Search

The purpose of this study was to analyze patients that did not return to play (RTP) following arthroscopic Bankart repair (ABR) compared to those who did RTP, and analyze factors associated with not returning to play.A retrospective review of patients who underwent ABR, and subsequently did not RTP after a minimum of 24-month follow-up was performed. Additionally, these were pair matched in a 3:1 ratio for age, gender, sport and level of pre-operative play with a control group who RTP. Patients were evaluated for their psychological readiness to return to sport using the SIRSI score. Multivariate regression models were used to evaluate factors affecting RTP.The study included a total of 52 patients who were unable to RTP and 156 who returned to play. Ten patients (19.2 %) who did not RTP passed the SIRSI benchmark of 56 with a mean overall score of 39.8 ± 24.6, in those who returned 73.0 % passed the SIRSI benchmark of 56 with a mean overall score of 68.9 ± 22.0 (p 0.0001 for both). The most common primary reasons for not returning were 27 felt physically unable to return, whilst 21 felt it was a natural end to their career or their lifestyle had changed. Multi-logistic regression revealed that 4 of the 12 components of the SIRSI score (p 0.05 for all) and SSV (p = 0.0049), were the factors that were associated with RTP.Following ABR, those that do not return to play exhibit poor psychological readiness to return to play, with multi-linear regression revealing the SIRSI questions associated with fear of re-injury were associated with a lower rate of RTP. Additionally, functional limitations were found to be associated with a lower rate of RTP.Level III; Retrospective Comparative Cohort Study.

The purpose of this study was to compare the preoperative magnetic resonance arthrography findings in patients who underwent glenohumeral stabilization with a history of primary instability, recurrent instability, or failed stabilization.All patients who presented with glenohumeral instability and underwent stabilization performed by a single surgeon in our institution between 2008 and 2020 were considered for inclusion in this study. The magnetic resonance arthrography findings of all patients were recorded. Imaging findings were compared between patients with primary instability, those with recurrent instability, and those with failed prior stabilization. P.05 was considered statistically significant.Overall, 871 patients were included, of whom 814 (93.5%) were male patients; the mean age was 23.1 years (range, 13-57 years). There were 200 patients with primary instability, 571 with recurrent instability, and 100 who required revision stabilization surgery, with no significant differences in demographic characteristics between the groups. A significantly higher amount of glenoid bone loss was noted in patients with recurrent instability (43.4%) and failed prior stabilization (56%) than in those with primary instability (26.5%) (P.0001). Additionally, a significantly higher number of Hill-Sachs lesions were observed in patients with recurrent instability (70.1%) and failed prior stabilization (89%) than in those with primary instability (67.5%) (P.0001). We found no significant differences between the groups regarding articular cartilage damage, glenolabral articular disruption, anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligaments, or superior labral anterior-posterior tears (P.05).Patients presenting for stabilization with recurrent instability or following a failed stabilization procedure have higher rates of glenohumeral bone loss than those with primary instability. Therefore, stabilization of primary instability, particularly in high-functioning athletes with a view to preventing recurrence, may reduce the overall progression of glenohumeral bone loss and potential subsequent inferior clinical outcomes.

Context: The COVID-19 pandemic has had catastrophic impact on a global scale, affecting people from all walks of life including elite athletes. Objectives: The purpose of this study was to evaluate the reported rates of return to play (RTP) in conjunction with the expert-derived guidelines previously recommended to enable safe RTP post COVID-19 infection. Evidence Acquisition: Two independent reviewers searched the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, utilizing the MEDLINE, Embase, and Scopus databases. Only studies that reported rates of RTP and/or recommended guidelines for safe RTP were included. Evidence Synthesis: Overall, 17 studies (3 level III and 14 level V) were included. A total of 3 studies reported rates of RTP in a total of 1255 athletes and 623 officials; 72 (30 symptomatic) were infected with COVID-19, 100% of whom were able to RTP post COVID-19 infection. Of the 14 studies recommending guidelines for safe RTP, 3 and 9 studies recommended 7 and 14 days of rest in isolation respectively for asymptomatic patients with COVID-19 infection, prior to safe RTP. In contrast, 7 studies recommended 3 to 6 months of rest (following 14 d isolation) in cases of COVID-19-induced myocarditis as a safe timeframe for safe RTP. Of the 11 studies reporting on whether blanket testing prior to RTP was recommended, only 7 studies recommended a negative test result as mandatory prior to RTP for athletes previously infected with COVID-19. Conclusions: Although excellent rates of RTP have been reported for elite athletes post COVID-19 infection, discrepancies in recommended rest periods, requirement for mandatory negative test results, and the magnitude of screening investigations required continue to exist in the literature, with a need for further standardized international guidelines required in future. Level of Evidence: Level V; systematic review of all forms of evidence.

Background: Injuries of the acromioclavicular joint (ACJ) are common shoulder injuries that often lead to pain and dysfunction of the affected shoulder. Regardless of operative or nonoperative treatment, a relatively large number of patients remain symptomatic and experience pain. However, the specific source of persistent pain in the ACJ remains ambiguous. Purpose: To investigate the presence of sensory nerve fibers or pain-generating neurotransmitters within the intra-articular disk of the ACJ to determine its potential role as an independent pain generator in ACJ disorders. Study Design: Descriptive laboratory study. Methods: Twelve paired ACJs from 6 fresh human cadavers (mean age, 56 years; range, 41-82 years) were harvested and freed from surrounding soft tissues, leaving only the ACJ capsule intact. The specimens were placed in 4.5% formaldehyde fixative for a minimum of 48 hours. Coronal plane sections were obtained and demineralized in EDTA for a week, embedded in paraffin for 12 hours, and dehydrated overnight. With a rotation microtome, 2-μm sections were cut and stained with hematoxylin and eosin to investigate tissue architecture and confirm the presence of a fibrocartilaginous intra-articular disk. The sections were immunohistochemically stained with antisera against S100, neuropeptide Y (NPY), and substance P (SP) to detect for neural tissue. Additionally, a nerve fiber count per 10 high-power fields representing an area of 0.2 mm2 was conducted for S100 stains. All sections were examined for the presence of positive immunoreactivity to S100, NPY, and SP. Results: The presence of a fibrocartilaginous intra-articular disk could be observed in all 12 examined ACJs. In all specimens, an immunoreactivity to S100, NPY, and SP could be observed within the superior peripheral region of the intra-articular disk. High-power field nerve counts of the S100 stains revealed a mean ± SD of 7.9 ± 2.28 nerves per 10 high-power fields (range, 4-12). Conclusion: The documented immunoreactivity to S100, NPY, and SP indicates the presence of somatic and autonomic nerve fibers within the intra-articular disk of the ACJ. Clinical Relevance: Confirming the presence of nerve fibers within the intra-articular disk of the ACJ suggests that the disk itself could be an independent source of pain after injury and thus a possible explanation for recalcitrant pain after treatment.

PURPOSE The purpose of this study was to evaluate the outcomes of athletes 5-years post-operatively following arthroscopic Bankart repair, and to evaluate factors associated with satisfaction and shoulder function, as defined by subjective shoulder value. METHODS A retrospective review of athletes who underwent arthroscopic Bankart repair, with a minimum of 5-year follow-up was performed. Recurrence, Visual Analogue Scale (VAS) score, Subjective Shoulder Value (SSV), satisfaction, and whether they would undergo the same surgery again, and rate, level and timing of return to play, and Shoulder Instability-Return to Sport after Injury (SIRSI) score were evaluated. Multi-linear regression models were used to evaluate factors affecting postoperative Satisfaction, and SSV level. RESULTS Overall, 144 athletes who underwent arthroscopic Bankart repair were included, with a mean age of 26.9 years (SD: 8.1), 132 (91.7%) were males, and mean follow-up of 75.7 months. At final follow up, 82.6% were satisfied/very satisfied, and the mean SSV was 85.8 (SD: 14.4). Overall, the rate of return to play was 80.5%, with 63.9% returning at the same level at a mean of 6.2 months (SD: 2.7). Overall, there was 18 (12.5%) had recurrent instability, and a further procedure was performed in 15 (10.4%) patients. Linear regression revealed that the SIRSI score (p

Purpose To compare the outcomes of athletes who have been treated for either primary or recurrent anterior shoulder instability with arthroscopic Bankart repair (ABR). Methods A retrospective review of patients who underwent ABR for anterior shoulder instability, with a minimum of 24 months’ follow-up, was performed. Those who underwent ABR for primary instability were matched in a 1:1 ratio for age, sex, sport, and level of preoperative play to those who underwent ABR for recurrent instability. The rate, level, and timing of return to play (RTP), as well as the Shoulder Instability–Return to Sport After Injury score, were evaluated. Additionally, the recurrence rate, visual analog scale score, Subjective Shoulder Value, Rowe score, satisfaction, and whether patients would undergo the same operation again were compared. Results After analysis of 467 patients, 100 athletes who underwent ABR for primary instability were identified and subsequently pair matched to 100 patients who underwent ABR for recurrent instability, with a mean age of 27.2 years, 87% male patients, 68% collision athletes, and a mean follow-up period of 61.9 months. There was no significant difference between the groups in the rate of RTP (80% vs 79%, P = .86) or RTP at the preinjury level (65% vs 65%, P >. 999); however, there was a significant difference in time to RTP (6.9 ± 2.9 months vs 5.9 ± 2.5 months, P = .02). There were no significant differences in visual analog scale score, Shoulder Instability–Return to Sport After Injury score, Subjective Shoulder Value, Rowe score, patient satisfaction, and whether patients would undergo the operation again (P > .05 for all). There was no difference in the rate of recurrent instability after ABR (10% vs 16%, P = .29). Conclusions ABR results in excellent clinical outcomes, high rates of RTP, and low recurrence rates for both athletes with primary instability and those with recurrent instability. Level of Evidence Level III, retrospective comparative cohort study.

Importance Tears of the ulnar collateral ligament (UCL) of the elbow occur predominantly as an overuse injury, most commonly affecting throwing athletes, particularly baseball players. UCL reconstruction (UCLR) has been described as an effective treatment modality in the short term. Objective The purpose of this study was to systematically review the evidence in the literature to ascertain the clinical outcomes, complication and revision rates in baseball players following UCLR of the elbow at a minimum of 48 months of follow-up. Evidence review Two independent reviewers performed a search of the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the EMBASE, PubMed and Scopus databases. Clinical studies were included if they reported outcomes of baseball players at a minimum of 48 months following UCLR. Findings Our review included 8 studies including 1104 baseball players (1105 elbows) at mean 69.9 months (48–205) following UCLR. The majority of baseball players were pitchers (92.3%), with a mean age of 22.2 years (13–42). At final follow-up, the overall return to play (RTP) was 95.3%%, with 85.3% returning at pre-injury level. In addition, the mean reported Conway-Jobe score was 86.8%, the revision rate was 6.0% with postoperative neuropathy reported in 2.4% of patients. A total of 479 (43.4%) were professional baseball players, with an overall RTP rate of 97.5% and 82.3% managing to RTP at their pre-injury level. The mean number of career years following UCLR was 4.7 years (0–22). Conclusion and relevance UCLR provides excellent patient-reported and clinical outcomes to patients at medium-term follow-up with low complication and revision rates. In addition, high rates of RTP at pre-injury level and career longevity were reported by baseball players following UCLR. Level of evidence Level IV; Systematic Review

The purpose of this study was to compare the outcomes of open Latarjet (OL) in competitive athletes with primary shoulder instability versus those with recurrent instability versus those undergoing OL for failed prior instability surgery.A retrospective review of patients who underwent OL with a minimum of 24-month follow-up was performed. Additionally, these were pair-matched in a 1:2:1 ratio for age, gender, sport, level of preoperative play, and follow-up length for primary instability, recurrent instability and failed prior instability surgery. Return to sport, the level of return and the timing of return were assessed. Additionally, recurrence, Visual Analogue Scale for pain (VAS), Subjective Shoulder Value (SSV), Rowe score, Shoulder Instability-Return to Sport after Injury (SIRSI) score, satisfaction, and whether they would undergo the same surgery again were compared.After pair-matching, a total of 200 patients were included, with a mean age of 22.7 years and a mean follow-up of 38.8 months. Overall, there was no significant difference in any of the clinical outcome scores (VAS, Rowe, SIRSI, SSV) used for the 3 groups (P0.05 for all). However, there was a significantly lower rate of return to play for those undergoing OL because of failed prior instability surgery (88% vs 91% vs 64%, P0.0001) and for return at the same or a higher level (66% vs 78% vs 56%, P = 0.02). There was no significant difference in the rate of recurrent instability among the 3 groups (6% vs 5% vs 6%, P = 0.95).OL results in excellent clinical outcomes and low recurrence rates for those with primary shoulder instability, those with recurrent instability and those undergoing OL for failed prior instability surgery. However, in those undergoing OL for failed prior stabilization surgery, there was a lower rate of return to play.Level III: Retrospective Comparative Study.

Purpose To evaluate clinical outcomes and rate of return to play (RTP) among athletes aged 30 years or younger who have undergone an arthroscopic rotator cuff repair (ARCR) after trauma. Methods We performed a retrospective review of patients who underwent an ARCR with a minimum of 12 months’ follow-up between 2012 and 2019. Patients were followed up to assess the American Shoulder and Elbow Surgeons score, Subjective Shoulder Value, visual analog scale score, and satisfaction level. Whether patients were able to RTP was reported, in addition to the timing of return and the level to which they returned. Results Our study included 20 athletes (20 shoulders), with a mean follow-up period of 31.8 months. All patients were satisfied with their surgical procedure, and all would opt to undergo surgery again. Overall, 85% returned to sport and 50.0% returned to the same level or a higher level. The overall mean American Shoulder and Elbow Surgeons score was 92.4; mean Subjective Shoulder Value, 87.0; and mean visual analog scale score, 0.7. At final follow-up, only 1 patient (5.0%) had undergone a revision procedure. Of the 15 patients who played collision sports, 93.3% returned to sport but only 60.0% returned to the same level or a higher level. Conclusions After ARCR, athletes aged 30 years or younger show excellent functional outcomes with high rates of patient satisfaction and RTP after the procedure. Level of Evidence Level IV, therapeutic case series.

The aim of this review was to compare clinical and radiological outcome of acromio-clavicular joint reconstruction with allografts versus autografts. The PubMed, MEDLINE, The Cochrane Library and WEB OF SCIENCE databases were searched in accordance with the PRISMA guidelines until February 2020 using the terms: ‘coracoclavicular’ OR ‘coraco-clavicular’ OR ‘acromioclavicular’ OR ‘acromio-clavicular joint’, AND ‘reconstruction’. All studies reporting on clinical and radiological outcome as well as complications after ACJ reconstruction using allo- and/or autografts were included. A total of 29 articles, including 2 prospective and 27 retrospective studies, involving 622 patients, reconstructed with either allo- (n = 360) or auto-grafts (n = 262), for acromio-clavicular joint instability were identified and included in this review. The majority of studies had low sample sizes (66.7% below n = 20), were retrospective (93.3%), with short-term follow-ups (average 26.2 ± 12.6 months; range 6–186). The study with the largest sample size (n = 128) did not report clinical outcome. A comparison between allo- and auto-graft showed no significant differences regarding age, gender, and follow-up times. Clinical outcome was comparable in both groups, loss of reduction (LOR) and complication rates were higher in the allograft group. Overall a reduction of LOR was shown if additional horizontal stabilization was performed. Also a higher LOR and revision rate was documented in allografts without suture or suture-tape augmentation. The use of more clavicular drill-holes correlated with a higher frequency of fracture. A systematic review of the available peer-reviewed literature addressing allograft and autograft reconstruction of unstable coracoclavicular ligaments shows that the published studies are generally of low quality with low levels of evidence. The published literature shows no significant difference in clinical outcomes between the use of autografts or allografts in ACJ reconstruction surgery. Surgical techniques utilizing additional horizontal stabilization may contribute to lower rates of LOR. In cases where allograft tissue is used for ACJ reconstruction the use of suture/tape augmentation may reduce LOR rates as well as revision rates. III.

The purpose of this study was to evaluate the rate of return to play (RTP) in patients who underwent Type V superior labrum anterior–posterior (SLAP) repair compared to patients who underwent isolated Bankart repair in the setting of traumatic anterior shoulder instability. A retrospective review of patients who underwent arthroscopic Bankart repair and SLAP repair by a single surgeon between 2012 and 2017 was performed. Additionally, these were pair-matched in a 1:2 ratio for age, sex, sport and level of pre-operative play, with those undergoing isolated arthroscopic Bankart repair alone as a control group. RTP, level of RTP and the timing of RTP were assessed. The study included a total of 96 patients, with 32 in the study group and 64 in the control group, and a mean follow-up of 59 months. Overall, there was no significant difference in the overall rate of return to play (26/32 (81.3%) vs 56/64 (87.5%), n.s), but there was a significantly higher rate of RTP at the same/higher level in the control group (14/32 (43.6%) vs 43/64 (67.2%), p = 0.0463). There was no significant difference in timing of RTP between the groups (n.s). There was no significant difference in recurrent instability (6/32 (18.8%) vs 5/64 (7.8%), n.s) but there was a significant difference in revision rates (5/32 (15.6%) vs. 2/64 (3.1%), p = 0.0392) between the Type V SLAP repair group and the control group. Following arthroscopic repair, patients with Type V SLAP tears had a similar overall rate of RTP when compared directly to a control group of patients who underwent arthroscopic Bankart repair alone. However, those who underwent Type V SLAP repair reported significantly lower rates of RTP at the same or higher level compared to the control group. III.

Purpose To perform a meta-analysis of the current evidence in the literature comparing arthroscopic Bankart repair versus conservative management for first-time anterior shoulder dislocation. Methods A literature search of the MEDLINE, Embase, and Cochrane Library databases was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Prospective studies comparing arthroscopic Bankart repair versus conservative management as treatment for first-time anterior shoulder dislocation were included. Recurrence, further treatment, and return to play were compared, with all statistical analysis performed using Review Manager, version 5.3. P Results Ten prospective studies with 569 patients were included. Arthroscopic Bankart repair resulted in a lower rate of total recurrent instability (9.7% vs 67.4, I2 = 0, P Conclusions Arthroscopic Bankart repair resulted in a 7-fold lower recurrence rate and a higher rate of return to play than conservative management. Thus, arthroscopic Bankart repair may be advisable to perform routinely in patients with first-time dislocation who participate in sports. Level of Evidence Level II, systematic review of Level I and II studies.

Purpose To systematically review the comparative studies in the literature to compare joint stability, clinical outcomes, and complications of acromioclavicular joint fixation using a hook plate versus arthroscopic suture-button (SB) fixation. Methods A literature search was performed in accordance with the PRISMA guidelines to identify clinical studies comparing the hook plate and arthroscopic SB techniques for acromioclavicular joint injuries. Qualitative statistical analysis was performed using SPSS, and a P value of ≤.05 was considered to be statistically significant. Results Six clinical studies including 285 patients were included in the systematic review. In 3 of the studies, there was a significant difference in favor of SB for Constant score. Patients treated with the SB technique had a lower visual analog scale score at final follow-up in 2 of the 4 studies that measured this outcome. In addition, there were no significant difference in the rate of complications, revisions, or joint malreduction in any of the included studies. Conclusions The arthroscopic SB procedure resulted in lower postoperative pain scores, and improved postoperative functional outcomes, although this was not a clinically significant difference. In addition, there were no significant differences in the rate of complications, revisions, or joint malreduction. Level of Evidence Level III, systematic review of Level I, II, and III studies.

Surgical options for pathology affecting the long head of the biceps tendon (LHBT) include tenotomy and tenodesis, both of which can be performed with a variety of fixation methods. This study aimed to compare surgical treatment options for LHBT lesions using a network meta-analysis of published clinical studies.A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Clinical studies comparing surgical treatment options for LHBT lesions were included. Postoperative outcomes were compared between surgical treatment options using a frequentist approach to network meta-analysis.There were 22 studies comparing surgical treatment options for LHBT pathology including arthroscopic tenotomy, arthroscopic suprapectoral tenodesis, arthroscopic intracuff tenodesis, and open subpectoral tenodesis, consisting of 1804 patients. Compared with arthroscopic tenotomy, open subpectoral tenodesis resulted in a significantly greater American Shoulder and Elbow Surgeons score (mean difference, 4.58; P = .014). On the basis of the P-score, all 3 tenodesis techniques ranked above tenotomy with respect to the Constant score. Compared with arthroscopic tenotomy, the incidence of Popeye deformity was reduced with arthroscopic suprapectoral tenodesis (odds ratio [OR], 0.23; P.001) and open subpectoral tenodesis (OR, 0.25; P = .022). The incidence of bicipital groove pain was increased after arthroscopic intracuff tenodesis (OR, 2.89; P = .021) compared with arthroscopic tenotomy.Lesions of the LHBT treated with open or arthroscopic tenodesis resulted in comparatively superior functional outcomes and a lower incidence of Popeye deformity, whereas arthroscopic intracuff tenodesis resulted in a higher incidence of bicipital groove pain.

Purpose The purpose of this study was to identify modifiable factors associated with research activity among residents working in orthopedic surgery and traumatology. Methods Residents at 796 university-affiliated hospitals in Austria, Germany, and Switzerland were invited to participate. The online survey consisted of questions that ascertained 13 modifiable and 17 non-modifiable factors associated with the residents’ current research activities. Responses of 129 residents were analyzed. Univariate linear regression was used to determine the association of individual factors with the current research activity (hours per week). The impact of significant non-modifiable factors (with unadjusted p values Results The univariate analysis demonstrated six non-modifiable factors that were significantly associated with the current research activity: a University hospital setting (p p = 0.024), Swiss residents (p = 0.0012), the completion of a dedicated research year (p = 0.007), female gender (p = 0.016), and the department’s size (p = 0.048). Multivariate regression demonstrated that the number of protected research days per year (p p p Conclusions As hypothesized, more frequent and predictable protected research days were associated with higher research activity among residents in orthopedic surgery and traumatology. Level of evidence III.

Biceps tenodesis is widely used as a primary treatment for long head of the biceps brachii pathology and superior labral anterior and posterior (SLAP) lesions. However, rates and timing of full return to sports (RTSs)/duty have not been systematically analysed. This systematic review examines the literature to ascertain the rate and timing of return to athletic activity, and the availability of specific criteria for safe return to atheletic activity following the biceps tenodesis. Based on PRISMA guidelines, this systematic review utilised the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to athletic activity following biceps tenodesis. Statistical analysis was performed using SPSS. This review identified 17 studies including 374 cases meeting the inclusion criteria. The majority of patients were men 260 (69.7%), with an median age of 42.2 years (range 16–88) and a mean follow-up of 37.4 months. The overall rate of RTS was 217/269 (80.7%), with 43/59 (72.9%) returning to the same level. In overhead athletes, the overall rate of return to play was 39/49 (79.6%). Among military personnel, the overall rate of return to duty was 61/74 (82.4%). The average time to RTS was 5.4 (range 3–11) months. 10 (58.8%) Studies reported a recommended time window within which patients were allowed to return to full activity. Specific criteria for return to play were not reported in any of the identified studies. While overall rate of return to athletic activity was reportedly high following biceps tenodesis, one in four patients were not able to resume athletic activity at the same level. At present, there is no objective assessment of when patients can return to full activity reported in the literature. IV.

Background: The rotator cuff is known to consist of 2 macroscopically visible layers that have different biomechanical properties. Sometimes the inferior layer may be neglected during rotator cuff repair. However, it is controversial whether double-layer (DL) repair is superior to single-layer (SL) repair in terms of retear rate and outcome. Purpose: To investigate whether DL as compared with SL repair could decrease retear rates after arthroscopic reconstruction of posterosuperior rotator cuff tears. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 70 patients were 1:1 randomized to receive an arthroscopic DL reconstruction (study group: DL suture-bridge repair) or SL reconstruction (control group: SL suture-bridge repair) for posterosuperior tears of the rotator cuff between 2.0 and 3.5 cm of the footprint detachment. Exclusion criteria were subscapularis tendon rupture (Lafosse >1°), fatty muscular infiltration >2°, and nondelaminated tendons. Tendon integrity according to Sugaya, fatty degeneration, and muscular atrophy were evaluated by magnetic resonance tomography. Pre- and postoperative evaluations included the Constant score, range of motion, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, subjective shoulder value, and postoperative satisfaction with the procedure. Complications were monitored throughout the study. Results: Ninety percent of patients (n = 34, DL; n = 29, SL) were followed-up. There were no significant group differences regarding baseline characteristics and pre- and postoperative fatty degeneration of the supraspinatus and atrophy of the supraspinatus and infraspinatus. The rate of magnetic resonance–verified intact repairs (Sugaya grades 1 + 2) was significantly higher in the DL group (70.6%) than in the SL group (44.8%; P = .045). One patient in the control group with a retear underwent revision. All functional and subjective scores improved significantly pre- to postoperatively in both groups ( P < .05). No significant group differences were detected regarding postoperative Constant score, forward flexion, external rotation, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, subjective shoulder value, and visual analog scale and between intact and retorn tendons. The majority of patients were very satisfied or satisfied with their arthroscopic procedure (DL, 94.1%; SL, 92.9%). Conclusion: This randomized controlled trial showed significantly lower retear rates after DL repair as compared with SL repair in delaminated rotator cuff tears. Clinical short-term outcome was not different between the DL and SL repair groups. Registration: NCT003362320 (ClinicalTrials.gov identifier).

Purpose To identify an effective, nonenzymatic method for maximizing the yield of subacromial bursa-derived nucleated cells for augmenting rotator cuff repair. Methods Subacromial bursa (minimum 0.2 g) was collected prospectively over the supraspinatus from patients (n = 7) with at least one full-thickness tendon tear undergoing arthroscopic primary rotator cuff repair. Samples were processed and analyzed prospectively using 4 different methods: (1) mechanical digestion with scissors (chopping), (2) collagenase digestion, (3) mechanical digestion with a tissue homogenizer, and (4) whole tissue with minimal manipulation. Tissue from each method were plated and cultured in a low oxygen tension, humidified incubator for 7 days. Following incubation, cellularity was assessed with nucleated cell count using a Coulter Counter. Flow cytometry was performed on the non-enzymatic method that demonstrated the greatest cell count to confirm the presence of mesenchymal stem cells (MSCs). The Kruskal–Wallis H test and post hoc Dunn's test were used for statistical analysis. Results Following incubation, mean nucleated cell counts (cells/mL) were (1) 102,681 ± 73,249 for chopping, (2) 76,190 ± 66,275 for collagenase, (3) 31,686 ± 29,234 for homogenization, and (4) 11,162 ± 4016 for whole tissue. There was no significant difference between chopping and collagenase (P = .45) or between homogenization and collagenase (P = .52). Both chopping (P = .003) and collagenase (P = .03) produced significantly more cells when compared with whole tissue. Flow cytometry confirmed the presence of MSC markers on samples processed by chopping. Conclusions Mechanical isolation of subacromial bursa-derived cells using a chopping technique demonstrated similar nucleated cell count compared with collagenase, along with the confirmed presence of MSCs. Clinical Relevance This study demonstrated a nonenzymatic, mechanical method for isolating subacromial bursa-derived cells to potentially augment rotator cuff repair. Further clinical studies are required to assess its possible advent in the tendon–bone healing process.

Scientific interest in optimizing outcomes after anterior cruciate ligament (ACL) reconstruction is ongoing, and some recent developments have focused on graft shape as one of the most important factors of anatomic graft placement. The double-bundle or fanlike structure of the native ACL seems to more closely restore normal function and control of rotational stability of the knee with implant-free or press-fit techniques, creating a favorable situation in terms of direct graft-tunnel healing. The ACL reconstruction technique presented in this article enables safe, reproducible, and anatomic fixation of the patellar tendon autograft, providing the biological and biomechanical benefits of direct bony integration of the ribbonlike bone–patellar tendon–bone graft. Because press-fit fixation represents a technically challenging surgical procedure, the goal of the described technique is to enable direct bone-to-bone healing by using secondary extracortical femoral and tibial fixation without the need for a true press-fit situation. Safe and anatomic femoral tunnel drilling is achieved with an outside-in technique (retrograde drilling), hence providing advantages in the routine clinical setting in terms of applicability and time effort. To reduce donor-site morbidity caused by bone block harvesting, refilling of the harvest sites with autologous material is performed.

Background: In athletes with a first-time shoulder dislocation, arthroscopic Bankart repair (ABR) and the open Latarjet procedure (OL) are the most commonly utilized surgical procedures to restore stability and allow them to return to play (RTP). Purpose: To compare the outcomes of ABR and OL in athletes with a first-time shoulder dislocation. Study Design: Cohort study; Level of evidence, 3. Methods: We performed a retrospective review of patients with first-time shoulder dislocation who underwent primary ABR and OL and had a minimum 24-month follow-up. Indications for OL over ABR in this population were those considered at high risk for recurrence, including patients with glenohumeral bone loss. Patients who underwent ABR were pair-matched in a 2:1 ratio with patients who underwent OL by age, sex, sport, and level of preoperative play. The rate, level, and timing of RTP, as well as the Shoulder Instability–Return to Sport after Injury (SIRSI) score were evaluated. Additionally, we compared recurrence, visual analog scale pain score, Subjective Shoulder Value, Rowe score, satisfaction, and whether patients would undergo the surgery again. Results: Overall, 80 athletes who underwent ABR and 40 who underwent OL were included, with a mean follow-up of 50.3 months. There was no significant difference between ABR and OL in rate of RTP, return to preinjury level, time to return, or recurrent dislocation rate. There were also no differences between ABR and OL in patient-reported outcome scores or patient satisfaction. When collision athletes were compared between ABR and OL, there were no differences in RTP, SIRSI score, or redislocation rate. Conclusion: ABR and OL resulted in excellent clinical outcomes, with high rates of RTP and low recurrence rates. Additionally, there were no differences between the procedures in athletes participating in collision sports.

The purpose of this study is to systematically review the randomized controlled trials on the various treatment options that can be utilized in the management of displaced proximal humerus fractures.Based on the PRISMA guidelines, three independent reviewers performed a systematic review of the literature. Randomized control trials (RCTs) focusing on the outcomes of the following interventions in the management of PHFs were considered for inclusion; (1) non-operative or conservative (NOC) management, (2) open reduction and internal fixation (ORIF), (3) intra-medullary nailing (IMN), (4) shoulder hemi-arthroplasty (HA), and (5) reverse shoulder arthroplasty (RSA). Network meta-analyses were performed using R and studies were ranked according to their P-score.Our study included 13 RCTs. RSA had improvements in abduction, constant score, flexion, as well as lowest rates of malunion and osteonecrosis when compared to other management modalities (P-Score = 0.9786, P-Score = 0.9998, P-Score = 0.9909, P-Score = 0.9590 and P-Score = 0.8042 respectively). HA was found to have improvements in health-related quality of life scores when compared to other management modalities (P-Score = 0.9672). ORIF had the highest improvement in quick disability of arm, shoulder and hand scores and visual analogue scale scores (P-Score = 0.8209 and P-Score = 0.7155 respectively). NOC was found to have the lowest rate of conversion to surgical intervention, with RSA having the lowest rate of surgical interventions (P-Score = 0.9186 and P-Score = 0.7497 respectively).RSA offers satisfactory improvements in clinical and functional outcomes when compared to other non-operative and operative treatment options in the management of carefully selected proximal humerus fractures, with a minimal revision rate when compared to other surgical management modalities.I - Systematic ReviewMeta-Analysis of Randomized Control Trials.

Background: Mechanisms previously described for traumatic shoulder injuries in rugby may not adequately describe all the mechanisms that result in shoulder dislocations. Purpose: To investigate the mechanism of shoulder dislocation events in professional rugby players through use of systematic video analysis. Study Design: Case series; Level of evidence, 4. Methods: In our series, 39 cases of shoulder dislocations from games played in top professional leagues and international matches across a 2-year period were available for video analysis. All cases were independently assessed by 2 analysts to identify the sequence of events occurring during shoulder dislocation. This included injury circumstance such as contact with another player or the ground, game scenario, injury timing, and the movements and force vectors involved in the dislocation mechanism. Results: We identified 4 distinct injury mechanisms. The previously described mechanisms “try scorer,”“tackler,” and “direct impact” were identified in 67% of cases. We describe a new injury mechanism occurring in the “poach position,” accounting for 18% of all shoulder dislocations studied. The remaining 15% could not be categorized. Shoulder dislocations occurred to a ball carrier in 15% of cases (n = 6) and a non–ball carrier in 85% of cases (n = 33). The injury most commonly occurred during a tackle (49%; n = 19) followed by ruck/maul (26%; n = 10). Time of injury showed that 36% (n = 14) of cases occurred in the last quarter of the game. Conclusion: Shoulder dislocations have now been shown to occur predominantly as a result of 1 of 4 distinct mechanisms, most frequently in the second half of the game. A new mechanism for shoulder dislocation has been described in this series, termed the poach position.

Background Massive irreparable rotator cuff tears (RCT) may cause severe functional impairment and pain as a result of loss of superior humeral stability. Reconstruction of the superior capsule (SCR) has been reported to restore glenohumeral stability and function. Objective The purpose of this study was to investigate short-term functional and radiological outcome after arthroscopic SCR with a human dermal allograft for irreparable RCT. Methods In total, 21 patients (mean age 65.9 years, 50–77), who underwent arthroscopic SCR were prospectively enrolled in the present study. Magnetic resonance images (MRI) were obtained before and 12 months after surgery to evaluate graft survival. Functional and subjective outcome including the Constant score (CS), the American Shoulder and Elbow Surgeons score (ASES), and the Simple Shoulder Test (SST) was evaluated preoperatively as well as 3–6 and 12 months postoperatively and was compared between patients with and without preoperative pseudoparalysis. Complications were recorded. Results The MRI evaluation revealed intact grafts in 71.4% of patients 1 year postoperatively; these patients showed significant improvements from baseline to follow-up time points regarding the total CS and its subgroups pain, activity of living, range of motion, strength, ASES, and SST (p Conclusion Arthroscopic SCR with a human dermal allograft in patients with irreparable RCT restored shoulder function and relieved pain in patients without and with preoperative pseudoparalysis.

To evaluate the prevalence of Cutibacterium acnes in the shoulder region and to analyze changes in C acnes contamination during shoulder arthroscopy, as well as to investigate the influence of sex and type of arthroscopic surgery on those parameters.Forty-eight consecutive patients undergoing reconstructive or non-reconstructive shoulder arthroscopy, after hair removal with a medical clipper, routine antibiotic prophylaxis, and skin preparation with an alcohol-based skin disinfectant, were prospectively enrolled in this study. The shoulder was divided into 4 regions of interest (anterior, medial, posterior, and axilla). Skin swabs were taken from each region at 3 time points (preoperatively before and after skin preparation, and at the conclusion of surgery), cultured for 21 days, and analyzed for the prevalence of C acnes.The rate of C acnes-positive skin cultures was significantly increased at the end of surgery compared with preoperatively before (44.3% vs 27.6%, P.001) and after (44.3% vs 31.3%, P = .001) skin preparation. No reduction in C acnes was observed with preoperative skin preparation (27.6% vs 31.3%, P = .401). At the end of shoulder arthroscopy, 64.6% of patients showed at least 1 culture positive for C acnes. The C acnes prevalence was significantly higher in male patients (48.3%) than female patients (20.1%, P.001), at all time points (P.016), and in all regions of interest (P.001) except the axilla. No differences in the prevalence of C acnes were found between non-reconstructive and reconstructive procedures.Skin contamination with C acnes around the shoulder increased significantly from before and after skin preparation to the conclusion of surgery in patients undergoing shoulder arthroscopy despite perioperative preventive measures.Level IV, therapeutic case series.

To compare functional outcomes and magnetic resonance image (MRI) tendon integrity following either the suture bridge or the knotless cinch-bridge technique used for arthroscopic double-layer rotator cuff repair. 37 prospectively enrolled patients (46–76 years), who were treated with arthroscopic double-layer rotator cuff repair (group 1: suture bridge n = 20, group 2: cinch bridge n = 17) were clinically and radiographically assessed before and at an average of 24.0 ± 4.7 months after the procedure. Shoulder function was evaluated by the constant score (CS), range of motion, and various patient-related scores. Repaired tendon integrity was evaluated by MRI. Peri- and postoperative complications were recorded. All functional and patient-related scores significantly improved from pre- to postoperative. Significantly better postoperative CS (P = 0.037), flexion (P

Purpose To perform a systematic review of randomized controlled trials on the use of platelet-rich plasma (PRP) for nonoperative treatment of rotator cuff disease. Methods Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2 reviewers independently screened the MEDLINE, Embase, and Cochrane Library databases for prospective, randomized controlled trials comparing PRP with a control in the nonoperative treatment of chronic rotator cuff disease for inclusion. Clinical data were extracted and evaluated. The quality of evidence was assessed using The Cochrane Collaboration risk-of-bias tool. Results Five randomized controlled trials met the inclusion criteria, with 108 patients treated with PRP and 106 treated with a control. The mean age was 53.7 years, and 61.6% of patients were female patients. All of the studies found that the groups receiving PRP injections experienced improved clinical outcomes at final follow-up compared with baseline. Two studies found that PRP resulted in improved outcomes, mostly pain scores, compared with a control. One study compared PRP with formal exercise versus a saline solution injection with formal exercise therapy. It showed no difference in clinical outcomes between PRP and a saline solution injection when formal exercise therapy was used. Two other studies reported that PRP alone resulted in inferior outcomes to control groups receiving formal exercise therapy. Conclusions The currently limited available evidence on PRP for nonoperative treatment of chronic rotator cuff disease suggests that in the short term, PRP injections may not be beneficial. When directly compared with exercise therapy, PRP does not result in superior functional outcomes, pain scores, or range of motion. However, interpretation of this literature is confounded by the lack of reporting of the cytology and characteristics of PRP. Level of Evidence Level II, systematic review of Level I and II evidence.

To investigate (1) tendon delamination according to different rotator cuff tear patterns as well as (2) the association of tendon retraction and fatty muscle infiltration with delamination of the rotator cuff. Furthermore, we aimed to establish the accuracy of magnetic resonance imaging for the detection of rotator cuff delamination.Magnetic resonance imaging scans of patients who underwent arthroscopic rotator cuff repair from 2013 to 2015 were retrospectively compared to intraoperative findings. Prevalences of tendon delamination, tendon retraction, and fatty muscle infiltration were categorized according to different rotator cuff tear patterns. For comparability of the amount of tendon retraction of delaminated and non-delaminated rotator cuff tears, we introduced the global retraction index, a description individually assessing tendon retraction in magnetic resonance imaging scans of all visible layers.Of 349 shoulders, tendon delamination was observed in 231 patients (66.2%). Of these, rotator cuff delamination was most commonly seen in posterosuperior rotator cuff tears (84.6%). Delaminated rotator cuff tears presented with a significantly higher global retraction index (P.001) as well as higher fatty muscle infiltration of the supraspinatus (P = .001) and infraspinatus (P = .001). Magnetic resonance imaging had only moderate accuracy (57.3%) to detect rotator cuff delamination, with a positive predictive value of 100% (95% confidence interval [CI] 95.6% to 100.0%) and a negative predictive value of 44.2% (95% CI 38.1% to 50.4%).Tendon delamination was most commonly observed in posterosuperior rotator cuff tears. Delaminated rotator cuff tears showed a significantly greater tendon retraction as well as a higher amount of fatty muscle infiltration of the supraspinatus and infraspinatus. Magnetic resonance imaging has only moderate accuracy for detection of rotator cuff delamination.III, retrospective cohort study.

The purpose of this study was to evaluate the outcomes of athletes 5-years post-operatively following arthroscopic Bankart repair, and to evaluate factors associated with satisfaction and shoulder function, as defined by subjective shoulder value.A retrospective review of athletes who underwent arthroscopic Bankart repair, with a minimum of 5-year follow-up was performed. Recurrence, Visual Analogue Scale (VAS) score, Subjective Shoulder Value (SSV), satisfaction, and whether they would undergo the same surgery again, and rate, level and timing of return to play, and Shoulder Instability-Return to Sport after Injury (SIRSI) score were evaluated. Multi-linear regression models were used to evaluate factors affecting postoperative Satisfaction, and SSV level.Overall, 144 athletes who underwent arthroscopic Bankart repair were included, with a mean age of 26.9 years (SD: 8.1), 132 (91.7%) were males, and mean follow-up of 75.7 months. At final follow up, 82.6% were satisfied/very satisfied, and the mean SSV was 85.8 (SD: 14.4). Overall, the rate of return to play was 80.5%, with 63.9% returning at the same level at a mean of 6.2 months (SD: 2.7). Overall, there was 18 (12.5%) had recurrent instability, and a further procedure was performed in 15 (10.4%) patients. Linear regression revealed that the SIRSI score (p 0.0001), SSV (p 0.0001), VAS (p 0.0031), no sleep trouble (p = 0.0129) was associated with satisfaction. Logistic regression revealed whether a patient required revision surgery (p = 0.0029), or had re-dislocation (p = 0.0031) was also associated with satisfaction. Linear regression revealed that the SIRSI score (p 0.0001), VAS score (p 0.0001), and no sleep trouble (p 0.0001), were associated with SSV score.There was a high rate of satisfaction at 5-year follow-up, with excellent patient-reported outcomes and a high rate of return to play among athletes. However, there was a moderate rate of recurrent instability and further revision surgery. This study identified that the SIRSI score, VAS score, no sleep trouble and ability to return to play at the same level were associated with both satisfaction and SSV score.III.

Background The purpose of this study was to systematically review the literature to evaluate the functional outcomes, radiologic outcomes, and revision rates following radial head arthroplasty (RHA) at a minimum of 8 years follow-up. Methods Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using PubMed, Embase, and Web of Science databases. Only studies reporting on outcomes of RHA with a minimum of mean 8 years' follow-up were considered for inclusion. Results Our search found 10 studies including 432 elbows (51% males), with average age of 50 years (15-93) and mean follow-up of 117 months (98-145) met our inclusion criteria. At final follow-up, the mean Mayo Elbow Performance Score and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score were 83 (45-100) and 17 (0-63) respectively, and 86% of patients reported having no or minimal pain. The overall dislocation, subluxation, ulnar neuritis, and infection rates were 2%, 4%, 3%, and 3%, respectively. The rates of radiologic loosening, radiolucency, degenerative change, and heterotopic ossification were 9%, 46%, 27%, and 38%, respectively. The overall surgical revision rates were 20%, with 3%, 15%, and 5% requiring RHA implant revision, removal of metal or implants, and arthrolysis, respectively. Conclusion Our systematic review established that RHA results in satisfactory clinical outcomes and modest complication and revision rates at long-term follow-up, despite high levels of radiologic degenerative changes over the same period.

Background: The Latarjet procedure is indicated for patients with recurrent anterior shoulder instability, previous failed soft tissue stabilization, glenoid bone loss, or high-risk factors for recurrence, although there is still a concern with the surgical complication rates associated with the Latarjet procedure. Purpose: To evaluate the 90-day complication rate after the open Latarjet procedure in a high-volume center. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review was performed of patients who underwent an open Latarjet procedure at our institution over a 5-year period between January 2015 and December 2019. The complications, readmissions, and reoperations within 90 days were evaluated. Results: A total of 441 patients with a mean age of 23.0 ± 5.7 years was included; 97.5% of the patients were male. There were 2 intraoperative complications (0.5%): 1 coracoid fracture and 1 anaphylactic reaction to vancomycin. Overall, there were 19 postoperative complications (4.3%) in 18 patients, with 4 (0.9%) readmissions for revision surgery. Hematomas were the most common complication, occurring in 12 patients (2.7%), with 9 (2.0%) requiring a return to the operating theater during their stay for an evacuation. In those who required a readmission for a reoperation, 1 was for a hematoma requiring a washout, 2 were for irrigation and debridement of a surgical site infection, and the third was for a biceps tenodesis in a patient with severe bicipital pain. No patients had recurrence or any postoperative graft complications; additionally, there were no neurovascular complications. Conclusion: We found that in a high-volume center, the open Latarjet procedure has a low 90-day complication rate with a low revision rate. Hematomas were the most common complication experienced by patients who underwent the Latarjet procedure, while there was no recurrent instability or neurological or hardware complications reported among the 441 patients included in this study.