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» Suture button fixation has emerged as an effective surgical construct in arthroscopic and open Latarjet and anterior glenoid reconstruction with free autograft bone with high rates of bone block healing.» Biomechanical data suggest that screw and suture button mechanical fixation constructs provide similar load to failure and stability for the Latarjet procedure.» Preliminary bone healing models have identified that flexible fixation may exhibit a higher degree of bone callus maturation, whereas rigid fixation results in excessive callus hyperplasia» Mechanical tensioner use provides consistent tensioning of suture button constructs and improves bone-to-bone healing rates when used for anterior glenoid reconstruction surgery.» Evidence is lacking regarding the reliability of bone-to-bone healing of allografts to native bone with use of suture button constructs.» Suture button fixation provides good short- and mid-term clinical outcomes for the arthroscopic Latarjet and anterior glenoid reconstruction with free autograft bone., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B180)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

The glenohumeral joint is the least congruent and least constrained joint with a complex relationship of static and dynamic stabilizers to balance its native mobility with functional stability. In the young athlete, anterior shoulder instability is multifactorial and can be a challenge to treat, requiring a patient-specific treatment approach. Surgical decision-making must consider patient-specific factors such as age, sport activity and level, underlying ligamentous laxity, and goals for return to activity, in addition to careful scrutiny of the underlying pathology to include humeral and glenoid bone loss and surrounding scapular bone morphology., Competing Interests: Disclosure Dr S.A. Parada serves as a consultant to Arthrex, Inc and Exactech, Inc and receives research support from Exactech, Inc., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The incremental biological changes in the synovial microenvironment of the shoulder in acute and chronic instability that may contribute to joint degeneration are poorly understood. Proteomic analysis of synovial fluid in patients with shoulder instability may improve our understanding of proteins that are shed into shoulder synovial fluid after an injury., Hypothesis: Injury-specific factors such as the direction of instability and the severity of glenoid and humeral bone loss are associated with the proteome of synovial fluid in patients with shoulder instability., Study Design: Descriptive laboratory study., Methods: Synovial fluid lavage samples were compared between patients with anterior (n = 12) and posterior (n = 8) instability and those without instability (n = 5). Synovial proteins were identified with liquid chromatography-tandem mass spectrometry. Orthogonal validation of protein targets found to be significant on tandem mass spectrometry was performed in a separate set of prospective patients with Western blotting. Data were processed and analyzed, and P values were adjusted with the Benjamini-Hochberg method for multiple comparisons., Results: A total of 25 patients were included. Tandem mass spectrometry identified 720 protein groups in synovial fluid of patients with shoulder instability. There were 4 synovial proteins that were significantly expressed in patients with anterior instability relative to posterior instability: periostin (POSTN) (adjusted P value = .03; log fold change [logFc] = 4.7), transforming growth factor beta-induced protein ig-h3 (adjusted P value = .05; logFc = 1.7), collagen type VI alpha-3 chain (adjusted P value = .04; logFc = 2.6), and coagulation factor V (adjusted P value = .04; logFc = -3.3). Among these targets, POSTN showed a moderate correlation with the Hill-Sachs lesion size ( r = 0.7). Prospective validation with Western blotting confirmed a significantly higher level of POSTN in synovial fluid of patients with anterior instability ( P = .00025; logFc = 5.1)., Conclusion: Proteomic analysis enriched our understanding of proteins that were secreted into shoulder synovial fluid of patients with shoulder instability. The identification of POSTN, a proinflammatory catabolic protein involved with tissue remodeling and repair, as a significant target in anterior shoulder instability is a novel finding. Therefore, further study is warranted to determine the role that POSTN may play in the progression of bone loss and posttraumatic osteoarthritis., Clinical Relevance: Proteomic analysis of synovial fluid in patients with shoulder instability improved our understanding of this abnormality after an injury., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study was funded through the Musculoskeletal Injury Rehabilitation Research for Operational Readiness program administered by the Geneva Foundation (award No. HU00011920011). J.W.G. has received support for education from Smith & Nephew, Kairos Surgical, Summit Surgical, and ImpactOrtho; consulting fees from FH Orthopedics; and hospitality payments from Encore Medical and Wright Medical. B.M.P. has received support for education from Wright Medical, Stryker, Arthrex, Wardlow Enterprises, and Encore Medical; and hospitality payments from Zimmer Biomet. J.V.N. has received consulting fees from Zimmer Biomet. J.A.B. has received honoraria from the Musculoskeletal Transplant Foundation. B.R.W. has received royalties and consulting fees from Conmed Linvatec. 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.

A biorepository, also referred to as a "biobank," is a collection of biologic samples that are stored for laboratory research. With the emergence of precision medicine, the importance of leveraging individual patient biomolecular signatures to improve diagnosis, prognosis, and treatment is becoming increasingly recognized. Successful development and sustainment of a biorepository provides the potential for transformative preclinical research. Establishing a biobank requires a team approach with involvement of the institutions' research laboratory team and regulatory body. Execution of research activities requires a coordinated team approach for case identification, consent process, data and specimen collection, specimen processing, and storage and archiving. The advancing fields of precision medicine and orthobiologics provide incredible opportunities for institutions to generate novel lines of inquiry in musculoskeletal diseases through a multiomics approach (genomic, transcriptomic, proteomic, microbiomic). In addition, a biobank is an important component of post-market surveillance for the rapidly emerging field of orthobiologics., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Purpose: To determine the percentage of patients who report the ability to run 1 mile at various time points after arthroscopic and open shoulder surgery., Methods: We performed a retrospective review of prospectively collected data for all active-duty military patients aged 18 to 45 years who underwent shoulder surgery at a single institution over a 2-year period. The rehabilitation protocol discouraged running before 3 months, but all patients were able to return to unrestricted running at 3 months postoperatively. Patients were excluded if they lacked 1-year follow-up data. Parameters collected included demographic information and validated patient-reported outcome measures at the preoperative and short-term postoperative visits, as well as patients' ability to run at least 1 mile postoperatively., Results: A total of 126 patients were identified who underwent shoulder surgery with return-to-running data. Compared with baseline, significant improvements in patient-reported outcomes were shown at 1 and 2 years postoperatively ( P  = .001). The percentage of patients reporting the ability to run 1 mile postoperatively was 59% at 3 months, 74% at 4.5 months, 79% at 6 months, 83% at 12 months, and 91% at 24 months. There was no significant difference in patients undergoing shoulder surgery for instability versus non-instability diagnoses or in patients undergoing open versus arthroscopic anterior stabilization. All 11 patients unable to return to running at final follow-up had chronic lower-extremity diagnoses limiting their running ability., Conclusions: Young military athletes undergoing arthroscopic and open shoulder surgery have a high rate of early return to running. Approximately 60% of patients report the ability to run 1 mile at 3 months postoperatively, and three-quarters of patients do so at 4.5 months. Age, sex, military occupation, underlying diagnosis or type of surgery did not influence the rate of return to running after shoulder surgery., Level of Evidence: Level IV, therapeutic case series.

Purpose: The purposes of this study were to use computed tomography (CT) scans to compare the radius of curvature (ROC) of the inferior concave surface of the distal clavicle to the glenoid, determine graft dimensions, and compare the ROC of the congruent-arc distal clavicle autograft (DCA) to the congruent-arc Latarjet graft., Methods: Patients who underwent bony glenoid reconstruction via a Laterjet procedure between January 2018 and January 2023 at a single institution were retrospectively identified. CT scans were used to measure the ROC of the glenoid on the axial and coronal sequences, measure the ROC of the distal clavicle on the sagittal oblique sequences, and determine the dimensions of the distal clavicle and coracoid graft., Results: A total of 42 patients were included (Latarjet, n = 22; control, n = 20). The mean ROC of the inferior surface of the distal clavicle was not significantly different from the ROC of the glenoid in the coronal ( P  = .15) or axial planes ( P  = .65). The ROC of the coracoid when measured in the sagittal plane was not significantly different from the ROC of the distal clavicle ( P  = .25). The length, depth, and surface area of the coracoid in the congruent arc orientation were significantly larger than the distal clavicle ( P < .005). Patients in the control group tended to have both a larger inferior clavicle ROC and a larger coracoid ROC compared to the Latarjet group (32.8 mm vs 29.6 mm, P < .0001; 31.8 mm vs 30.9 mm, P  = .02)., Conclusions: The ROC of the inferior distal clavicle is similar to that of the glenoid in both the axial and coronal planes and similar to the inferior coracoid., Clinical Relevance: CT analysis reveals that the congruent-arc DCA technique provides a robust graft with dimensions that are suitable for reconstruction of the anterior glenoid., (© 2023 The Authors.)

Arthroscopic shoulder surgery can be performed for retrieval of bullets and retained metallic fragments in the glenohumeral and subacromial spaces. Previous case reports and case series have demonstrated the effectiveness of an arthroscopic approach over an open procedure, as it is less invasive, allows for improved inspection and documentation of the joint surfaces and periarticular structures, and potentially leads to a faster recovery. An arthroscopic approach for extracting foreign bodies from both the quadrilateral space and the posterior extra-articular space by first accessing the glenohumeral space has yet to be described. This inside-out technique may afford surgeons the potential for improved visualization and less morbidity compared with a traditional open posterior approach. We report a technique for an arthroscopic inside-out approach for removal of extra-articular foreign bodies retained in either the quadrilateral space or the posterior extra-articular space.

Background: Prior evidence has identified specific posterior acromial morphology as significantly associated with unidirectional posterior shoulder instability. The purpose of this study is to determine the influence of posterior acromial morphology on the outcomes of arthroscopic posterior capsulolabral repair (APCLR) for unidirectional posterior shoulder instability. Additionally, we sought to determine the influence of posterior acromial morphology on the rate and time to return to pushups following APCLR., Methods: We performed a retrospective review of prospectively collected data. The study included consecutive patients undergoing APCLR. Data collected included demographics, radiographic measurements including posterior acromial height (PAH) and posterior acromial tilt on preoperative scapular-Y radiographs, and patient-reported outcome measures at the preoperative and postoperative visits. In addition, starting at 6 months postoperative, patients were asked if they could perform pushups defined as at least 10 repetitions. At the final follow-up, we collected the number of pushups patients were able to perform., Results: Thirty-two consecutive patients underwent APCLR with a mean follow-up of 26 months (range, 12-41). Significant improvement from preoperative to 2 years postoperative was demonstrated in Subjective Shoulder Value (50-85), VAS (6-2.5), American Shoulder and Elbow Surgeons (48 to 83), and Western Ontario Shoulder Instability (WOSI) (1437-777), P  = .001. The recurrent instability rate was 3/32 (9%). Patients with PAH > 23 (N = 17) had a recurrent instability rate of 18% (3/17) versus PAH ≤ 23 (N = 15) 0% (0/15), worse WOSI scores ( P  = .41), and a lower number of pushups ( P  = .48). The percentage of patients reporting the ability to perform pushups was (6 months/1 year/2 years) (50%/78%/95%). The mean number of pushups reported at the final follow-up was 33 (range, 1-60)., Discussion: Following APCLR, approximately 50% of patients resume pushups at 6 months postoperatively, and 80% return at 1 year. Patients reported performing a mean of 33 pushups following APCLR at the final follow-up. Patients with a PAH greater than 23 on preoperative scapular-Y radiographs had a higher rate of recurrent posterior instability, worse WOSI scores, and lower return to pushups; however, the results did not meet statistical significance. Therefore, future larger studies are needed to determine if posterior acromial morphology is independently associated with worse outcomes and increased recurrent instability rates following APCLR.

Purpose: To compare failure rates and clinical outcomes after hamstring autograft anterior cruciate ligament (ACL) reconstruction with and without allograft augmentation by a single surgeon otherwise using the same surgical technique., Methods: This was a retrospective analysis with prospectively collected patient-reported outcomes of primary hamstring autograft ACL reconstruction with and without allograft augmentation performed in a military population by a single surgeon. The primary outcome measure was graft failure, defined as graft rupture confirmed by use of magnetic resonance imaging scans and/or revision ACL reconstruction. The secondary outcome measure was the postoperative Knee Injury and Osteoarthritis Outcome Score., Results: This study included 112 patients with a mean follow-up period of 65.3 months. In patients with a graft diameter of 8 mm or greater, there was no difference in failure rates (9.4% for autograft only vs 6.3% for hybrid, P  = .59). There was a higher failure rate in patients in the autograft-only group with a graft diameter of less than 8 mm (29.4%) when compared with the hybrid graft group (6.3%, P  = .008). There were no hybrid grafts less than 8 mm in diameter. There were no differences in the Knee Injury and Osteoarthritis Outcome Score between groups as long as the graft diameter was 8 mm or greater., Conclusions: In patients undergoing hamstring ACL reconstruction, there was no significant difference in graft failure rates or outcome scores between autograft only and autograft with allograft augmentation as long as grafts were 8 mm or greater. High failure rates were seen when the graft diameter was less than 8 mm., Level of Evidence: Level III, retrospective cohort study.

Background: The purpose of this study is to utilize elbow magnetic resonance imaging (MRI) to compare the radius of curvature (ROC) of the radial head peripheral cartilaginous rim and the cartilage contour of the capitellum to evaluate if the radial head could be a suitable osteochondral autograft for capitellar pathology., Methods: All patients who underwent an MRI of the elbow over a three-year period were reviewed. Patients with the following diagnoses were excluded: osteochondritis dissecans, osteomyelitis, tumor, and osteoarthritis. The radius of curvature of the radial head (RhROC) was measured on the axial oblique MRI sequence. The radius of curvature of the capitellum (CapROC) was measured on sagittal oblique MRI sequences, the width of the articular surface of the capitellum on coronal MRI sequences and the radial head height (RhH) and capitellar vertical height on sagittal oblique sequences. All measurements were obtained at the midpoint of the radiocapitellar joint. Spearman's coefficient was used to assess the correlation between ROC measurements., Results: Eighty-three patients were included with a mean age of 43 +/- 17 years (57 males and 26 females, 51 right and 32 left elbows). The median RhROC and CapROC measurements were 12.3 mm (interquartile range [IQR] 1.6) and 11.9 mm (IQR 1.7), respectively. The median difference was 0.3 mm (IQR = 0.6; CI 95% = [0.24, 0.46]; P  < .001). A strong positive correlation was found between RhROC and CapROC (ρ = 0.89; r2 = 0.819; P  < .001). Ninety-four percent (78/83) of patients had a median difference between the RhROC and CapROC of less than or equal to 1 mm, and 63% (52/83) were within 0.5 mm. The inter-rater and intra-rater reliability for RhROC and CapROC was good, intraclass correlation coefficient (ICC) = 0.89, ICC = 0.87, and ICC = 0.96, ICC = 0.97, respectively. RhH was 10.6 ± 1.3 mm, and the width of the articular surface of the capitellum was found to be 13.8 ± 1.6 mm., Conclusion: The ROC of the convex peripheral cartilaginous rim of the radial head is similar to the ROC of the capitellum. In addition, the RhH was approximately 78% of the capitellar articular width. Based on this imaging analysis, the radial head could prove to be a robust local osteochondral autograft with a similar cartilage contour in the reconstruction of the capitellum in complex intra-articular distal humerus fractures with associated radial head fractures and in the setting of "kissing lesions" of the radiocapitellar joint. Furthermore, an osteochondral plug harvested from the "safe zone" of the peripheral cartilaginous rim of the radial head could be utilized to treat isolated osteochondral lesions of the capitellum.

Background: Primary reverse shoulder arthroplasty (rTSA) is an effective treatment option for reducing pain and improving function for patients with rotator cuff tear arthropathy, irreparable rotator cuff tears, glenoid deformity, and other challenging clinical scenarios, including fracture sequelae and revision shoulder arthroplasty. There has been a wide range of reported outcomes and postoperative complication rates reported in the literature. The purpose of this systematic review and meta-analysis is to provide an updated review of the clinical outcomes and complication rates following primary rTSA., Methods: A systematic review and meta-analysis was performed to evaluate outcomes and complications following primary rTSA according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Demographics, range of motion, patient-reported outcome measures (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant scores), number of complications, and revisions were extracted, recorded, and analyzed from the included articles., Results: Of the 1415 studies screened, 52 studies met the inclusion criteria comprising a total of 5824 shoulders. The mean age at the time of surgery was 72 years (range: 34-93), and the mean follow-up was 3.9 years (range: 2-16). Patients demonstrated a mean improvement of 56° in active flexion, 50° in active abduction, and 14° in active external rotation. Regarding functional outcome scores, rTSA patients demonstrated a mean clinically significant improvement of 37 in Constant score (minimal clinically important difference [MCID] = 5.7) and ASES score (42.0; MCID = 13.6). The overall complication rate for rTSA was 9.4% and revision rate of 2.6%. Complications were further subdivided into major medical complications (0.07%), shoulder- or surgical-related complications (5.3%), and infections (1.2%). The most frequently reported shoulder- or surgical-related complications were scapular notching (14.4%), periprosthetic fracture (0.8%), glenoid loosening (0.7%), and prosthetic dislocation (0.7%)., Discussion: Primary rTSA is a safe and reliable procedure with low complication, revision, infection, and scapular notching rates. Additionally, patients demonstrated clinically significant improvements in both range of motion and clinical outcome scores., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

Posterior shoulder instability is becoming increasingly recognized in young active patient populations. Diagnosing posterior instability can be challenging because patients commonly present with a complaint of pain without a history of a dislocation or subluxation event. Additionally, a posterior labral tear is not always clearly visualized on advanced imaging studies. As such, physical examination is critical to the diagnosis. We report a simple physical examination maneuver for the diagnosis of symptomatic posterior shoulder instability. The thumb test attempts to replicate a posterior bone block procedure, helping to re-establish stability and relieve pain. The examiner places his or her thumb over the posterior glenohumeral joint line while the patient actively forward elevates the affected arm overhead. Improvement in pain and stability with this maneuver is diagnostic for symptomatic posterior shoulder instability. This test augments current physical examination maneuvers to assist with correctly diagnosing posterior shoulder instability., (© 2022 The Authors.)

Background: There is limited information on return to shooting following shoulder surgery. The purpose of this study is to determine the rate and timing for resuming shooting a rifle following shoulder surgery., Methods: We performed a retrospective review of prospectively collected data. The study included patients undergoing arthroscopic and open shoulder stabilization for unidirectional shoulder instability, and arthroscopic surgery for rotator cuff tears, SLAP lesions, biceps tendinopathy, and acromioclavicular pathology. Data collected included the laterality of surgery, shooting dominance, and patient-reported outcome measures at the preoperative and postoperative visits. Starting at the 4.5-month clinic visit, patients were asked if they could shoot a military rifle., Results: One hundred patients were identified with arthroscopic and open shoulder surgery with a mean age of 30 years (range, 18-45) and a mean follow-up of 24 months (range, 12-32). The cohort consisted of patients undergoing arthroscopic Bankart repair (n = 23), arthroscopic posterior labral repair (n = 18), open Latarjet (n = 16), mini-open subpectoral biceps tenodesis (OBT) (n = 25), OBT with open distal clavicle resection (DCR) (n = 10), open DCR (n = 4), and arthroscopic rotator cuff repair with concomitant OBT (n = 4). Significant improvement in SSV, VAS, ASES, and WOSI was shown at 1-year postoperative, SSV 85, VAS 2, ASES 85, WOSI 239, P  = .001. The percentage of patients reporting the ability to shoot a military rifle postoperatively were 47%, 63%, 85%, and 94% at 4.5 months, 6 months, 1 year, and 2 years, respectively. At 4.5 months postoperatively, patients who underwent surgery ipsilateral to their shooting dominance (n = 59) had a rate of return to shooting (33%) versus shoulder surgery on the contralateral side of shooting dominance (n = 41) (60%), P  = .04. However, there was no significant difference in the groups at 6 months and 1 year. Additionally, there was a significant difference in the rate of return to shooting at 6 months in patients undergoing arthroscopic posterior labral repair versus the remainder of the cohort (posterior instability (33%) vs. (69%), P  = .016), and a significant difference between posterior shoulder stabilization and anterior shoulder stabilization (70%), P  = .03., Conclusion: Patients undergoing arthroscopic and open shoulder surgery have a high rate of return to shooting. Approximately 60% of patients resume shooting at 6 months postoperatively and 85% return at 1 year. Patients undergoing shoulder surgery on the contralateral side of their shooting dominance return to shooting significantly faster than those with shoulder surgery ipsilateral to their shooting dominance. Additionally, those undergoing arthroscopic posterior shoulder stabilization return to shooting at a slower rate than anterior stabilization surgery.

Background: The purpose of this study was to analyze the long-term results of arthroscopic Bankart repair compared with an open Latarjet procedure in adolescents who are at high risk for recurrent anterior shoulder instability. We hypothesized that the long-term stability rate of an open Latarjet procedure would be superior to that of arthroscopic Bankart repair., Methods: Forty eligible patients (41 shoulders) with a mean age of 16.4 years (range, 13 to 18 years) underwent arthroscopic Bankart repair, and 37 patients (40 shoulders) with a mean age of 16.7 years (range, 14 to 18 years) underwent an open Latarjet procedure. Of these, 34 patients (35 shoulders) in the Bankart group and 30 patients (31 shoulders) in the Latarjet group with long-term follow-up were compared; the overall follow-up rate was 82%. Clinical and radiographic results were obtained after a mean follow-up of 12.2 years (range, 8 to 18 years)., Results: Treatment failure occurred in 20 shoulders (57%) in the Bankart repair group and in 2 shoulders (6%) in the open Latarjet procedure group (p < 0.001), representing a significantly higher revision rate for instability in the Bankart group (13) compared with the Latarjet group (1) (p < 0.001). In patients without recurrent shoulder instability (15 in the Bankart group and 29 in the Latarjet group), there was a significant improvement in the Constant score (p = 0.006 in the Bankart group and p < 0.001 in the Latarjet group) and Subjective Shoulder Value (p = 0.009 in the Bankart group and p < 0.001 in the Latarjet group), without any significant difference between the 2 groups. Younger age was the only variable significantly correlated with failure following a Bankart repair (p = 0.01)., Conclusions: Adolescents are at a high risk for treatment failure after Bankart repair, and, therefore, the Latarjet procedure should be strongly considered as a primary procedure for recurrent anterior shoulder instability in this population., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H33)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

➤: Muscle tendon transfers (MTTs) are effective surgical procedures for reducing pain and for improving active shoulder range of motion and patient-reported outcomes for a wide range of pathologies, including serratus anterior and trapezius muscle palsy, irreparable subscapularis tears, irreparable posterosuperior rotator cuff tears, irreparable posterior rotator cuff tears in the setting of reverse shoulder arthroplasty, and symptomatic complete deltoid deficiency., ➤: The principles of MTT include ensuring that the transferred muscle is expendable, the muscle tendon unit has similar excursion, the line of pull of the transferred tendon and of the recipient muscle are similar in terms of biomechanical force, and the transferred muscle should replace at least 1 grade of strength of the deficient recipient muscle., ➤: When MTT procedures are considered, patients must have exhausted all nonoperative management, have preserved passive range of motion, and have an understanding of the postoperative expectations and potential complications., ➤: For patients with scapulothoracic abnormal motion (STAM) due to long thoracic nerve palsy, the indirect or direct pectoralis major tendon transfer is an effective procedure for reducing pain and improving active forward elevation. For patients with STAM due to spinal accessory nerve palsy, the Eden-Lange or the triple tendon transfer procedures reduce pain and improve active forward elevation and abduction as well as patient-reported clinical outcomes., ➤: Both pectoralis major and latissimus dorsi transfer procedures for isolated irreparable subscapularis deficiency without anterosuperior humeral head escape result in improvement with respect to pain, patient-reported outcomes, and forward elevation, with the pectoralis major tendon transfer demonstrating durable long-term outcomes., ➤: The latissimus dorsi or lower trapezius tendon transfer procedures for irreparable posterosuperior rotator cuff tears reliably improve patient-reported outcomes, forward elevation, abduction, and external rotation range of motion. Additionally, latissimus dorsi transfer with or without teres major transfer can be used to restore active external rotation, both in the native shoulder and in the setting of reverse shoulder arthroplasty., ➤: The complications of MTTs include infection, hematoma, and failure of tendon transfer healing; therefore, it is recommended that these complex procedures be performed by shoulder surgeons with appropriate training., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G956)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Biceps tenodesis and tenotomy are both effective surgical procedures for management of shoulder pain and dysfunction secondary to SLAP tears, biceps tendinitis, rotator interval pulley lesions, and failed SLAP repairs. These procedures are generally safe with low complication rates. However, failure of a proximal biceps tenodesis or tenotomy can rarely lead to symptomatic Popeye deformity with pain and cramping with repetitive forearm supination and elbow flexion. Surgical revision is indicated in young active patients to restore the length tension relationship of the biceps brachii to improve supination and flexion strength, as well as to provide symptomatic relief and improved endurance. Failed biceps tenodesis can be a challenging surgical scenario, as oftentimes there is limited available proximal biceps tendon tissue, especially in the setting of prior subpectoral biceps tenodesis. We report a technique of revision open subpectoral biceps tenodesis with allograft tendon augmentation for the management of symptomatic Popeye deformity in young active patients with little to no remaining proximal biceps tendon., (© 2022 The Authors.)

With the increased use of reverse shoulder arthroplasty, the complication of postoperative scapular fracture is increasingly recognized. The incidence is variable and dependent on a combination of factors including patient age, sex, bone mineral density, diagnosis of inflammatory arthritis, acromial thickness, and implant-related factors. Acromial stress reactions are a clinical diagnosis based on a history and physical examination. These are treated successfully with 4 to 6 weeks of immobilization. Acromial stress fractures are visible on imaging studies and are classified based on anatomic location by the classification systems of Crosby and Levy. In approximately 20% of fractures, a CT scan is necessary to make the diagnosis. Treatment is typically nonsurgical that leads to a high rate of nonunion or symptomatic malunion. Scapular spine fractures (type III) can be treated with either nonsurgical or surgical management; however, obtaining fracture union is challenging, and the outcomes are typically inferior to that of type I and II fractures. Although the nonsurgical and surgical treatment of acromial stress fractures improves the clinical outcomes from the patient's preoperative state, the outcomes of a control group undergoing reverse shoulder arthroplasty without fracture are better. The exception to this is oftentimes the displaced and angulated type III fracture., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Background: Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages., Purpose: To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis., Results: A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R 2 = 0.71-0.74; root mean square error = 9.3-10.0)., Conclusion: The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

Background: US Food and Drug Administration Investigation Device Exemption studies and academic journals emphasize the importance of two-year follow-up data in reporting outcomes of total shoulder arthroplasty, but there is limited data evaluating appropriate follow-up length. We aim to evaluate change in postoperative outcomes and complications between one and two years following anatomic and reverse total shoulder arthroplasties., Methods: We retrospectively identified 250 patients who underwent anatomic and reverse total shoulder arthroplasties between 2013 and 2016 from a single surgeon arthroplasty registry. Patients without both one- and two-year follow-up data were excluded. We compared American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale for pain, and goniometer-measured range of motion., Results: Patient-reported outcome measurements ( p  > 0.05) did not change between one and two years postoperatively following both reverse ( n  = 146) and anatomic ( n  = 104) total shoulder arthroplasties. Range of motion increased slightly ( p  < 0.05), but this change was not clinically relevant. There were no additional complications., Discussion: Minimum two-year clinical follow-up may not be necessary for future shoulder arthroplasty Investigation Device Exemption and other peer-reviewed investigations. Patient-reported outcomes (ASES and pain score) and range of motion plateau at one year postoperatively without additional complications. One-year follow-up is an acceptable minimum follow-up length., Level of Evidence: Level III-retrospective analysis., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Andrew Jawa has been a paid speaker and consultant for DJO Global, a paid consultant for Ignite Orthopedics, receives royalties from Depuy Synthesis, and has equity in Boston Outpatient Surgical Suites., (© 2020 The British Elbow & Shoulder Society.)

Background: There is controversy regarding the optimal treatment for infection following shoulder arthroplasty. The purpose of this systematic review is to analyze the bias in treatment selection, infection clearance rates, and functional outcomes after 1 versus 2-stage revision surgery for periprosthetic shoulder infections., Methods: A systematic search strategy following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted in 4 phases. Articles were identified using MEDLINE (PubMed), Embase (Elsevier), and Cochrane Library databases with Boolean search terms related to infection after shoulder arthroplasty. Included articles were analyzed for quality, and data were extracted for use. Preoperative treatment selection bias was analyzed and postoperative infection clearance rates and functional outcome scores were compared between 1 and 2-stage revision surgery for periprosthetic shoulder infection., Results: Overall, 163 1-stage shoulder procedures and 289 2-stage shoulder procedures were included in the analysis. Cutibacterium acnes was the organism most frequently grown on culture (37%) followed by coagulase-negative Staphylococcus (19%). The overall infection clearance rate was 95.6% for 1-stage and 85.2% for 2-stage procedures. In a comparison of the change in outcome scores from preoperatively to postoperatively between 1-stage and 2-stage revision, the Constant-Murley Score (CMS) improved 21.0 points (1-stage) versus 22.8 points (2-stage), the American Shoulder and Elbow Surgeons (ASES) score improved 26.2 points versus 33.6 points, and the Simple Shoulder Test (SST) score improved 3.5 points versus 6.4 points, respectively. Overall, 23 of 26 studies cited a reason for selection of a 1 versus 2-stage procedure, which was due to standard treatment protocol in 10 studies, based on the timing of the infection (acute versus subacute versus chronic) in 5, due to a combination of factors (age, comorbidities, intraoperative appearance, adequacy of debridement, bone loss) in 6, and due to preoperative identification of a specific organism in 2., Conclusions: One-stage revisions resulted in higher infection clearance rates; however, 2-stage revisions resulted in greater functional improvement as measured with ASES and SST scores from the preoperative assessment to the final postoperative follow-up. The decision between 1 and 2-stage revisions is due to a combination of factors including pathogen type, timing of infection, findings on the preoperative clinical examination, the patient's own decision, the surgeon's preference, and the intraoperative soft-tissue/osseous appearance, which may have biased the overall results. There is no consensus in the literature on the decision between 1 and 2-stage treatment for periprosthetic shoulder infection, which is based on a combination of factors. However, both treatment strategies are effective in treating periprosthetic shoulder infection., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A740)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Walch B2 glenoid morphology with glenohumeral osteoarthritis is a difficult degenerative pattern to manage for shoulder surgeons. Anatomic total shoulder arthroplasty (TSA) in combination with eccentric reaming or bone grafting are the traditional methods of treatment. Newer approaches such as TSA with posteriorly augmented glenoid components and reverse shoulder arthroplasty (RSA) may offer better stability for the posteriorly subluxated biconcave B2 wear pattern. The aim of this systematic review is to compare mid-term surgical and functional outcomes of Walch B2 glenoids without significant rotator cuff pathology treated with TSA and RSA., Methods: The review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by searching the MEDLINE (PubMed) and Embase (Elsevier) databases. Inclusion criteria were clinical studies that evaluated the outcomes and complications of TSA or RSA in the setting of B2 glenoid morphology without significant rotator cuff pathology. Data relevant to TSA and RSA surgical outcomes were extracted and compiled, and outcomes were compared. A meta-analysis of proportions of complication and revision rates among TSA and RSA groups was performed., Results: Overall, 16 articles were included with 414 TSAs and 78 RSAs. The average follow-up duration was 54.1 ± 14.8 months for patients undergoing TSA and 44.8 ± 10.1 months for patients undergoing RSA. The TSA group was further subdivided based on the use of eccentric reaming (135 TSAs), an augmented glenoid component (84 TSAs), or bone grafting (11 TSAs) or was unspecified (184 TSAs). Overall, patients undergoing TSA and RSA demonstrated mean improvements of 50.1 ± 8.5° and 64.7 ± 5.2° in active flexion, 58.5 ± 10.3° and 68.9 ± not reported° in active abduction, and 31.3 ± 5.7° and 29.0 ± 10.2° in active external rotation, respectively. In regard to functional outcome scores, patients undergoing TSA and RSA showed mean Constant score improvements of 38.8 ± 5.3 and 46.6 ± 3.1 points and American Shoulder and Elbow Surgeons score improvements of 48.2 ± 1.0 and 49.2 ± 25.3 points, respectively. Results of the meta-analysis with mid-term follow-up data demonstrated pooled complication rates of 9% (95% confidence interval [CI], 1%-22%) for TSA and 6% (95% CI, 0%-28%) for RSA and pooled revision rates of 2% (95% CI, 0%-8%) for TSA and 1% (95% CI, 0%-15%) for RSA., Conclusion: In the setting of Walch B2 glenoid morphology, TSA with eccentric reaming or an augmented component yields comparable outcomes to RSA. Based on the patient's age, activity level, and expectations, both TSA and RSA can be considered a reasonable option to treat Walch B2 glenoid morphology., (© 2021 The Author(s).)

Purpose: The purposes of this study were to determine the incidence of anterior shoulder pain in young athletes undergoing arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability and in patients with preoperative anterior shoulder pain treated without biceps tenodesis at the time of arthroscopic posterior labral repair who underwent a revision biceps tenodesis procedure at short-term follow up., Methods: A retrospective review was performed at a single institution over a 24-month period. The study included young patients who underwent an arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability. The electronic medical record, magnetic resonance arthrograms, and arthroscopic images were reviewed to exclude patients with posterior labral tears with anterior labral tear or SLAP (superior labrum anterior-to-posterior) tear extension on advanced imaging and arthroscopic examination. Data collected included the presence of preoperative tenderness to palpation of the biceps tendon in the groove, the results of a preoperative Speed test, postoperative Subjective Shoulder Value, the presence of postoperative anterior shoulder pain, and the need for a secondary biceps tenodesis., Results: We identified 65 patients who underwent arthroscopic labral repair for posterior shoulder instability. From this cohort, 26 patients with symptomatic unidirectional posterior shoulder instability underwent an arthroscopic posterior labral repair. The incidence of preoperative anterior shoulder pain with Zone 2 biceps groove tenderness and a positive Speed test was identified in 20 of 26 patients (76.9%). Of 26 patients, 5 (19%) had concomitant biceps tenodesis. The median postoperative Subjective Shoulder Value was 80 (interquartile range, 60-90) at median follow-up of 2.1 years. Of the 20 patients with preoperative anterior shoulder pain, 8 of 20 (40%) reported persistent anterior pain. One patient (4.7%) underwent a secondary biceps tenodesis., Conclusions: There is a high incidence of anterior shoulder pain and Zone 2 biceps groove tenderness in patients undergoing isolated arthroscopic posterior labral repair for unidirectional posterior shoulder instability. At short-term follow-up, few patients required a secondary biceps tenodesis procedure; however, 30% of patients had persistent anterior shoulder pain., Level of Evidence: Level IV, retrospective diagnostic case series.

Purpose: To evaluate the frequency of glenohumeral joint extravasation of ultrasound (US)-guided biceps tendon sheath injections., Methods: Fifty shoulders with a clinical diagnosis of bicipital tenosynovitis pain received a US-guided biceps sheath injection with anesthetic, steroid, and contrast (5.0 mL mixture) followed immediately by orthogonal radiographs to localize the anatomic distribution of the injection. Radiographic evaluation of contrast localization was determined and interobserver reliability calculated., Results: All 50 postinjection radiographs (100%) demonstrated contrast within the biceps tendon sheath. In addition, 30 of 50 (60%) radiographs also revealed contrast in the glenohumeral joint. Interobserver reliability for determination of intraarticular contrast was good (kappa value 0.87)., Conclusions: US-guided bicipital sheath injections reproducibly result in intrasheath placement of injection fluid. Bicipital sheath injections performed with 5 mL of volume result in partial extravasation into the joint 60% of the time. These data may be useful for surgeons who use the results of diagnostic biceps injections for diagnosis and surgical decision-making., Level of Evidence: III, prospective cohort study, diagnosis., (Copyright © 2021 Arthroscopy Association of North America. All rights reserved.)

»: Chronic quadriceps tendon (QT) ruptures are uncommon injuries that present treatment challenges due to their complex nature and the limited evidence to guide management., »: Timely diagnosis and surgical management of acute QT injury are imperative to optimize patient outcomes as delayed diagnosis leads to poorer results regardless of treatment modality., »: Elements of chronic QT ruptures that may complicate surgical management include patient age, comorbidity, scar-tissue formation, amount of quadriceps muscle/ tendon retraction, and distalmigration of the patella with contraction of the tendon., »: Treatment options for chronic QT ruptures include primary repair with or without vastus advancement, V-Y tendon lengthening with or without tissue augmentation, and autograft or allograft reconstruction., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJSREV/A690)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

The purpose of this case report is to report the long-term outcome following shoulder hemiarthroplasty in a patient with dwarfism. A 60-year old female with pseudoachondroplasia dwarfism presented 17 years post-operative with a Subjective Shoulder Value of 90% and minimal pain. Custom designed implants were critical for surgical success. Preoperative planning with a CT scan was important in assessing glenoid dysplasia and determining the feasibility of glenoid resurfacing. The emergence of 3D CT virtual preoperative planning tools can further assist in the recognition of deformity to determine if custom designed implants are needed. Shoulder arthroplasty in dwarfism can lead to excellent long-term outcomes., Competing Interests: Conflict of interest: The authors declare no potential conflict of interest., (©Copyright: the Author(s).)

Background: The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores., Purpose: To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain., Study Design: Cohort study (Diagnosis); Level of evidence, 3., Methods: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using "leave 1 out" techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis., Results: A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R 2 = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores., Conclusion: The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online (https://osf.io/ctmnd/), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.

Case: A 69-year-old woman with chronic upper extremity lymphedema secondary to bilateral mastectomy and axillary lymph node dissection for breast cancer 10 years before presented to the clinic with a massive rotator cuff tear. Her shoulder pain and dysfunction persisted despite nonoperative treatment. She underwent left shoulder arthroscopic rotator cuff repair (RCR) and biceps tenotomy. Arm, forearm, and wrist circumference measurements were obtained, preoperatively, immediately postoperatively, and 1-week and 2-weeks postoperatively. No permanent increase in extremity circumference measurements was observed., Conclusion: This case suggests that it is possible to perform an arthroscopic RCR in a patient with chronic upper extremity lymphedema without creating further morbidity., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B297)., (Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The treatment of severe proximal humeral bone loss (PHBL) secondary to tumor resection or failed arthroplasty is challenging. We evaluated the outcomes and complications of reconstruction with reverse shoulder-allograft prosthesis composite (RS-APC), performed with or without tendon transfer., Methods: An RS-APC procedure was performed in 25 consecutive patients with severe PHBL (>4 cm): 12 after failed reverse shoulder arthroplasty, 5 after failed hemiarthroplasty for fracture, 6 after failed mega-tumor prosthesis placement, and 2 after tumor resection. The median length of humeral bone loss or resection was 8 cm (range, 5-23 cm). Humeral bone graft fixation was obtained with a long monobloc reverse stem and a "mirror step-cut osteotomy," without plate fixation. Nine infected shoulders underwent a 2-stage operation with a temporary cement spacer. In addition, 9 patients (36%) underwent an associated L'Episcopo procedure. The median follow-up duration was 4 years (range, 2-11 years)., Results: Overall, 76% of patients (19 of 25) were satisfied. In 8 patients (32%), a reoperation was needed. At last follow-up, we observed incorporation at the allograft-host junction in 96% of the cases (24/25); partial graft resorption occurred in 3 cases and severe in 1. The median adjusted Constant score was 53% (range 18-105); Subjective Shoulder Value, 50% (range 10%-95%). Additional tendon transfers significantly improved active external rotation (20° vs. 0°, P < .001) and forward elevation (140° vs. 90°, P = .045)., Conclusions: (1) Shoulder reconstruction with RS-APC provides acceptable shoulder function and high rates of graft survival and healing. (2) Additional L'Episcopo tendon transfer (when technically possible) improves active shoulder motion. (3) The use of a long monobloc (cemented or uncemented) humeral reverse stem with mirror step-cut osteotomy provides a high rate of graft-host healing, as well as a limited rate of graft resorption, and precludes the need for additional plate fixation. (4) Although rewarding, this reconstructive surgery is complex with a high risk of complications and reoperations. The main advantages of using an allograft with a reverse shoulder arthroplasty (compared with other reconstruction options) are that this type of reconstruction (1) allows restoration of the bone stock, thus improving prosthesis fixation and stability, and (2) gives the possibility to perform a tendon transfer by fixing the tendons on the bone graft to improve shoulder motion., (Copyright © 2020. Published by Elsevier Inc.)

Biceps tenotomy is a common procedure performed in arthroscopic shoulder surgery. Numerous studies have demonstrated the effectiveness of both biceps tenotomy and tenodesis to relieve pain and restore function for the diagnoses of bicipital tenosynovitis, SLAP tears, rotator interval pulley lesions, and failed SLAP repairs. It is also frequently performed as a concomitant procedure with arthroscopic rotator cuff repair. We report a technique to improve the efficiency of arthroscopic bicep tenotomy using a biceps squeeze maneuver. This is a simple method of manually squeezing the biceps muscle belly while performing the arthroscopic biceps tenotomy. This shortens and tensions the intra-articular portion of the tendon to facilitate a more safe and efficient procedure.

Fractures of the coracoid process are relatively rare, and current management guidelines remain unclear. Most coracoid fractures occur in conjunction with other shoulder injuries, including dislocations and fractures. Identifying coracoid fractures can be difficult because most fractures are nondisplaced and can be missed on radiographs or may be masked by other injuries. Management is largely guided by fracture location and displacement. Conservative treatment is preferred for fractures that are minimally displaced, whereas indications for surgical fixation include fractures that are displaced (>1 cm), have progressed to a painful nonunion, or are associated with the disruption of the superior shoulder suspensory complex. Although conservative treatment has been historically favored, satisfactory outcomes have been reported for both surgical and nonsurgical treatment. We provide a comprehensive review of diagnosis and management strategies for coracoid fractures.

Purpose: Compare intraarticular pressure of the glenohumeral joint in patients with and without shoulder instability after a volume-limited arthrogram., Materials and Methods: Patients aged 18-45 years with shoulder instability or pain were included. After injecting 10 cc of contrast-mixture, intraarticular pressure was recorded using an arterial-line pressure-transducer connected to a portable monitor., Results: 14/16 (86%) patients were included - 7/14 (50%) had instability. Post-injection pressure measurement averaged 59.9 ± 44.0 mmHg (range 15-181). Instability patients averaged 60.8 ± 37.6 (range 15-117) versus 41.9 ± 14.0 mmHg (range 30-64) for non-instability (p > 0.1)., Conclusion: Glenohumeral pressure measurements are variable when utilizing standardized volume-limited arthrograms., (© 2019 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Rotator cuff repair (RCR) is an effective procedure to relieve shoulder pain and dysfunction. Postoperative physical therapy (PT) plays an integral role in the overall success of RCR. Insurance status has been shown to be an important predictor of postoperative PT utilization. This study evaluated the effect of insurance status on access to PT services following RCR. One hundred thirty-eight PT clinics were contacted in the Greater Boston metropolitan area. Clinics were contacted on two separate occasions and presented with a fictitious acutely postoperative RCR patient in need of PT. Insurance status was reported as Medicaid or private insurance. Overall, 133 (96.4%) accepted private insurance, whereas only 71 (51.4%) accepted Medicaid (P=0.019). Medicaid patients were offered a first available appointment at a mean of 8.3 days (95% CI: 7.13-9.38, range: 0-31) versus a mean of 6.3 days (95% CI: 5.3-7.22, range: 0-19, P=0.001) for private patients. Clinic location was not associated with access to PT or time to first appointment. Insurance status affects access to PT services and time to first available appointment in patients following RCR surgery in a major metropolitan area., Competing Interests: Conflict of interest: Dr. Xinning Li is on the editorial or governing board of the following journals: American Journal of Sports Medicine, Journal of Bone and Joint Surgery – American, Journal of Medical Insight, Orthopedic Reviews, and World Journal of Orthopedics. All other authors have no disclosures.

Background: Controversy exists as to the optimal treatment of superior labrum anterior to posterior (SLAP) tears in athletes. There are no systematic reviews evaluating return-to-sport (RTS) rates after arthroscopic SLAP repair and biceps tenodesis., Purpose: To compare the overall RTS rates in patients with primary type 2 SLAP tears who were managed with arthroscopic SLAP repair versus biceps tenodesis., Study Design: Systematic review; Level of evidence, 4., Methods: A review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching the MEDLINE (PubMed), Embase (Elsevier), and Cochrane Library databases. Inclusion criteria were clinical studies that evaluated RTS rates after arthroscopic SLAP repair, arthroscopic SLAP repair with partial rotator cuff debridement, and biceps tenodesis. The studies were analyzed for quality and inclusion in the final analysis. Data relevant to RTS rates were then extracted and compiled, and outcomes were compared., Results: Of the 337 studies initially identified, 15 (501 patient-athletes) met inclusion criteria. These consisted of 195 patients who underwent isolated arthroscopic SLAP repair (mean age, 31 years; mean follow-up, 3.2 years), 222 patients who underwent arthroscopic SLAP repair with partial rotator cuff debridement (mean age, 22 years; mean follow-up, 5.1 years), and 84 patients who underwent biceps tenodesis (mean age, 42 years; mean follow-up, 3.3 years). The overall RTS rates were high for all 3 procedures (SLAP repair, 79.5%; SLAP repair with rotator cuff debridement, 76.6%; biceps tenodesis, 84.5%), with biceps tenodesis having the highest overall rate. Biceps tenodesis also had the highest RTS rate at the preinjury level (78.6%) compared with SLAP repair (63.6%) and SLAP repair with rotator cuff debridement (66.7%)., Conclusion: Primary arthroscopic SLAP repair, arthroscopic SLAP repair with partial rotator cuff debridement, and biceps tenodesis all provide high RTS rates. Biceps tenodesis as an operative treatment of primary SLAP lesions may demonstrate an overall higher RTS rate when compared with traditional SLAP repair in older athletes. More, higher level studies are needed that control for age, level of activity, and type of sport (overhead vs nonoverhead) to determine the efficacy of biceps tenodesis as a primary alternative to arthroscopic SLAP repair in young athletes who present with type 2 SLAP tears., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: X.L. has received consulting fees from DePuy Mitek, Stryker, and Tornier and hospitality payments from Encore Medical. 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: For athletes, a return to preinjury activity levels with minimal time away is a metric indicative of successful recovery. The knowledge of this metric would be helpful for the sports medicine specialist to advise patients on appropriate expectations after surgery., Purpose: To evaluate the rate and amount of time needed for athletes to return to sport (RTS) after different surgical treatments for anterior shoulder instability., Study Design: Systematic review and meta-analysis., Methods: The MEDLINE, EMBASE, and Cochrane databases were searched for articles relevant to athletes' RTS after surgical anterior shoulder stabilization with variants of the Latarjet and Bankart procedures. Article selection was based on relevant inclusion and exclusion criteria. After the articles were reviewed, the data pertinent to rates of and time to RTS were extracted, compiled, and analyzed., Results: Sixteen articles met the inclusion criteria. Based on these articles, the rate of RTS was 97.5% after arthroscopic Bankart, 86.1% after open Bankart, 83.6% after open Latarjet, 94.0% after arthroscopic Latarjet, and 95.5% after arthroscopic Bankart with remplissage. Among the athletes who did RTS, arthroscopic Bankart had the highest rate of return to preinjury levels (91.5%), while arthroscopic Latarjet had the lowest rate (69.0%). The time to RTS was 5.9 months after arthroscopic Bankart, 8.2 months after open Bankart, 5.07 months after open Latarjet, 5.86 months after arthroscopic Latarjet, and 7 months after arthroscopic Bankart with remplissage., Conclusion: Of the pooled data, patients who underwent arthroscopic Bankart showed the highest rate of RTS, while patients who underwent open Latarjet showed the shortest time to RTS. Return to preinjury level was highest in the arthroscopic Bankart group and lowest in the arthroscopic Latarjet group. Physicians can utilize these data to set expectations for their patient-athletes regarding RTS after anterior shoulder stabilization procedures., Clinical Relevance: When treating an athlete, many factors must be taken into account to weigh treatment options. Two important factors to consider with the patient-athlete are the rate of return to the previous activity level and the timeline for this to occur. This study provides a guide for physicians and a time frame for athletes with respect to the mean percentage and time for return to sport after different surgical procedures for anterior shoulder instability.

There is a paucity of data on how racial disparities may affect early outcomes following shoulder arthroplasty. The purpose of this study was to evaluate differences in 30-day complications and readmission rates after shoulder arthroplasty based on race. White and black patients who underwent hemiarthroplasty, anatomic or reverse total shoulder arthroplasty (Current Procedural Terminology codes 23470 and 23472) between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Black patients were propensity score matched 1:4 based on preoperative demographics and comorbidities to white patients. Multivariable analysis was performed to assess postoperative complications based on race. Of the 12,663 patients with shoulder arthroplasty identified, 10,717 (84.6%) were white and 559 (4.4%) were black. Overall, 557 black patients were matched to 2228 white patients, for a total cohort of 2785 patients (mean age, 63.9±11.7 years; female, 61.0%). Surgical indications were similar between black and white patients. The 2 races had similar rates of overall complications, major complications, minor complications, readmissions, and discharge to facility. Mortality was significantly higher among black patients compared with white patients (0.6% vs 0.05%; P=.033). Black patients also experienced longer operative time (mean, 126.4 vs 112.5 minutes; P<.001) and length of stay (mean, 2.4 vs 2.1 days; P<.001). There was a significant disparity with underutilization of shoulder arthroplasty for black patients in the American College of Surgeons National Surgical Quality Improvement Program database. Black and white patients undergoing shoulder arthroplasty experienced similar rates of 30-day complications, readmissions, and discharge to facility. However, black patients experienced greater operative time, total length of stay, and mortality compared with white patients. [Orthopedics. 2019; 42(2):95-102.]., (Copyright 2019, SLACK Incorporated.)

Introduction: With the continued rise in the cost of U.S. health care, there is an increased emphasis on value-based care methodologies. Value is defined as health outcomes achieved per dollar spent. Few studies have evaluated the role of value-based care in the Military Health System (MHS), especially in a format which physicians and providers can understand. The purpose of this article is to provide a guide to understanding current reimbursement systems and value-based care in the MHS and discuss potential strategies for improving value and military readiness., Materials and Methods: We outlined the current value-based care methodologies in the MHS, and by using musculoskeletal care as an example, offer strategies for further improvement., Results: The MHS has been a leader in the health care industry in adopting value-based care strategies. Current value-based systems in the MHS are primarily designed to incentivize process measure compliance. Initial steps toward measurement and reporting health outcomes have been made, however, with the military's use of the Integrated Resourcing and Incentive System (IRIS), National Surgical Quality Improvement Program (NSQIP) database, and the Joint Outpatient Experience Survey (JOES)., Conclusion: As this article will describe, universal reporting of health outcomes, adoption of integrated practice units, and a focus on determining outcomes of illness over the entire care cycle offer a significant opportunity to accelerate the MHS journey to providing true value-based care. The universal measurement and systematic improvement of outcomes based on this measurement will contribute to military medical readiness and warfighter effectiveness., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.)