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Background: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions are associated with recurrent shoulder instability and higher rates of failure after capsulolabral repair compared with similarly treated Bankart lesions. Although these lesions can portend poor outcomes, there are limited data on the associated conditions and postoperative course in a young, active population., Purpose: To evaluate the mid- to long-term clinical course and failure rates after ALPSA repairs and assess features associated with these outcomes., Study Design: Cohort study; Level of evidence, 3., Methods: The authors identified all patients who underwent primary arthroscopic anterior or combined anterior and posterior labral repair between January 2010 and January 2020 at a single US military academy. Patient and injury characteristics were retrospectively reviewed while excluding patients with follow-up of <2 years. Patients were divided into 2 cohorts based on the presence of an ALPSA lesion as identified using arthroscopy, and patients with non-ALPSA lesions were matched to those with ALPSA lesions in a 5:1 ratio based on age, sex, time from injury to surgery, glenoid bone loss, and follow-up duration. The primary outcome measures were failure and revision surgery. Any recurrent shoulder instability event was considered a failure, including subjective or objective subluxation and/or dislocation, recurrence of pain consistent with instability, or functionally limiting apprehension. Survival analysis and both univariate and multivariate logistic regression analyses were performed to identify factors associated with ALPSA lesions and propensity for failure., Results: The authors compared 225 patients with non-ALPSA labral tears against 45 patients with ALPSA lesions. ALPSA lesions were associated with multiple preoperative dislocations (odds ratio [OR], 3.0; 95% CI, 1.5-5.9; P = .00096) and increased prevalence of Hill-Sachs lesions (HSLs) (OR, 6.7; 95% CI, 2.8-16.0; P < .0001) and near-track HSLs (OR, 3.6; 95% CI, 1.7-7.6; P = .00049). At the final follow-up, there was no difference in overall failure or recurrent instability between patients with and without ALPSA lesions (20% vs 16% [ P = .563] and 17.8% vs 10.2% [ P = .147], respectively). On multivariate regression, ALPSA did not affect the likelihood of failure ( P = .625). However, those with ALPSA lesions experienced failure earlier (1.7 vs 3.1 years; P = .020). When revision ALPSA repairs were performed, 43% failed., Conclusion: In patients with anterior instability treated with primary arthroscopic stabilization, ALPSA lesions were associated with HSLs and multiple dislocations. Although ALPSA repair failure occurred at a similar frequency in the mid- to long term compared with Bankart repairs, ALPSA repair failure tended to occur early in the postoperative course., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: S.M.F., J.-P.H.R., and B.W.H. have received educational funding from Supreme Orthopedic Systems. B.G.Y. has received hospitality payments from Arthrex and Stryker and research support from Arthrex. Z.J.B. has received hospitality payments from Arthrex, Smith & Nephew, and Stryker. K.G.K. has received support for education from Supreme Orthopedic Systems and fees for education support from Arthrex. J.F.D. has received funding or payments from SouthTech Orthopedics, support for education from Supreme Orthopedic Systems, fees for other than consulting from Arthrex, and royalties from SLACK Inc. L.E.L. has received funding or payments from Alpha Orthopedic Systems, research support from Ossio and DJO, and support for education from Arthrex and Supreme Orthopedic Systems. 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: Anchored transosseous equivalent suture-bridge technique (TOE) is widely used for arthroscopic rotator cuff repair. It is unknown how patient outcomes scores, ROM, and integrity of the rotator cuff after repair using this anchored technique compare with those after repair using an anchorless transosseous technique (TO)., Questions/purposes: (1) What are the differences in patient-reported outcomes (American Shoulder and Elbow Surgeons [ASES] score) and shoulder ROM between TO and TOE rotator cuff repair techniques at 1 and 2 years after surgery? (2) What is the difference in repair integrity as measured by the re-tear rate, assessed ultrasonographically at 1 year, between these two techniques? (3) What is the difference in procedure duration between the two techniques when performed by a surgeon familiar with each?, Methods: We reviewed 331 arthroscopic rotator cuff repairs performed by one surgeon from December 2011 to July 2016 in this retrospective, matched-pair study. Of these patients, 63% (208 of 331) underwent repair with standard anchored technique (anchors placed in a double-row, TOE manner) and 37% (123 of 331) underwent anchorless TO repair, with the same indications for surgery between groups. Forty-four percent (91 of 208) of patients in the TOE group and 61% (75 of 123) of patients in the TO group met the inclusion criteria. Eighty percent (73 of 91) of patients in the TOE group and 88% (66 of 75) in the TO group had minimum 2-year follow-up. We matched each group to a cohort of 50 patients by sex, age, smoking status, and tear size (by Cofield classification: small, < 1 cm; medium, 1-3 cm; large, > 3-5 cm; or massive, > 5 cm). The resulting cohorts did not differ in mean age (TO, 62 years [range 53-65 years]; TOE, 58 years [range 53-65 years]; p = 0.79), mean BMI value (TO, 30 [range 27-33]; TOE, 29 [range 27-35]; p = 0.97), or dominant arm involvement (TO, 80%; TOE, 78%; p = 0.81). The cohorts were followed for at least 2 years (median, 3.2 years [interquartile range (IQR) 2.2-4.3] for TO and 2.9 years [IQR 2.0-3.5 years] for TOE). ASES scores and ROM were evaluated before surgery and at follow-up visits and were recorded in a longitudinally maintained institutional database. Repair integrity was assessed using ultrasonography at 1 year, as is standard in our practice. For each tear-size group, we calculated the proportion of intact tendon repairs versus the proportion of re-tears. Duration of surgery was recorded for each patient., Results: At 1 year, we observed no difference in median ASES scores (90 [IQR 92-98] for TO and 88 [IQR 72-98] for TOE; p = 0.44); external rotation (50° [IQR 45°-60°) for TO and 50° [IQR: 40°-60°] for TOE; p = 0.58); forward flexion (165° [IQR 160°-170°] for both groups; p = 0.91); or abduction (100° [IQR 90°-100°] for TO and 90° [IQR 90°-100°] for TOE; p = 0.06). Fourteen percent of shoulders (seven of 50) in each treatment group had evidence of re-tear at 1 year (p > 0.99): 0 of 2 small tears in each group, 0 of 7 medium tears in each group, five of 32 large tears in each group, and two of 9 massive tears in each group (all, p > 0.99). At 2 years, we found no differences in median ASES scores (92 [IQR 74-98)] for TO and 90 [IQR 80-100] for TOE; p = 0.84); external rotation (60° [IQR 50°-60°] for both groups; p = 0.74); forward flexion (170° [IQR 160°-170°] for both groups; p = 0.69); or abduction (100° [IQR 90°-100°] for both groups; p = 0.95). We found no differences between groups in mean ± SD procedure time, which was 103 ± 20 minutes for TO repair and 99 ± 20 minutes for TOE repair (p = 0.45)., Conclusions: TO and TOE techniques for arthroscopic rotator cuff repair results in no differences in ROM, ASES scores, re-tear rates, and surgical time. Randomized control trials are needed to confirm these similarities or determine a superior method of repair. Future cost analyses may also help to determine the relative value of each technique., Level of Evidence: Level III, therapeutic study.

Thank you AANA for allowing us to participate in one of the most educational and transformative pieces of our careers to date. It was a great honor to be selected to participate in the 2018 Advanced Arthroscopy Training Fellowship. We journeyed to New York City, New Orleans, and Columbus, Ohio. This was a life-changing experience full of remarkable Friendship and Mentorship., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Nonoperative management of posterior shoulder instability is common. However, limited data are available to assess the pathomorphologic factors associated with its failure. Purpose/Hypothesis: The purpose of this study was 2-fold: (1) to determine glenohumeral pathomorphologic features predictive of nonoperative management failure of posterior instability; and (2) to determine the relationship between nonoperative management failure and posterior glenoid bone loss (pGBL) progression. It was hypothesized that greater posterior acromial height (PAH) would adversely affect nonoperative survivorship and that shoulders treated nonoperatively would have pGBL progression compared with those undergoing surgical stabilization. Study Design: Case-control study; Level of evidence, 3. Methods: This was a retrospective review of a consecutive series of patients with isolated posterior shoulder instability, defined as isolated posterior labral tear on magnetic resonance imaging (MRI) with corresponding physical examination findings, who underwent nonoperative management for 6 months and had no previous related surgical history. The primary outcome of interest was the failure of nonoperative management, defined as the inability to return to full military duty or requiring surgical intervention. The morphologic features assessed for association with nonoperative management failure included pGBL, glenoid version, acromial morphology, and posterior humeral head subluxation. We secondarily sought to determine the progression of pGBL on serial MRI scans. Cox proportional hazard analysis was used to evaluate risk factors for failure. Results: In this study, 42 of 90 (46.7%) patients had failed nonoperative management and went on to receive an arthroscopic stabilization procedure. The group with failed treatment demonstrated a greater humeral head subluxation ratio than those with successful nonoperative management (0.65 ± 0.2 vs 0.62 ± 0.2; P =.038). Cox proportional hazard analysis identified pGBL, greater PAH, less posterior acromial coverage, and posterior humeral subluxation as significant risk factors for failure. Of those with failed nonoperative management, 17 had repeat MRI scans at a mean of 488.2 ± 87 days after index MRI for comparison, demonstrating a statistically significant progression of pGBL (index MRI, 2.68% ± 1.71%) versus after nonoperative treatment failure (6.54% ± 1.59%; P =.003). Conclusion: Failure occurred 47% of the time in patients who underwent nonoperative management for isolated posterior glenohumeral instability for a minimum of 6 months, and it was associated with a greater posterior humeral head subluxation, less posterior acromial coverage, greater PAH, and greater amounts of glenoid retroversion on index MRI. Additionally, those who had repeat MRI approximately 1 year after the index MRI demonstrated greater pGBL compared with the index MRI. [ABSTRACT FROM AUTHOR]

Objectives: Suprascapular neuropathy due to nerve compression or tension at the suprascapular notch is an uncommon source of shoulder pain and rotator cuff weakness with recent increased recognition and treatment. Long considered an elusive diagnosis, work-up can be lengthy and patients may experience treatment delay. We aimed to review presentation patterns and outcomes of arthroscopic suprascapular nerve decompression in a predominantly young and active military population. Methods: The surgical databases of two surgeons were queried for patients treated with arthroscopic suprascapular nerve decompression at the suprascapular notch from 2013 to 2021. Patient data, presentation and workup findings, and outcome measures were collected through review of the electronic medical record. Primary outcome measures were rate of return to active-duty military service, shoulder abduction and external rotation strength, and VAS pain scores. Secondary outcome measures were American Shoulder and Elbow Surgeons (ASES) Shoulder Score, Visual Analogue Scale (VAS), and Single Assessment Numerical Evaluation (SANE) score. Results: Twenty-five patients were identified. Average age was 26.6 years and follow-up 17.9 months (4-62 months). There were two distinct primary presentation types in this cohort: the chief complaint was pain in 13 patients (52%) and weakness in 12 (48%). Supraspinatus and/or infraspinatus atrophy was present on MRI in 10/12 patients with weakness and 0/13 with pain. Electromyography was positive in 9/12 with weakness and negative when obtained in 5 patients with pain. Ultrasound-guided suprascapular nerve injection was performed in 10/13 with pain and provided mean 91% symptom relief. Patients with pain had longer duration of pre-operative symptoms (22.2 [±13.1] vs. 10.3 [±13.6] weeks). Postoperatively, the pain group had significant improvement in VAS scores (6.2 [±1.6] to 1.0 [±0.9]), while the weakness group had significant improvement in abduction and external rotation motor grading (3.7 [±0.7] to 4.7 [±0.4] and 3.3 [±0.8] to 4.4 [±0.6] respectively). Return to duty or sport was 92% at a mean of 14.6 (±9.3) weeks. Conclusions: In this young, active cohort, suprascapular neuropathy presented with one of two distinct primary presenting complaints: pain or weakness. Given different expected work-up findings, categorizing patients into one of these two groups may be beneficial in effectively diagnosing and treating suprascapular neuropathy. Outcomes after arthroscopic suprascapular nerve release at the suprascapular notch predictably led to successful pain relief and strength improvement in patients presenting with pain and weakness respectively. [ABSTRACT FROM AUTHOR]

Objectives: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions occur in patients with recurrent shoulder instability and are associated with higher rates of failure after capsulolabral repair surgery compared to typical Bankart lesions. Despite recognition that these lesions can portend poor outcomes, there is relatively limited data to understand the associated injuries and postoperative course in a young, active population. The purpose of this study is to evaluate ALPSA lesions for associated pathology and outcomes. Methods: Methods: We reviewed the records of 312 patients who underwent arthroscopic shoulder stabilization by one of two fellowship trained sports surgeons at a single facility between 1 January 2010 and 31 December 2015. Inclusion criteria were a minimum follow-up of five years after index surgical repair and presence of an ALPSA lesion as identified on arthroscopic exam, leaving 46 patients available for review. Our primary outcome measures were failure and operative revision surgery. We considered failure as any recurrent shoulder instability events including subjective subluxation and dislocation, recurrence of pain consistent with instability, or functionally limiting apprehension. We performed survival analysis and a multivariate logistic regression analysis to identify factors associated with failure. Results: Results: In total, 46 patients with average age 21.2 years met inclusion and underwent surgery a median of 7.1 months after initial recalled injury event. 11/46 had concomitant posterior pathology in addition to anterior labral lesion. Six patients were found to have SLAP lesions. All patients experienced subjective instability, and 44/46 endorsed pain prior to surgery. 38/46 reported having experienced complete dislocation. The median number of dislocations before surgery was 3. Repairs were performed with average 3.7 anchors. Eight patients failed surgery at median 15.1 months post-index procedure, with 75% of failures occurring before two years with the remaining 25% occurring later in follow-up. Three of these failed revision repair. Conclusions: Conclusions: ALPSA lesions frequently occur in the presence of other intra-articular shoulder lesions and portend a high rate of recurrent shoulder instability despite repair. Notably, while failure occurs at a high rate, most repair failure for these lesions tends to occur early. [ABSTRACT FROM AUTHOR]

Background: The debate continues regarding the optimal treatment of intercollegiate contact athletes with in-season anterior shoulder instability. Purpose: To examine return to sport and recurrent instability in the season after the index in-season anterior instability event. Study Design: Cohort study; Level of evidence, 2. Methods: Forty-five contact intercollegiate athletes treated nonoperatively or with arthroscopic stabilization were prospectively followed in a multicenter observational study to evaluate return to play (RTP) and recurrent instability in the season after an initial in-season anterior glenohumeral instability event. Baseline data collection included sport played, previous instability events, direction of instability, type of instability (subluxation or dislocation), and treatment method (nonoperative management or arthroscopic stabilization). All nonoperatively treated athletes underwent a standardized accelerated rehabilitation program without shoulder immobilization. Surgical stabilization was performed arthroscopically in all cases, and successful RTP was evaluated during the next competitive season after complete rehabilitation. Results: Thirty-nine of 45 intercollegiate contact athletes had remaining National Collegiate Athletic Association eligibility and were followed through the subsequent competitive season after the index instability event. Of the 10 athletes electing nonoperative treatment, 4 (40%) successfully returned to play without recurrence during the subsequent season. Of the 29 athletes treated surgically, 26 (90%) were able to successfully return to play without recurrence the following season (recurrence: n = 1; inadequate function: n = 2). Athletes who underwent surgical reconstruction before the next season were 5.8 times (95% CI, 1.77-18.97; P = .004) more likely to complete the subsequent season without recurrent instability. Of the 29 athletes electing surgical stabilization, there was no difference (risk ratio, 0.95; 95% CI, 0.10-9.24; P > .99) in RTP between the 9 stabilized after a single instability event (90% RTP rate) and the 20 stabilized after multiple in-season recurrent instability events (89% RTP rate). Conclusion: Collegiate contact and collision athletes with in-season anterior shoulder instability are significantly more likely to successfully return to sport without subsequent instability events the next season if they undergo surgical repair in the off-season. [ABSTRACT FROM AUTHOR]

Background: The original approach for the repair of torn rotator cuffs involved an open technique with sutures passing through the greater tuberosity and tendon. The development of suture anchors allowed for an all-arthroscopic approach with anchor configurations attempting to re-create a transosseous fixation pattern. Presently, an arthroscopic approach can be combined with a transosseous suture configuration without using anchors. Purpose: To evaluate cyclic loading, ultimate load to failure, and the failure mechanisms of transosseous-equivalent (TOE) repair with anchors and anchorless transosseous (AT) repair of rotator cuff tears. Study Design: Controlled laboratory study. Methods: Supraspinatus tears (25 mm) were created in 20 fresh-frozen, human cadaveric shoulders, which were randomized to TOE or AT repair (10 in each group, paired experimental design). Biomechanical testing was performed with an initial preload, cyclic loading, and load to failure. Optical markers were used to monitor gap formation in 3 planes, and the failure mode was recorded. Paired t tests were used to make comparisons of biomechanical parameters between the groups. Multinomial logistic regression was used to compare failure modes between the groups. Significance was set to .05. Results: The TOE group had a significantly higher mean (±SD) ultimate failure load (578.5 ± 123.8 N) than the AT group (468.7 ± 150.9 N) (P = .034). The TOE group also had a significantly less mean first-cycle excursion (2.97 ± 1.97 mm) than the AT group (4.70 ± 2.04 mm) (P = .046). There were no significant differences between the groups in cyclic elongation or linear stiffness during cyclic loading. Primary modes of failure were a type 2 tendon tear with medial tendon disruption in the TOE group (7/10) and a type 1 tendon tear with lateral tendon disruption in the AT group (6/10). Conclusion: TOE repair resulted in a significantly higher mean failure load compared with AT repair in a cadaveric model. The most common modes of failure were a type 2 tendon tear in the TOE group and a type 1 tendon tear in the AT group. Clinical Relevance: A higher mean failure load in TOE versus AT constructs may come at the cost of a less favorable failure mode adjacent to medial anchors at the musculotendinous junction, potentially making revision difficult. [ABSTRACT FROM AUTHOR]

Objectives: The Latarjet technique has been the gold standard treatment for glenoid bone loss following anterior shoulder instability due to its low recurrence rate, but other techniques including arthroscopic anatomic glenoid reconstruction (AAGR) have shown similar outcomes with fewer complications. The Latarjet requires a subscapularis split or take-down for placement of the coracoid, which may compromise post-operative subscapularis quality and strength. The AAGR is a subscapularis-sparing technique that obviates the need for a subscapularis split by using a far medial (Halifax) portal for graft placement. The purpose of this study was to compare subscapularis muscle changes before and after surgery between Latarjet and AAGR patients. Methods: This study was a retrospective analysis of patients treated surgically with AAGR and Latarjet that had pre- and post-operative CT scans. Patients' charts were reviewed to obtain demographic information, as well as CT scan cross-sectional area measurements of the subscapularis muscle on pre- and post-surgery scans. We used a pre-existing validated formula (volume=[0.06(A+C)]-13.02) for calculating the volume of the subscapularis pre- and postoperatively based on the cross-sectional area of the muscle. Results: Our cohort included 40 patients in each group with pre- and post-operative CT scans. On average, patients had a CT scan one year post-operatively. Pre-operatively, patients were estimated to have similar subscapularis volumes (p>0.05). We found that the change in medial area of the subscapularis muscle was significantly higher in the Latarjet group (-325.8 mm2) compared to the AAGR group (-73.2 mm2) (p<0.05). We found that AAGR patients had a 3% increase in subscapularis volume post-operatively, while the Latarjet patients had 3% decrease in volume (p<0.05) Conclusions: The AAGR technique is subscapularis-sparing both in surgical technique and structural outcomes, resulting in comparable subscapularis cross-sectional area and volume pre- and postoperatively. Latarjet using a subscapularis split results in lower subscapularis medial volumetric area. [ABSTRACT FROM AUTHOR]