89.0 ± 10.3; RC 81.4 ± 8.8), ASES Score (ACJ 95.5 ± 7.0; BR 92.5 ± 9.6; RC 96.5 ± 5.2), and VAS (ACJ 0.5 ± 0.9; BR 0.5 ± 0.8; RC 0.5 ± 0.8). Overall, the CG showed no significant side-to-side difference in COP, whereas the ACJ-group and the BR-group demonstrated significantly increased COP compared to the healthy side (ACJ 103 cm vs. 98 cm, p = 0.049; BR: 116 cm vs. 102 cm, p = 0.006). The RC-group revealed no significant side-to-side difference (120 cm vs. 108 cm, n.s.)., Conclusion: Centre of pressure measurement detected sensorimotor functional deficits following surgical treatment of the shoulder joint in patients with confirmed successful clinical and functional outcomes. This may indicate that specific postoperative training and rehabilitation protocols should be established for patients who underwent surgery of the upper extremity. These results underline that sensorimotor training should be an important component of postoperative rehabilitation and physiotherapeutic activities to improve postoperative function and joint control., Level of Evidence: IV., (© 2021. The Author(s).)

Purpose: To evaluate the effect of an isolated full-thickness supraspinatus (SSP) tear on glenohumeral kinematics and contact mechanics, as well as to quantify improvement following rotator cuff repair (RCR)., Methods: Ten fresh-frozen cadaveric shoulders (mean age: 63.1 ± 4.6 years) were tested using a dynamic shoulder simulator. A pressure-mapping sensor was placed between the humeral head and the glenoid. Each specimen underwent the following three conditions: 1) native, 2) isolated full-thickness SSP tear, and 3) RCR. Maximum abduction angle (MAA) and superior humeral head migration (SHM) were measured using 3D motion tracking software. Cumulative deltoid force (CDF) and glenohumeral contact mechanics, including contact area (GCA) and contact pressure (GCP), were assessed at the resting position, as well as at 15°, 30°, 45°, and 60° of glenohumeral abduction., Results: Compared to native, the SSP tear resulted in a significant decrease in MAA (Δ-8.3°; P < .001) along with a SHM of 6.4 ± 3.8 mm, while significantly increasing CDF (Δ20.5 N; P = .008), GCP (Δ63.1 kPa; P < .001), and peak GCP (Δ278.6 kPa; P < .001), as well as decreasing GCA (Δ-45.8 mm 2 ; P < .001) at each degree of abduction. RCR reduced SHM to 1.2 ± 2.5 mm, while restoring native MAA, CDF (Δ1.8 N), GCA (Δ4.5 mm 2 ), GCP (Δ-4.5 kPa) and peak GCP (Δ19.9 kPa) at each degree of abduction (P > .999, respectively)., Conclusion: In a dynamic biomechanical cadaveric model, increased glenohumeral joint loads due to a full-thickness SSP tear can be reversed with RCR. More specifically, RCR restored native glenohumeral contact area and contact pressure, while preventing superior humeral head migration and decreasing compensatory deltoid forces., Clinical Relevance: These time 0 observations indicate that undergoing rotator cuff repair may prevent the development of degenerative changes by significantly reducing glenohumeral joint loads and ensuring sufficiently stable joint kinematics., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Introduction: Elliptical shape humeral head prostheses have been proposed to reflect a more anatomic shoulder replacement. Its effect on the rotational range of motion (ROM) compared to a standard spherical head is still not understood. The purpose was to investigate if there would be a difference in rotational ROM when comparing elliptical and spherical prosthetic heads in a dynamic shoulder model. The authors hypothesized that the use of elliptical heads would result in significantly more rotational ROM compared to the spherical head design., Materials and Methods: Six fresh-frozen, cadaveric shoulders were evaluated using a dynamic shoulder model. After being tested in the native condition, each specimen underwent 6 conditions in the hemiarthroplasty state: (1) matched-fit spherical head, (2) oversized spherical head, (3) undersized spherical head, (4) matched-fit elliptical head, (5) oversized elliptical head, and (6) undersized elliptical head. Following conversion to total shoulder arthroplasty (TSA), the 6 prior conditions were rerun. Each condition was tested at 0°, 30° and 60° of glenohumeral abduction. Rotational ROM was quantified using 3-dimensional tracking, while dynamically applying alternating forces for internal and external rotation via the rotator cuff tendons., Results: Elliptical and spherical prosthetic heads showed no significant difference in the degree of the total, internal, and external rotational ROM for both the hemiarthroplasty and TSA state. Conversion from hemiarthroplasty to TSA resulted in less degree of total rotational ROM for both head designs in all abduction positions, without reaching statistical significance. There was a significant decrease in total, internal, and external rotational ROM for both elliptical and spherical heads in every replacement condition, when comparing 0° to 30° and 60° of abduction (P < 0.05, respectively)., Conclusion: In a dynamic shoulder model, elliptical and spherical prosthetic head designs showed no significant difference in the degree of the total, internal, and external rotational ROM in both the hemiarthroplasty and TSA state., Level of Evidence: Controlled laboratory study., (© 2020. The Author(s).)

Background: Current literature reports highly satisfactory short- and midterm clinical outcomes in patients with arthroscopic 270° labral tear repairs. However, data remain limited on long-term clinical outcomes and complication and redislocation rates in patients with traumatic shoulder instability involving anterior, inferior, and posterior labral injury., Purpose: To investigate, at a minimum follow-up of 10 years, the clinical outcomes, complications, and recurrent instability in patients with 270° labral tears involving the anterior, inferior, and posterior labrum treated with arthroscopic stabilization using suture anchors., Study Design: Case series; Level of evidence, 4., Methods: A retrospective outcomes study was completed for all patients with a minimum 10-year follow-up who underwent arthroscopic 270° labral tear repairs with suture anchors by a single surgeon. Outcome measures included pre- and postoperative Rowe score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test, visual analog scale for pain, and Single Assessment Numeric Evaluation (SANE). Western Ontario Shoulder Instability Index (WOSI) scores were collected postoperatively. Complication data were collected, including continued instability, subluxation or dislocation events, and revision surgery. Failure was defined as any cause of revision surgery., Results: In total, 21 patients (mean ± SD age, 27.1 ± 9.6 years) with 270° labral repairs were contacted at a minimum 10-year follow-up. All outcome measures showed statistically significant improvements as compared with those preoperatively: Rowe (53.9 ± 11.4 to 88.7 ± 8.9; P = .005), ASES (72.9 ± 18.4 to 91.8 ± 10.8; P = .004), Simple Shoulder Test (8.7 ± 2.4 to 11.2 ± 1.0; P = .013), visual analog scale (2.5 ± 2.6 to 0.5 ± 1.1; P = .037), and SANE (24.0 ± 15.2 to 91.5 ± 8.3; P = .043). The mean postoperative WOSI score at minimum follow-up was 256.3 ± 220.6. Three patients had postoperative complications, including a traumatic subluxation, continued instability, and a traumatic dislocation, 2 of which required revision surgery (14.2% failure rate)., Conclusion: Arthroscopic repairs of 270° labral tears involving the anterior, inferior, and posterior labrum have highly satisfactory clinical outcomes at 10 years, with complication and redislocation rates similar to those reported at 2 years. This suggests that repairs of extensile labral tears are effective in restoring and maintaining mechanical stability of the glenohumeral joint in the long term.

Purpose: To clinically evaluate patients who underwent a biologic augmentation technique in revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated stem cells isolated from bone marrow aspirate (BMA) obtained from the proximal humerus., Methods: This is a retrospective review of prospectively collected data from patients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and BMA obtained from the proximal humerus between 2014 and 2015. Minimum follow-up was 12 months. Outcome measures were collected preoperatively and postoperatively including range of motion as well as American Shoulder and Elbow Surgeons Shoulder Form, Simple Shoulder Test, single assessment numeric evaluation, and visual analog score. In addition, BMA samples of each patient were assessed for the number of nucleated cells and colony-forming units. Regression analysis was performed to investigate whether the number of nucleated cells and colony-forming units had an influence on outcome and failure., Results: Ten patients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated BMA obtained from the proximal humerus between 2014 and 2015 were included. The mean follow-up time was 30.7 (range: 12-49) months. Four patients were revised at final follow-up. Postoperative clinical scores improved significantly: American Shoulder and Elbow Surgeons (28.1 ± 5.4 to 60.9 ± 9.0; P  < .01), single assessment numeric evaluation (6.6 ± 2.3 to 65.1 ± 10.9; P < .01), visual analog scale (7.2 ± 0.9 to 3.1 ± 0.9; P < .01), and Simple Shoulder Test (1.6 ± 0.5 to 10.3 ± 5.7; P < .01). Postoperative range of motion increased significantly with regard to flexion (97.0 ± 13.6 to 151.0 ± 12.2; P < .01) and abduction (88.0 ± 14.0 to 134.0 ± 15.1; P  = .038) but not with external rotation (38.0 ± 5.7 to 50.5 ± 6.5; P  = .16). Less pain was correlated to an increased number of nucleated cells ( P  = .026); however, there was no correlation between failure rate and number of nucleated cells ( P  = .430)., Conclusions: Patients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated BMA demonstrated a significant improvement in shoulder function along with reduction of pain. However, the overall revision rate for this procedure was 40%., Level of Evidence: Level IV, therapeutic case series., (© 2021 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Purpose: To compare the clinical outcomes of patients who underwent successful nonoperative treatment for type III-V acromioclavicular joint (ACJ) injuries to those who eventually required conversion to anatomic coracoclavicular ligament reconstruction (ACCR) at a minimum 5-year follow-up., Methods: Patients with primary, chronic type III-V ACJ injuries who either underwent successful conservative treatment or conversion to ACCR after failing a trail of conservative management between 2003 and 2014 with a minimum 5-year follow-up were included in the study. Clinical outcome measures comprised the American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) score, collected preoperatively and at final visit for the ACCR group. Outcome scores for patients with successful conservative treatment were only collected at final visit. A Self- Assessment Numeric Evaluation (SANE) score was obtained at terminal follow-up for both groups., Results: Twenty-two patients (mean age: 40.1 ± 15.6 years) with successful nonoperative treatment and twenty-one patients (mean age: 43.6 ± 12.0 years) who required conversion to ACCR were included in the study. At final follow-up, patients with successful non-operative treatment achieved similar ASES (93.0±12.0NonOP vs. 86.1±16.8ACCR), SST (11.2±1.4NonOP vs. 10.7±2.0ACCR) and SANE scores (80.9±19.7NonOPvs. 90.5±14.7ACCR) compared to those who were converted to ACCR. Additionally, patients who underwent conversion to ACCR showed significant improvement in ASES (49.8±18.1pre vs. 86.1±16.8post; Δ36.3±19.7) and SST scores (6.5±3.2prevs. 10.7±2.0post; Δ4.2±4.0) from pre- to postoperative., Conclusion: At a minimum 5-year follow-up, patients with successful non-operative treatment for type III-V ACJ injuries achieved similar clinical outcomes compared to those who were converted to ACCR. In patients with chronic severe ACJ dislocation a trial of conservative treatment may be attempted, astime from injuryto eventual conversion to ACCR had no significant influence on postoperative clinical outcomes., Level of Evidence: Level IV.

Purpose: To evaluate the clinical and radiographic outcomes of patients undergoing anatomic coracoclavicular ligament reconstruction (ACCR) using free tendon allografts for the treatment of chronic acromioclavicular joint (ACJ) injuries with a minimum 1-year follow-up., Methods: Patients who underwent ACCR for chronic ACJ injuries between 2003 and 2017 were analyzed. Clinical outcome measures included American Shoulder and Elbow Surgeons (ASES), Constant-Murley (CM), Simple Shoulder Test (SST), and Single Assessment Numerical Evaluation (SANE) scores. Radiographic loss of reduction during follow-up was evaluated by calculating the difference (mm) in the coracoclavicular distance (CCD) of the involved side immediately postoperatively and at terminal follow-up., Results: Forty-two patients (mean age: 42.7 ± 12.8 years) were included in the study with an average follow-up of 3.8 ± 3.1 years (range: 1.1-11.5 years). Patients achieved significant improvement in ASES (50.2 ± 20.1 pre to 85.2 ± 16.3 post), CM (60.2 ± 18.5 pre to 88.2 ± 9.1 post), SST (6.1 ± 3.2 pre to 9.5 ± 3.7 post), and SANE (24.0 ± 25.7 pre to 89.0 ± 12.7 post) scores (P < 0.001, respectively). There were no significant differences in functional improvement when comparing type III and V injuries (n.s.). Mean increase in CCD of the involved side from immediately postoperative to final radiographic follow-up was 4.1 ± 3.9 mm, with no significant correlation to clinical outcomes scores. Complications occurred in 33.3% of cases, with postoperative heterotopic ossification being most frequent (14.3%)., Conclusion: Patients undergoing ACCR using free tendon allografts for chronic ACJ injuries achieved significant improvement in shoulder function at a mean follow-up of 3.8 years. No correlation was observed between the amount of loss of reduction and clinical outcome scores. Free tendon allografts may be a reliable alternative to autografts in the treatment of chronic ACJ dislocations., Level of Evidence: IV.

Purpose: To develop a consensus on diagnosis and treatment of acromioclavicular joint instability., Methods: A consensus process following the modified Delphi technique was conducted. Panel members were selected among the European Shoulder Associates of ESSKA. Five rounds were performed between October 2018 and November 2019. The first round consisted of gathering questions which were then divided into blocks referring to imaging, classifications, surgical approach for acute and chronic cases, conservative treatment. Subsequent rounds consisted of condensation by means of an online questionnaire. Consensus was achieved when ≥ 66.7% of the participants agreed on one answer. Descriptive statistic was used to summarize the data., Results: A consensus was reached on the following topics. Imaging: a true anteroposterior or a bilateral Zanca view are sufficient for diagnosis. 93% of the panel agreed on clinical override testing during body cross test to identify horizontal instability. The Rockwood classification, as modified by the ISAKOS statement, was deemed valid. The separation line between acute and chronic cases was set at 3 weeks. The panel agreed on arthroscopically assisted anatomic reconstruction using a suspensory device (86.2%), with no need of a biological augmentation (82.8%) in acute injuries, whereas biological reconstruction of coracoclavicular and acromioclavicular ligaments with tendon graft was suggested in chronic cases. Conservative approach and postoperative care were found similar CONCLUSION: A consensus was found on the main topics of controversy in the management of acromioclavicular joint dislocation. Each step of the diagnostic treatment algorithm was fully investigated and clarified., Level of Evidence: Level V.

Purpose: To evaluate tunnel widening and its relationship in loss of reduction and clinical outcomes in patients undergoing anatomic coracoclavicular ligament reconstruction (ACCR) using free tendon grafts for chronic acromioclavicular (AC) joint injuries., Methods: A retrospective chart review was performed on patients undergoing ACCR for type III-VI AC joint injuries between January 2003 and December 2017. For radiographic analysis, pre- and post-operative coracoclavicular distance (CCD) and tunnel width of the medial and lateral clavicular bone tunnel were measured at the earliest (EPO) and latest postoperative follow-up (LPO). To determine the clinical relevance of improvement in clinical outcome score (American Shoulder and Elbow Surgeons score) substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds were used., Results: Twenty-four patients with a mean clinical follow-up of 37 ± 35 months (mean age 44.7 ± 13.4) were included in the study. Both the medial (5.6 ± 0.2 mm EPO -6.6 ± 0.7 mm LPO; p < 0.001) and lateral (5.6 ± 0.5 mm EPO -6.8 ± 1 mm LPO ; p < 0.001) clavicular bone tunnel showed significant widening from EPO to LPO. There was a significant loss of reduction at LPO (CCD LPO 10.1 ± 4 mm) compared to EPO (CCD EPO : 6.2 ± 3.8 mm) (p < 0.001). No significant correlation between loss of reduction and medial (p = 0.45; r = - 0.06) or lateral (p = 0.69; r = - 0.06) tunnel widening was found. Alterations in tunnel width were shown having no influence on clinical outcomes., Conclusion: Patients who underwent ACCR using a free tendon graft for the treatment of chronic type III-VI ACJ injuries showed significant clavicular bone tunnel widening during the postoperative course. No correlation between tunnel widening and loss of reduction was shown with radiographic findings having no influence on clinical benefit and satisfaction., Study Design: Case Series; Level of evidence, IV.

Purpose: The purpose of the study was to evaluate the frontal gait patterns in patients with chronic patellofemoral instability compared to healthy controls. The hypothesis was that internal-rotation-adduction moment of the knee as altered dynamic Q-angle is evident in patients and correlates positively with increased femoral torsion., Methods: Thirty-five patients with symptomatic recurrent patellofemoral instability requiring surgical treatment were matched for average age, sex, and body mass index with 15 healthy controls (30 knees). Several clinical and radiographic measurements were taken from each participant: internal and external rotation (hipIR, hipER), Q-angle, tubercle sulcus angle (TS-angle), femoral antetorsion (femAT), tibial tubercle-trochlear groove (TT-TG) distance, and frontal leg axis. Additionally, three frontal gait patterns were defined and recorded: (1) internal-rotation-adduction moment of the knee during normal walking, (2) dynamic valgus of the knee, and (3) Trendelenburg's sign in a single-leg squat. Randomized videography was evaluated by three independent blinded observers. Statistical analysis was performed using regression models and comparisons of gait patterns and clinical and radiological measurements. Furthermore, observer reliability was correlated to gradings of radiological parameters., Results: Patients showed altered dynamic Q-angle gait pattern during normal walking (p < 0.001) compared to healthy controls (interrater kappa = 0.61), whereas highest observer agreement was reported if femAT was greater than 20° (kappa = 0.85). Logistic regression model revealed higher femAT (18.2° ± 12.5 versus 11.9° ± 7.0 (p = 0.004) as a significant variable, as well as lower TT-TG distance (23.6 mm ± 2.8 vs. 16.6 mm ± 4.9, p = 0.004) on evident dynamic Q-angle gait pattern. Dynamic valgus in a single-leg squat was observed significantly more often in patients (p < 0.001) compared to controls (interrater kappa = 0.7). However, besides the static measured Q-angle as the only significant variable on evident dynamic valgus pattern (13.6° ± 4.6 vs. 10.3° ± 5.2, p = 0.003), no radiological parameter was detected to correlate significantly with dynamic valgus and Trendelenburg's sign (n.s.)., Conclusions: Clinical detection of pathologic torsion and bony alignment may be difficult in patients with patellofemoral instability. The present study demonstrated that dynamic Q-angle gait pattern is significantly altered in patients with chronic patellofemoral instability compared to healthy controls. Moreover, dynamic Q-angle correlates positively with higher femoral torsion and negatively with higher TT-TG distance. Therefore, clinical and radiological assessment of maltorsion should be added to the standard diagnostic workup in cases of patellofemoral instability., Level of Evidence: Level II.

Previous attempts to measure lateralization, distalization or inclination after reverse total shoulder arthroplasty (rTSA) and to correlate them with clinical outcomes have been made in the past years. However, this is considered to be too demanding and challenging for daily clinical practice. Additionally, the reported findings were obtained from heterogeneous rTSA cohorts using 145° and 155° designs and are limited in external validity. The purpose of this study was to investigate the prognostic preoperative and postoperative radiographic factors affecting clinical outcomes in patients following rTSA using a 135° prosthesis design. In a multi-center design, patients undergoing primary rTSA using a 135° design were included. Radiographic analysis included center of rotation (COR), acromiohumeral distance (AHD), lateral humeral offset (LHO), distalization shoulder angle (DSA), lateralization shoulder angle (LSA), critical shoulder angle (CSA), and glenoid and baseplate inclination. Radiographic measurements were correlated to clinical and functional outcomes, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (STT), Single Assessment Numeric Evaluation (SANE), and Visual Analogue Scale (VAS) score, active forward elevation (AFE), external rotation (AER), and abduction (AABD), at a minimum 2-year follow-up. There was a significant correlation between both DSA ( r = 0.299; p = 0.020) and LSA ( r = -0.276; p = 0.033) and the degree of AFE at final follow-up. However, no correlation between DSA ( r = 0.133; p = 0.317) and LSA ( r = -0.096; p = 0.471) and AER was observed. Postoperative AHD demonstrated a significant correlation with final AFE ( r = 0.398; p = 0.002) and SST ( r = 0.293; p = 0.025). Further, postoperative LHO showed a significant correlation with ASES ( r = -0.281; p = 0.030) and LSA showed a significant correlation with ASES ( r = -0.327; p = 0.011), SANE ( r = -0.308, p = 0.012), SST ( r = -0.410; p = 0.001), and VAS ( r = 0.272; p = 0.034) at terminal follow-up. All other correlations were found to be non-significant ( p > 0.05, respectively). Negligible correlations between pre- and postoperative radiographic measurements and clinical outcomes following primary rTSA using a 135° prosthesis design were demonstrated; however, these observations are of limited predictive value for outcomes following rTSA. Subsequently, there remains a debate regarding the ideal placement of the components during rTSA to most sufficiently restore active ROM while minimizing complications such as component loosening and scapular notching. Additionally, as the data from this study show, there is still a considerable lack of data in assessing radiographic prosthesis positioning in correlation to clinical outcomes. As such, the importance of radiographic measurements and their correlation with clinical and functional outcomes following rTSA may be limited.

Background: Correction of high posterior tibial slope is an important treatment option for revision of anterior cruciate ligament (ACL) failure as seen in clinical and biomechanical studies. In cases with moderate to severe medial compartment arthritis, an additional varus correction osteotomy may be added to improve alignment., Purpose: To investigate the influence of coronal and sagittal correction high tibial osteotomy in ACL-deficient and ACL-reconstructed knees on knee kinematics and ACL graft load., Study Design: Controlled laboratory study., Methods: Ten cadaveric knees were selected according to previous computed tomography measurements with increased native slope and slight varus tibial alignment (mean ± SD): slope, 9.9°± 1.4°; medial proximal tibia angle, 86.5°± 2.1°; age, 47.7 ± 5.8 years. A 10° anterior closing-wedge osteotomy, as well as an additional 5° of simulated varus correction osteotomy, were created and fixed using an external fixator. Four alignment conditions-native, varus correction, slope correction, and combined varus and slope correction-were randomly tested in 2 states: ACL-deficient and ACL-reconstructed. Compressive axial loads were applied to the tibia while mounted on a free-moving X-Y table and free-rotating tibia in a knee testing fixture. Three-dimensional motion tracking captured anterior tibial translation (ATT) and internal tibial rotation. Change of tensile forces on the reconstructed ACL graft were recorded., Results: In the ACL-deficient knee, an isolated varus correction led to a significant increase of ATT by 4.3 ± 4.0 mm ( P = .04). Isolated slope reduction resulted in the greatest decrease of ATT by 6.2 ± 4.3 mm ( P < .001). In the ACL-reconstructed knee, ATT showed comparable changes, while combined varus and slope correction led to lower ATT by 3.7 ± 2.6 mm ( P = .01) than ATT in the native alignment. Internal tibial rotation was not significantly altered by varus correction but significantly increased after isolated slope correction by 4.0°± 4.1° ( P < .01). Each isolated or combined osteotomy showed decreased forces on the graft as compared with the native state. The combined varus and slope osteotomy led to a mean decrease of ACL graft force by 33% at 200 N and by 58% at 400 N as compared with the native condition ( P < .001)., Conclusion: A combined varus and slope correction led to a relevant decrease of ATT in the ACL-deficient and ACL-reconstructed cadaveric knee. ACL graft forces were significantly decreased after combined varus and slope correction. Thus, our biomechanical findings support the treatment goal of a perpendicular-aligned tibial plateau for ACL insufficiencies, especially in cases of revision surgery., Clinical Relevance: This study shows the beneficial knee kinematics and reduced forces on the ACL graft after combined varus and slope correction.

Background: In the past decade, superior capsular reconstruction has emerged as a potential surgical approach in young patients with irreparable posterosuperior rotator cuff tears (RCT) and absence of severe degenerative changes. Recently, the use of locally available and biological viable autografts, such as the long head of the biceps tendon (LHBT) for SCR has emerged, with promising early results., Purpose/hypothesis: The purpose of this study was to investigate the effect of using the LHBT for reconstruction of the superior capsule on shoulder kinematics, along with different fixation constructs in a dynamic biomechanical model. The authors hypothesized that each of the 3 proposed fixation techniques would restore native joint kinematics, including glenohumeral superior translation (ghST), maximum abduction angle (MAA), maximum cumulative deltoid force (cDF), and subacromial peak contact pressure (sCP)., Study Design: Controlled laboratory study., Methods: Eight fresh-frozen cadaveric shoulders (mean age, 53.4 ± 14.2 years) were tested using a dynamic shoulder simulator. Each specimen underwent the following 5 conditions: (1) intact, (2) irreparable posterosuperior rotator cuff tear (psRCT), (3) V-shaped LHBT reconstruction, (4) box-shaped LHBT reconstruction, and (5) single-stranded LHBT reconstruction. MAA, ghST, cDF and sCP were assessed in each tested condition., Results: Each of the 3 LHBT techniques for reconstruction of the superior capsule significantly increased MAA while significantly decreasing ghST and cDF compared with the psRCT ( P < .001 and P < .001, respectively). Additionally, the V-shaped and box-shaped techniques significantly decreased sCP ( P = .009 and P = .016, respectively) compared with the psRCT. The V-shaped technique further showed a significantly increased MAA ( P < .001, respectively) and decreased cDF ( P = .042 and P = .039, respectively) when compared with the box-shaped and single-stranded techniques, as well as a significantly decreased ghST ( P = .027) when compared with the box-shaped technique., Conclusion: In a dynamic biomechanical cadaveric model, using the LHBT for reconstruction of the superior capsule improved shoulder function by preventing superior humeral migration, decreasing deltoid forces and sCP. As such, the development of rotator cuff tear arthropathy in patients with irreparable psRCTs could potentially be delayed., Clinical Relevance: Using a biologically viable and locally available LHBT autograft is a cost-effective, potentially time-saving, and technically feasible alternative for reconstruction of the superior capsule, which may result in favorable outcomes in irreparable psRCTs. Moreover, each of the 3 techniques restored native shoulder biomechanics, which may help improve shoulder function by preventing superior humeral head migration and the development of rotator cuff tear arthropathy in young patients with irreparable rotator cuff tears.

Background: Superior capsular reconstruction (SCR) for massive, irreparable rotator cuff tears has become more widely used recently; however, ideal tensioning of the graft and the influence on joint kinematics remain unknown., Purpose/hypothesis: The purpose of this study was to assess the effects of graft tensioning on glenohumeral joint kinematics after SCR using a dermal allograft. The hypothesis was that a graft fixed under tension would result in increased glenohumeral abduction motion and decreased cumulative deltoid forces compared with a nontensioned graft., Study Design: Controlled laboratory study., Methods: A total of 10 fresh-frozen cadaveric shoulders were tested using a dynamic shoulder simulator. Each shoulder underwent the following 4 conditions: (1) native, (2) simulated irreparable supraspinatus (SSP) tear, (3) SCR using a nontensioned acellular dermal allograft, and (4) SCR using a graft tensioned with 30 to 35 N. Mean values for maximum glenohumeral abduction and cumulative deltoid forces were recorded. The critical shoulder angle (CSA) was also assessed., Results: Native shoulders required a mean (±SE) deltoid force of 193.2 ± 45.1 N to achieve maximum glenohumeral abduction (79.8° ± 5.8°). Compared with native shoulders, abduction decreased after SSP tears by 32% (54.3° ± 13.7°; P = .04), whereas cumulative deltoid forces increased by 23% (252.1 ± 68.3 N; P = .04). The nontensioned SCR showed no significant difference in shoulder abduction (54.1° ± 16.1°) and required deltoid forces (277.8 ± 39.8 N) when compared with the SSP tear state. In contrast, a tensioned graft led to significantly improved shoulder abduction compared with the SSP tear state ( P = .04) although abduction and deltoid forces could not be restored to the native state ( P = .01). A positive correlation between CSA and maximum abduction was found for the tensioned-graft SCR state ( r = 0.685; P = .02)., Conclusion: SCR using a graft fixed under tension demonstrated a significant increase in maximum shoulder abduction compared with a nontensioned graft; however, abduction remained significantly less than the intact state. The nontensioned SCR showed no significant improvement in glenohumeral kinematics compared with the SSP tear state., Clinical Relevance: Because significant improvement in shoulder function after SCR may be expected only when the graft is adequately tensioned, accurate graft measurement and adequate tension of at least 30 N should be considered during the surgical procedure. SCR with a tensioned graft may help maintain sufficient acromiohumeral distance, improve clinical outcomes, and reduce postoperative complications., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The University of Connecticut Health Center/UConn Musculoskeletal Institute received direct funding and material support for this study from Arthrex. The company had no influence on study design, data collection, or interpretation of the results or the final manuscript. K.B. is a paid consultant for Arthrex. C.R.A. is an employee of Arthrex. A.D.M. has received research grants from Arthrex, consulting fees from Arthrex and Astellas Pharma, royalties from Arthrex, and honoraria from Arthrosurface. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Purpose: To evaluate the clinical outcomes of patients who underwent arthroscopic rotator cuff repair augmented using subacromial bursa, concentrated bone marrow aspirate (cBMA), and platelet-rich plasma., Methods: Sixteen patients were included in the study who underwent arthroscopic rotator cuff repair augmented using subacromial bursa, cBMA, and platelet-rich plasma from January 2018 to July 2018 and had a minimum 1-year follow-up. American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test, Constant-Murley, and Single Assessment Numerical Evaluation (SANE) scores were collected preoperatively and at terminal follow-up. To determine the clinical relevance of ASES scores, the minimal clinically important difference, substantial clinical benefit, and the patient acceptable symptomatic state thresholds were used. In vitro cellular proliferation of subacromial bursa (nucleated cells/gram) and cBMA (nucleated cells and colony-forming units/cc) samples was evaluated and correlated to clinical outcomes scores., Results: Mean follow-up was 12.6 ± 1.8 months (range 12-19 months). Patients achieved significant improvement in ASES (45.8±22.5 pre vs 88.5 ± 14.6 post, Δ44.7 ± 20.7; P  = .001), Simple Shoulder Test (4.3 ± 3.2 pre vs 10.4 ± 1.6 post , Δ5.7 ± 3.9, P  = .002), Constant-Murley (44.3 ± 18.2 pre vs 83.6 ± 17.5 post, Δ37.2 ± 21.8; P  = .001), SANE (13.3 ± 10.7 pre vs 86.3 ± 17.5 post, Δ71.9 ± 22.9; P  = .001), and pain scores (5.0±2.8 pre vs 1.1 ± 1.6 post, Δ3.5±2.5, P  = .001) at final follow-up. With regards to ASES score, 93.8% of patients achieved the minimal clinically important difference, 93.8% the substantial clinical benefit, and 62.5% reached or exceeded the patient acceptable symptomatic state criteria. There was a significant positive correlation of nucleated cell count of cBMA with postoperative SANE score (r = 0.707; P  = .015) and delta in ASES score (r = 0.727; P  = .011). All other correlations were found to be nonsignificant ( P > .05, respectively)., Conclusions: Patients undergoing arthroscopic rotator cuff repair augmented using the Mega-Clot with bursa technique achieved significant improvement in functional outcomes at a minimum 1-year follow-up, with 93.8% of patients reaching substantial clinical benefit., Level of Evidence: Level IV, therapeutic case series., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier.)

Background: Revision surgery in cases of previously failed primary acromioclavicular (AC) joint stabilization remains challenging mainly because of anatomic alterations or technical difficulties. However, anatomic coracoclavicular ligament reconstruction (ACCR) has been shown to achieve encouraging biomechanical, clinical, and radiographic short-term to midterm results., Purpose: To evaluate the clinical and radiographic long-term outcomes of patients undergoing revision ACCR after failed operative treatment for type III through V AC joint injuries with a minimum 10-year follow-up., Study Design: Case series; Level of evidence, 4., Methods: A retrospective chart review was performed on prospectively collected data within an institutional shoulder registry. Patients who underwent revision ACCR for type III through V AC joint injuries between January 2003 and December 2009 were analyzed. Clinical outcome measures included the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE). The coracoclavicular distance (CCD) was measured for radiographic analysis immediately postoperatively and at last postoperative follow-up., Results: A total of 8 patients with a mean age at the time of surgery of 44.6 ± 10.6 years and a mean follow-up of 135.0 ± 17.4 months (range, 120-167 months) were eligible for inclusion in the study. The time from initial AC joint stabilization until revision surgery was 10.2 ± 12.4 months (range, 0.5-36 months); 62.5% of the patients had undergone more than 2 previous AC joint surgical procedures. The ASES score improved from 43.9 ± 22.4 preoperatively to 80.6 ± 28.8 postoperatively ( P = .012), the SST score improved from 4.4 ± 3.6 preoperatively to 11.0 ± 2.2 postoperatively ( P = .017), and the SANE score improved from 31.4 ± 27.3 preoperatively to 86.9 ± 24.1 postoperatively ( P = .018) at final follow-up. There was no significant difference in the CCD ( P = .08) between the first (7.6 ± 3.0 mm) and final (10.6 ± 2.8 mm) radiographic follow-up (mean, 50.5 ± 32.7 months [range, 18-98 months])., Conclusion: Patients undergoing revision ACCR after failed operative treatment for type III through V AC joint injuries maintained significant improvement in clinical outcomes at a minimum 10-year follow-up., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The University of Connecticut Health Center/UConn Musculoskeletal Institute has received direct funding and material support from Arthrex; the company had no influence on the study design, data collection, or interpretation of the results or the final article. K.B. has received consulting fees from Arthrex. R.A.A. has received research support from Arthrex and DePuy and consulting fees from Biorez. A.D.M. has received research support from Arthrex, consulting fees from Arthrex and Astellas Pharma, and honoraria from Arthrosurface. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Purpose: To biomechanically investigate the influence of osseous valgus alignment, with and without deficiency of the posteromedial ligament complex (PMC), on ACL-graft forces under axial load., Methods: ACL reconstruction was performed on ten cadaveric knee joints. A lateral distal femur osteotomy was then done to adjust for three different alignment conditions according to the position, where the axial weight bearing line (WBL) dissected the tibial plateau (% from medial to lateral): 50%, 85% and 115%. Each alignment was tested with the PMC intact, deficient and reconstructed. Axial loads of 400 N were applied in 15° of knee flexion and changes of ACL-graft forces and dynamic valgus angle (DVA) were recorded., Results: In the PMC intact state, lateralization of the WBL to 85% and to 115% led to significantly increased ACL graft forces (85%: p = 0.010; 115%: p < 0.001) and DVAs (85%: p = 0.027; 115%: p = 0.027). Dissection of the PMC led to a significant increase of ACL graft forces and DVAs at 85% and 115% valgus alignment (p < 0.001) only. In comparison to valgus aligned knees with additional PMC deficiency, ligament reconstruction alone was able to significantly decrease ACL graft forces (p < 0.001) and DVAs (p < 0.001). However, alignment correction alone was significantly more effective in reducing ACL graft forces (p < 0.001) and DVAs (p = 0.010)., Conclusion: Osseous valgus alignment led to significantly increased forces on ACL grafts under axial joint compression, which was even further enhanced, when the PMC was deficient. In the valgus aligned and PMC deficient knee, correction to a straight leg axis was significantly more effective in decreasing forces on the ACL graft than reconstruction of the PMC. In patients with valgus alignment and combined injuries of the ACL and PMC, a correction osteotomy to a straight leg axis as well as reconstruction of the PMC should be considered to protect the reconstructed ACL.

Purpose: To biomechanically compare the effect of superior capsule reconstruction (SCR) using a 3- and 6-mm thick acellular dermal allograft for the treatment of irreparable rotator cuff tears., Methods: Eight fresh-frozen cadaveric shoulders were tested using a dynamic shoulder model. Maximum abduction angle (MAA), glenohumeral superior translation (ghST), subacromial peak contact pressure (sPCP), and cumulative deltoid force (cDF) were compared among 4 conditions: (1) intact shoulder, (2) simulated irreparable rotator cuff tear (RCT), (3) SCR using a 3-mm-thick acellular dermal allograft, (4) SCR using a 6-mm-thick acellular dermal allograft., Results: Compared with the intact state, simulated irreparable RCTs significantly decreased MAA (P < .001), while significantly increasing ghST (P = .001), sPCP (P < .001), and cDF (P < .001). SCR with a 3-mm-thick graft significantly increased MAA (P = .01) and decreased ghST (P = .01) compared with the RCT state, however, showed similar sPCP and cDF. Compared with the torn state, SCR with a 6-mm-thick graft significantly increased MAA (P < .001) and significantly decreased ghST (P < .001), sPCP (P < .001), and cDF (P = .001). Using a 6-mm-thick graft demonstrated similar MAA, ghST, sPCP, and cDF compared with the intact state. When comparing the 3-mm to the 6-mm thick graft, significant differences were found in ghST (P = .03), sPCP (P < .001), and cDF (P = .02)., Conclusions: SCR with a 6-mm-thick acellular dermal allograft better restored normal glenohumeral joint position and forces compared with a 3-mm-thick graft for the treatment of irreparable RCTs., Clinical Relevance: Graft thickness may affect the clinical success following SCR with commercially available dermal allografts. Using a thicker (>3 mm) graft was able to biomechanically better restore native glenohumeral joint properties., (Copyright © 2019 Arthroscopy Association of North America. All rights reserved.)

Purpose: To compare suture tape-augmented MPFL repair with allograft MPFL reconstruction using patellofemoral contact pressure and joint kinematics to assess the risk of patellofemoral over-constrainment at point zero., Methods: A total of ten fresh frozen cadaveric knee specimens were tested in four different conditions of the MPFL: (1) native, (2) cut, (3) reconstructed with tendon graft, and (4) augmented with suture tape. The patellofemoral mean pressure (MP), peak pressure (PP) and contact area (CA) were measured independently for the medial and lateral compartments using pressure-sensitive films. Patellar tilt (PT) and shift (PS) were measured using an optical 3D motion tracking system. Measurements were recorded at 0°, 10°, 20°, 30°, 60° and 90° of flexion. Both the tendon graft and the internal brace were preloaded with 2 N, 5 N, and 10 N., Results: There was no significant differences found between surgical methods for medial MP, medial PP, medial CA, lateral MP and PS at any preload or flexion angle. Significant differences were seen for lateral PP at 20° knee flexion and 10 N preload (suture tape vs. reconstruction: 1045.9 ± 168.7 kPa vs. 1003.0 ± 151.9 kPa; p = 0.016), for lateral CA at 10° knee flexion and 10 N preload (101.4 ± 39.5 mm 2 vs. 108.7 ± 36.6 mm 2 ; p = 0.040), for PT at 10° knee flexion and 2 N preload (- 1.9 ± 2.5° vs. - 2.5 ± 2.3°; p = 0.033) and for PT at 0° knee flexion and 10 N preload (- 0.8 ± 2.5° vs. - 1.8 ± 3.1°; p = 0.040). A preload of 2 N on the suture tape was the closest in restoring the native joint kinematics., Conclusions: Suture tape augmentation of the MPFL resulted in similar primary contact pressures and joint kinematics in comparison with MPFL reconstruction using a tendon graft. A pretension of 2 N was found to restore the knee joint closest to normal patellofemoral kinematics.

Background: Lesser trochanter avulsions are rare injuries in adolescents. Severe cases with relevant fragment displacement can be treated surgically. However, no standard approach is available in the literature. Operative techniques are presently limited to anterograde fixations. A new retrograde approach to reduce operative difficulty and postoperative morbidity has been proposed. So far, no biomechanical comparison of these techniques is available., Hypothesis: Retrograde repair of the lesser trochanter with a titanium cortical button will produce superior stability under load to failure and similar displacement under cyclic loading compared with anterograde fixation with titanium suture anchors., Study Design: Controlled laboratory study., Methods: Sixteen paired hemipelvic cadaveric specimens (mean age, 62.5 ± 10.7 years) were dissected to isolate the lesser trochanter and iliopsoas muscle. After repair of a simulated lesser trochanter avulsion, specimens were tested under cyclic loading between 10 and 125 N at 1 Hz for 1500 cycles before finally being loaded to failure at a rate of 120 mm/min in a material testing machine. Motion tracking was used to assess displacement at the superior and inferior aspects of the iliopsoas tendon under cyclic loading., Results: Load to failure was significantly greater for the retrograde repair compared with the anterograde repair (1075.24 ± 179.39 vs 321.85 ± 62.45 N; P = .012). Mean displacement at the superior repair aspect (retrograde vs anterograde: 3.29 ± 1.84 vs 4.39 ± 4.50 mm; P = .779) and mean displacement at the inferior aspect (3.54 ± 2.13 vs 4.22 ± 4.48 mm; P = .779) of the iliopsoas tendon did not significantly differ by the type of repair. Mode of failure was tendon tearing by the sutures for each retrograde repair and anchor pullout for each anterograde repair., Conclusion: Surgical repair of lesser trochanter avulsion fractures with retrograde fixation using a titanium cortical button demonstrated superior load to failure and similar displacement under cyclic loading compared with anterograde fixation using suture anchors., Clinical Relevance: The retrograde approach provides a biomechanically validated alternative to other surgical techniques for this injury., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The University of Connecticut Health Center/UConn Musculoskeletal Institute received direct funding and material support for this study from Arthrex. K.C. has received educational support from Arthrex and Pylant Medical, speaking fees from Arthrex, consulting fees from Johnson & Johnson, and hospitality payments from Biomet and Smith & Nephew. K.B. has received consulting fees from Arthrex. A.B.I. has received consulting fees from Arthrosurfance, Arthrex, and Medi. A.D.M. has received grant support and consulting fees from Arthrex and honoraria from Arthrosurface. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Background: Proximal hamstring avulsions are severe tendon injuries and are commonly sports-related. Open and endoscopic techniques as well as different anchor configurations have already been described for proximal hamstring repair. Novel all-suture anchors have been developed to provide decreased bone loss during placement and reduced occupied bone volume when compared with titanium suture anchors., Hypothesis: Complete proximal hamstring avulsions repaired with all-suture anchors will demonstrate equal load to failure and comparable displacement under cyclic loading when compared with titanium suture anchors., Study Design: Controlled laboratory study., Methods: Complete proximal hamstring avulsions were created in 18 paired cadaveric specimens (mean ± SD age, 63.0 ± 10.4 years). Either all-suture anchors or titanium suture anchors were used for repair. Cyclic loading from 10 to 125 N at 1 Hz was performed for 1500 cycles with a material testing machine. Displacement was assessed along anterior and posterior aspects of the tendon repair with optical tracking. Specimens were loaded to failure at a rate of 120 mm/min. Displacement, load to failure, and repair construct stiffness were compared between matched pairs with the Wilcoxon signed-rank test. Correlations were determined by Spearman rho analysis., Results: The all-suture anchors showed significantly higher load-to-failure values when compared with the titanium anchor repairs (799.64 ± 257.1 vs 573.27 ± 89.9 N; P = .008). There was no significant difference in displacement between all-suture anchors and titanium suture anchors at the anterior aspect (6.60 ± 2.2 vs 5.49 ± 1.1 mm; P = .26) or posterior aspect (5.87 ± 2.08 vs 5.23 ± 1.37 mm; P = .678) of the repaired hamstring tendons., Conclusion: All-suture anchors demonstrated similar displacement and superior load to failure when compared with titanium suture anchors., Clinical Relevance: The results of this study suggest that all-suture anchors are an equivalent alternative to titanium suture anchors for proximal hamstring avulsion repair., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The University of Connecticut Health Center/UConn Musculoskeletal Institute has received direct funding and material support for this study from Arthrex. A.O. received material support from Arthrex during the conduct of this study. A.B.I. has received consulting fees from Arthrosurface, Arthrex, and Medi. K.B. has received consulting fees from Arthrex. A.D.M. has received grant support and consulting fees from Arthrex and honoraria from Arthrosurface. K.C. has received educational support from Arthrex and Pylant Medical, speaking fees from Arthrex, consulting fees from Johnson & Johnson, and hospitality payments from Biomet and Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Purpose: Treatment of failed primary reconstruction of the unstable acromioclavicular (AC) joint remains challenging for orthopaedic surgeons. When approaching revision cases, the reason for failure has to be precisely identified. The purpose of this manuscript was to perform a critical review of the literature regarding treatment options for failed AC joint stabilization techniques and to provide a treatment algorithm for salvage procedures., Methods: A thorough search included electronic databases for articles published up to April 15th, 2019. Inclusion criteria were set as (1) studies that reported on clinical outcomes following surgical or conservative treatment of AC joint dislocation; (2) studies reporting on failure or complications of primary treatment; (3) chronic instabilities caused by delayed or secondary treatment as well as (4) revision and salvage procedures., Results: The search strategy identified a total of 3269 citations. The final dataset comprised 84 studies published between 1954 and 2019. A total of 5605 patients (9.63% females) were involved with a mean age of 34.5 years. Overall, complication rates varied between 5 and 88.9% in patients with AC joint instability., Conclusion: In the current literature, evidence for treatment of revision AC joint instability is still lacking, however, surgical treatment continues to evolve. The importance of failure analysis and clinically relevant algorithms were highlighted in this review. Adequately restoring native joint biomechanics is needed for ensuring an optimal healing environment that will translate into patient satisfaction and long-term stability., Level of Evidence: V.

Purpose: The acromioclavicular ligament complex (ACLC) is the primary stabilizer against horizontal translation with the superior ACLC providing the main contribution. The purpose of this study was to evaluate the specific regional contributions in the superior half of ACLC, where the surgeon can easily access and repair or reconstruct, for posterior translational and rotational stability., Methods: The superior half of ACLC was divided into three regions; Region A (0°-60°): an anterior 1/3 region of the superior half of ACLC, Region B (60°-120°): a superior 1/3 region of the superior half of ACLC, and Region C (120°-180°): a posterior 1/3 region of the superior half of ACLC. Fifteen fresh-frozen cadaveric shoulders were used. Biomechanical testing was performed to evaluate the resistance force against passive posterior translation (10 mm) and the resistance torque against passive posterior rotation (20°) during the following the four conditions. (1) Stability was tested on all specimens in their intact condition (n = 15). (2) The ACLC was dissected and stability was tested (n = 15). (3) Specimens were randomly divided into three groups by regions of suturing. Stability was tested after suturing Region A, Region B, or Region C (n = 5 per group). (4) Stability was tested after suturing additional regions: Region A + B (0°-120°), Region B + C (60°-180°), or Region A + C (0°-60°, 120°-180°, n = 5 per group)., Results: The translational force increased after suturing Region A when compared with dissected ACLC (P = 0.025). The force after suturing Region A + B was significantly higher compared to the dissected ACLC (P < 0.001). The rotational torque increased after suturing Region A or Region B compared with dissected ACLC (P = 0.020, P = 0.045, respectively). The torque after suturing the Region A + C was significantly higher compared to the dissected ACLC (P < 0.001)., Conclusion: The combined Region A + B contributed more to posterior translational stability than Region B + C or Region A + C. In contrast, combined Region A + C contributed more to posterior rotational stability than Region A + B or Region B + C. Based on these findings, surgical techniques restoring the entire superior ACLC are recommended to address both posterior translational and rotational stability of the AC joint.

Purpose: Glenoid retroversion is a known independent risk factor for recurrent posterior instability. The purpose was to investigate progressive angles of glenoid retroversion and their influence on humeral head centration and posterior translation with intact, detached, and repaired posterior labrum in a cadaveric human shoulder model., Methods: A total of 10 fresh-frozen human cadaveric shoulders were investigated for this study. After CT- canning, the glenoids were aligned parallel to the floor, with the capsule intact, and the humerus was fixed in 60° of abduction and neutral rotation. Version of the glenoid was created after wedge resection from posterior and fixed with an external fixator throughout the testing. Specimens underwent three conditions: intact, detached, and repaired posterior labrum, while version of the glenoid was set from + 5° anteversion to - 25° retroversion by 5° increments. Within the biomechanical setup, the glenohumeral joint was axially loaded (22 N) to center the joint. At 0° of glenoid version and intact labrum, the initial position was used as baseline and served as point zero of centerization. After cyclic preloading, posterior translation force (20 N) was then applied by a material testing machine, while start and endpoints of the scapula placed on an X-Y table were measured., Results: The decentralization of the humeral head at glenoid version angles of 5°, 10°, 15°, and 20° of retroversion and 5° of anteversion was significantly different (P < 0.001). Every increment of 5° of retroversion led to an additional decentralization of the humeral head overall by (average ± SD) 2.0 mm ± 0.3 in the intact and 2.0 mm ± 0.7 in the detached labrum condition. The repaired showed significantly lower posterior translation compared to the intact condition at 10° (P = 0.012) and 15° (P < 0.01) of retroversion. In addition, CT measured parameters (depth, diameter, and native version) of the glenoid showed no correlation with angle of dislocation of each specimen., Conclusion: Bony alignment in terms of glenoid retroversion angle plays an important role in joint centration and posterior translation, especially in retroversion angles greater than 10°. Isolated posterior labrum repair has a significant effect on posterior translation in glenoid retroversion angles of 5° and 10°. Bony correction of glenoid version may be considered to address posterior shoulder instability with retroversion > 15°.

Background: Low aspiration volumes have been recommended to allow for higher concentrations of progenitor cells during bone marrow harvesting. However, these guidelines then require multiple aspiration attempts in order to maximize cellular yield. The purpose of this study was to investigate the effect of a single, high-volume aspiration with four consecutive aliquots on the number of nucleated cells (NCs) and colony-forming units (CFUs) in concentrated bone marrow aspirate (cBMA) taken from the proximal humerus., Methods: cBMA was taken from the proximal humerus of patients undergoing arthroscopic rotator cuff surgery. Four 12-mL double syringes were used consecutively from a single trocar to obtain four 10 cc aliquots. Each then underwent centrifugation to create a fractionated layer rich in nucleated cells. Following cellular separation, NCs were counted and CFUs were evaluated after incubation of 7-10 days. Cellular comparisons between each aliquot were performed along with their interaction with patient age and sex., Results: Twenty-nine patients (55.9 ± 4.6 years) were included in this study. The number of NCs and CFUs showed significant differences between the four aliquots of aspirate, with the first 10 cc aliquot providing the highest amount (p < 0.001, respectively). No significant differences were found between the sum of the three sequential aliquots compared to the initial 10 cc sample. There were no significant differences between male and female patients (p > 0.05). Increasing age resulted in no significant decrease in the number of NCs and CFUs across the four consecutive aliquots (p > 0.05)., Conclusion: In conclusion, while the initial aliquot provided the greatest number of nucleated cells and cultured CFUs, the addition of each sequential volume aspirate yielded similar amounts in total. This demonstrates the potential effectiveness of obtaining of higher volume aspirates from the proximal humerus during rotator cuff repair.

Reasons for failure of anterior cruciate ligament (ACL) reconstructions are manifold and require a multifactorial explanatory approach. In addition to technical failures, many modifiable and non-modifiable risk factors for a new ACL injury have to be considered. Technical failures primarily include non-anatomical tibial and femoral tunnel position. In comparison to the transtibial drilling technique, the tibial tunnel-independent technique results in a more anatomical position of the femoral tunnel and should therefore be preferred. One can differentiate between non-modifiable and modifiable risk factors. At the same time, the combination of more than one risk factor increases the risk of injury significantly. Non-modifiable risk factors include genetic predisposition, female sex, young age and ligament hyperlaxity. Young age at the time of the first injury is the most important risk factor for graft failure. Modifiable risk factors include high body mass index (BMI), deficits in jump landing mechanics, a steep posterior tibial slope and narrow intercondylar notch width. Neuromuscular training or additional surgical procedures modify these risk factors and reduce the probability of further injuries. A high tibial osteotomy (HTO) is the surgical procedure of choice for a reduction in the posterior tibial slope and anterior tibial translation. In case of a tibial slope over 12°, this procedure should be considered. In revision anterior cruciate ligament reconstructions with remaining anterolateral rotatory instability, additional lateral extraarticular tenodesis should be taken into account. This is also recommended for patients participating in pivoting sports, having concomitant hyperlaxity or additional injury of peripheral structures with insufficiency of the ACL. In addition, the surface of the pitch can be modified and thus influence the risk of an ACL injury. In summary, a substantiated failure analysis is required to initiate specific and individualised therapy - not only in the case of ACL rerupture. These factors should already be considered in risk assessment during patient information., Competing Interests: The authors declare that they have no conflict of interest./Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Posterior tibial slope (PTS) represents an important risk factor for anterior cruciate ligament (ACL) graft failure, as seen in clinical studies. An anterior closing wedge osteotomy for slope reduction was performed to investigate the effect on ACL-graft forces and femoro-tibial kinematics in an ACL-deficient and ACL-reconstructed knee in a biomechanical setup., Methods: Ten cadaveric knees with a relatively high native slope (mean ± SD): (slope 10° ± 1.4°, age 48.2 years ± 5.8) were selected based on prior CT measurements. A 10° anterior closing-wedge osteotomy was fixed with an external fixator in the ACL-deficient and ACL-reconstructed knee (quadruple Semi-T/Gracilis-allograft). Each condition was randomly tested with both the native tibial slope and the post-osteotomy reduced slope. Axial loads (200 N, 400 N), anterior tibial draw (134 N), and combined loads were applied to the tibia while mounted on a free moving and rotating X-Y table. Throughout testing, 3D motion tracking captured anterior tibial translation (ATT) and internal tibial rotation (ITR). Change of forces on the reconstructed ACL-graft (via an attached load-cell) were recorded, as well., Results: ATT was significantly decreased after slope reduction in the ACL-deficient knee by 4.3 mm ± 3.6 (p < 0.001) at 200 N and 6.2 mm ± 4.3 (p < 0.001) at 400N of axial load. An increase of ITR of 2.3° ±2.8 (p < 0.001) at 200 N and by 4.0° ±4.1 (p < 0.001) at 400 N was observed after the osteotomy. In the ACL-reconstructed knee, ACL-graft forces decreased after slope reduction osteotomy by a mean of 14.7 N ± 9.8 (p < 0.001) at 200 N and 33.8 N ± 16.3 (p < 0.001) at 400N axial load, which equaled a relative decrease by a mean of 17.0% (SD ± 9.8%), and 33.1% (SD ± 18.1%), respectively. ATT and ITR were not significantly changed in the ACL-reconstructed knee. Testing of a tibial anterior drawing force in the ACL-deficient knee led to a significantly increased ATT by 2.7 mm ± 3.6 (p < 0.001) after the osteotomy. The ACL-reconstructed knee did not show a significant change (n.s.) in ATT after the osteotomy. However, ACL-graft forces detected a significant increase by 13.0 N ± 8.3 (p < 0.001) after the osteotomy with a tibial anterior drawer force, whereas the additional axial loading reduced this difference due to the osteotomy (5.3 N ± 12.6 (n.s.))., Conclusions: Slope-reducing osteotomy decreased anterior tibial translation in the ACL-deficient and ACL-reconstructed knee under axial load, while internal rotation of the tibia increased in the ACL-deficient status after osteotomy. Especially in ACL revision surgery, the osteotomy protects the reconstructed ACL with significantly lower forces on the graft under axial load.

Background: In cases of acute combined posteromedial and anterior cruciate ligament (ACL) injuries, primary repair of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with suture tape augmentation may be a reasonable alternative to standard tendon reconstruction techniques., Purpose/hypothesis: The purpose was to examine the rotational and valgus laxity with ACL strain following sMCL and POL repair with suture tape augmentation at various degrees of knee flexion. It was hypothesized that this technique would restore knee laxity and kinematics comparable with those of the intact state., Study Design: Controlled laboratory study., Methods: Ten cadaveric knee specimens (mean ± SD, 57.9 ± 5.9 years) were obtained. Specimens were tested with the tibia fixed and the femur mobile on an X-Y table. Each specimen was tested in 4 conditions according to the state of the sMCL and POL: native, deficient, repaired with suture tape augmentation, and reconstructed with tendon allografts. Valgus laxity was tested with 40-N force applied in the lateral direction of the femur, and rotational motion was tested with 5-N torque applied to the tibia. ACL strain during valgus stress was also measured. Each condition was tested in 0°, 15°, 30°, 45°, and 60° of knee flexion., Results: Dissection of the sMCL and POL led to significantly increased valgus laxity in all flexion angles, with a significant increase in ACL strain at 30° ( P < .001) and 45° ( P < .001). Ligament repair with suture tape augmentation demonstrated similar valgus and rotational laxity as compared with intact specimens, with the exception of increased internal rotation at 30° ( P = .005). Ligament reconstruction resulted in significantly increased valgus opening at 45° ( P = .048) and significantly increased internal rotation at 30° ( P < .001) as compared with the native state. Direct comparison between surgical techniques showed no significant differences., Conclusion: At time zero, ligament repair of the posteromedial knee with suture tape augmentation restored close-to-native valgus and rotatory laxity, as well as native ACL strain for cases of complete sMCL and POL avulsion., Clinical Relevance: Ligament repair of the sMCL and POL with suture tape augmentation may be a reasonable alternative to tendon reconstruction techniques in cases of acute combined posteromedial and ACL injuries with valgus and rotatory instability.

Purpose: In recent literature medial meniscus extrusion (MME) was demonstrated as an age, BMI and load dependent physiological phenomenon in healthy knees. The aim of the present study was to evaluate the influence of mountain ultramarathon running on the medial meniscus extrusion (MME) in healthy athletes., Methods: Healthy athletes of the 2017 Gore-Tex® Transalpine run (seven stages with in total 270.5 km and 16453 m altitude) with asymptomatic knee, and no history of knee injuries or surgeries were included. All athletes underwent standard knee examination, MRI to exclude further knee pathologies and ultrasound imaging (USI) for measurement of MME before the competition. Extrusion in USI was determined in supine position (unloaded) and in standing position with full weight bearing and 20° of flexion (loaded). After the 1st, 3rd, and 7th stage ultrasound measurements were repeated directly after the competition. For evaluation of recovery, ultrasound measurement of MME was repeated 2 weeks after the race. Difference between ultrasound measurements of MME was assessed by unpaired t-test with significance set at p < 0.05., Results: Eighteen athletes (mean age 37.4 ± 8.3 years, 5 females, 13 males) were included in the study. The mean USI MME before the race was 1.9 mm ± 0.3 mm in supine position and 2.4 mm ± 0.4 mm under full weight bearing. During the race the mean MME increased significantly compared to baseline measurements. After 7th stage the mean MME in supine position was 2.7 mm ± 0.7 mm and 3.1 mm ± 0.6 mm under full weight bearing. After 2 weeks of recovery medial meniscus demonstrated a complete reversibility of the extrusion to normal (N.S)., Conclusion: Medial meniscus extrusion observed under extreme loads generated by a mountain ultramarathon is a temporary and reversible phenomenon in healthy athletes. This suggests, that the meniscus has viscoelastic capacities showing short-term adaptions to high loads, which are completely reversible over time. For clinical practice assessment of the MME by ultrasound might be favorable compared to MRI due to the ability of dynamic evaluation and the easy access. Furthermore, load should be taken in account when assessing the MME and the current cut-off value of 3 mm for meniscus pathologies should be reconsidered., Level of Evidence: IV.

Background: The primary objective was to assess whether a patient's early postoperative quality of life (QOL) correlates with the retear rate following single-tendon double-row rotator cuff repair., Methods: We performed a secondary analysis of a randomized clinical trial of 58 patients who underwent single-tendon arthroscopic rotator cuff repair of full-thickness tears performed by a single surgeon. Patients were randomized to an early- or delayed-motion protocol. At 6 months, all patients underwent magnetic resonance imaging to assess whether the rotator cuffs were intact or retorn. QOL was assessed preoperatively and at 3 weeks, 6 weeks, 12 weeks, 6 months, and 12 months postoperatively using the Western Ontario Rotator Cuff (WORC) index., Results: After 6 months of rehabilitation, 41 patients (71%) had intact rotator cuff repairs whereas 17 (29%) had full-thickness tears. Patients with torn rotator cuffs at 6 months postoperatively had significantly lower WORC scores at 6 weeks postoperatively (P = .041). Patients with greater improvements in QOL perioperatively (preoperative WORC score minus 6-week postoperative WORC score > 264.5) were more likely to have full-thickness tears by 6 months postoperatively. Compliant patients assigned to the delayed-motion protocol had a failure rate of 11% (2 of 19) compared with 38% (15 of 39) in the noncompliant and early-motion protocol patients (P < .01). Overall, patients who were noncompliant with the shoulder immobilizer were 8.2 times more likely to have a failed repair on magnetic resonance imaging (P = .01)., Conclusions: Patients with better QOL shortly after arthroscopic rotator cuff repair were more likely to have retears by 6 months., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare a conventional single-row (SR) repair technique and 2 double-row (DR) repair techniques to restore and protect the superolateral aspect of the subscapularis (SSC) tendon and ensure SSC leading-edge reconstruction in a cadaveric model., Methods: The native footprint was measured in 15 pairs of human cadaveric shoulders (N = 30) with a mean age of 67.2 years. According to the Fox-Romeo classification, a 25% defect or 50% defect in a superior-inferior direction was created. Specimens were mounted onto a servohydraulic test system to analyze contact variables at 0° and 20° of abduction with a force-controlled ramped program up to 50 N. In addition, each specimen was cyclically loaded (10-100 N, 300 cycles). The tears were repaired with 1 of 3 constructs: a 2-anchor medially based conventional SR construct, a 2-anchor-based hybrid DR construct, or a 3-anchor-based DR construct. The outcome variables were ultimate tensile load, displacement, and pressurized footprint coverage., Results: All reconstructions resulted in stable constructs with peak loads exceeding 450 N (P = .68). The overall displacement during cyclic loading was between 1.2 and 3.0 mm (P = .70). A significant difference was seen when the 2 arm positions of 0° and 20° of abduction were compared, showing a constant reduction of pressurized footprint coverage with the arm abducted (P = .01). Analyzing footprint coverage with respect to the region of interest-the leading edge of the SSC-we observed a significant difference between the SR construct and a construct using a superolaterally placed anchor (25% defect, P = .01; 50% defect, P = .01), whereas no statistical differences were detectable between the hybrid DR construct and the DR construct., Conclusions: The leading edge of the SSC tendon can best be restored by using a superolateral anchor, whereas no statistical difference in load to failure in comparison with an SR construct or with the addition of a third anchor was detectable., Clinical Relevance: The SSC is critical for proper shoulder function. Without an increase in the number of implants, a significantly better footprint reconstruction can be achieved by placing an anchor superior and lateral to the native footprint area close to the entrance of the bicipital groove., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The concept of dynamic anterior shoulder stabilization (DAS) combines a Bankart repair with the additional sling effect of the long head of the biceps (LHB) tendon to treat anterior glenohumeral instability. This surgical technique was created to close the gap between the indications for isolated Bankart repair and those requiring bone transfer techniques., Purpose: To biomechanically investigate the stabilizing effects of the DAS technique in comparison with the standard Bankart repair in different defect models., Study Design: Controlled laboratory study., Methods: Twenty-four fresh-frozen cadaveric shoulders (mean ± SD age, 60.1 ± 8.6 years) were mounted in a 6 degrees of freedom shoulder testing system. With cross-sectional area ratios, the rotator cuff muscles and LHB tendon were loaded with 40 N and 10 N, respectively. Anterior and inferior glenohumeral translation was tested in 60° of abduction and 60° of external rotation (ABER position) while forces of 20 N, 30 N, and 40 N were applied to the scapula in the posterior direction. Total translation and relative translation in relation to the native starting position were measured with a 3-dimensional digitizer. Maximal external rotation and internal rotation after application of 1.5-N·m torque to the humerus were measured. All specimens went through 4 conditions (intact, defect, isolated Bankart repair, DAS) and were randomized to 1 of 3 defect groups (isolated Bankart lesion, 10% anterior glenoid defect, 20% anterior glenoid defect). The DAS was performed by transferring the LHB tendon through a subscapularis split to the anterior glenoid margin, where it was fixed with an interference screw., Results: Both surgical techniques resulted in decreased anterior glenohumeral translation in comparison with the defect conditions in all defect groups. As compared with isolated Bankart repair, DAS showed significantly less relative anterior translation in 10% glenoid defects at translation forces of 20 N (0.3 ± 1.7 mm vs 2.2 ± 1.8 mm, P = .005) and 30 N (2.6 ± 3.4 mm vs 5.3 ± 4.2 mm, P = .044) and in 20% glenoid defects at all translation forces (20 N: -3.2 ± 4.7 mm vs 0.8 ± 4.1 mm, P = .024; 30 N: -0.9 ± 5.3 mm vs 4.0 ± 5.2 mm, P = .005; 40 N: 2.1 ± 6.6 mm vs 6.0 ± 5.7 mm, P = .035). However, in 20% defects, DAS led to a relevant posterior and inferior shift of the humeral head in the ABER position and to a relevant increase in inferior glenohumeral translation. Both surgical techniques did not limit the rotational range of motion., Conclusion: In the context of minor glenoid bone defects, the DAS technique demonstrates less relative anterior translation as compared with an isolated Bankart repair at time zero., Clinical Relevance: The new DAS technique seems capable of closing the gap between the indications for isolated Bankart repair and bone transfer techniques.

Purpose: Increased femoral antetorsion influences patellofemoral joint kinematics. The aim of this study was to retrospectively evaluate the clinical outcome after derotational osteotomies and combined procedures in patients with patellofemoral instability., Methods: All patients with derotational osteotomies and combined procedures in patients with patellofemoral instability and increased femoral antetorsion performed between 2007 and 2016 were retrospectively analyzed. Exclusion criteria were open growth plates, posttraumatic deformities, and a follow-up period less than 12 months. Simple radiography and magnetic resonance imaging to evaluate cartilage lesions, trochlear dysplasia, tubercle distance, and osseous malalignment as frontal axis and torsion were performed on every patient. Patients were evaluated pre- and postoperatively using the visual analog scale (VAS) for pain, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, the subjective IKDC evaluation form, the Lysholm score, and the Tegner activity score., Results: Out of 222 femoral osteotomies, a total of 42 patients (44 knees) met the inclusion criteria. Mean preoperative femoral antetorsion of 31° (SD ± 9°) and mean valgus malalignment of 1° (SD ± 3°) were observed. An intended derotation of 12° (SD ± 5°) was set overall. The additional procedures included correction of valgus in 50% (n = 22), MPFL reconstruction in 64% (n = 28), patellofemoral arthroplasty in 18% (n = 8), trochleoplasty in 14% (n = 6), tibial tubercle transfer in 14% (n = 6). During the mean follow-up period of 44 months (SD ± 27, range 12-88), a total of five patients were lost to follow-up, resulting in a follow-up rate of 89% (n = 39). A significant pain relief from VAS 4 (SD ± 3) to VAS 2 (SD ± 2) (p = 0.006) as well as improved scores, WOMAC: from 80 (SD ± 14) to 88 (SD ± 16) (p = 0.007), Lysholm: from 46 (SD ± 21) to 71 (SD ± 24) (p < 0.001), IKDC: from 54 (SD ± 13) to 65 (SD ± 17) (p < 0.001), were observed postoperatively. During the follow-up period, no patellar re-dislocation was observed., Conclusion: Combined derotational osteotomy is a suitable treatment for patellar instability due to torsional malformity, as it leads to a significant reduction of pain, and a significant increase of knee function with good-to- excellent results in the short-term follow-up., Level of Evidence: IV.

Background: The synergistic effect of the acromioclavicular (AC) capsule and coracoclavicular (CC) ligaments on AC joint stability has gained recent recognition for its importance. Biomechanical and clinical studies have shown the benefit of combined reconstruction with multiple variations of surgical techniques for AC capsule augmentation. The ideal configuration remains unknown for such capsular repair aimed at achieving optimal stability with anatomic reconstruction., Hypothesis: Primary AC joint stability can be restored by AC capsule augmentation, while position of the additional suture construct is critical. It was hypothesized that techniques that reconstruct the anterior capsular structures would restore native stability against rotations and translations., Study Design: Controlled laboratory study., Methods: Thirty fresh-frozen human cadaveric shoulders were used. Each sample was tested in the native state and served as its own control. After complete capsulotomy, 1 of 5 AC capsular repair configurations was performed: anterior, superior, posterior, O-frame, and X-frame. After testing of the AC capsular repair configurations, the tests were repeated after dissection of the CC ligaments and after CC ligament reconstruction with a suture button system. AC joint stability was immediately tested after each step under rotation and horizontal translation. To accomplish this, the AC joints were anatomically positioned on a custom fixture linked to a servohydraulic testing system. A 3-dimensional optical measuring system was used to evaluate the 3-dimensional joint motion. Clavicle posterior translation in relation to the acromion, rotation around the long axis of the clavicle, and displacement of the lateral clavicle in relation to the center of rotation were measured. The torques and forces required to rotate and translate the clavicle were recorded., Results: In terms of translational testing, after the complete capsulotomy, a significant reduction of resistance force was found across all groups, with a mean 13% to 20% remaining ( P < .05). All AC suture augmentations were able to significantly increase the average resistance force as compared with the native ( P = .01) against posterior translation. Subsequent cutting of the CC ligaments did not result in a significant change in any of the groups ( P = .23). The synergistic effect of AC capsule augmentation and CC ligament reconstruction could be demonstrated without exception. In terms of rotational testing, the complete capsulotomy resulted in a significant reduction of resistance torque in all groups ( P < .05), with a remaining torque ranging between 2% and 11% across the groups. However, all AC suture constructs significantly increased the resistance torque as compared with the capsulotomy ( P = .01). The subsequent cutting of the CC ligaments resulted in a significant change in 2 of the 5 groups (O-frame, P = .01; X-frame, P = .02) and an overall remaining torque reduction ranging from 3% and 42%. The combined reconstruction of the AC capsule and CC ligaments achieved the highest percentage of regained resistance torque but remained significantly weaker than the native specimen ( P = .01)., Conclusion: Native translational stability could be restored by the addition of AC capsule augmentation, while partial rotational instability remained. The tested constructs revealed no significant individual differences., Clinical Relevance: Combined stabilization of the AC capsule and CC ligaments demonstrated the greatest capacity to restore the native stability against translational and rotational loads, with the specific configuration of the AC capsule repair to be chosen according to the personal preferences of the surgeon.

Purpose: To evaluate the effect of critical shoulder angle (CSA), acromion index (AI), and glenoid inclination (GI) on the postoperative healing rate after arthroscopic supraspinatus tendon repair., Methods: Patients after arthroscopic repair of a symptomatic, unilateral, single-tendon, full-thickness supraspinatus tear in whom nonoperative management had failed were retrospectively reviewed. Magnetic resonance imaging (MRI) studies were obtained 6 months postoperatively and were evaluated by 2 independent observers. Repair integrity was classified as either intact or torn. Preoperative true anteroposterior radiographs were used to measure CSA, AI, and GI., Results: Fifty-seven patients were evaluated 6 months postoperatively. The mean patient age at surgery was 54.7 ± 7.7 years. On MRI studies, 41 patients (71.9%) had an intact repair and 16 patients (28.1%) had a full-thickness retear. There were no significant differences between the intact and retear group in regard to patient age (P = .648), initial tear size (P = .205), or fatty degeneration (P = .508). The mean CSA for the retear group (37° ± 4°) was significantly higher than that in the intact group (35° ± 3°; P = .014). If the CSA was >38°, the odds ratio of having a retear was 3.78 (95% confidence interval 1.05 to 13.58; P = .042). Average AI for the retear group (0.73 ± 0.09) was significantly higher than that in the intact group (0.69 ± 0.06; P = .049). The mean GI was 17° ± 6° for the intact group and 16° ± 6° for the retear group (P = .739)., Conclusions: At short-term follow-up, higher CSA and AI significantly increased the retear risk after arthroscopic supraspinatus tendon repair. CSA >38° increased the retear risk almost 4-fold. Overall GI was elevated but did not correlate with failure rate., Level of Evidence: III, case control study., (Copyright © 2018 Arthroscopy Association of North America. All rights reserved.)

Background: The retear rate after primary rotator cuff (RC) reconstruction is high and commonly leads to poorer clinical outcomes and shoulder function. In the case of primary failure, revision RC reconstruction (RCR) has become increasingly important to re-create RC integrity and improve outcomes. To date, clinical and structural outcomes after RCR have not been sufficiently investigated and described at midterm follow-up. Hypothesis/Purpose: The purpose was to evaluate the clinical and radiological outcomes after revision RCR. It was hypothesized that revision RCR significantly improves clinical outcomes and that the outcomes positively correlate with tendon integrity on magnetic resonance imaging (MRI)., Study Design: Case series; Level of evidence, 4., Methods: Patients who underwent revision RCR between 2008 and 2014 were retrospectively evaluated with a minimum follow-up of 2 years. Outcomes were assessed by a clinical examination, a visual analog scale for pain (VAS), the Constant Score (CS), the American Shoulder and Elbow Surgeons (ASES) score, and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Tendon integrity was determined using 3-T MRI and graded according to the Sugaya classification., Results: Thirty-one of 40 patients (77.5%) were available for the final assessment at a mean follow-up of 50.3 ± 20.4 months. Clinical outcome scores significantly improved from preoperatively to postoperatively for the CS (39.7 ± 16.7 to 65.1 ± 19.7; P < .001), ASES (44.2 ± 17.7 to 75.2 ± 24.8; P < .001), and DASH (68.6 ± 15.1 to 21.5 ± 19.1; P < .001). The VAS score decreased from 6.1 ± 1.8 preoperatively to 1.3 ± 1.8 at final follow-up ( P < .001). MRI demonstrated a retear rate of 55.5%. No differences in CS, ASES, and DASH scores were detected between patients with an intact repair and failure. Abduction strength was not significantly different in patients with an intact repair and retears (55.5 N vs 44.0 N, respectively, P = .52)., Conclusion: Revision RCR improves clinical outcomes and shoulder function at midterm follow-up. The clinical outcome scores were comparable in patients with an intact repair and those with failed RC healing. Therefore, tendon integrity was not correlated with better clinical outcomes after revision RCR at final follow-up.

Background: Septic arthritis (SA) of the knee after anterior cruciate ligament reconstruction (ACLR) is a rare but potentially devastating condition. In certain cases, graft removal becomes necessary., Purpose: To evaluate clinical, subjective, and radiologic outcomes of patients with SA after ACLR and assess whether graft retention has superior clinical results as compared with graft removal., Study Design: Cohort study; Level of evidence, 3., Methods: All patients who were at least 12 months out from arthroscopic treatment of SA after isolated ACLR at our institution were eligible for inclusion. Patients were categorized into 2 groups: group 1, patients with initial graft retention; group 2, patients with initial graft removal. Group 2 was subdivided into 2 groups: group 2a, patients with graft reimplantation; group 2b, patients without graft reimplantation. Objective and subjective assessments were obtained at follow-up, including the International Knee Documentation Committee (IKDC) knee examination form, KT-1000 arthrometer measurements, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score, Lysholm score, and IKDC subjective evaluation. Radiologic assessment was performed with pre- and postoperative magnetic resonance imaging., Results: Of the 41 patients included, 33 (81%) were available for follow-up at a mean ± SD 54.7 ± 24.4 months at an age of 28.4 ± 9.3 years. When compared with patients from group 2 (n = 12), patients from group 1 (n = 21) obtained significantly better results on the objective IKDC score (normal or nearly normal: group 1, 66.6%; group 2, 36.4%; P = .047) and KT-1000 measurements (group 1, 1.3 ± 1.0 mm; group 2, 2.9 ± 1.5 mm; P = .005). Group 1 also scored better than group 2 on the Lysholm ( P = .007), IKDC subjective ( P = .011), and WOMAC ( P = .069) measures. Between groups 2a (n = 4) and 2b (n = 8), no significant differences in outcomes could be detected ( P values, .307-.705), although patients with anterior cruciate ligament graft reimplantation showed a clear tendency toward better results in objective and not subjective parameters. Magnetic resonance imaging evaluation showed higher rates of cartilage damage and meniscal tears among patients with graft resection versus graft retention., Conclusion: Patients with graft retention showed superior postoperative results when compared with patients who underwent initial graft resection, although subanalysis showed comparable outcomes between graft retention and reimplantation. Thus, while graft-retaining protocols should have the highest priority in the treatment of SA after ACLR, graft reimplantation should be performed in cases where graft resection becomes necessary, to avoid future cartilage and meniscal lesions. Finally, further studies with larger numbers of patients are needed to gain a better understanding of the outcomes of patients with SA after ACLR.