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Background: Augmented (internal braced) lateral ulnar collateral ligament (LUCL) repair has been biomechanically compared with reconstruction techniques in the elbow. However, LUCL repair alone has not yet been compared with augmented repair and reconstruction techniques. Hypothesis: Internal bracing of LUCL repair would improve time-zero stabilization regarding gap formation, stiffness, and residual torque as compared with repair alone and reconstruction techniques to restore native elbow stability. Study Design: Controlled laboratory study. Methods: Overall, 24 cadaveric elbows were used for either internal braced LUCL repair (Repair-IB) or single- and double-strand ligament reconstruction with triceps (Recon-TR) and palmaris longus tendon graft (Recon-PL), respectively. Laxity testing in external rotation was consecutively performed at 90° of elbow flexion on the intact, dissected, and repaired conditions and with the previously assigned techniques. First, intact elbows were loaded to 7.0-N·m external torque to evaluate time-zero ligament rotations at 2.5, 4.0, 5.5, and 7.0 N·m. Rotation-controlled cycling was performed (total of 1000 cycles) for each surgical condition. Gapping, stiffness, and residual torque were analyzed. Finally, these and 8 additional intact elbows underwent torque-to-failure testing (30 deg/min). Results: The dissected state showed the highest gap formation and lowest peak torques ( P < .001). While gap formation of Repair-IB ( P < .021) was significantly lower than that of repair without internal bracing at all rotation levels, gaps of Recon-PL were similar to and Recon-TR were significantly higher than those of Repair-IB except for the highest torsion level. Residual peak torques at specific rotation angles between native state and Recon-TR (α2.5), Recon-PL (α4.0), and Repair-IB (α5.5) were similar; all other comparisons were significantly different ( P < .027). Torsional stiffness of Repair-IB was significantly higher at all rotation angles measured. Analysis of covariance showed significantly less gap formation over residual peak torques for Repair-IB ( P < .001) as compared with all other groups. The native state failure load was significantly higher than Recon-PL and Recon-TR failure loads, with similar stiffness to all other groups. Conclusion: Repair-IB and Recon-PL of the LUCL showed increased rotational stiffness relative to the intact elbow for restoring posterolateral stability to the native state in a cadaveric model. Recon-TR demonstrated lower residual peak torques but provided near-native rotational stiffness. Clinical Relevance: Internal bracing of LUCL repair may reduce suture-tearing effects through tissue and provide sufficient stabilization for healing throughout accelerated and reliable recovery without the need for a tendon graft.

One of the leading challenges for surgeons shifting to stemless anatomic total shoulder arthroplasty (TSA) is subscapularis repair. In the available literature reporting outcomes after stemless TSA, subscapularis tenotomy with side-to-side repair is the most common technique despite some concerns regarding this technique in the biomechanical and clinical literature. Accordingly, this study investigated subscapularis tenotomy repair with stemless TSA with 2 primary objectives: (1) to evaluate the subscapularis tendon dimensions with reference to subscapularis tenotomy to determine the amount of tendon remaining for side-to-side repair after shoulder arthroplasty and (2) to biomechanically compare 2 methods of subscapularis tenotomy repair after stemless TSA-side-to-side repair and anchor-based repair.We used 12 male shoulder specimens for this study. To address our first objective, measurements were made to calculate the dimensions of the subscapularis tendon at the superior, middle, and inferior levels to determine the amount of tendon remaining after tenotomy. These specimens were then divided into 2 groups (n = 6 in each group) to biomechanically compare subscapularis tenotomy repair with (1) traditional side-to-side repair and (2) anchor-based repair. The shoulders then underwent biomechanical testing with primary outcomes including load to failure and cyclic displacement.The mean subscapularis tendon width measured from the medial insertion at the lesser tuberosity to the muscle-tendon junction varied depending on the level: 19.5 mm superiorly (95% confidence interval [CI], 16.2-22.8 mm); 18.3 mm at the midportion (95% CI, 13.6-23.0 mm); and 13.1 mm inferiorly (95% CI, 9.1-17.1 mm). With a tenotomy made 1 cm medial to the lesser tuberosity insertion, a mean of 3.1 mm of tendon remained medially at the inferior subscapularis, with one-third of specimens having no tendon left medially at this level. On comparison of tenotomy repair techniques, the anchor-based technique had a 57% higher ultimate load to failure compared with the side-to-side repair (448 N vs. 249 N, P.001). There were no significant differences in cyclic displacement (6.1 mm vs. 7.1 mm, P = .751) and construct stiffness (38.1 N/mm vs. 42.9 N/mm, P = .461) between techniques.With traditional techniques for subscapularis tenotomy for anatomic TSA, there is very little tendon remaining inferiorly for side-to-side repair. When subscapularis tenotomy is performed for stemless TSA, a double-row anchor-based repair has a better time-zero ultimate load to failure compared with side-to-side repair.

PURPOSE To evaluate the effect of suture augmentation (SA) of 7-mm and 9-mm diameter graft on load sharing, elongation, stiffness, and load to failure for all-inside anterior cruciate ligament reconstruction (ACLR) in a biomechanical Study was funded by Arthrex ID: EMEA-16020. full-construct porcine model. METHODS Bovine tendon grafts, 7-mm and 9-mm diameter, with and without SA were tested using suspensory fixation (n = 8). The independent SA was looped over a femoral button and knotted on a tibial button. Preconditioned constructs were incrementally increased loaded (100N/1,000 cycles) from 100N to 400N for 4,000 cycles (0.75 Hz) with final pull to failure (50 mm/min). Isolated mechanical and optical measurements during construct loading of the SA allowed to quantify the load and elongation range during load sharing. Construct elongation, stiffness and ultimate strength were further assessed. RESULTS Load sharing in 7-mm grafts started earlier (200N) with a significant greater content than 9-mm grafts (300N) to transfer 31% (125N) and 20% (80N) of the final load (400N) over the SA. Peak load sharing with SA reduced total elongation for 7-mm (1.90 ± 0.27 mm vs 4.77 ± 1.08 mm, P < .001) and 9-mm grafts (1.50 ± 0.33 mm vs 3.57 ± 0.54 mm, P < .001) and adequately increased stiffness of 7-mm (113.4 ± 9.3 N/mm vs 195.9 ± 9.8 N/mm, P < .001) to the level of augmented 9-mm grafts (208.9 ± 13.7N/mm). Augmentation of 7-mm (835 ± 92N vs 1,435 ± 228N, P < .001) and 9-mm grafts (1,044 ± 49N vs 1,806 ± 157N, P < .001) significantly increased failure loads. CONCLUSIONS Load sharing with SA occurred earlier (200N vs 300N) in lower stiffness 7-mm grafts to carry 31% (7-mm) and 20% (9-mm) of the final load (400N). Loads until peak load sharing were transferred over the graft. Augmented constructs showed significantly lower construct elongation and increased stiffness without significance between variable grafts. Failure load of augmented grafts were significantly increased. CLINICAL RELEVANCE Suture tape ligament augmentation may potentially protect biological grafts from excessive peak loading and elongation, thus reducing the risk of graft tears.

Background and Hypothesis Morphologic analysis of the proximal humerus has been performed to provide information about regions of best bone quality for stemless implant fixation. However, implant design-related bone analysis regarding primary fixation strength has not been reported. The purpose of this study was to investigate bone volume fraction (BV/TV) and bone mineral density (BMD) in the spatial vicinity of humeral implant fixation and biomechanical performance following placement of two different stemless RSA designs. It was hypothesized that peripheral expandable implant fixation (PEF) would result in residual peri-implant bone with higher BMD and BV/TV and higher fixation strength compared to a central-hexagonal impaction fixation (CHIF) design. Methods Overall 25 human cadavers were prepped for stemless RSA using either a CHIF (n = 5) or PEF design (n = 20). Micro computed tomography scans were obtained post-preparation to analyze overall BV/TV and BMD in the anchoring region of 2 stemless implant designs. Bone volumes of paired specimens (each group n = 5) were further segmented and divided into three even planar subsections along the implantation direction with four additional radial sectors, each according to their anterior-posterior and medial-lateral direction. Following implantation, biomechanical testing was performed to evaluate ultimate failure load and stiffness of the 2 implants. Results Postpreparation paired humeral bone analysis revealed significantly greater residual peri-implant BMD (P 0.69) with significantly higher bone density for PEF (P= .003). Further division in proximal to distal planar subsections of paired specimens showed overall statistically higher BMD and BV/ TV for PEF (at least P 0.89 with significantly higher primary stability for PEF (P = .046). Conclusion Implant design in stemless RSA affects residual bone quality in the anchoring region and primary fixation strength. Peripheral implant anchoring along the insertion direction provides significantly higher residual peri-implant BMD and BV/TV to achieve improved primary fixation with a radial expandable anchoring implant compared to a central-hexagonal impacted design. Level of Evidence Basic Science Study; Anatomy Study; Imaging; Biomechanics

Background Stemless anatomic total shoulder arthroplasty (TSA) has been gaining significant popularity but poses unique challenges for subscapularis repair. Tenotomy with side-to-side repair has been the most frequently reported technique for subscapularis repair with stemless TSA but has the poorest biomechanical properties, and clinical failures have been reported. There is limited biomechanical evidence evaluating other subscapularis repair techniques for stemless TSA. Therefore, the goal of this study was to investigate 2 additional techniques using a subscapularis peel for subscapularis repair with a stemless TSA. Methods We used 18 male cadaveric specimens to investigate the native subscapularis (n = 6) and 2 subscapularis repair techniques (n = 12) after stemless anatomic TSA (Eclipse). A subscapularis peel with double-row, knotless anchor–based repair (n = 6) was compared with a subscapularis peel with a “backpack” repair (n = 6). The specimens then underwent biomechanical testing, including cyclic displacement and load-to-failure testing. The mode of failure was also recorded. Results The native tendon had the highest ultimate load to failure (mean, 1017.1 N). Load to failure was similar between the 2 study groups: 397.9 N for the peel and backpack repair and 593.7 N for the knotless anchor–based repair (P > .05 for all comparisons). Moreover, no significant differences in cyclic displacement or construct stiffness were found between the groups (P > .05 for all comparisons). Conclusions A double-row, knotless anchor–based repair of a subscapularis peel for stemless anatomic shoulder arthroplasty has similar biomechanical properties to a backpack repair technique; however, both techniques fail to reproduce the native biomechanical properties at time zero.

Purpose To determine whether patients who are prescribed ibuprofen after arthroscopic rotator cuff repair have significantly different patient-reported outcomes for pain, function, and overall health at baseline and 1 and 2 years after operation relative to patients only prescribed opioids. Methods Patients who underwent a rotator cuff repair by a total of 3 surgeons and participated in the outcomes registry from 2012 to 2016 were screened for inclusion in this study. Inclusion criteria were primary arthroscopic rotator cuff repair, at least 2 years from the date of surgery and over the age of 18. Exclusion criteria were revision and open rotator cuff repair. All patients followed the standard postoperative rehabilitation protocol for rotator cuff repair. Patients were divided into 2 cohorts. Group I included patients who received ibuprofen/nonsteroidal anti-inflammatory agents (NSAID) after surgery (n = 281), and Group II consisted of patients who did not receive ibuprofen/NSAID after surgery (n = 182). Patient-reported outcome measures for Visual Analogue Scale, American Shoulder Elbow Surgeons score, Single Assessment Numeric Evaluation score, Simple Shoulder Test and The Veterans Rand 12-Item Health Survey were collected preoperatively and at 3 and 6 months, 1 year, and 2 years after surgery. Statistical analysis was performed to compare patient-reported outcome measures between Group I and II. Results This study consisted of 463 patients who underwent arthroscopic rotator cuff repair, and patients were divided into 2 cohorts. There were 281 patients who did not receive ibuprofen/NSAID after operation in Group I and 182 patients who did receive ibuprofen in Group II. There were no statistically significant differences between the 2 groups in age at treatment, mean body mass index, gender, ethnicity, diabetes, and number of rotator cuff tendons involved; however, there was a statistically significant difference in receiving worker’s compensation (P = .005), and this was subsequently adjusted for in our analysis. There were no significant differences in patient-reported outcomes for all metrics between the group prescribed ibuprofen and the group that was not prescribed ibuprofen at 1 and 2 years after surgery or in change from baseline. Conclusion Patients receiving ibuprofen did as well as patients who did not receive ibuprofen after arthroscopic rotator cuff repair on patient-reported outcome measures assessing shoulder pain, function, and overall health. Level of Evidence Level III, retrospective comparative study.

Background Bone grafting during primary reverse shoulder arthroplasty (RSA) is a technique used to restore poor glenoid bone, increase lateralization, and restore abnormal inclination or version. The purpose of this article is to analyze early outcomes of bone grafting during RSA, assessing the influence of technical and patient considerations. Methods In a 4.5-year time period, 137 RSAs with glenoid bone grafting were performed with a minimum 3 months' follow-up. The mean follow-up was 17 months (range, 3-38). The mean age was 71 years (range, 45-89), and body mass index was 28 (range, 19-44). The source of the autografts were humeral head (n = 113) and iliac crest autograft (ICBG; n = 24). The humeral components included 84 onlay and 53 inlay designs. Results Overall, there were 16 complications (12%), of which 6 were major (5%) (3 graft nonunions and 3 infections) and 10 minor (8%) (1 carpal tunnel syndrome and 9 transient axillary neuropraxias). Of the 9 axillary neuropraxias, 8 resolved by the most recent follow-up, whereas 1 patient was lost to follow-up. There were 4 reoperations (3%): 2 for glenoid baseplate loosening, 1 for severe notching associated with severe glenoid bone loss, and 1 for deep periprosthetic infection. One additional patient had a baseplate failure and is undergoing further treatment. There was no difference in the occurrence of graft nonunions, revision surgery, or glenoid component loosening when comparing type of graft or humeral component used. There was an association of revision surgery (P = .02) with ICBG and older age at the time of surgery (P = .02) and an association of transient neuroapraxia with onlay humeral components (P = .01) and workers' compensation cases (P = .04). Conclusions There is a high union rate and low complication rate after bone grafting of the glenoid performed with RSA. Transient neuropraxias are the most frequent complication, but the majority resolve within the first postoperative year. These early findings can serve as the basis for future long-term, comprehensive analysis of complications and outcomes after bone grafting during RSA.

Fixation of periprosthetic humeral fractures is most commonly obtained with steel-based wires or cables; however, disadvantages with these constructs are numerous. Suture-based cerclages offer the advantage of easy handling, less radiographic interference, and risk of metallosis, as well as decreased risk of cutting into the soft humeral bone. Therefore, the purpose of this study was to compare a suture-based cerclage to a stainless steel wire cerclage (SSWC) for stabilization of the humerus during shoulder arthroplasty.In part I of the study, SSWC fixation was compared with single-looped tape cerclage and a double-looped tape cerclage (DLTC) fixation. In part II, a subsidence test was performed on 12 cadaveric humeri. After an osteotomy, the humeri were secured with either a SSWC or DLTC. Subsequently, a metal wedge was introduced into the humerus to simulate the stem of a shoulder arthroplasty.In part I, load to 2-mm displacement was significantly higher for the DLTC construct compared with the SSWC construct (2,401 ± 483 N versus 750 ± 33 N; P0.0001). Load to failure was 935 ± 143 N with the SSWC, 1,737 ± 113 N with the single-looped tape cerclage, and 4,360 ± 463 N with the DLTC constructs, and all differences were statistically significant (P0.05). In part II, load at 20-mm subsidence was higher for the DLTC (320 ± 274 N) compared with the SSWC (247 ± 137 N), but no significant difference was observed (P0.05). However, gap displacement at 20 mm subsidence was significantly lower with the DLTC construct (0.33 ± 0.31 mm versus 0.77 ± 0.23 mm; P = 0.009). Load to failure was higher with the DLTC construct compared with the SSWC construct (4,447 ± 2,325 N versus 1,880 ± 1,089 N; P = 0.032), but the final gap displacement did not differ significantly (DLTC 5.23 ± 6.63 mm versus SSWC 6.03 ± 8.82 mm; P0.05).A DLTC has higher load to failure and trends toward lower gap displacement compared with a SSWC. The DLTC construct may therefore be a viable alternative for fixation of periprosthetic fractures or osteotomies of the humeral shaft during shoulder arthroplasty.

Objectives The purpose of this study is to compare early postoperative recovery following open and arthroscopic-assisted latissimus dorsi tendon (aa-LDT) transfer to arthroscopic-assisted lower trapezius tendon (aa-LTT) transfer for patients with massive irreparable posterosuperior rotator cuff pathology. Methods A multicentre retrospective analysis comparing the postoperative outcomes after open LDT, arthroscopic-assisted LDT (aa-LDT) or arthroscopic-assisted LTT (aa-LTT) was performed. Active range of motion and patient-reported subjective outcomes were reported preoperatively and postoperatively. Overall, there were 10 patients who underwent open LDT transfer, 16 aaLDT transfers and 8 aa-LTT transfers with mean age of 55±3, 57±6 and 53±13, respectively. Mean follow-up was 22±10 months. Results Arthroscopic-assisted LDT had significantly improved postoperative forward flexion (85–124, p Conclusions Arthroscopic-assisted LDT and aa-LTT transfers provided improvement in pain and function at 2-year follow-up. The aa-LTT transfer provided significantly improved outcomes at 2 years compared with the open-LDT (latissimus dorsi tendon transfer) transfer. This study demonstrates superiority of arthroscopic-assisted tendon transfer techniques over traditional open techniques while establishing the aa-LTT transfer as a safe and effective alternative in the management of massive irreparable rotator cuff tears. Level of evidence IV.

Background There remains a paucity of studies examining the impact of workers' compensation (WC) on a variety of outcomes after biceps tenodesis. The purpose of this study was to compare the postoperative recovery curves after biceps tenodesis in patients with and without WC claims. Methods Using the Surgical Outcomes System database, we assessed the postoperative recovery outcomes of all patients who had outcomes recorded at least 6 months after isolated biceps tenodesis for the treatment of a diagnosis of biceps tendinitis, stratified by WC status. The outcomes analyzed included visual analog scale, American Shoulder and Elbow Surgeons, VR-12 (Veterans RAND 12 Item Health Survey) mental and physical, Simple Shoulder Test, and Single Assessment Numeric Evaluation scores. Results Overall, 139 patients with WC claims underwent isolated biceps tenodesis vs. 786 patients without WC claims. Demographic characteristics and comorbidities were similar in the 2 groups. Patients without WC claims had significantly improved visual analog scale, VR-12, American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and Simple Shoulder Test scores at all times points after 3 months and 1 year compared with patients with WC claims. Conclusions On analysis of patients' recovery after isolated biceps tenodesis, WC claims led to significantly worse pain and functional outcomes at every time point of analysis (3, 6, 12, and 24 months). Furthermore, patients with WC claims had worse preoperative-to-postoperative improvements in most outcomes. This information can be used to educate surgeons and patients on postoperative expectations, as well as to perform analyses focused on health economics, value, and policy.

BackgroundFatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited.MethodsWe recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n=80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n=158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates.ResultsA total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m2 was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men.ConclusionsAmong patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients.

BACKGROUND: The American Shoulder and Elbow Surgeons Standardized Shoulder Form (ASES), the Shoulder Pain and Disability Index (SPADI), and the shortened Disability of the Arm, Shoulder, and Hand (quickDASH) are patient-reported upper extremity-specific outcome scales currently used to evaluate patients with rotator cuff tears. This heterogeneity does not allow for a uniform metric for research and patient care. QUESTIONS/PURPOSES: Our objective was to determine psychometric properties (reliability, convergent and discriminant validity, and responsiveness) of five commonly used outcome instruments (the ASES, the SPADI, the quickDASH, the SF-12, and the EuroQol-5D) in a longitudinal study of patients undergoing treatment for rotator cuff tears. METHODS: From February 2011 through June 2015, 120 patients completed a standardized history, the five outcome scales under study, a physical examination, and an MRI. Of these, 47 (39%) were lost to followup before 18 months, and another 24 (20%) were accounted for at 18 months but had missing data at one or more of the earlier prespecified followup intervals (3, 6, or 12 months). Reliability (the reproducibility of an outcome instrument between subjects; tested by Cronbach’s alpha), convergent and discriminant validity (determining which outcome measures correlate most strongly with others; tested by Spearman’s correlation coefficients), and responsiveness (the change in outcome scales over time based on percent improvement in shoulder functionality using the minimal clinically important difference [MCID] and the subjective shoulder value) were calculated. RESULTS: All outcomes measures had a Cronbach’s alpha above 0.70 (range, 0.74–0.94) and therefore were considered reliable. Convergent validity was demonstrated as the upper extremity-specific measures (SPADI, ASES, and quickDASH) were more strongly correlated with each other (rho = 0.74–0.81; p < 0.001) than with any of the other measures. Discriminant validity was demonstrated because the Spearman’s correlation coefficients were stronger for the relationships between upper extremity measures compared with the correlations between upper extremity measures and general health measures for 53 of the 54 correlations that were compared. Both internal and external responsiveness of the measures was supported. Patients who achieved the MCID and at least a 30% change on the subjective shoulder value had more positive change in scores over time compared with those who did not. Mixed model linear regressions revealed that all three upper extremity-specific measures had a group by time interaction for the MCID, indicating that patients who achieved the MCID had greater change over time compared with those who did not achieve the MCID. Results showed that the measure with the best discrimination between groups, or best internal responsiveness, was the ASES (beta = -8.26, 95% confidence interval [CI], -11.39 to -5.14; p < 0.001; η(2) = 0.089) followed by the SPADI (beta = 6.88, 95% CI, 3.78–9.97; p < 0.001; η(2) = 0.088) then the quickDASH (beta = 3.43, 95% CI, 0.86–6.01; p = 0.009, η(2) = 0.027). Measures with the best external responsiveness followed the same pattern of results. CONCLUSIONS: All the upper extremity-specific scales had acceptable psychometric properties. Correlations were high and thus only one upper extremity-specific instrument is needed for outcome assessment. Given the overall psychometric assessment, we recommend SPADI be the shoulder-specific instrument used to assess outcomes in patients with rotator cuff tears. LEVEL OF EVIDENCE: Level III, diagnostic study.

Background Since the approval of reverse shoulder arthroplasty (RSA) in 2004, the use of shoulder arthroplasty increased dramatically. Although the success of RSA in the revision setting has been demonstrated, there remains a paucity of studies examining the epidemiology of RSA in revision arthroplasty. This study describes trends of revision arthroplasty during the “era of the reverse,” from 2005 through 2016. Methods In a multicenter retrospective analysis, we analyzed 274 revision shoulder arthroplasties converted to a RSA (n = 182), anatomic total shoulder arthroplasty (TSA, n = 68), or hemiarthroplasty (n = 24) from 2005 to 2016. Demographics, surgical indications, and types of prosthesis were analyzed. Results The number of revision arthroplasties increased over 12 years. From 2005 to 2010, TSA (33%) or hemiarthroplasty (16%) were used in similar rates as RSA (51%). From 2011 to 2016, there was a much higher incidence of revision arthroplasty with RSA (78%) compared with TSA (19%) or hemiarthroplasty (3%). Specifically, the number of RSAs increased in 2011 to 2016 compared with 2005 to 2010 in patients aged younger than 60 years, obese patients, patients with indications of glenoid loosening, and those with a diagnosis of diabetes mellitus or rheumatoid arthritis. Conclusions The use of RSA for revision arthroplasty increased over the “era of the reverse” and became the majority by 2016. The reverse prosthesis has had expanding indications regarding both patient demographics and pathology. This study demonstrates the reverse prosthesis has had a similar and even more profound effect on revision shoulder arthroplasty than what has previously been well documented in the primary setting.

Recurrent anterior glenohumeral instability is a disabling pathology that can be successfully treated by arthroscopic Bankart repair or open Latarjet. However, there is a paucity of studies comparing the postoperative recovery. The purpose of this study is to evaluate the postoperative pain and functional recovery following arthroscopic Bankart versus open Latarjet.This is a retrospective analysis of a multicenter prospective outcomes registry database. Postoperative recovery outcomes of either a primary or revision arthroscopic Bankart and open Latarjet procedures were compared. A minimum of 1-year follow-up was required. Outcomes measures included pain visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) function score, ASES index score, and single assessment numeric evaluation (SANE) score. Overall, 787 patients underwent primary arthroscopic Bankart, 36 underwent revision arthroscopic Bankart and 75 underwent an open Latarjet procedure.When compared to primary arthroscopic Bankart, open Latarjet demonstrated significantly lower VAS scores at 6 weeks (p = 0.03), 3 months (p = 0.01), and 2 years (p 0.05). Medium-term outcomes for ASES scores and SANE score, at 1 and 2 years showed no difference. Latarjet demonstrated significantly lower (p 0.05) preoperative early postoperative VAS pain scores with no difference at 1 year or 2 years when compared to primary Bankart. There was no difference in ASES function or index between Bankart and Latarjet. Revision Bankart provided inferior outcomes for VAS, ASES function, and ASES index when compared to primary Bankart and Latarjet at 1 year and 2 years.Primary arthroscopic Bankart repair and open Latarjet provided nearly equivalent improvements in pain (VAS) and functional outcomes (ASES, SANE, VR-12) during the early recovery phase (2 years). This study supports the use of either procedure in the primary treatment of anterior glenohumeral instability. Revision arthroscopic Bankart repair demonstrated deteriorating outcomes at 1 and 2 years postoperatively.

Objective Although rotator cuff tear is one of the most common musculoskeletal disorders, its etiology is poorly understood. We assessed factors associated with the presence of rotator cuff tears in a cohort of patients with shoulder pain. Design From February 2011 to July 2016, a longitudinal cohort of patients with shoulder pain was recruited. Patients completed a detailed questionnaire in addition to a magnetic resonance imaging scan and a clinical shoulder evaluation. The association of multiple factors associated with rotator cuff tears was assessed using multivariate logistic regression. Results In our cohort of 266 patients, 61.3% of patients had a rotator cuff tear. Older age (per 1 yr: odds ratio = 1.03, 95% confidence interval = 1.02-1.07), involvement of the dominant shoulder (odds ratio = 2.02, 95% confidence interval = 1.16-3.52), and a higher body mass index (per 1 kg/m2: odds ratio = 1.06, 95% confidence interval = 1.03-1.12) were independently associated with rotator cuff tears. Sex, depression, smoking status, shoulder use at work, hypertension, and diabetes were not significantly associated with rotator cuff tear. Conclusions In a cohort of patients with shoulder pain, we identified older age, involvement of the dominant shoulder, and a higher body mass index to be independently associated with rotator cuff tear. The mechanism of how these factors possibly lead to rotator cuff tears needs further research. To claim cme credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. Cme objectives Upon completion of this article, the reader should be able to: (1) Identify factors associated with an increased risk of developing rotator cuff tears in adults; (2) Describe the current epidemiological trends of rotator cuff tears in the United States; and (3) Discuss the pathophysiological role of aging in the development of nontraumatic rotator cuff tears. Level Advanced. Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

To evaluate the role of concomitant partial rotator cuff repair (RCR) (i.e., infraspinatus) on patient-reported clinical outcomes following superior capsule reconstruction (SCR).Postoperative recovery outcomes of SCR alone were compared with SCR with concomitant infraspinatus rotator cuff repair (SCR+RCR) at 3, 6, 12, and 24 months. Patients were included if they had an SCR surgery with or without a concomitant infraspinatus repair. Patients were excluded if they did not have a minimum of 6 months' follow-up or if a preoperative baseline questionnaire was not performed. Outcome measures included pain visual analog scale, American Shoulder and Elbow Surgeons (ASES) Shoulder Function, ASES Shoulder Index, and Single Assessment Numeric Evaluation (SANE) score.Overall, 180 patients were evaluated, including 163 patients who underwent SCR alone and 17 patients who underwent concomitant infraspinatus repair (SCR+RCR). There was no difference in demographic data including age, sex, and body mass index. The postoperative recovery curves demonstrated SCR alone and SCR+RCR both provide significantly improved pain and functional scores at 2 years postoperatively (SCR provides modest improvements in pain and function at 2 years postoperatively in patients with irreparable rotator cuff tears. Patients who underwent SCR and concomitant infraspinatus repair demonstrated significantly improved ASES Index and ASES Function scores and statistically nonsignificant improvement in SANE scores at 24 months postoperatively when compared with SCR alone.III, retrospective cohort study.

The purpose of this study is to analyze the outcomes of open and arthroscopic capsular release following total shoulder arthroplasty.Over 15 years, 19 patients experienced persistent shoulder stiffness after anatomic total shoulder arthroplasty refractory to nonoperative treatment, requiring either open (n = 5) or arthroscopic (n = 14) capsular release. There were seven (39%) patients who had a prior diagnosis of stiffness before the primary arthroplasty.At a follow-up of 2.3 years (1-5.5), there were changes in range of motion, including forward flexion (77°-117°), abduction (49°-98°), external rotation (9°-19°), internal rotation at 0° (Sacrum to L1), and pain (4.1-2.3) scores (p 0.01). There were seven (37%) patients that required a reoperation following the initial capsular release. The survival-free of reoperation at 2 and 5 years was 76% and 53%, respectively, while the survival-free of revision surgery at 2 and 5 years was 83%. Furthermore, three (16%) patients required a repeat capsular release. Overall, there were 11 (58%) complications, including stiffness (n = 9), infection (n = 1), subscapularis rupture (n = 2), glenoid loosening (n = 3), and pain with weakness requiring reoperation (n = 1).Shoulder stiffness after total shoulder arthroplasty is a very difficult pathology to treat, with high rates of complications and reoperations after capsular release. Overall, in patients that do not develop glenoid loosening, capsular release does improve the patient's pain and shoulder motion. Furthermore, when patients develop stiffness, it is critical to rule out other etiologies, such as glenoid loosening, prior to proceeding with capsular release.Retrospective case series.

BACKGROUND: Comparative time to recovery after operative and nonoperative treatment for rotator cuff tears is an important consideration for patients. Hence, we compared the time to achieve clinically meaningful reduction in shoulder pain and function after treatment. METHODS: From February 2011 to June 2015, a multicenter cohort of patients with rotator cuff tears undergoing operative or nonoperative treatment was recruited. After propensity score weighting, the Kaplan-Meier method was used to estimate the time to achieve a minimal clinically important difference (MCID), >30% reduction, and >50% reduction in the Shoulder Pain and Disability Index (SPADI) and the American Shoulder and Elbow Surgeons (ASES) scores. (In our analysis, both ASES and SPADI were coded such that a lower number corresponded to a better outcome; thus, the word “reduction” was used to indicate improvement in both ASES and SPADI scores.) A 2-stage test was conducted to detect a difference between the 2 groups. RESULTS: In this cohort, 96 patients underwent nonoperative treatment and 73 patients underwent a surgical procedure. The surgical treatment group and the nonoperative treatment group were significantly different with respect to SPADI and ASES scores (p < 0.05). The maximum difference between groups in achievement of the MCID for the SPADI scores was at 3.25 months, favoring the nonoperative treatment group. The probability to achieve the MCID was 0.06 (95% confidence interval [CI], 0.00 to 0.12) for the surgical treatment group compared with 0.40 (95% CI, 0.29 to 0.50) for the nonoperative treatment group. The surgical treatment group had a greater probability of achieving >50% reduction in SPADI scores at 15.49 months (0.20 [95% CI, 0.12 to 0.29] for the surgical treatment group compared with 0.04 [95% CI, 0.00 to 0.09] for the nonoperative treatment group). The surgical treatment group had a greater probability of achieving >50% reduction in ASES scores at 24.74 months (0.96 [95% CI, 0.84 to 0.99] for the surgical treatment group compared with 0.66 [95% CI, 0.53 to 0.75] for the nonoperative treatment group). The differences for >30% reduction in SPADI and ASES scores and the MCID for ASES scores were not significant. CONCLUSIONS: Patients undergoing nonoperative treatment had significantly better outcomes in the initial follow-up period compared with patients undergoing a surgical procedure, but this trend reversed in the longer term. These data can be used to inform expectations for nonoperative and operative treatments for rotator cuff tears. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: Biomechanical studies have compared augmented primary repair with internal bracing versus reconstruction techniques of the anterior ulnar collateral ligament (aUCL) in the elbow. However, aUCL repair alone has not been compared with augmented repair or reconstruction techniques. Hypothesis: Internal bracing of aUCL repair provides improved time-zero stabilization in terms of gap formation, torsional stiffness, and residual torque compared with both repair alone and the modified docking technique, with enhanced valgus stability restoration to that of the native ligament. Study Design: Controlled laboratory study. Methods: We randomized 8 matched pairs of cadaveric elbows to undergo either augmented aUCL repair or a modified docking technique through use of the palmaris longus tendon. Valgus laxity testing was consecutively performed at 90° of flexion on the intact, torn, and repaired conditions as well as the previously assigned techniques. First, intact elbows were loaded up to 10 N·m valgus torque to evaluate time-zero ligament rotations at valgus moments of 2.5, 5.0, 7.5, and 10 N·m. Rotation controlled cycling was performed (total 1000 cycles) for each surgical condition. Gap formation, stiffness, and residual torque were analyzed. Finally, these elbows and 8 additional intact elbows underwent torque to failure testing (30 deg/min). Results: Repair alone revealed low torsional resistance and gapping, similar to the torn state. The augmented repair technique showed significantly higher torsional stiffness ( P < .001) and residual torque ( P < .001) compared with all other conditions and restored native function. Although reconstruction revealed similar initial stiffness and residual torque compared with an intact ligament, a steady decrease of torsional resistance led to a completely loose state at higher valgus rotations. Analysis of covariance between all groups showed significantly less gap formation for augmented repair ( P < .001). The native failure load and stiffness were significantly higher and were similar to those of augmented repair ( P = .766). Conclusion: Internal bracing of aUCL repair restored valgus stability to the native state with statistically improved torsional resistance, loading capability, and gap formation compared with reconstruction, especially at the upper load range of native aUCL function in the elbow. Clinical Relevance: We found that aUCL repair with an internal brace effectively improves time-zero mechanical characteristics and may provide stabilized healing with accelerated and reliable recovery without the need for a tendon graft.

Background: A variety of thrower’s exostoses are grouped under the term Bennett lesion, which makes understanding diagnosis and treatment difficult. Purpose: To identify all types of reported thrower’s and overhead athlete’s exostoses and categorize them into a classification system to allow a morphology-based classification. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of all articles pertaining to Bennett lesions and thrower’s exostosis was performed. The classification and treatments were evaluated to describe the types, proposed causes, diagnosis, and treatment options. Results: A total of 27 studies were included in the systematic review. The anatomic locations referenced in the study demonstrated posteroinferior, posterior, and posterosuperior glenoid lesions. Aggregate radiographic data demonstrated 158 of 306 patients (52%) with a thrower’s exostosis of any type and location. Of these 158 patients with a radiographic lesion, 119 (75%) patients were symptomatic. The locations were posteroinferior in 110 patients (70%), directly posterior in 2 patients (1.3%), posterosuperior in 44 patients (28%), and unknown in 2 patients (1.3%). Avulsed lesions were present in 9 (5.7%) posteroinferior lesions, 0 direct posterior lesions, and 2 (1.3%) posterosuperior lesions. Treatment plans included both nonoperative and operative strategies, but operative intervention was more commonly reported for detached lesions. After operative intervention, only 61% of reported athletes returned to preinjury performance. Conclusion: Based on a comprehensive review of the literature, we identified several anatomic locations for a thrower’s exostosis beyond the classic Bennett lesion. We categorized the reported exostoses into a new classification system for description of location and type (subperiosteal or free fragment) of the thrower’s exostosis, which may be used to study future treatments. Current treatment strategies recommend that surgical treatment of thrower’s exostosis is considered only after exhausting nonoperative management because reported return to sport is variable after surgery. The effectiveness of excision or repair for both subperiosteal and detached lesions has not been established.

It is widely believed that structured rehabilitation programs by professional therapists help guide patients through the various recovery periods after shoulder arthroplasty, speeding up their recovery and improving their final functional gains. However, to our knowledge, there are no studies providing information about the current state of physical rehabilitation use after shoulder arthroplasty.To describe the variation in physical rehabilitation utilization after total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA), and to identify differences in utilization based on type of insurance (private versus public), sex, age, and region of the country.This epidemiological retrospective database study utilized a commercially available database, PearlDiver, with longitudinal patient tracking linking all patients' Current Procedural Terminology and International Classification of Diseases-Ninth Revision codes to their specific records to analyze patterns of physical rehabilitation usage after TSA and RSA in the United States. Two main patient populations were analyzed within the PearlDiver database, the Humana private insurance population and the Medicare insurance population. The period analyzed was 2010 to 2015.There was significantly higher utilization of physical rehabilitation in the Humana population when compared to the Medicare population (P.001, Cramer's V = 0.270). In the Humana population, 36% of patients had 5 or fewer physical rehabilitation visits in the 6 months following their operation, while in the Medicare population, 56% of patients had 5 or fewer physical rehabilitation visits in the same period. Those with TSA had a higher utilization rate than those with RSA in the Humana (P.001, V = 0.104; TSA, 31% had 5 or fewer physical rehabilitation visits; RSA, 40% had 5 or fewer physical rehabilitation visits within 6 months) and Medicare populations (P.001, V = 0.135; TSA, 51% had 5 or fewer physical rehabilitation visits; RSA, 61% had 5 or fewer physical rehabilitation visits within 6 months).Postoperative utilization of physical rehabilitation after anatomic TSA and RSA is markedly higher in privately insured patients than in patients with Medicare, regardless of age, sex, diagnosis, or region of country. These findings have important implications, from the individual patient's experience and outcomes to system-wide resource utilization.Economic and decision analyses, level 4. J Orthop Sports Phys Ther 2018;48(11):856-863. Epub 8 May 2018. doi:10.2519/jospt.2018.8176.

Second only to the knee, the shoulder is the most commonly reported area of chronic joint pain. By practicing evidence-based methods for improved outcomes at lower costs, providers can increase both efficiency and margin, while patients experience better care and higher satisfaction. Current cost studies on shoulder care provide a base for improving evidence-based care and improving value.

Background:Meniscal extrusion refers to meniscal displacement out of the joint space and over the tibial margin, altering knee mechanics and increasing the risk of osteoarthritis. The meniscotibial ligaments have been shown to have an important role in meniscal stability. However, it remains unclear whether an isolated lesion of the medial meniscotibial ligaments will result in meniscal extrusion and whether repairing the detached ligament will reduce extrusion.Hypothesis:A lesion of the medial meniscotibial ligament will result in meniscal extrusion, and repairing the joint capsule will eliminate the extrusion by returning the meniscus back to its original position.Study Design:Controlled laboratory study.Methods:Fresh-frozen human cadaveric knees (N = 6) were used for biomechanical testing. The test protocol involved 100 flexion-extension cycles. In full extension, meniscal extrusion was measured using ultrasound, in both an otherwise unloaded state and while subjected to a 10-N·m varus load. Each knee was tested in its native condition (baseline), after creating a detachment of the medial meniscotibial ligament, and finally with the joint capsule repaired using 3 knotless SutureTak anchors. We also performed a retrospective review of 15 patients who underwent meniscotibial ligament repair with a minimal follow-up of 5 weeks (mean, 14 weeks; range, 5-35 weeks).Results:During biomechanical testing, the mean absolute meniscal extrusion at baseline was 1.5 ± 0.6 mm. After creation of the meniscotibial ligament lesion, the mean absolute meniscal extrusion was significantly increased (3.4 ± 0.7 mm) ( P < .001). After repair, the extrusion was reduced to 2.1 ± 0.4 mm ( P < .001). Clinically, a reduction in absolute meniscal extrusion of approximately 48% was reached (1.2 ± 0.6 vs 2.4 ± 0.5 mm preoperatively; P < .001).Conclusion:This study indicates that the medial meniscotibial ligaments contribute to meniscal stability as lesions cause the meniscus to extrude and that repair of those ligaments can significantly reduce extrusion. Early clinical results using this meniscotibial ligament repair technique support our biomechanical findings, as a significant reduction in meniscal extrusion was achieved.Clinical Relevance:Our biomechanical findings suggest that repair of medial meniscotibial ligaments reduces meniscal extrusion and clinically may improve meniscal function, with the possible long-term benefit of reducing the risk for osteoarthritis.

Introduction Propionibacterium acnes infection after shoulder arthroplasty remains a source of morbidity. Determining practices amongst shoulder surgeons is the first step in developing infection-prevention best-practices. Methods A survey was sent to a shoulder fellowship alumni group to determine their arthroplasty infection prevention methods Results 74% completed the survey. Cefazolin (90%), vancomycin (50%) and clindamycin (18%) were the most commonly used antibiotics, 61% utilized more than one antibiotic. Most (76%) reported using an experience-based protocol learned during residency/fellowship. Discussion and conclusion There are no clear standards for prevention of Propionibacterium acnes infections in shoulder arthroplasty. There is a general non-scientific approach to the prevention of shoulder arthroplasty infection.

Outcome is the numerator for the value equation, with the denominator being cost; measurement of each is essential to determine the most effective care. With regard to both total shoulder arthroplasty and rotator cuff repair, outcomes of low (vs high) volume providers are associated with longer hospital stay, longer length of operating room time, increased hospital complications, and cost. This suggests that volume thresholds are a key to providing greater value. However, this effect can be modified through systematic efforts to measure outcome and thus improve. To quote Codman, "To effect improvement, the first step is to admit and record the lack of perfection. The next step is to analyze the causes of failure and to determine whether these causes are controllable." Thus, although volume most certainly plays a role in determining outcomes and cost, the more important principle is to measure outcomes and improve with such measurement.

The purpose of this study is to analyze the outcomes of open and arthroscopic capsular release following total shoulder arthroplasty. Over 15 years, 19 patients experienced persistent shoulder stiffness after anatomic total shoulder arthroplasty refractory to nonoperative treatment, requiring either open (n = 5) or arthroscopic (n = 14) capsular release. There were seven (39%) patients who had a prior diagnosis of stiffness before the primary arthroplasty. At a follow-up of 2.3 years (1–5.5), there were changes in range of motion, including forward flexion (77°–117°), abduction (49°–98°), external rotation (9°–19°), internal rotation at 0° (Sacrum to L1), and pain (4.1–2.3) scores (p

The aggregation of power among healthcare systems, covertly cradled under the mantra of improving efficiency, increasing access and enhancing value (bending the so-called ‘cost curve’), embodies an existential threat to both creation and adoption of disruptive and cost-effective technologies. This disruption in innovation will ultimately interfere with doing more of the right things rather than doing the wrong things more effectively. The seismic shift in hospital-based employment models for physicians restricts physician participation in competitive ventures, actively disincentivizes collaboration, dampens free trade and directly inhibits innovation. In addition, group purchasing organizations (GPOs) further degrade innovation by restricting free trade and creating artificial barriers to market entry. Their unique congressional exemption to anti-kickback statutes allows manufacturers to provide GPOs with ‘administrative fees’ (frequently characterized as kickbacks by opponents) designed to block competitive products. We believe that the dramatic cost reductions necessary to transition to more effectively deliver care can only germinate and flourish in an environment conducive to innovation that focuses on outcomes, questions the status quo, embraces teamwork, is inspiring and welcomes experimentation.

Background: Rotator cuff repair is one of the most common surgical procedures performed on the shoulder. Previous studies have indicated that pain and disability can vary significantly between patients with similarly appearing rotator cuff tears on diagnostic imaging. Prior literature has compared functional outcomes between operative and nonoperative treatments as well as variability in surgical techniques. However, few studies have examined postoperative outcomes based on patient factors such as sex. Purpose: To compare patient-reported outcomes after rotator cuff repair between men and women. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 283 patients (153 male, 130 female) who underwent primary arthroscopic rotator cuff repair were included in this study; of those, 275 patients (97.2%) completed 1-year follow-up. Patient-reported pain visual analog scale (VAS), Veterans RAND 12-item Health Survey (VR-12 mental and physical components), American Shoulder and Elbow Surgeons (ASES), and Single Assessment Numeric Evaluation (SANE) scores were collected preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively using an electronic outcomes system. Results: Women reported higher VAS pain scores when compared with men preoperatively ( P < .01) and at 2 weeks ( P < .01), 6 weeks ( P < .01), and 3 months ( P = .02) postoperatively. Additionally, women experienced a greater overall change in the mean VAS score preoperatively when compared with 1 year postoperatively ( P < .01). The use of narcotic pain medication 2 weeks after surgery was greater in women ( P = .032). Women had significantly lower preoperative VR-12 mental scores ( P = .03) and experienced a greater increase in the mean VR-12 mental score preoperatively when compared with 1 year postoperatively ( P < .01). Men had higher ASES scores preoperatively ( P < .01) and at 3 months postoperatively ( P < .01). Women experienced a greater overall change in the ASES score preoperatively when compared with 1 year postoperatively ( P < .01). Conclusion: Women reported greater pain and decreased shoulder function compared with men during the initial 3 months after arthroscopic rotator cuff repair. There were no sex-based differences in patient-reported outcomes at 1-year follow-up. The results of this study indicate that there are sex-related differences in the early postoperative recovery of patients undergoing rotator cuff repair, contributing to postoperative expectations for both clinicians and patients alike.

Anterior glenohumeral instability is common, with 21.9 first-time dislocations per 100,000 individuals per year. Recurrent instability is more likely to occur in patients who are younger, of male sex, and have bone defects or ligament laxity. The open Latarjet procedure is effective for the treatment of recurrent anterior glenohumeral instability and is preferred over arthroscopic Bankart repair in the presence of glenoid bone loss. The Latarjet procedure involves transferring the coracoid to the anterior aspect of the glenoid in the following steps. Step 1: Preoperative planning includes an assessment of glenoid deformation and the integrity of the rotator cuff. The degree of bone loss is measured with use of the circle-line method. Step 2: The patient is in the beach-chair position with the arm in a pneumatic arm holder. A parallel drill guide system with 3.75-mm cannulated screws is utilized. Step 3: A 5-to-6-cm incision is made along the anterior axillary line. The deltopectoral interval is established, and the cephalic vein is mobilized laterally. The coracoacromial ligament is transected 15 mm lateral to the coracoid to allow later repair to the anterior capsule. The pectoralis minor is released subperiosteally off the medial coracoid. A 90° oscillating saw is used to transect the coracoid medially to laterally. The coracohumeral ligament is released. Step 4: Two 4.0-mm drill-holes are made 1 cm apart through the coracoid. The undersurface is decorticated. Step 5: The subscapularis is split at the junction of the upper two-thirds and lower one-third. A longitudinal capsulotomy is performed parallel to the glenoid. Step 6: Soft tissue, including the capsule and labrum, is removed from the anterior aspect of the glenoid. The bone is decorticated with an osteotome and a rasp. Step 7: The coracoid is positioned flush or 1 mm recessed relative to the glenoid. Two 1.6-mm guidewires are placed with use of a parallel drill guide followed by a cannulated reamer and two 3.75-mm cannulated screws. Step 8: The coracoacromial ligament is repaired to the capsule. Step 9: The subscapularis split is repaired laterally. The deltopectoral interval and skin are closed in a standard fashion. A standardized rehabilitation protocol is employed postoperatively. The Latarjet procedure results in significantly lower rates of recurrent glenohumeral instability and revision compared with the arthroscopic Bankart procedure (3% and 1% compared with 28.4% and 21%, respectively); however, complication rates as high as 30% have been reported, as well as a risk for nerve injury. The videos included in this article highlight the critical steps required to optimize outcomes and minimize complications when performing the Latarjet procedure.

Background Evidence suggests a relationship between glenoid retroversion and posterior instability, but no literature exists comparing glenoid version referencing the scapular body versus the endosteal vault. This study evaluated glenoid version and its relationship to unidirectional instability and labral tears. Methods Glenoid version in patients with unidirectional instability or labral tears was measured with magnetic resonance imaging by either the Friedman method or the Poon and Ting method. Analyses of variance followed by independent t tests were used to compare 3 groups: anterior instability or labral tears (anterior pathology group, n = 33); posterior instability or labral tears (posterior pathology group, n = 34); and stable controls (n = 30). The referencing error for 2-dimensional axial images was evaluated for variance by imaging facility. Interobserver and intraobserver reliability scores were calculated. Results With the Friedman method, the posterior pathology group (−9°) was more retroverted than the control group (−4°) ( P = .0005) and the anterior pathology group (−5°) ( P = .0104) but there was no difference between the control group and anterior pathology group ( P = .38). The referencing error in the sagittal plane averaged 23° and varied by facility ( P = .0365). The coronal-plane error averaged 1° and did not vary by facility ( P = .7180). Intraclass correlation coefficient scores showed good to excellent intrarater and inter-rater reliability. Conclusion The posterior pathology group had 5° more retroversion than controls using the Friedman method. Glenoid version using the Poon and Ting method or the Friedman method did not predict anterior instability or labral tears. Axial magnetic resonance images were constructed with a referencing error in the sagittal plane that varied by magnetic resonance imaging facility and has implications for improving 2-dimensional axial imaging protocols.

The societal burden of rotator cuff disease continues to increase with the aging of our population. Rotator cuff repairs have also become increasingly common over the last 2 decades. In our current cost conscious health care environment it is imperative to understand the value delivered to patients

Background Shoulder arthroplasty in individuals aged 50 years or younger reportedly leads to worse outcomes than in older patients. Current methods of determining survivorship may be inadequate and may not reflect actual patient definitions of satisfaction. The purpose of this study is to evaluate and contrast the survival of patient satisfaction and implant survival in the youngest reported patients undergoing either a primary hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) using a third-generation stemmed prosthesis. Methods Outcomes in 71 patients aged 50 years or younger who were treated with primary HA or TSA were evaluated for patient satisfaction and implant survival rates. Patient satisfaction survival was based on yes or no answers to 2 binary questions regarding willingness to undergo surgery again and whether surgery improved the patient's shoulder. Results The Kaplan-Meier patient satisfaction survival rates at 5 years were 71.6% (95% confidence interval [CI], 46%-87%) for HAs and 95% (95% CI, 81%-99%) for TSAs. Multivariable regression analysis implicated postoperative pain as the primary causative factor for failure of patient satisfaction in all patients. In contrast, the implant survival rates at 5 years were 89% (95% CI, 69%-96%) for HAs and 95% (CI, 85%-100%) for TSAs. Conclusions Patients aged 50 years or younger who undergo shoulder arthroplasty have declining rates of self-reported satisfaction despite high implant survival rates, and this finding highlights the discordance between patient satisfaction and implant survival. Primary TSA outperforms HA in both implant survival and patient satisfaction survival rates at short-term follow-up. Future studies and registries must incorporate measurements of patient satisfaction and not just revision rates to truly interpret outcomes.

This study examines the association between strength measurements and supraspinatus tear in patients with shoulder pain. This study characterized determinants of abduction strength among patients with tears.A total of 208 patients with shoulder pain were recruited. Strength was tested using a handheld dynamometer. Supraspinatus tears were diagnosed by combination of clinical assessment and blinded magnetic resonance imaging review. Associations of supraspinatus tear with patient characteristics and strength measurements (abduction, internal rotation and external rotation) were assessed using multivariable logistic regression models.Patients with supraspinatus tear had decreased abduction strength (P = 0.02) and decreased external rotation strength (P0.01). When adjusted for age, sex, tear laterality, and body mass index, decreased abduction strength (odds ratio, 1.18/kg; 95% confidence interval, 1.06-1.32) and decreased external rotation strength (odds ratio, 1.29/kg; 95% confidence interval, 1.14-1.48) were associated with supraspinatus tear. In patients with tear, age 60 yrs or older, female sex, and visual analog scale pain score were significantly associated with decreased abduction strength but tear size, fatty infiltration, and atrophy were not.Decreased abduction and external rotation strength were associated with supraspinatus tear in patients with shoulder pain. In this cohort, the abduction strength of patients with tears was influenced by demographic factors but not tear characteristics.

Complication rates remain high after reverse total shoulder arthroplasty (RTSA). Salvage options after implant failure have not been well defined. This study examines the role of reimplantation and revision RTSA after failed RTSA, reporting outcomes and complications of this salvage technique.Sixteen patients underwent component revision and reimplantation after a prior failed RTSA from 2004 to 2011. Indications included baseplate failure (7 patients, 43.8%), instability (6 patients, 37.5%), infection (2 patients, 12.5%), and humeral loosening (1 patient, 6.3%). The average age of the patient during revision surgery was 68.6 years. Outcomes information at follow-up was recorded, including visual analog scale score for pain, subjective shoulder value, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score, and these were compared with pre-revision values. Repeated surgeries and complications were noted.Average time to follow-up from revision was 58.9 months (minimum, 2 years; range, 24-103 months). The average postoperative visual analog scale score for pain was 1.7/10 (7.5/10 preoperatively; P.0001), and the subjective shoulder value was 62% (17% preoperatively; P.0001). The average postoperative American Shoulder and Elbow Surgeons score was 66.7, and the Simple Shoulder Test score was 52.6. Fourteen patients (88%) noted that they felt "better" postoperatively than before their original RTSA and would go through the procedure again if given the option. Nine patients suffered major complications (56%), and 6 of these ultimately underwent further procedures (38% of cohort).Salvage options after failure of RTSA remain limited. Component revision and reimplantation can effectively relieve pain and improve function compared with baseline values, and patient satisfaction levels are moderately high. However, complication rates and reoperation rates are significant.

Background: Optimal patient selection is key to the success of nonoperative treatment for rotator cuff tears. Purpose: To assess the predictors of pain and functional outcomes in a longitudinal cohort of patients undergoing nonoperative treatment. Study Design: Cohort study; Level of evidence, 2. Methods: A multicenter cohort of patients with rotator cuff tears undergoing nonoperative treatment was recruited from March 2011 to February 2015. Patients completed a detailed health questionnaire, completed standardized shoulder questionnaires including the Shoulder Pain and Disability Index (SPADI), and underwent magnetic resonance imaging. In addition to baseline assessments, patients received follow-up questionnaires at 3, 6, 12, and 18 months. Longitudinal mixed models were used to test predictors of the SPADI score, and interactions with time were assessed. Results: In our cohort of 70 patients, being married as compared with being single/divorced/widowed ( P = .02), a shorter duration of symptoms ( P = .02), daily shoulder use at work that included light or no manual labor versus moderate or heavy manual labor ( P = .04), alcohol use of 1 to 2 times per week or more as compared with 2 to 3 times per month or less ( P = .007), and absence of fatty infiltration ( P = .0009) were significantly associated with decreased SPADI scores (improved shoulder pain and disability) over time. When interactions with time were assessed, having a college level of education or higher compared with less than a college education showed a differential effect over time, with those with a college level of education or more having lower SPADI scores ( P = .004). Partial-thickness tear versus full-thickness tear also had an interaction with follow-up duration, such that those with a partial-thickness tear had lower SPADI scores ( P = .0002). Conclusion: Longitudinal predictors of better outcomes of the nonoperative treatment of rotator cuff tears included being married, having at least a college education, shorter duration of symptoms, light or manual labor in daily work, alcohol use of 1 to 2 times per week or more, partial-thickness tear, and absence of fatty infiltration of the rotator cuff. Our results suggest that nonoperative treatment should be performed early for optimal outcomes. These data can be used to select optimal candidates for the nonoperative treatment of rotator cuff tears and to assist with patient education and expectations before treatment.

Background: Rotator cuff tears are the leading cause of shoulder pain and disability. However, the diagnosis of a rotator cuff tear based on patient characteristics, symptoms, and physical examination findings remains a challenge because of a lack of data. Moreover, data on the predictive ability of a combination of these characteristics and tests are not available from a large cohort of patients. Consequently, clinicians rely on expensive imaging, such as magnetic resonance imaging (MRI), to make a diagnosis. Purpose: To model patient characteristics, symptoms, and physical examination findings that predict a rotator cuff tear. We present a nomogram based on our predictive model that can be used in patients with shoulder pain to determine the probability of the diagnosis of a rotator cuff tear without the need for imaging. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: We recruited patients from outpatient clinics who were ≥45 years of age and who had shoulder pain of at least 4 weeks’ duration. A rotator cuff tear was diagnosed based on expert clinical impression and the presence/absence of a tear on a blinded review of MRI. Ultimately, 301 patients were included in the analysis. Results: A total of 123 patients (41%) had rotator cuff tears, and 178 patients (59%) did not. The predictors of the diagnosis of a rotator cuff tear included external rotation strength ratio of the affected versus unaffected shoulder (odds ratio [OR], 1.20 [95% CI, 1.08-1.34]), male sex (OR, 1.98 [95% CI, 1.10-3.56]), positive lift-off test result (OR, 4.33 [95% CI, 1.46-12.86]), and positive Jobe test result (OR, 9.19 [95% CI, 4.69-17.99]). A nomogram based on these predictor variables was plotted. Conclusion: Presented is a model that can accurately predict the diagnosis of a rotator cuff tear with satisfactory discrimination and calibration based on 4 variables: sex, lift-off test, Jobe test, and external rotation strength ratio. Data from this study can be used to aid in the diagnosis of a rotator cuff tear in day-to-day clinical practice in outpatient settings without the need for expensive imaging such as MRI.

BACKGROUND: We compared the outcomes of patients who performed physical therapy versus those who did not in a longitudinal cohort of patients undergoing nonoperative treatment of rotator cuff tears. We also assessed whether there was a dose effect in which the pain and functional outcomes in patients performing physical therapy plateaued. METHODS: From February 2011 to June 2015, a multicenter cohort of patients with rotator cuff tears undergoing nonoperative treatment completed a detailed health and demographic questionnaire and the Shoulder Pain and Disability Index (SPADI) at baseline and 3, 6, 12, and 18 months. Longitudinal mixed models were used to assess whether physical therapy in the first 3 months predicted SPADI scores and dose effect. RESULTS: Among the 55 patients in our cohort, the performance of physical therapy within the first 3 months predicted better SPADI scores versus nonperformance of physical therapy at 3 months (P = .02). Scores were similar between groups at 6, 12, and 18 months. A threshold of 16 physical therapy sessions was observed for pain and functional improvement during follow-up, after which significant improvement was not seen. CONCLUSIONS: Patients who performed physical therapy within the first 3 months had statistically significant improvements in pain and function as measured by the SPADI score at 3 months compared with patients who did not report performing physical therapy. Depending on the minimal clinically important difference used for the SPADI score, our results could be interpreted as meeting the minimal clinically important difference threshold or not. Improvement in outcomes was observed up to 16 sessions of physical therapy, after which outcomes plateaued. LEVEL OF EVIDENCE: Level III; Retrospective Cohort Comparison; Treatment Study

Background Massive irreparable rotator cuff tears in both the primary and the revision setting are challenging problems. There remains controversy over the ideal treatment methods for these patients. In the case of an irreparable posterosuperior rotator cuff tear, tendon transfers1-12 have emerged as a reliable option, with a durable outcome. The most commonly used tendon transfer options are the latissimus dorsi (LD)1-6and the lower trapezius (LT)12. Description The LD transfer is performed by first harvesting the LT tendon from the humeral shaft. It is critical to release the many adhesions to the muscle belly as well as to separate it from the teres major muscle. The tendon is then transferred intra-articularly, in an interval between the deltoid and the teres minor. The tendon is anchored arthroscopically after preparation of the anterolateral aspect of the tuberosity. The LT transfer is performed by harvesting the LT muscle and tendon off its insertion on the medial aspect of the scapular spine. It should be mobilized to maximize excursion by releasing adhesions. An Achilles tendon allograft is anchored into the anterior aspect of the greater tuberosity arthroscopically. The Achilles tendon is then secured to the LT tendon. Alternatives In addition to tendon transfer, options include:Partial or complete attempted repair13-17.Augmentation or bridging with allografts18-23.Superior capsular reconstruction24.Subacromial balloon25. Rationale There remains a paucity of literature comparing tendon transfers with alternatives. However, when considering a tendon transfer, certain principles are critical in order to achieve an optimal outcome:The recipient and transferred tendons must have similar musculotendinous excursion.The recipient and transferred tendons should have similar lines of pull.One tendon (the transferred) should be designed to replace 1 function (of the recipient).The function of the transferred tendon and muscle should be expendable without substantial donor site morbidity.The strength of the transferred muscle must be at least grade 4.When deciding between the LT and LD transfer, certain considerations should be taken into account. The LD transfer has a proven history of successfully treating massive irreparable posterosuperior rotator cuff tears in studies with long-term follow-up1-6. Alternatively, although the LT transfer has only recently gained popularity, it has the advantage of "in-phase" muscle function, since the trapezius naturally contracts during shoulder external rotation. Furthermore, its line of pull almost completely mimics the infraspinatus.

Shared decision-making provides patients a measure of autonomy in making choices for their health and their future. Patient-reported outcome measures (PROMs) use clinically sensitive and specific metrics to evaluate a patient's self-reported pain, functional ability, and mental state. We conducted a study to create an evidence-based clinical decision-making tool. We used PROMs to create a predictive model of a patient's outcome to help set patient expectations and facilitate a collaborative decision-making environment for patient and physician. The study used a comprehensive prospective database that stores preoperative and 1-year postoperative patient demographics and total shoulder arthroplasty PROM data. Linear regression models were used to evaluate the predictive ability of each factor and the overall predictive ability of each model. One model predicts 1-year postoperative visual analog scale (VAS) pain scores; the other predicts 1-year postoperative American Shoulder and Elbow Surgeons (ASES) Function scores. The total number of observations was 1004 for modeling 1-year postoperative VAS pain scores and 986 for modeling 1-year postoperative ASES Function scores. Regression coefficients and P and ω2 values are reported. Preoperative VAS pain scores predicted 1-year postoperative VAS pain scores (P.001) but not 1-year postoperative ASES Function scores (P = .485). Preoperative Veterans RAND 12-Item Health Survey (VR-12) mental health component summary (MCS) scores predicted self-reported pain and function (Ps.001) 1 year after surgery. In these models, preoperative VR-12 MCS score was the most predictive PROM for 1-year postoperative VAS pain score (ω2 = .023) and 1-year postoperative ASES Function score (ω2 = .029). Together, a patient's preoperative VAS pain score, ASES Function score, VR-12 MCS score, age, sex, and type of arthroplasty can provide significant predictive value that may aid in setting appropriate expectations for pain and function 1 year after surgery.

We conducted a study to compare the clinical results and operative times of knotted and knotless fixation of anterior and posterior glenohumeral labral repairs and superior labrum anterior to posterior (SLAP) repairs. We retrospectively evaluated data that had been prospectively collected from a Surgical Outcomes System database. Knotted and knotless techniques for 226 repairs (59 isolated anterior labral, 95 posterior labral, 72 SLAP) were compared on patient-reported outcome measures (PROMs), including American Shoulder and Elbow Surgeons (ASES) score, visual analog scale pain score, and Veterans RAND 12-Item Health Survey score, obtained before surgery and 6 months and 1 year after surgery. Operative time was recorded as well. One-year follow-up was available for all 226 repairs. There was no statistically difference in PROMs between knotted and knotless anterior labral or SLAP repairs at any point (P.05). ASES scores were higher 6 months after surgery in the knotless group (88.6 vs 84.2; P = .022), but scores 1 year after surgery were the same (88.6 vs 89.8; P = .451). Operative time per anchor was shorter for knotless anterior labral repairs (26 vs 31 min; P = .02) and knotless posterior labral repairs (18 vs 21 min; P = .031) and trended shorter for knotless SLAP repairs (26 vs 37 min; P = .080). There is no difference in PROMs between knotted and knotless labral repairs. Operative times were shorter for anterior and posterior knotless anchors than for knotted anchors. Obtaining equivalent outcomes in less operative time may help decrease healthcare costs and minimize potential complications.