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Background: It is well known that glenoid osseous defects >13.5% of the glenoid width critically destabilize the shoulder, as do labral tears. Chondrolabral defects often occur with anterior dislocation of the shoulder. It is unclear whether glenoid chondrolabral defects contribute to shoulder stability and, if so, at what size they become critical., Purpose/hypothesis: The purpose of this study was to determine the effect of incremental chondrolabral defect sizes on anterior shoulder stability in the setting of labral deficiency. The hypothesis was that chondrolabral defects ≥13.5% of the glenoid width will decrease anterior shoulder stability., Study Design: Controlled laboratory study., Methods: This controlled laboratory study tested 12 fresh-frozen shoulders. Specimens were attached to a custom testing device in abduction and neutral rotation with 50-N compression applied to the glenoid. The humeral head was translated 10 mm anterior, anteroinferior, and anterosuperior with the conditions of intact cartilage and labrum and anterior full-thickness chondrolabral defects of 3-, 6-, and 9-mm width. Translation force was measured continuously. Peak translation force divided by 50-N compressive force defined the stability ratio. Data were analyzed using analysis of variance., Results: The anterior stability ratio decreased between the intact state (36% ± 7%) and all defects ≥3 mm (≤32% ± 8%; P ≤ .023). The anteroinferior stability ratio decreased between the intact state (52% ± 7%) and all defects ≥3 mm (≤47% ± 7%; P ≤ .006). The anterosuperior stability ratio decreased between the intact state (36% ± 4%) and all defects ≥6 mm (≤33% ± 4%; P ≤ .006). A 3-mm defect equated to 10% of the glenoid width. There were moderate to strong negative correlations between chondrolabral defect size and stability ratio in the anterior, anteroinferior, and anterosuperior directions ( r = -0.79, -0.63, and -0.58, respectively; P ≤ .001). There were moderate to strong negative correlations between the percentage of glenoid chondrolabral defect size to the glenoid width and the stability percentage in all directions ( r = -0.81, -0.63, and -0.61; P ≤ .001)., Conclusion: An anterior glenoid chondrolabral defect ≥3 mm (>10% of the glenoid width) significantly decreased anterior and anteroinferior stability. Chondrolabral defect size negatively correlated with stability., Clinical Relevance: To fully restore glenohumeral stability, in addition to labral repair, it may be necessary to reconstruct chondrolabral defects as small as 3 mm (10% of the glenoid width)., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.Z.T. has received consulting fees from Cayenne Medical and Mitek and royalties from Shoulder Innovations, Wright Medical, and Zimmer; he also has stock/stock options in Conextions, Intrafuse, and Kator. P.N.C. has received consulting fees from DJO and DePuy, speaking fees from DePuy, and royalties from DePuy and Responsive Arthroscopy. 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) 2022.)

Background: Although the cause of rotator cuff tearing is likely multifactorial and a genetic predisposition has been proposed, the biochemical basis remains unknown., Purpose: To determine gene expression profiles in torn rotator cuff tendon tissue through use of RNA sequencing., Study Design: Controlled laboratory study., Methods: The supraspinatus tendon edge was biopsied in 24 patients undergoing arthroscopic rotator cuff repair for full-thickness supraspinatus rotator cuff tears. The supraspinatus tendon was also biopsied in 9 patients undergoing open reduction and internal fixation for a proximal humeral fracture (controls). Total RNA was extracted and sequenced. Differential gene expression was analyzed between the tear and control groups, and a secondary analysis was conducted between groups defined by an unbiased clustering., Results: Tear and control transcriptomes demonstrated significant differential expression in more than 3000 genes. The identified differential genes were highlighted in pathways involved in inflammation in control patients and extracellular matrix generation in patients with tears. Secondary analysis using unsupervised and thus unbiased hierarchical clustering revealed 2 clusters (c2 and c3). Cluster c3 contained smaller ( P < .001) and less retracted ( P = .018) tears (ie, tears earlier in the progression of rotator cuff disease) with increased expression of hypoxia target genes. Cluster c2 contained larger, more retracted tears (ie, tears further in the progression of rotator cuff disease) with increased expression of endothelial cell markers and chronic inflammation target genes. Tears in c2 had significantly worse healing rates compared with tears in c3 (0% vs 89%; P = .007)., Conclusion: Smaller, less retracted tears had increased expression of hypoxia target genes and improved healing, whereas larger, more retracted tears were associated with endothelial cell markers and worse healing. Thus, hypoxia may be the inciting event for tear development, whereas with tear enlargement, a chronic, inflammatory, angiogenic process may predominate., Clinical Relevance: Identification of differential gene expression in rotator cuff tears may be a reliable tool to predict repair healing in the future., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study received support from the LS Peery Foundation Discovery Program in Musculoskeletal Restoration. R.Z.T. has received consulting fees from Zimmer Biomet, Cayenne Medical, Wright Medical, and DePuy; royalties from Wright Medical, Shoulder Innovations, Zimmer Biomet, and Springer; hospitality payments from Wright Medical; and has stock in Conextions, INTRAFUSE, Genesis, and KATOR. P.N.C. has received educational support from Tornier and Active Medical, consulting fees from DePuy and Arthrex, and royalties from DePuy. K.B.J. has received research support from Pfizer. 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: The optimal surgical treatment of anterior shoulder instability remains controversial., Hypothesis: (1) Implants and facility-related costs are the primary drivers of variation in direct costs between arthroscopic Bankart and Latarjet procedures, and (2) distal tibial allograft (DTA) is more costly than Latarjet as a function of the graft expense., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Intraoperative cost data were derived for all arthroscopic anterior stabilizations and Latarjet and DTA procedures performed at a single academic institution from January 2012 to September 2017. Cost comparisons were made between those undergoing arthroscopic stabilization and Latarjet and between Latarjet and DTA. Multivariate regressions were performed to determine the difference in direct costs accounting for various patient- and surgery-related factors., Results: A total of 87 arthroscopic stabilizations, 44 Latarjet procedures, and 5 DTA procedures were performed during the study period. Arthroscopic Bankart repair was found to be 17% more costly than Latarjet, with suture anchor implant cost being the primary driver of cost. DTA was 2.9-fold more costly than Latarjet, with greater costs across all domains. Multivariate analysis also found the number of prior arthroscopic procedures performed ( P = .007) and whether the procedure was performed in an ambulatory or inpatient setting ( P < .0001) to be significantly associated with higher direct costs., Conclusion: Latarjet is less costly than arthroscopic Bankart repair, largely because of implant cost. Value-driven strategies to narrow the cost differential could focus on performing these procedures in an outpatient setting in addition to reducing overall implant cost for arthroscopic procedures. Perceived potential benefits of DTA over Latarjet may be outweighed by higher costs., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.T.B. has received royalties from Arthrex; consulting fees from Arthrex, DePuy, VirtaMed, and Cayenne Medical; research support from DePuy; speaking fees from DePuy; and educational support from Pinnacle. R.Z.T. has received royalties from Wright Medical and Zimmer-Biomet; has received consulting fees from Zimmer-Biomet, DePuy, and Cayenne Medical; and has stock/stock options in Connextions, Imascap, Shoulder Innovations, and DePuy. P.N.C. has received consulting fees from DePuy and hospitality payments from Tornier. 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) 2019.)

Background: Acromioclavicular osteoarthritis and rotator cuff tears are commonly coincident., Purpose: To determine the rate of subsequent distal clavicle excision (DCE) when rotator cuff repair (RCR) is performed without DCE and the risk factors for subsequent DCE after RCR., Study Design: Case-control study; Level of evidence, 3., Methods: The operative logs of 2 surgeons from 2007 to 2016 were retrospectively reviewed for all patients who underwent RCR with or without DCE. Preoperative demographic data, symptoms, physical examination, and standardized outcomes (visual analog scale for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) were noted. Acromioclavicular (AC) arthritis was classified on preoperative radiographs. The rate of subsequent surgery on the AC joint was determined via chart review, and univariate and multivariate analyses were conducted to determine risk factors for revision., Results: In total, 894 patients underwent isolated RCR, and 46 underwent concomitant RCR and DCE. On retrospective chart review, of those who underwent isolated RCR, the revision rate for any reason was 7.5% (67 patients), and the rate of subsequent AC surgery was 1.1% (10 patients). Preoperatively, 88% of the total cohort was considered to have a radiographically normal AC joint. On multivariate analysis of patients who underwent isolated RCR, the risk factors for subsequent AC surgery included preoperative tenderness to palpation at the AC joint (10% vs 63%, P < .001), female sex (35% vs 80%, P < .001), and surgery on the dominant side (60% vs 100%, P = .002). On multivariate analysis, these 3 factors explained 50% of the variance in revision AC surgery. When these 3 factors were present in combination, there was a 40% rate of revision AC surgery., Conclusion: This records review found that 10 of 894 (1.1%) rotator cuff repairs underwent subsequent distal clavicle resection. Risk factors for subsequent DCE included tenderness to palpation at the AC joint, female sex, and surgery on the dominant side, with subsequent DCE performed in 40% of cases with a combination of these 3 factors. Because the duration of follow-up was short and the number of reoperations small, some caution is recommended in interpreting these results, as the analyses may be underpowered., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: P.N.C. is a paid consultant for DePuy Mitek and has received hospitality payments from Tornier. R.T.B. receives royalties from Arthrex, has stock in KATOR, is a paid consultant and paid presenter/speaker for DePuy Mitek, and has received educational support from Pinnacle. R.Z.T. has received consulting fees from DePuy, Cayenne Medical, and Zimmer Biomet. 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.

Background: Although healing rates and outcomes of arthroscopic single-row rotator cuff repairs have been compared with double-row repairs, none have utilized triple-loaded anchors., Purpose: To compare healing and function after single-row repairs with triple-loaded anchors versus double-row repairs with a suture-bridge technique., Study Design: Cohort study; Level of evidence, 3., Methods: A single surgeon performed arthroscopic rotator cuff repair on 47 consecutive patients with an easily reducible full-thickness rotator cuff tear of medium size (1-3 cm). A retrospective cohort study was performed in which the first 25 patients underwent repair with a double-row suture-bridge (DRSB) technique. The next 22 patients underwent repair with a single-row technique with triple-loaded anchors and simple stitches (SRTL) after a change in technique by the surgeon. Twenty-one DRSB and 18 SRTL repairs were evaluated preoperatively and at a minimum of 12 months postoperatively with a visual analog scale for pain, the American Shoulder and Elbow Surgeons form, and the Simple Shoulder Test. Healing was evaluated with magnetic resonance imaging at a minimum of 12 months., Results: When DRSB repairs were compared with SRTL repairs, there were no significant differences in patient age (61 vs 65 years), tear size (2.3 vs 2.1 in the sagittal plane; 2.0 vs 1.8 cm in the coronal plane), Goutallier fatty infiltration (supraspinatus grade: stage 0, 38%; stage 1, 38%; stage 2, 19%; stage 3, 5%; vs stage 0, 56%; stage 1, 39%; stage 2, 5%; stage 3, 0%), tendon healing (71% vs 78%), improvement in visual analog scale pain score (3.7 vs 3.2), or improvement in American Shoulder and Elbow Surgeons scores (34.6 vs 36.9), with P > .05 in all cases. SRTL repairs had significantly greater improvement in Simple Shoulder Test scores versus DRSB repairs (6.6 vs 4.5; P = .03)., Conclusion: DRSB and SRTL repairs have similar improvements in pain and function with equivalent healing rates for arthroscopic repair of mobile full-thickness rotator cuff tears of medium size (1-3 cm)., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.Z.T. receives royalties from Cayenne Medical, Shoulder Innovations, Wright Medical, and Zimmer Biomet; owns stock/stock options in Conextions, Genesis, Intrafuse, and KATOR; and is a consultant for DePuy Mitek and Wright Medical. P.N.C. has received hospitality payments from Tornier. 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.

Background: Rotator cuff repair (RCR) leads to improved patient outcomes, which may or may not coincide with biological healing of the tendon. Many patient factors may play a role in subjective and objective patient outcomes of surgery., Purpose: To evaluate the effect of various patient factors and tendon healing on range of motion, strength, and functional outcomes after arthroscopic RCR., Study Design: Case-control study; Level of evidence, 3., Methods: We reviewed patients who underwent arthroscopic RCR. Postoperative endpoints included physical examination, repeat magnetic resonance imaging (MRI), and patient-reported outcome measures. The Short Form-36 (SF-36) was also completed at enrollment. Physical examination included range of motion and strength testing. Preoperative tear characteristics and postoperative healing on MRI were recorded. Associations between these characteristics and rotator cuff healing were determined. Multivariate models investigated factors affecting healing and final outcomes., Results: A total of 81 patients had MRI before and a minimum of 1 year after RCR. Patient-reported outcomes were available for all patients at mean 2.7 years (range, 1-7.7 years) after RCR. Seventy-five patients had physical examination data. Patients were less likely to heal if they had tears involving multiple tendons ( P = .037), tears >2.2 cm ( P = .037), tears retracted >2.0 cm ( P = .006), and tears with cumulative Goutallier grade ≥3 ( P = .003). Patients who healed were stronger on manual muscle testing in forward elevation ( P < .001) and external rotation ( P = .005) and on forward elevation isometric testing ( P = .033), and they reported better patient-reported outcomes ( P ≤ .01) at final follow-up. In multivariate models, tendon healing was associated with less pain ( P = .019) and better patient-reported outcomes (all P ≤ .006). Lower SF-36 mental component summary (MCS) score was associated with increased pain ( P = .025) and lower final American Shoulder and Elbow Surgeons score ( P = .035), independent of healing status., Conclusion: Larger, more retracted tears with greater fatty infiltration are less likely to heal per MRI. Patients who do not heal are weaker and have worse patient-reported outcome measures. Lower SF-36 MCS score was associated with poorer patient-reported outcomes independent of tendon healing., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.D.W. receives research funding from Arthrex. R.Z.T. is a paid consultant at Cayenne Medical and Mitek; receives intellectual property royalties from IMASCAP, Shoulder Innovations, and Zimmer; has stock or stock options at KATOR, INTRAFUSE, and Conextions; and receives publishing royalties, and financial or material support from Journal of Bone & Joint Surgery.

Background: Rotator cuff tearing has been found to be clinically associated with other tendinopathies and compression neuropathies; a significant excess of these phenotypes has been seen in patients with rotator cuff tears. It is unclear if the association is secondary to environmental or genetic influences., Purpose: To examine population-based data for comorbid association of rotator cuff tearing and tendinopathies and compression neuropathies and to determine whether the association extends to relatives of patients with rotator cuff tears, which could suggest a genetic contribution., Study Design: Cross-sectional study; Level of evidence, 3., Methods: The Utah Population Database (UPDB) contains health and genealogical data on over 2 million Utah residents. Current Procedural Terminology, Fourth Revision, codes (CPT 4) and International Classification of Diseases, Ninth Revision, codes (ICD-9) entered in patient records were used to identify patients with rotator cuff tearing and with comorbid tendinopathies and compression neuropathies. We tested the hypothesis of excess familial clustering of these other phenotypes with rotator cuff tearing using a well-established method (estimation of relative risks) in the overall study group of rotator cuff patients (N = 1889)., Results: Significantly elevated risk for elbow, hand/wrist, foot/ankle, knee, and hip tendinopathies, as well as for all tendinopathies and compression neuropathies, was observed in rotator cuff tear cases themselves (P < 2.8e(-13)), in their spouses (P < .02), and in their first-degree relatives (P < 5.5e(-4)). A significant excess of elbow (P = .01), foot/ankle (P = .04), and all tendinopathies (P = 3.1e(-3)) was also observed in second-degree relatives, and a significant excess of compression neuropathies (P = .03) was observed in third-degree relatives., Conclusion: The current study shows strong evidence of familial clustering of rotator cuff tearing with other tendinopathies and with compression neuropathy. Observed increased risks in spouses and first-degree relatives supports shared environmental risk factors for rotator cuff tearing, most tendinopathies, and compression neuropathies. Increased risks to third-degree relatives for compression neuropathy suggest an association of these phenotypes that may have a shared genetic etiology.

Background: Arthroscopic scapulothoracic bursectomy with partial superomedial angle scapulectomy has been described as a treatment for persistent scapulothoracic bursitis with varying results., Purpose: To evaluate patients after arthroscopic scapulothoracic bursectomy utilizing validated functional outcome instruments., Study Design: Case series., Methods: Fifteen patients underwent arthroscopic scapulothoracic bursectomy and partial superomedial angle scapulectomy. Thirteen patients were available for review at a mean 27-month follow-up (range, 13-65 months). Patients were evaluated preoperatively with a history, physical examination evaluating medial scapula border tenderness and crepitus, pain visual analog scale (VAS) score, and the simple shoulder test (SST). Postoperatively, patients were evaluated with all preoperative questionnaires as well as a satisfaction survey and the American Shoulder and Elbow Surgeons (ASES) score., Results: SST scores improved significantly from a mean 7.7 ± 3.1 preoperatively to 10.3 ± 2.3 postoperatively (P = .03). VAS pain scores reduced significantly from 6.5 ± 2.2 preoperatively to 2.3 ± 2.4 postoperatively (P < .001). Ninety-two percent (12/13) of patients were satisfied, and 92% (12/13) stated they would have the surgical procedure performed again. The mean ASES postoperative score was 80.1 (range, 38-100). The 2 clinical failures (ASES scores <50) had either a workers' compensation claim with persistent medial border tenderness or ongoing rotator cuff disease. Despite lower ASES scores, these patients were still satisfied with the procedure and would undergo it again., Conclusion: Arthroscopic scapulothoracic bursectomy with partial superomedial angle scapulectomy provides significant improvements in pain and functional outcomes. Even in patients at risk for poorer clinical outcomes, patient satisfaction and willingness to undergo the surgical procedure again was still high.