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Background: The treatment of patients who sustain a first-time anterior glenohumeral dislocation (FTAGD) is controversial. The purpose of this study was to find consensus among experts using a validated iterative process in the treatment of patients after an FTAGD., Methods: The Neer Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons. Consensus among 72 identified experts from this group was sought with a series of surveys using the Delphi process. The first survey used open-ended questions designed to identify patient-related features that influence treatment decisions after an FTAGD. The second survey used a Likert scale to rank each feature's impact on treatment decisions. The third survey used highly impactful features to construct 162 clinical scenarios. For each scenario, experts recommended surgery or not and reported how strongly they made their recommendation. These data were analyzed to find clinical scenarios that had >90% consensus for recommending treatment. These data were also used in univariate and multivariate mixed-effects models to identify odds ratios (ORs) for different features and to assess how combining these features influenced the probability of surgery for specific populations., Results: Of the 162 scenarios, 8 (5%) achieved >90% consensus for recommending surgery. All of these scenarios treated athletes with meaningful bone loss at the end of their season. In particular, for contact athletes aged > 14 years who were at the end of the season and had apprehension and meaningful bone loss, there was >90% consensus for recommending surgery after an FTAGD, with surgeons feeling very strongly about this recommendation. Of the scenarios, 22 (14%) reached >90% consensus for recommending nonoperative treatment. All of these scenarios lacked meaningful bone loss. In particular, surgeons felt very strongly about recommending nonoperative treatment after an FTAGD for non-athletes lacking apprehension without meaningful bone loss. The presence of meaningful bone loss (OR, 6.85; 95% confidence interval, 6.24-7.52) and apprehension (OR, 5.60; 95% confidence interval, 5.03-6.25) were the strongest predictors of surgery. When these 2 features were combined, profound effects increasing the probability of surgery for different populations (active-duty military, non-athletes, noncontact athletes, and contact athletes) were noted, particularly non-athletes., Conclusion: Consensus for recommending treatment of the FTAGD patient was not easily achieved. Certain combinations of patient-specific factors, such as the presence of meaningful bone loss and apprehension, increased the probability of surgery after an FTAGD in all populations. Over 90% of shoulder instability experts recommend surgery after an FTAGD for contact athletes aged > 14 years at the end of the season with both apprehension and meaningful bone loss. Over 90% of experts would not perform surgery after a first dislocation in patients who are not athletes and who lack apprehension without meaningful bone loss., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Scapular fractures following reverse total shoulder arthroplasty (RSA) are devastating complications with substantial functional implications. The role of the coracoacromial ligament (CAL), which is often transected during surgical exposure for RSA, is not fully known. We hypothesized that the CAL contributes to the structural integrity of the "scapular ring" and that the transection of this ligament during RSA alters the scapular strain patterns., Methods: RSA was performed on 8 cadaveric specimens without evidence of a prior surgical procedure in the shoulder. Strain rosettes were fixed onto the acromial body (at the location of Levy type-II fractures) and the scapular spine (Levy type III). With use of a shoulder simulator, strains were recorded at 0°, 30°, and 60° glenohumeral abductions before and after CAL transection. The deltoid and glenohumeral joints were functionally loaded (middle deltoid = 150 N, posterior deltoid = 75 N, and joint compression = 300 N). Maximum principal strains were calculated from each rosette at each abduction angle. A repeated-measures analysis of variance with post hoc analysis was performed to compare the maximum principal strain at each abduction angle., Results: With the CAL intact, there was no significant difference between strain experienced by the acromion and scapular spine at 0°, 30°, and 60° of glenohumeral abduction. CAL transection generated significantly increased strain in the scapular spine at all abduction angles compared with an intact CAL. The maximum scapular spine strain observed was increased 19.7% at 0° of abduction following CAL transection (1,216 ± 300.0 microstrain; p = 0.011). Following CAL transection, acromial strains paradoxically decreased at all abduction angles (p < 0.05 for all). The smallest strains were observed at 60° of glenohumeral abduction at the acromion following CAL transection (296 ± 121.3 microstrain; p = 0.048)., Conclusions: The CAL is an important structure that completes the "scapular ring" and therefore serves to help distribute strain in a more normalized fashion. Transection of the CAL substantially alters strain patterns, resulting in increased strain at the scapular spine following RSA., Clinical Relevance: CAL preservation is a modifiable risk factor that may reduce the risk of bone microdamage and thus the occurrence of fatigue/stress fractures in the scapular spine following RSA.

Background: Shoulder instability in young athletes is a complex problem with higher recurrence, higher reoperation, and lower return to sport (RTS) rates after arthroscopic shoulder stabilization compared with adults., Methods: This is a prospective case series of young athletes with anterior shoulder instability after arthroscopic stabilization surgery. Primary outcomes were RTS and revision surgery, minimum follow-up was 24 months. Exclusion criteria were more than 3 preoperative episodes of instability, significant bone loss, or primary posterior instability. Demographic data, recurrent instability, revision surgery, sports pre- and postsurgery, patient satisfaction, level of RTS, time to RTS, and Single Assessment Numeric Evaluation (SANE) scores were analyzed., Results: Sixty-seven athletes met inclusion criteria, 19 females and 48 males, with a mean age of 17.5 years (range, 13-21 years). Fifty-nine (88%) athletes returned to sport at an average of 7.1 months (standard deviation, ±1.8); 50 (75%) returned to the same level or higher. Football and lacrosse were the most common sports. Four of 67 athletes (6%), all male, underwent revision stabilization at 11-36 months for recurrent instability. The overall mean SANE score was 88., Conclusion: This study demonstrates that when the high-risk athlete, 21 years old or younger, is appropriately selected for arthroscopic shoulder stabilization by excluding those with 3 or more preoperative shoulder instability episodes and those with off-track and engaging instability patterns, excellent outcomes can be achieved with low revision surgery rates, high RTS rates, and high patient satisfaction., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to evaluate the psychometric properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function computer adaptive test (PF-CAT) relative to the American Shoulder and Elbow Surgeons (ASES) score in patients with glenohumeral osteoarthritis undergoing primary anatomic total shoulder arthroplasty (TSA)., Methods: A retrospective study of an institutional TSA registry was performed. Preoperative PROMIS PF-CAT and ASES scores were collected. Floor and ceiling effects were determined, and convergent validity was established through Pearson correlations. Rasch partial credit modeling was used for psychometric analysis of the validity of PF-CAT and ASES question items. Person-item maps were generated to characterize the distribution of question responses along the latent dimension of shoulder disability., Results: Responses from 179 patients (184 shoulders) were included. PF-CAT had a moderate correlation to ASES (r = 0.487; P < .001), with no floor or ceiling effects; ASES had a 1.1% floor effect and no ceiling effect. With iterative Rasch model item-reduction analysis eliminating poorly fitting question items, all possible PF-CAT items were eliminated after 6 iterations. With ASES, just 1 function question item was dropped. Person-item maps showed ASES to be superior to PROMIS PF-CAT psychometrically, with sequential and improved coverage of the latent dimension of shoulder disability., Conclusion: Despite moderate correlation with ASES, PROMIS PF-CAT demonstrated inferior validity and psychometric properties in patients undergoing TSA. PF-CAT should not replace the ASES in this population of patients., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To prospectively evaluate the return-to-sports rates after arthroscopic anterior stabilization in patients aged younger than 25 years., Methods: Fifty-eight patients underwent arthroscopic capsulolabral repair for isolated anterior instability. The mean age at the time of surgery was 19.5 years (range, 12 to 24 years). At a mean follow-up of 27 months (range, 20 to 32 months), 53 patients (42 male and 11 female patients) were assessed with American Shoulder and Elbow Surgeons, L'Insalata, and visual analog scale scores, as well as physical examination. The rate of return to sports and risk factors for postoperative recurrence were evaluated., Results: The overall rate of return to sports at final follow-up was 87%. Forty patients returned to a preinjury level of sports activity after surgery. Six patients returned to less competitive activities. Seven patients who had a subsequent traumatic event resulting in dislocation or subluxation did not return to sports activities. Open revision repairs were performed in 5 patients with recurrent instability. The American Shoulder and Elbow Surgeons and L'Insalata scores improved from 66.9 to 83.2 and from 60.4 to 79.2, respectively (P < .001). The visual analog scale score improved from 3.1 to 1 (P < .001). No significant loss of external rotation was noted postoperatively (mean, 79°). Mattress repair was associated with a higher return-to-sports rate (P < .05). Multiple instability episodes (>5) and the presence of a Hill-Sachs lesion were associated with postoperative failure (P < .05)., Conclusions: Arthroscopic stabilization is a feasible surgical option in the young, athletic population. Mattress labral repair was associated with a higher rate of return to sports, whereas patients who had ligamentous laxity, multiple instability episodes (>5), and Hill-Sachs lesions had the greatest risk of recurrence. These factors should be given consideration in planning the appropriate treatment for anterior instability in this age group., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Reverse total shoulder replacement (RTSR) depends on adequate deltoid function for a successful outcome. However, the anterior deltoid and/or axillary nerve may be damaged due to prior procedures or injury. The purpose of this study was to determine the compensatory muscle forces required for scapular plane elevation following RTSR when the anterior deltoid is deficient. The soft tissues were removed from six cadaver shoulders, except for tendon attachments. After implantation of the RTSR, the shoulders were mounted on a custom-made shoulder simulator to determine the mean force in each muscle required to achieve 30° and 60° of scapular plane elevation. Two conditions were tested: 1) Control with an absent supraspinatus and infraspinatus; and 2) Control with anterior deltoid deficiency. Anterior deltoid deficiency resulted in a mean increase of 195% in subscapularis force at 30° when compared with the control (p = 0.02). At 60°, the subscapularis force increased a mean of 82% (p < 0.001) and the middle deltoid force increased a mean of 26% (p = 0.04). Scapular plane elevation may still be possible following an RTSR in the setting of anterior deltoid deficiency. When the anterior deltoid is deficient, there is a compensatory increase in the force required by the subscapularis and middle deltoid. Attempts to preserve the subscapularis, if present, might maximise post-operative function.

Background: Reverse total shoulder arthroplasty offers pain relief and functional improvement for patients with rotator cuff-deficient shoulders. The purpose of this study was to determine the optimal amount of humeral retroversion for this prosthesis., Materials and Methods: Six cadaveric shoulders underwent computed tomography (CT) imaging and were then dissected of soft tissues, except for their tendinous attachments. A reverse total shoulder arthroplasty was implanted in 0°, 20°, 30°, and 40° of retroversion, and the shoulders were mounted on a simulator to determine the muscle forces required to achieve 30° and 60° of scaption. CT images were converted into 3-dimensional models, and the amount of internal and external rotation was determined with computer modeling at various scaption angles., Results: No differences were found in the forces required for 30° or 60° of scaption for any muscle, at any retroversion. With increasing retroversion, more impingement-free external rotation was obtained, with a concomitant decrease in the amount of internal rotation. Above 60°, the humerus was allowed to rotate around the glenosphere unencumbered., Conclusions: Increasing retroversion did not affect the muscle force requirements for scaption across the shoulder. Placing the humeral component in 0° to 20° of retroversion allows maximum internal rotation with the arm at the side, a movement that is required for daily activities. This limits external rotation with the arm at the side, but has no effect on external rotation with the arm elevated., (Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: The objectives of this study were to characterize and compare the vascularity of arthroscopically repaired rotator cuff tendons at short-term and intermediate-term follow-up., Materials and Methods: Nineteen patients who underwent arthroscopic rotator cuff repair were prospectively monitored for an average of 21.2 months. Initial baseline, grayscale ultrasound images of the operated-on shoulder were obtained on all patients at 3 months and at a minimum of 10 months postoperatively. Perflutren-lipid microsphere contrast (DEFINITY, Lantheus Medical Imaging, North Billerica, MA, USA) was injected after baseline grayscale images and after exercise to obtain contrast-enhanced images of the repair. Three regions of interest--supraspinatus tendon, peribursal tissue, and bone anchor site--were evaluated before and after rotator cuff-specific exercises., Results: The peribursal tissue demonstrated the greatest blood flow, followed by the bone anchor site and tendon, in pre-exercise and postexercise states. Significantly less blood flow was observed in all regions of interest before exercise (P < .05) and only at the bone anchor site after exercise (P < .001) at latest follow-up compared with the 3-month values. Intratendinous blood flow remained relatively low at both evaluation points after surgical repair., Conclusion: Preliminary findings suggest that the peribursal tissue and bone anchor site are the main conduits of blood flow for the rotator cuff tendon after arthroscopic repair, with the supraspinatus tendon being relatively avascular. Blood flow of the repaired rotator cuff tendon decreases with time. Furthermore, exercise significantly enhances blood flow to the repaired rotator cuff., (Copyright © 2012. Published by Mosby, Inc.)

Background: Despite advances in technique and implant design, instability after reverse total shoulder arthroplasty remains a challenging postoperative complication., Materials and Methods: We examined our institutions' first 57 reverse total shoulder arthroplasties performed during a 3-year period (2004-2006). There were 9 cases of instability, all occurring within the first 6 months after surgery., Results: All 9 patients had compromise of the subscapularis tendon at the time of initial reverse total shoulder implantation. With regard to implant positioning, 2 patients had superiorly inclined metaglenes and 3 had metaglenes positioned superior to the inferior glenoid. Each patient with a dislocation had at least 1 revision surgery, and 4 patients had underlying infection. At most recent follow-up, only 3 patients had a concentrically reduced reverse total shoulder arthroplasty in place whereas 3 remained explanted, 2 chronically dislocated, and 1 chronically subluxated., Conclusions: Early instability after reverse total shoulder arthroplasty can be related to inadequate soft tissue, inadequate deltoid tension, malpositioned implants, and/or infection, and outcomes of treatment of early instability are generally poor., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Hypothesis: This study reviewed a series of patients diagnosed with Propionibacterium acnes infection after shoulder arthroplasty in order to describe its clinical presentation, the means of diagnosis, and provide options for treatment., Materials and Methods: From 2002 to 2006, 11 patients diagnosed with P acnes infection after shoulder arthroplasty were retrospectively reviewed and analyzed for (1) clinical diagnosis; (2) laboratory data, including white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP); (3) fever; (4) number of days for laboratory growth of P acnes; (5) organism sensitivities; (6) antibiotic regimen and length of treatment; and (7) surgical management. Infection was diagnosed by 2 positive cultures., Results: Five patients had an initial diagnosis of infection and underwent implant removal, placement of an antibiotic spacer, and staged reimplantation after a course of intravenous antibiotics. In the remaining 6 patients, surgical treatment varied according to the clinical diagnosis. When infection was recognized by intraoperative cultures, antibiotics were initiated. The average initial ESR and CRP values were 33 mm/h and 2 mg/dL, respectively. The average number of days from collection to a positive culture was 9. All cultures were sensitive to penicillin and clindamycin and universally resistant to metronidazole., Discussion: Prosthetic joint infection secondary to P acnes is relatively rare; yet, when present, is an important cause of clinical implant failure. Successful treatment is hampered because clinical findings may be subtle, many of the traditional signs of infection are not present, and cultures may not be positive for as long as 2 weeks., (Copyright 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: To our knowledge, there has been no prospective study on the results of arthroscopic repair of superior labrum-biceps anchor complex (SLAP) tears with use of modern techniques. The purpose of the present study was to prospectively evaluate the minimum two-year results for patients with type-II SLAP tears that were treated with arthroscopic suture anchor fixation., Methods: Forty-seven patients with symptomatic type-II SLAP tears were evaluated preoperatively and at least two years postoperatively with use of the American Shoulder and Elbow Surgeons (ASES) and L'Insalata outcomes instruments and physical examination. The study group included thirty-nine male and eight female patients with a mean age of thirty-six years; thirty-four of the forty-seven patients were athletes. Patients with rotator cuff tears requiring repair or concomitant shoulder instability were excluded., Results: At an average of 2.7 years, the median ASES and L'Insalata scores were 97 and 93, respectively, compared with baseline scores of 62 and 65 (p < 0.05). The median patient-reported satisfaction rating was 9 (of 10); forty-one patients (87%) rated the outcome as good or excellent. The median patient-reported satisfaction rating was significantly higher for patients with a discrete traumatic etiology than for those with an atraumatic etiology (9 compared with 7); however, there was no significant difference between these groups in terms of the ASES or L'Insalata outcome scores. Overall, twenty-five (74%) of the thirty-four athletes were able to return to their preinjury level of competition, whereas eleven (92%) of the twelve athletes who reported a discrete traumatic event were able to return to their previous level of competition. There were five complications, including four cases of refractory postoperative stiffness., Conclusions: Our findings indicate that favorable outcomes can be anticipated in the majority of patients after arthroscopic SLAP lesion repair. While only three of four patients overall may be capable of returning fully to their previous level of competition, patients with a distinct traumatic etiology have a greater likelihood of a successful return to sports.

This clinical study was performed to document the prevalence of deep vein thrombosis (DVT) after prosthetic shoulder replacement surgery. We prospectively followed 100 consecutive shoulder arthroplasty procedures (total shoulder replacement in 73 and hemiarthroplasty in 27) in 44 male and 56 female patients for 12 weeks (mean age, 67 years; range, 17-88 years). Risk factors for venous thromboembolic disease were assessed preoperatively and postoperatively. A 4-limb surveillance color flow Doppler ultrasound was performed at 2 days (100 patients) and 12 weeks (50 patients randomly selected) after surgery, and the presence and location of DVT were recorded. Postoperative symptomatic or fatal pulmonary emboli (PE) were also recorded. The overall prevalence of DVT was 13.0%, consisting of 13 DVTs in 12 patients. These included 6 ipsilateral and no contralateral upper extremity DVTs and 5 ipsilateral and 2 contralateral lower extremity DVTs. The prevalence of DVT was 10.0% (10/100) at day 2 after surgery and 6.0% (3/50) at week 12 after surgery. The incidence of symptomatic nonfatal PE was 2.0% (2/100), and that of fatal PE was 1.0% (1/100). Risk factors associated with venous thromboembolic disease did not reach statistical significance because of the small study population sample size. At our institution, the prevalence of DVT after reconstructive shoulder arthroplasty was 13.0%, a rate comparable to that after hip arthroplasty (10.3%) but lower than that after knee arthroplasty (27.2%). Shoulder arthroplasty surgeons should be aware of the potential risk of perioperative thromboembolic complications in both the acute and subacute postoperative periods.

Background: Rotator cuff tears, Bankart lesions, and superior labral anterior posterior lesions commonly occur in isolation, but there is a subgroup of patients who experience combined injuries. Prior studies have excluded such patients as confounding groups., Hypothesis: In patients with combined lesions of the labrum and rotator cuff, arthroscopic repair of both lesions will restore range of motion and stability and provide good clinical results., Study Design: Cohort study; Level of evidence, 3., Methods: We retrospectively evaluated the clinical outcomes of a series of patients with combined rotator cuff and labral (Bankart or superior labral anterior posterior) lesions treated arthroscopically., Results: Thirty patients (average age, 47.8 years) with combined rotator cuff and labral lesions were evaluated at a mean follow-up of 2.7 years (range, 24-54 months). Sixteen patients had Bankart lesions and 14 patients had SLAP lesions. Significant improvements in forward flexion (20.5 degrees, P = .005), external rotation (9.0 degrees, P = .008), and internal rotation (2 vertebral levels, P = .016) were observed. The mean L'Insalata and American Society of Shoulder and Elbow Surgeons scores for all patients were 92.9 and 94.3, respectively. Twenty-seven (90%) patients reported satisfaction as good to excellent, and 23 of 30 (77%) returned to their preinjury level of athletics. Two patients suffered recurrent rotator cuff tears., Conclusion: In patients with rotator cuff and labral lesions, arthroscopic treatment of both lesions yields good clinical outcomes, restoration of motion, and a high degree of patient satisfaction.

Young adult patients with shoulder arthritis present challenging treatment decisions for the orthopaedic surgeon. Patients treated with shoulder arthroplasty have the youngest average age of all patients who undergo joint arthroplasty. However, in the young, active patient or in those without advanced disease, joint arthroplasty may not be appropriate. Arthroscopic treatment or interposition arthroplasty may provide symptomatic relief without radically compromising future procedures.

The purpose of this study was to evaluate outpatient rotator cuff repair on the basis of patient satisfaction, pain control, early postoperative complications, and cost control. Patients were considered good candidates for an outpatient repair if they were in good health and had adequate support at home. Seventy-five rotator cuff repairs were performed on an outpatient basis. The average age of the patients was 58 years. Patients with tears smaller than 2 cm in diameter were excluded. Postoperative pain was managed effectively in 74 of 75 outpatients. There were no cases of deltoid origin compromise, deep infection, or early failure of repair, and no outpatient required readmission to the hospital. This study demonstrates that outpatient rotator cuff repair is possible in the appropriately selected patient and can be performed safely and effectively with a 43% reduction in overall cost.