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To investigate the association between preoperative mental health disorders and postoperative complications, readmissions, and ipsilateral revision procedures among patients undergoing arthroscopic rotator cuff repair (RCR). A retrospective cohort study from 2010 to 2020 was performed using the PearlDiver database. Current Procedural Terminology and International Classification of Diseases codes were used to compare patients with and without mental health disorders who underwent arthroscopic RCR. Mental health disorders evaluated in this study include depressive disorder, major depressive disorder, major depressive affective disorder, bipolar disorder, dysthymic disorder, adjustment disorder, separation anxiety disorder, and posttraumatic stress disorder. Patients were matched at a 1:1 ratio based on age, sex, Charlson Comorbidity Index, body mass index, and tobacco use. Rates of complications and subsequent surgeries were compared between patients with and without a preoperative diagnosis of a mental health disorder. The 1-year preoperative prevalence of a mental health disorder from 2010 to 2020 was 14.6%. After 1:1 matching, patients with a mental health disorder who underwent arthroscopic RCR were nearly twice as likely to undergo a revision procedure (odds ratio 1.94, 95% confidence interval 1.76-2.14, P <.001) and more than twice as likely to experience conversion to shoulder arthroplasty (odds ratio 2.29, 95% confidence interval 1.88-2.80, P <.001) within 2 years of initial arthroscopy when compared with patients without a mental disorder. Patients with a mental disorder also experienced increased risk for 90-day readmission (1.9% vs 0%, P <.001) as well as multiple postoperative medical complications. Patients with pre-existing mental health diagnoses experience increased rates of 90-day postoperative complications and readmissions following arthroscopic RCR. In addition, patients with mental health diagnoses are more likely to undergo revision repair and conversion to shoulder arthroplasty within 2 years of the index procedure. Level III. [ABSTRACT FROM AUTHOR]

Purpose: To determine the rate of symptomatic venous thromboembolism (VTE) among patients undergoing arthroscopic knee procedures, risk factors associated with postoperative VTE, and current perioperative thromboprophylaxis prescription patterns associated with this population in the United States.Methods: Medical records for patients ≥18 years of age were queried from the Mariner database using Current Procedural Terminology codes for knee arthroscopy performed in the United States from 2010 to 2020 in this cross-sectional study. Patients who received thromboprophylaxis and those diagnosed with VTE, including deep-vein thrombosis or pulmonary embolism, within 90 days of surgery were identified using International Classification of Diseases and National Drug Codes. Two multivariable logistic regression models were used to identify VTE risk factors and likelihood of perioperative thromboprophylaxis. Covariates included procedure type, age, oral contraceptive pill (OCP) use, and medical comorbidities.Results: A total of 718,289 patients met inclusion criteria and 7,618 patients (1.06%) experienced VTE, including deep-vein thrombosis (n = 6,394, 0.9%) and/or pulmonary embolism (n = 2,211, 0.3%). A total of 10,769 patients (1.5%) filled perioperative thromboprophylaxis, including aspirin (n = 5,353, 0.7%), low-molecular-weight heparin (n = 4,563, 0.6%), and oral factor Xa inhibitors (n = 947, 0.1%). Perioperative thromboprophylaxis was associated with decreased odds of experiencing VTE (adjusted odds ratio [aOR] 0.65, 95% confidence interval [CI] 0.51-0.80). Procedure types categorized as moderate-to-greater risk were associated with increased odds of VTE (aOR 1.42, 95% CI 1.34-1.50). OCP use (aOR 1.63, 95% CI 1.38-1.91), obesity (aOR 1.17, 95% CI 1.11-1.24), renal disease (aOR 1.33, 95% CI 1.18-1.50) and congestive heart failure (aOR 1.30, 95% CI 1.13-1.50) were associated with increased odds of VTE.Conclusions: While the overall rate of symptomatic VTE following knee arthroscopy remains low, procedure types that are more complex and generally require restrictive rehabilitation protocols, OCP use, obesity, renal disease, and congestive heart failure are associated with increased odds of postoperative VTE. Conversely, the use of perioperative thromboprophylaxis is associated with significantly lower VTE risk.Level Of Evidence: III, retrospective comparative prognostic trial. [ABSTRACT FROM AUTHOR]

Purpose: To identify factors predictive of a large labral tear at the time of shoulder instability surgery.Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects.Results: After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007).Conclusions: Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf.Level Of Evidence: I, prognostic study. [ABSTRACT FROM AUTHOR]

To analyze the effects of surgeon-specific factors, including case volume, career duration, fellowship training, practice type, and region of practice, on rates of 2-year revision surgery, conversion to total hip arthroplasty (THA), and 90-day hospitalizations following hip arthroscopy. The PearlDiver Mariner Database was used to query patients undergoing hip arthroscopy between 2015 and 2018. Surgeons performing these procedures were identified, and surgeon-specific demographics and variables were collected from publicly available data. Patients were followed for 2 years to assess for reoperations, including revision hip arthroscopy and conversion to THA, as well as 90-day hospitalizations, including emergency department visits and hospital readmissions. International Classification of Diseases, Tenth Revision codes were used to track the laterality of revision hip procedures. Associations between surgeon-specific factors and postoperative outcomes were assessed through univariate and multivariate analyses. In total, 20,834 patients underwent hip arthroscopy procedures by 468 surgeons. Multivariate analysis with logistic regression adjusted for patient-related factors (age, sex, obesity, Charlson Comorbidity Index, and smoking status) identified increasing surgeon case volume to be associated with increased risk for 2-year revision hip arthroscopy (P <.001), but not 2-year conversion to THA or 90-day hospitalizations. Nonsports medicine fellowship-trained surgeons were associated with greater risk for 2-year THA conversion (P <.001) and 90-day hospital readmissions (P <.01). Surgeons practicing in an academic setting demonstrated greater risk for 90-day hospital readmissions (P <.001). Surgeons practicing in the West region of the United States were more likely to incur 2-year revision hip arthroscopy procedures compared to surgeons in the South, Midwest or Northeast (P <.001). Increasing surgeon hip arthroscopy case volume is associated with an increased risk for 2-year revision hip arthroscopy but not conversion to THA or 90-day hospitalizations. Further, non-sports medicine fellowship-trained surgeons were associated with higher risk for 2-year THA conversion after hip arthroscopy. Level III, retrospective cohort analysis. [ABSTRACT FROM AUTHOR]

Purpose: To analyze patients undergoing knee arthroscopy stratified by body mass index (BMI) and assess the tradeoffs in complications avoided versus access to care that occur when instituting BMI eligibility criteria.Methods: The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients who underwent knee arthroscopy from 2015 to 2016. Patients were categorized by BMI, and differences in complication rates between BMI categories were assessed. The positive predictive value (PPV) was calculated for various BMI cutoffs, with further analysis performed to identify the number of surgeries that would be denied to avoid a single complication.Results: There were 44,153 knee arthroscopy cases identified and an overall complication rate of 1.7%. There was no significant difference found in major complication rate between those with a BMI >40 kg/m2 and those with a BMI <40 (1.7% vs 1.7%, P = .70), and no significant associations between increased complications and a higher BMI were found on binary logistic regression. Instituting a BMI cutoff of 40 has a PPV of 1.7% and would result in the avoidance of 11% of complications while denying 10% of otherwise uncomplicated surgeries. This cutoff would deny 57 surgeries for every complication avoided.Conclusion: In patients undergoing knee arthroscopy, this study failed to detect a significant increased risk of major complications associated with having a BMI >40. The institution of BMI eligibility cutoffs would result in low PPVs and a high number of denials for surgery that would otherwise be complication free.Level Of Evidence: Level IV, retrospective cohort-based database study. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the longitudinal changes in landing mechanics and knee kinematics for patients both before and 3 years after anterior cruciate ligament reconstruction (ACLR) and to investigate the association between changes in landing mechanics and magnetic resonance knee kinematics.Methods: Thirty-one ACLR patients were included in the study. All patients underwent magnetic resonance imaging and biomechanical analysis of a drop-landing task using the injured knee and contralateral knee preoperatively and at 6 months and 3 years after ACLR. For evaluations of knee joint anteroposterior laxity, tibial position was calculated using quantitative loaded magnetic resonance methods.Results: The ACLR knee exhibited a significantly lower peak vertical ground reaction force and peak external knee flexion moment and angle at 6 months compared with the contralateral knee; however, the differences were resolved at 3 years. Tibial position was significantly more anterior on the injured side, and the side-to-side difference (SSD) in tibial position exhibited a significant increase from 6 months to 3 years. Among ACLR knees, a greater SSD in peak knee flexion moment at 6 months was associated with an increase in the SSD in anterior tibial translation from 6 months to 3 years.Conclusions: Although landing mechanics and clinical outcomes recovered in patients with ACLR in this study, anteroposterior translation failed to be restored at 3 years after surgery. In addition, patients who have low knee flexion moments in early stages could have greater anteroposterior laxity.Clinical Relevance: Because of the adverse consequences of abnormal knee kinetics on anterior laxity after ACLR, efforts to improve knee movement patterns should be initiated. [ABSTRACT FROM AUTHOR]

Purpose: To analyze minimum 2-year postoperative patient-reported outcomes of a large group of patients after arthroscopic subscapularis (SSc) repair with respect to surgical findings and concurrent procedures.Methods: Patients who underwent arthroscopic SSc repair from January 2010 to April 2016 completed the Patient-Reported Outcomes Measurement Information System for Upper Extremity (PROMIS-UE) test and postoperative visual analog scale pain score. Medical records were reviewed for the preoperative visual analog scale pain score and surgical findings. SSc tears were considered partial or complete. Concomitant pathology and treatment of the supraspinatus (SS), infraspinatus (IS), and biceps tendon were recorded. We compared preoperative variables and outcomes between isolated partial SSc repair, partial SSc with SS and/or IS repair, isolated complete SSc repair, and complete SSc with SS and/or IS repair.Results: One hundred forty-five shoulders were included with an average age of 62.0 ± 9.8 years and average follow-up period of 52.2 ± 19.5 months. A significant reduction in the pain score occurred, from 4.8 (95% confidence interval [CI], 4.4-5.2) to 0.9 (95% CI, 0.6-1.1) (P < .001), with a mean postoperative PROMIS-UE score of 50.7 (95% CI, 49.5-52.0). Most SSc tears were partial with SS and/or IS repair (44.1%). Isolated partial SSc tears (29.9%), complete SSc tears with SS and/or IS repair (20.1%), and isolated complete SSc tears (5.9%) were less common. A significant difference in the mean postoperative PROMIS-UE score was not found between groups (P = .609). Biceps tendon pathology was significantly more common in complete SSc tears than partial SSc tears (P < .001), but there was no difference in the rate of biceps intervention (P = .110) or the PROMIS-UE score based on biceps intervention (P = .471).Conclusions: We observed significant improvements in pain and patient-reported outcomes in line with population means for a large group of patients after SSc tendon repair. Importantly, outcomes were similar despite the size of SSc tear or concurrent SS and/or IS repairs. Biceps pathology was common, and neither its presence nor its treatment influenced postoperative patient outcomes.Level Of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

Purpose: The goal of this study is to analyze postoperative complications after shoulder arthroscopy stratified by body mass index (BMI) and to quantify the trade-off in postsurgical complications and access to care that occurs with BMI eligibility cutoffs.Methods: Patients who underwent shoulder arthroscopy in the National Surgical Quality Improvement Program database from 2015 to 2016 were identified. Patients were categorized on the basis of their BMI. χ2 tests were used to identify differences in complication rates between different BMI categories. Logistic regression was used to calculate the odds ratio of having a major complication by BMI category. The positive predictive value (PPV) was calculated at different BMI cutoffs.Results: There were 26,509 shoulder arthroscopy cases identified in the National Surgical Quality Improvement Program database with 383 major complications, for an overall rate of 1.4%. Patients with a BMI >40 had a higher overall complication rate (2.3% vs 1.4%, P = .001), as well as higher rates of readmission (P = .012), pneumonia (P = .030), progressive renal insufficiency (P = .006), and cardiac arrest (P = .008). BMI >40 was associated with an increased risk of major complications (odds ratio, 1.84; confidence interval, 1.29-2.61). A BMI cutoff of 40 would avoid 12% of major complications while excluding 8% of complication-free surgeries. At a BMI cutoff of 40, the PPV was 2.3% where 43 surgeries would be denied for every complication avoided.Conclusion: Patients with a BMI >40 have a statistically significant but only slightly increased risk of 30-day complications after shoulder arthroscopy. Instituting a BMI eligibility cutoff at 40 has a low PPV and would prevent 43 complication-free surgeries from proceeding for every complication prevented. Patients should be counseled individually about their risk factors, but denial of shoulder arthroscopy on the basis of BMI alone may not be an appropriate strategy for risk reduction.Level Of Evidence: Level III, comparative prognostic trial. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the changes in landing biomechanics over a 3-year period and their correlation with cartilage degenerative changes in the medial tibiofemoral joint of the knee after anterior cruciate ligament reconstruction (ACLR) using magnetic resonance T1ρ mapping.Methods: Thirty-one anterior cruciate ligament-injured patients underwent magnetic resonance imaging of the injured knee before ACLR and 3 years after ACLR, as well as biomechanical analysis of a drop-landing task at 6 months and 3 years after ACLR. Sixteen healthy individuals were recruited and underwent knee magnetic resonance imaging and biomechanical assessment during a drop-landing task. T1ρ cartilage relaxation times were calculated for the medial femur and tibia.Results: ACLR patients exhibited increased peak vertical ground reaction force (VGRF), VGRF impulse, peak knee flexion moment (KFM), and KFM impulse from 6 months to 3 years (P < .001 for each). Although the ACLR knees showed significantly lower peak VGRF and KFM at 6 months (P < .001 for both) when compared with the controls, there were no significant differences at 3 years. At 3 years, ACLR patients showed higher T1ρ values over the medial femur (P < .001) and tibia (P = .012) when compared with their preoperative values and with healthy control values. Within the ACLR group, side-to-side differences in peak VGRF and sagittal knee biomechanics at 6 months were associated with increased T1ρ values from baseline to 3 years.Conclusions: The results of this longitudinal study show that landing biomechanics are altered after ACLR but biomechanical abnormalities tend to recover at 3 years after ACLR. Differences in lower-extremity mechanics during a landing task at 6 months may be associated with cartilage degeneration at 3 years after anterior cruciate ligament injury and reconstruction.Level Of Evidence: Level II, prospective trial. [ABSTRACT FROM AUTHOR]

Purpose: The primary purpose of this study was to assess the use of autologous chondrocyte implantation (ACI) procedures in the knee during last decade, and the secondary aims of the study were to determine reoperation rates after ACI and to identify associated risk factors.Methods: A retrospective cohort study from 2010-2020 was performed using the PearlDiver database. The database was queried for the Current Procedural Terminology (CPT) code for ACI performed in any knee location, including the patellofemoral and tibiofemoral joints. Reoperation was defined as interventional knee procedures or total knee arthroplasty after ACI. Reoperations were identified using CPT and International Classification of Diseases codes. Univariate and multivariate logistic regression were used to identify risk factors for reoperation. Significance was defined as P < .05.Results: Among the 2010 patients included in this study, there were 90-day and overall reoperation rates of 2.24% and 30.4%, respectively, with an average follow up of 4.8 ± 3.3 years. The most common reoperations included chondroplasty, meniscectomy, and microfracture. There was an increased rate of ACI performed from 2017-2019 (5.53/100,000) compared to 2014-2016 (4.16/100,000; P < .001). ACI surgeries performed in 2017-2019 were associated with decreased risk of reoperation within 2 years relative to 2014-2016 (odds ratio [OR] = 0.70; 95% confidence interval [CI], 0.52-0.94; P = .019). In the entire ACI cohort, older age (OR = 1.07; 95% CI, 1.05-1.09; P < .001) and tobacco use (OR = 2.13; 95% CI, 1.06-3.94; P = .022) were associated with increased risk of conversion to arthroplasty. Male sex was associated with decreased overall reoperation rates (OR = 0.73; 95% CI, 0.60-0.89; P = .002).Conclusions: There has been increasing use of ACI in the knee with decreased risk of reoperation since 2017 and the introduction of matrix-associated autologous chondrocyte implantation. Older age and tobacco use were predictors of increased risk of conversion to arthroplasty. Male sex was associated with decreased risk of reoperation.Level Of Evidence: Level IV, retrospective cohort design; database study. [ABSTRACT FROM AUTHOR]

Purpose: To determine incidence and risk factors for symptomatic venous thromboembolism following hip arthroscopy (HA) and thromboprophylaxis prescription utilization for these procedures.Methods: The PearlDiver Mariner Database was queried using Current Procedural Terminology (CPT) codes to identify adult patients (≥18 years old) who underwent HA between 2010 to 2020. Patient demographic information, including age, oral contraceptive use, medical comorbidities, and perioperative thromboprophylaxis utilization was recorded using International Classification of Disease (ICD) and National Drug Codes (NDCs). Incidence of postoperative venous thromboembolism (VTE) within 90 days was determined. Multivariate logistic regression was used to identify predictors of perioperative thromboprophylaxis utilization and VTE risk factors.Results: Queried records found that 60,181 patients met inclusion criteria and 367 patients (0.6%) experienced VTE, including DVT (0.5%) and/or PE (0.2%). Approximately 2.1% of patients utilized thromboprophylaxis, including aspirin (1.1%), low-molecular-weight heparin (LMWH) (0.9%) and oral factor Xa inhibitors (0.1%). Oral contraceptive pill use (adjusted odds ratio [aOR]=2.16, 95% confidence interval [CI]=1.34-3.46), obesity (aOR=1.37, 95% CI = 1.05-1.79), and a history of malignancy (aOR=1.69, 95% CI = 1.12-2.54) were associated with increased odds of experiencing VTE. Perioperative thromboprophylaxis (aOR=0.52, 95% CI=0.19-1.39) was not significantly associated with decreased odds of experiencing VTE. However, obesity (aOR=1.17, 95% CI=1.00-1.38) and hypertension (aOR=1.17, 95% CI=1.02-1.36) were associated with increased odds of thromboprophylaxis prescription utilization.Conclusions: While the overall risk of symptomatic VTE following HA remains low, oral contraceptive use, obesity, and a history of malignancy are associated with increased odds of thrombotic event within 90 days. Routine thromboprophylaxis after hip arthroscopy may not be indicated for all patients but can be considered based on patient-specific risk factors.Level Of Evidence: Level III, Retrospective Prognostic Comparative Trial. [ABSTRACT FROM AUTHOR]

Successful anterior cruciate ligament (ACL) reconstruction requires definition. Some focus on return to sport or early return to sport. Others focus on reproduction of normal ACL anatomy or biomechanics. Recent focus includes restoration of secondary stabilizers. However, each new focus can have positive, but also adverse, consequences. In general, positive results in 4 categories are equally important for the success of ACL reconstruction: early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. We are moving the needle to achieve the "best" ACL reconstruction, but we should never change treatment based on one parameter or "fashion." [ABSTRACT FROM AUTHOR]

Purpose: To analyze and correlate the clinical, radiographic, and surgical presentation of subscapularis (SSc) tears treated with arthroscopic repair.Methods: We retrospectively identified 455 patients who underwent rotator cuff tear repairs at our institution from 2010 to 2014. Of these patients, 139 underwent an SSc repair either in isolation or concurrently with other rotator cuff procedures. Tear size was classified arthroscopically by whether tears involved the superior one-third of the SSc tendon, superior two-thirds of the SSc tendon, or complete SSc tendon. Patient demographic characteristics, assessments of belly-press weakness and the lift-off test, magnetic resonance imaging (MRI) findings, and data on concurrent supraspinatus and biceps tendon pathology were collected and analyzed according to tear size.Results: Our cohort had a mean age of 61.8 ± 12.5 years, with a male-female gender ratio of 1.7:1. There were 22 tears of the superior one-third of the SSc (16%), 96 tears of the superior two-thirds of the SSc (69%), and 21 complete SSc tears (15%). Overall, MRI diagnosis of SSc tears had a sensitivity of 83% and specificity of 70%. MRI sensitivity was associated with tear severity (P = .02), with complete tears having an MRI sensitivity of 100%; superior two-thirds, 82%; and superior one-third, 67%. Physical examination sensitivity for belly-press weakness and the lift-off test was 61% and 63%, respectively, and did not correspond with tear size. Increased SSc tear size corresponded with a history of trauma (P = .04) and the presence of concurrent supraspinatus tears (P = .03) and biceps pathology (P = .003).Conclusions: The diagnosis of SSc tears remains challenging because of the limited sensitivity of MRI and physical examination. The diagnostic sensitivity of MRI is associated with SSc tear size, whereas physical examination is independent of tear size. Additional associations identified in this study include increased SSc tear size corresponding with a history of trauma, presence of concurrent supraspinatus tears, and presence of concurrent biceps tendon pathology.Level Of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate recent trends in the treatment of meniscal tears with arthroscopic repair and debridement and to assess revision surgery within 2 years using a large cross-sectional database.Methods: Patients with a diagnosis of meniscal tear from 2010 to 2017 were queried using the Mariner data set from PearlDiver. Patient demographic data were analyzed and tracked via International Classification of Diseases, Tenth Revision codes to investigate subsequent ipsilateral meniscal procedures and conversion to total knee arthroplasty within 2 years after index meniscal surgery.Results: Of the 1,383,161 patients with a diagnosis of meniscal tear, 53.0% underwent surgical treatment. Surgical treatment consisted of meniscal debridement in 96.6% of patients and meniscal repair in 3.4%. The percentage of meniscal repairs increased from 2.7% to 4.4% over the 8-year period evaluated, whereas the percentage of meniscal debridement decreased from 97.3% to 95.6% (P < .0001). Younger patients were more likely to undergo meniscal repair (23% of those aged 10-19 years) than older patients (<1% of those aged ≥60 years). Among the 191,729 patients with International Classification of Diseases, Tenth Revision coding and 2-year follow-up, 10.6% of patients with index meniscal repair required a revision meniscal operation and 1.2% underwent conversion to arthroplasty. Subsequent meniscal procedures within 2 years after index meniscal repair included meniscal debridement in 81.6% of patients and revision repair in 18.4%. Patients who initially underwent meniscal debridement were less likely to undergo revision meniscal surgery (5.1%), but 4.7% required conversion to arthroplasty. Patients aged 10 to 19 years were most likely to undergo revision meniscal procedures after both index meniscal repair (12.8%) and meniscal debridement (8.8%).Conclusions: The rate of meniscal repair is increasing over time, with patients younger than 30 years most likely to undergo repair for a meniscal tear. Revision surgery for meniscal repair or debridement is more common in adolescents and patients who undergo an index meniscal repair.Level Of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Purpose: To use a contemporary cross-sectional data set to evaluate trends in surgical treatment for superior labrum anterior and posterior (SLAP) tears and compare surgical outcomes with respect to 2-year revision surgery rates following index SLAP repair versus biceps tenodesis (BT).Methods: Patients diagnosed with a SLAP tear between 2010 and 2017 were queried using the Mariner PearlDiver database and stratified by demographic variables and surgical treatment with arthroscopic SLAP repair or arthroscopic/open BT. From 2015 to 2017, Current Procedural Terminology (CPT) and International Classification of Diseases 10th revision (ICD-10) codes were used to track ipsilateral subsequent reoperation within 2-years of index surgery.Results: Between 2010 to 2017, 16.6% of 377,463 patients diagnosed with a SLAP tear underwent surgery (62.3% SLAP repair vs 37.7% BT). 52.4% of BT procedures were arthroscopic (47.6% open). The frequency of SLAP repairs decreased from 74.0% to 46.2% (61%), while the frequency of BTs increased from 26.0% to 53.8% (202%) during the study period. Patients under age 50 were more likely to undergo SLAP repair, and those undergoing BT were more likely to be over 50 with higher CCI and comorbidity risk. 6.3% of 16,186 patients identified with ICD-10 coding required reoperation within 2-years postoperatively. SLAP repair demonstrated a higher revision rate (6.8%; 95% CI, 6.3-7.4%) than BT (5.7%; 95% CI, 5.2-6.2%; P =.0002), (open 5.8% vs arthroscopic BT 5.5%). Arthroscopic debridement, including biceps tenotomy, revision SLAP repair, and revision BT were the most common subsequent procedures. Patients aged 40 to 49 had the highest rate of revision surgery (7.8%).Conclusions: The treatment trend for SLAP tears is changing, with SLAP repair becoming significantly less utilized and BT now becoming the preferred option, especially in patients over 50. Arthroscopic and open BT demonstrated slightly lower risk for reoperation than SLAP repair.Level Of Evidence: IV, cross-sectional study. [ABSTRACT FROM AUTHOR]

Purpose: To provide a comprehensive summary of the available literature on the influence of bone morphology on outcomes after anterior cruciate ligament reconstruction (ACLR).Methods: Our protocol was prospectively registered with PROSPERO (International Prospective Register of Systematic Reviews) and followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Embase, and MEDLINE databases were searched for studies investigating knee morphologic features and outcomes after ACLR. Articles were screened and references lists were reviewed to identify relevant studies, after which methodologic quality was assessed for each study included in this review. Because of significant variability in terminology and methodology between studies, no meta-analyses were conducted.Results: Systematically screening a total of 19,647 studies identified from the search revealed 24 studies that met the inclusion and exclusion criteria. Among tibial shape features identified as predictors of poor outcomes after ACLR, increased posterior tibial slope was most common (16 studies). Other features such as increased tibial plateau area (1 study), decreased medial plateau width (1 study), and increased medial plateau height (1 study) were also associated with poor outcomes. For the femur, features related to notch width and condylar morphology were most common (4 studies and 7 studies, respectively). An increased condylar offset ratio, increased lateral femoral condylar ratio, and larger notch width were each found to be associated with negative ACLR outcomes, including increased cartilage degeneration, worse patient-reported outcomes, and graft failure.Conclusions: Posterior tibial slope, notch width, condylar morphology, trochlear inclination, and tibiofemoral mismatch are associated with and predictive of outcomes after ACLR.Level Of Evidence: Level IV, systematic review of Level II-IV studies. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to use magnetic resonance (MR) imaging to evaluate the translational and rotational kinematics of anterior cruciate ligament (ACL) reconstructed knees with transtibial (TT) and anteromedial (AM) femoral tunnel drilling. Methods: ACL reconstruction was performed in 21 subjects: 12 with AM drilling (5 men and 7 women; mean age, 33 ± 9 years; imaged 18 ± 5 months after surgery) and 9 with TT drilling (5 men and 4 women; mean age, 32 ± 9 years; imaged 12 ± 8 months after surgery). Three-tesla MR imaging was obtained bilaterally at extension and 30° to 40° of flexion under simulated loading (125 N). MR images were segmented and kinematic calculations done with in-house MATLAB software (The MathWorks, Natick, MA). Translation and rotation of the tibia and the tibiofemoral contact area were measured. Statistical analysis treated reconstructed and contralateral knees as independent groups. Reconstructed groups were compared with analysis of covariance using contralateral knees as baseline. P < .05 indicated significance. Results: All kinematic measures in the AM group were similar to contralateral knees. The TT group showed significantly more total tibial rotation than contralateral knees (TT, 8.4° ± 3.9°; contralateral, 2.9° ± 6.8°) (P = .03), whereas the AM group did not (AM, 3.1° ± 5.6°; contralateral, 2.3° ± 5.4°) (P = .36). At knee extension, the tibia was more externally rotated in the TT group than in controls. Medial tibial translation was greater in the TT group than in controls. The AM group showed increased contact area in the lateral compartment compared with controls; no differences were seen in the TT group. Conclusions: Using an MR-based approach, we found that knee kinematics were better restored with the AM femoral tunnel drilling ACL reconstruction than with the TT femoral tunnel drilling approach, which resulted in increased knee laxity. Our in vivo results support previous cadaveric and clinical studies that have found AM ACL reconstruction to restore anatomy and stability better than the TT approach. However, the clinical significance of increased contact area in the AM group remains unclear. Level of Evidence: Level III, retrospective comparative study. [Copyright &y& Elsevier]

Purpose: We aim to determine the prevalence of fatty infiltration and tears in the infraspinatus and to identify any associated risk factors. Methods: Shoulder magnetic resonance imaging scans from 2006 to 2009 were reviewed. Arthrograms, inflammatory arthropathies, neoplasms, and fractures were excluded. Rotator cuff tears were graded in 4 categories: no tear, partial tear, and complete tear with and without retraction. Fatty infiltration was graded by radiologists using the modified Goutallier classification. Supraspinatus muscle atrophy (size) was measured by use of the ratio of the cross-sectional area of the muscle to the supraspinatus fossa on a sagittal T1-weighted sequence. Results: Three hundred seventy-seven scans were included. The prevalence of infraspinatus tears was as follows: no tear, 74.8%; partial tear, 17.5%; complete tear, 3.2%; and complete tear with retraction, 4.5%. Fatty infiltration of grade 2 or higher was found in 18.1% of the infraspinatus without tears, 39.4% with partial tears, 66.7% with a complete tear, and 82.4% with a complete tear with retraction. In the infraspinatus without tears, increasing fatty infiltration was correlated with the severity of a concomitant supraspinatus tear. Fatty infiltration of grade 2 or higher in the infraspinatus without tears was found in 7.8% of shoulders with an intact supraspinatus, 18.6% with a partial supraspinatus tear, 23.5% with a complete supraspinatus tear, and 54.6% with a retracted complete supraspinatus tear. Supraspinatus muscle atrophy was correlated with infraspinatus fatty infiltration. Conclusions: Increased infraspinatus fatty infiltration was correlated with the severity of an infraspinatus tear. However, substantial fatty infiltration of the infraspinatus was seen even in the absence of a tear, and it was correlated with a worsening severity of a concomitant supraspinatus tear and atrophy. Concern over tear progression and increasing fatty infiltration of the infraspinatus may impact the management of isolated supraspinatus tendon tears. Level of Evidence: Level IV, prognostic case series. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to compare the biomechanical performance of a completely knotless double-row repair system (SutureCross Knotless Anatomic Fixation System; KFx Medical, Carlsbad, CA) with 2 commonly used hybrid double-row repair (medial knot-tying, lateral knotless) systems (Bio-Corkscrew/PushLock [Arthrex, Naples, FL] and Spiralok/Versalok [DePuy Mitek, Raynham, MA]). Methods: Fourteen pairs of fresh-frozen cadaveric shoulders were harvested, the supraspinatus tendons were isolated, and full-thickness supraspinatus tears were created. One of each pair was repaired with the completely knotless system, and the contralateral side was repaired with either of the hybrid systems. The repairs were then subjected to cyclic loading followed by load to failure. Conditioning elongation, peak-to-peak elongation, ultimate load, and mechanism of failure were recorded and compared by use of paired t tests. Seven additional shoulders were tested to determine the effect of refrigeration storage on the completely knotless system by use of the same mechanical testing protocol. Results: For the completely knotless repair group, 11 of 14 paired specimens failed during the cyclic loading period. Only 1 of 14 hybrid repair systems had failures during cyclic loading, and both hybrid repair systems had statistically lower conditioning elongation than the completely knotless repair group. The mean ultimate load of the SutureCross group was 166 ± 87 N, which was significantly lower than that in the Corkscrew/PushLock (310 ± 82 N) and Spiralok/Versalok (337 ± 44 N) groups. There was an effect of refrigeration storage on the peak-to-peak elongation and stiffness of the SutureCross group; however, there was no difference in ultimate tensile load or conditioning elongation. Conclusions: The completely knotless repair system has lower time-zero biomechanical properties than the other 2 hybrid systems. Clinical Relevance: The SutureCross system has lower time-zero biomechanical properties when compared with other hybrid repair systems. Clinical outcome studies are needed to determine the significance. [Copyright &y& Elsevier]

Purpose: To quantitate bone marrow edema-like lesions (BMELs) and the radiologic properties of cartilage in knees with acute anterior cruciate ligament (ACL) injuries using T(1ρ) magnetic resonance imaging over a 1-year period.Methods: Nine patients with ACL injuries were studied. Magnetic resonance imaging scans were acquired within 8 weeks of the injury, after which ACL reconstruction surgery was performed. Images were then acquired 0.5, 6, and 12 months after reconstructions. The volume and signal intensity of BMELs were quantified at baseline and follow-up examinations. T(1ρ) values were quantified in cartilage overlying the BMEL (OC) and compared with surrounding cartilage at all time points.Results: BMELs were most commonly found in the lateral tibia and lateral femoral condyle. Nearly 50% of BMELs resolved over a 1-year period. The T(1ρ) values of the OC in the lateral tibia, medial tibia, and medial femoral condyle were elevated compared with respective regions in surrounding cartilage at all time points; the difference was significant only in the lateral tibia (P < .05). The opposite results were found in the lateral femoral condyle. For the medial tibia and medial femoral condyle, none of the time periods was significantly different. The percent increase in T(1ρ) values of OC in the lateral tibia was significantly correlated with BMEL volume (r = 0.74, P < .05). At 1 year, the OC in the lateral tibia, medial tibia, and medial femoral condyle showed increased T(1ρ) values despite improvement of BMEL.Conclusions: In patients after ACL tear and reconstruction, (1) the cartilage overlying BMEL in the lateral tibia experiences persistent T(1ρ) signal changes immediately after acute injuries and at 1-year follow-up despite BMEL improvement, (2) the superficial layers of the overlying cartilage show greater matrix damage than the deep layers, and (3) the volume of the BMEL may predict the severity of the overlying matrix's damage in the lateral tibia. T(1ρ) is capable of quantitatively and noninvasively monitoring this damage and detecting early cartilage changes in the lateral tibia over time.Level Of Evidence: Level IV, therapeutic case series. [ABSTRACT FROM AUTHOR]

Purpose: To quantitate bone marrow edema–like lesions (BMELs) and the radiologic properties of cartilage in knees with acute anterior cruciate ligament (ACL) injuries using T1ρ magnetic resonance imaging over a 1-year period. Methods: Nine patients with ACL injuries were studied. Magnetic resonance imaging scans were acquired within 8 weeks of the injury, after which ACL reconstruction surgery was performed. Images were then acquired 0.5, 6, and 12 months after reconstructions. The volume and signal intensity of BMELs were quantified at baseline and follow-up examinations. T1ρ values were quantified in cartilage overlying the BMEL (OC) and compared with surrounding cartilage at all time points. Results: BMELs were most commonly found in the lateral tibia and lateral femoral condyle. Nearly 50% of BMELs resolved over a 1-year period. The T1ρ values of the OC in the lateral tibia, medial tibia, and medial femoral condyle were elevated compared with respective regions in surrounding cartilage at all time points; the difference was significant only in the lateral tibia (P < .05). The opposite results were found in the lateral femoral condyle. For the medial tibia and medial femoral condyle, none of the time periods was significantly different. The percent increase in T1ρ values of OC in the lateral tibia was significantly correlated with BMEL volume (r = 0.74, P < .05). At 1 year, the OC in the lateral tibia, medial tibia, and medial femoral condyle showed increased T1ρ values despite improvement of BMEL. Conclusions: In patients after ACL tear and reconstruction, (1) the cartilage overlying BMEL in the lateral tibia experiences persistent T1ρ signal changes immediately after acute injuries and at 1-year follow-up despite BMEL improvement, (2) the superficial layers of the overlying cartilage show greater matrix damage than the deep layers, and (3) the volume of the BMEL may predict the severity of the overlying matrix''s damage in the lateral tibia. T1ρ is capable of quantitatively and noninvasively monitoring this damage and detecting early cartilage changes in the lateral tibia over time. Level of Evidence: Level IV, therapeutic case series. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to compare the biomechanical properties of transosseous versus suture anchor repair of the subscapularis tendon. We also performed real-time measurement of contact area and pressure of the repair site under rotational loads. Methods: Six paired human cadaveric shoulders were subjected to rotational loading after repair of the subscapularis tendon. Both shoulders were randomized to transosseous or suture anchor repairs. Real-time pressure sensors were placed between the subscapularis tendon and lesser tuberosity. The repair was subjected to cyclical rotational loading and load-to-failure testing. Results: No significant difference was detected in initial pressurized contact area between transosseous repairs (1.70 ± 0.99 cm2, 57.88 ± 30.02% footprint) and suture anchor repairs (1.08 ± 0.58 cm2, 34.26% ± 17.32% footprint). Under cyclical loading, the conditioning elongation of transosseous repairs (0.64 ± 0.40 mm) was significantly lower (P < .05) than that of suture anchor repairs (2.38 ± 1.58 mm). No significant difference was found in mean pressurized contact area between the transosseous repairs (2.72 ± 1.25 cm2, 94.2% ± 37.4% footprint) and suture anchor repairs (2.01 ± 0.89 cm2, 65.9% ± 27.9% footprint). For suture anchor repairs, repair-site contact area was significantly (P < .05) smaller than the area of corresponding native insertional footprints; for transosseous repairs, no significant difference was detected. There were no significant differences in peak pressures between the 2 repairs. In the load-to-failure tensile test, there was no significant difference between transosseous repairs (453.2 ± 66.1 N) and suture anchor repairs (392.6 ± 78.0 N). Conclusions: Transosseous and suture anchor repairs of the subscapularis tendon have comparable biomechanical properties. Despite increased conditioning elongation in suture anchor repairs, we found no significant differences in mean contact area between the 2 repairs under cyclical loading. The suture anchor repairs do have a smaller contact area than the native insertional area. Real-time pressure and contact area measurements enabled mapping of the repair site throughout cyclical loading. Clinical Relevance: Rotational loading of the subscapularis tendon may provide a more accurate representation of subscapularis tendon injuries. Both techniques showed adequate repair strength; however, neither surgical technique exhibited normal insertional behavior in this time-zero biomechanical study. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to test whether (1) the 3-dimensional in vivo patellofemoral kinematics and patellofemoral contact area of anterior cruciate ligament (ACL)-deficient knees are different from those of normal, contralateral knees and (2) ACL reconstruction restores in vivo patellofemoral kinematics and contact area. Methods: Ten ACL-deficient knees and twelve ACL-reconstructed knees, as well as the contralateral uninjured knees, were tested. Magnetic resonance imaging was performed at full extension and 40 degrees of flexion under simulated partial weight-bearing conditions. Six-degrees of freedom patellofemoral kinematics, patellofemoral contact area, and contact location were analyzed by use of magnetic resonance image-based 3-dimensional patellofemoral knee models. Results: The patella in the ACL-deficient knees underwent significantly more lateral tilt during flexion (P < .05) and tended to translate more laterally (P = .083) than the patella in contralateral knees. After ACL reconstruction, no kinematic parameters were significantly different from those in contralateral knees. The patellofemoral contact areas of ACL-deficient knees at both the extended and flexed positions (37 +/- 22 mm(2) and 357 +/- 53 mm(2), respectively) were significantly smaller than those of contralateral knees (78 +/- 45 mm(2) and 437 +/- 119 mm(2), respectively) (P < .05). After reconstruction, the patellofemoral contact area of ACL-reconstructed knees in the extended position (86 +/- 41 mm(2)) was significantly larger (P < .05) than that of contralateral knees (50 +/- 34 mm(2)), but no difference was detected in the flexed position. Reproducibility of all patellofemoral kinematic parameters, contact centroid translation, and contact area showed coefficients of variation of less than 6.8%. Conclusions: ACL injuries alter patellofemoral kinematics including patellar tilt and patellar lateral translation, but ACL reconstruction with hamstring or allograft restores altered patellar tilt. ACL injuries reduce the patellofemoral contact area at both the extended and flexed positions, but ACL reconstruction enlarges the patellofemoral contact area at extension and restores the normal contact area at low angles of flexion. Level Of Evidence: Level III, case-control study. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to test whether (1) the 3-dimensional in vivo patellofemoral kinematics and patellofemoral contact area of anterior cruciate ligament (ACL)–deficient knees are different from those of normal, contralateral knees and (2) ACL reconstruction restores in vivo patellofemoral kinematics and contact area. Methods: Ten ACL-deficient knees and twelve ACL-reconstructed knees, as well as the contralateral uninjured knees, were tested. Magnetic resonance imaging was performed at full extension and 40° of flexion under simulated partial weight-bearing conditions. Six–degrees of freedom patellofemoral kinematics, patellofemoral contact area, and contact location were analyzed by use of magnetic resonance image–based 3-dimensional patellofemoral knee models. Results: The patella in the ACL-deficient knees underwent significantly more lateral tilt during flexion (P < .05) and tended to translate more laterally (P = .083) than the patella in contralateral knees. After ACL reconstruction, no kinematic parameters were significantly different from those in contralateral knees. The patellofemoral contact areas of ACL-deficient knees at both the extended and flexed positions (37 ± 22 mm2 and 357 ± 53 mm2, respectively) were significantly smaller than those of contralateral knees (78 ± 45 mm2 and 437 ± 119 mm2, respectively) (P < .05). After reconstruction, the patellofemoral contact area of ACL-reconstructed knees in the extended position (86 ± 41 mm2) was significantly larger (P < .05) than that of contralateral knees (50 ± 34 mm2), but no difference was detected in the flexed position. Reproducibility of all patellofemoral kinematic parameters, contact centroid translation, and contact area showed coefficients of variation of less than 6.8%. Conclusions: ACL injuries alter patellofemoral kinematics including patellar tilt and patellar lateral translation, but ACL reconstruction with hamstring or allograft restores altered patellar tilt. ACL injuries reduce the patellofemoral contact area at both the extended and flexed positions, but ACL reconstruction enlarges the patellofemoral contact area at extension and restores the normal contact area at low angles of flexion. Level of Evidence: Level III, case-control study. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to use magnetic resonance imaging (MRI) to determine 3-dimensional knee kinematics after anterior cruciate ligament (ACL) reconstruction. Methods: Nine ACL-reconstructed and contralateral knees were tested 12 ± 8 months after surgery. MRI was performed at full extension and 40° of knee flexion under simulated weight-bearing conditions. Femoral condyle positions, tibial rotation, contact area, and contact location were analyzed by use of MRI-based 3-dimensional models. Results: When knees were fully extended, tibiae in ACL-reconstructed knees were externally rotated by 3.6° ± 4.2° compared with contralateral knees. The external rotation was due to anterior subluxation of the medial side of the tibia. At 40° of knee flexion, tibiae in ACL-reconstructed knees and contralateral knees were both internally rotated by 5.3°. There were no significant differences in contact area or contact location between ACL-reconstructed and contralateral knees. When moving from extension to flexion, ACL-reconstructed knees exhibited 3.5° ± 5.9° more internal tibial rotation than contralateral knees. Conclusions: Reconstruction of the ACL restored normal motion on the lateral side of the knee but not on the medial side, resulting in increased internal tibial rotation when moving from full extension to 40° of flexion. These results suggest that ACL reconstruction does not restore normal kinematics on the medial side of the knee, which may lead to early cartilage degeneration. Level of Evidence: Level IV, therapeutic case series. [Copyright &y& Elsevier]

Purpose: To identify the price of treatment at which platelet-rich plasma (PRP) is cost-effective relative to hyaluronic acid (HA) and saline solution intra-articular injections.Methods: A systemized review process of the PubMed, Embase, and MEDLINE databases was undertaken to identify randomized controlled trials comparing PRP with HA and saline solution with up to 1 year of follow-up. Level I trials that reported Western Ontario and McMaster Universities Arthritis Index Likert scores were included. These scores were converted into utility scores. Cost data were obtained from Centers for Medicare & Medicaid Services fee schedules. Total costs included the costs of the injectable, clinic appointments, and procedures. The change in utility scores from baseline to 6 months and 1 year for the PRP, HA, and saline solution groups was divided by total cost to determine utility gained per dollar and to identify the price needed for PRP to be cost-effective relative to these other injection options.Results: Nine randomized controlled trials met the inclusion criteria. A total of 882 patients were included: 483 in the PRP group, 338 in the HA group, and 61 in the saline solution group. Baseline mean utility scores ranged from 0.55 to 0.57 for the PRP, HA, and saline solution groups. The 6-month gains in utility were 0.12, 0.02, and -0.06, respectively. The 12-month gains in utility from before injection were 0.14, 0.03, and 0.06, respectively. The lowest total costs for HA and saline solution were $681.93 and $516.29, respectively. For PRP to be cost-effective, the total treatment cost would have to be less than $3,703.03 and $1,192.08 for 6- and 12-month outcomes, respectively.Conclusions: For patients with symptomatic knee osteoarthritis, PRP is cost-effective, from the payer perspective, at a total price (inclusive of clinic visits, the procedure, and the injectable) of less than $1,192.08 over a 12-month period, relative to HA and saline solution.Level Of Evidence: Level I, systematic review. [ABSTRACT FROM AUTHOR]

We have had significant progress in improving the biomechanical strength of arthroscopic rotator cuff repairs over the past 3 decades. The field has advanced from simple suture repairs to double-row, transosseous, massive cuff and rip-stop constructs. I do think our focus next should be on improving the biology of tendon healing to improve our clinical outcomes. [ABSTRACT FROM AUTHOR]

Osteoporosis is associated with failure of rotator cuff repair. Optimizing bone density, as well as rotator cuff tendon-to-bone fixation in an osteoporotic humeral head, is a necessary approach to the patient as a whole. [ABSTRACT FROM AUTHOR]

Injury to the posterolateral corner of the knee is a difficult condition to treat. We know a lot about the anatomy and different methods with which we can reconstruct this complex area of the knee. Despite these advances, injuries to this area still do not lead to great surgical outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To report the prevalence of obesity in shoulder arthroscopy, determine a body mass index (BMI) threshold most predictive of complication within 30 days, and evaluate obesity as an independent risk factor for medical and surgical complications.Methods: Using the National Surgical Quality Improvement Program database, we reviewed all patients who underwent shoulder arthroscopy during 2011 to 2013. Receiver operating characteristic and Youden coefficient were calculated to find an optimal BMI cutoff to predict complications within 30 days of surgery. A case-control matched analysis was then performed by stratifying patient BMI by this cutoff and matching patients one to one according to age, sex, type of shoulder arthroscopy, American Society of Anesthesiology rating, surgical setting, and 8 comorbidities. Operating time, complications, and readmissions were also compared.Results: Of the 15,589 patients who underwent shoulder arthroscopy, 6,684 (43%) were classified as obese when using the optimal cutoff point of BMI = 30 according to the Youden coefficient. Obese patients had a higher risk of superficial site infection than nonobese patients (0.3% vs 0.0%; odds ratio [OR]: 6.00; 95% confidence interval [CI], 1.3 to 26.8; P = .015). Obese patients did not have significantly increased risk for overall early postoperative complication (1.2% compared with nonobese 0.8%; OR: 1.54; 95% CI, 1.0 to 2.4), readmissions (OR: 0.85; 95% CI, 0.5 to 1.5), or increased operating time (P = .068).Conclusions: Up to 43% of patients undergoing shoulder arthroscopy can be classified as obese, but early perioperative complications are uncommon. Higher patient BMI is associated with increased risk of superficial site infection but not an overall risk for complication, readmission, or increased operating time.Level Of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Purpose: To assess the inter- and intraobserver agreement for classification and management of subscapularis tendon pathology based on arthroscopy and magnetic resonance imaging (MRI). Methods: Twenty-two orthopaedic surgeons from the Multicenter Orthopaedic Outcomes Network (MOON) shoulder group reviewed still arthroscopic and MRI images of the subscapularis tendon from patients with a random assortment of subscapularis morphology. The surgeons were asked to classify the pathology based on 2 systems (Lafosse and Lyons) and choose whether they would repair the tendon and, if so, the method of repair (open or arthroscopic). The survey was administered 3 times to each surgeon. Inter- and intraobserver reliability between testing rounds was determined by kappa analysis. Results: Interobserver reliability on classification of tears was poor based on MRI (k = 0.18 to 0.19) and fair based on arthroscopy (k = 0.26 to 0.29). Interobserver agreement on whether surgical treatment was indicated was fair for both MRI (k = 0.28) and arthroscopy (k = 0.38), while the agreement for type of surgery was poor based on MRI (k = 0.18) and fair based on arthroscopy (k = 0.28). Interobserver agreement did not improve when both MRI and arthroscopy were provided simultaneously (k = 0.24 to 0.30). Intraobserver reliability for classification and treatment was fair to moderate for both MRI (k = 0.32 to 0.50) and arthroscopic imaging (k = 0.39 to 0.56). When considering just those patients with normal tendons, surgeon agreement improved. For all questions, the arthroscopic images had a higher level of agreement among surgeons than the MRI (P < .001). Conclusions: Although surgeons tended to have higher reliability when presented with arthroscopic images compared with MRI, there was very little agreement on the classification and management of subscapularis tendon tears. [ABSTRACT FROM AUTHOR]