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Advances in the understanding and management of glenoid bone loss in shoulder instability have led to the development of alternative bony reconstruction techniques to the Latarjet using free bone grafts, but little is known about surgeon adoption of these procedures. This study sought to characterize surgeon variation in the use of glenoid bone reconstruction procedures for shoulder instability and ascertain reasons underlying procedure choice.A 9-question survey was created and distributed to 160 shoulder surgeons members of the PacWest Shoulder and Elbow Society, of whom 65 (41%) responded. The survey asked questions regarding fellowship training, years in practice, surgical volume, preferred methods of glenoid bone reconstruction, and reasons underlying treatment choice.All surgeons completed a fellowship, with an equal number of sports medicine fellowship-trained (46%) and shoulder and elbow fellowship-trained (46%) physicians. The majority had been in practice for at least 6 years (6-10 years: 25%;10 years: 59%). Most (78%) performed ≤10 glenoid bony reconstructions per year, and 66% indicated that bony procedures represented10% of their total annual shoulder instability case volume. The open Latarjet was the preferred primary reconstruction method (69%), followed by open free bone block (FBB) (22%), arthroscopic FBB (8%), and arthroscopic Latarjet (1%). Distal tibia allograft (DTA) was the preferred graft (74%) when performing an FBB procedure, followed by iliac crest autograft (18%), and distal clavicle autograft (6%). The top 5 reasons for preferring Latarjet over FBB were the sling effect (57%), the autologous nature of the graft (37%), its robust clinical evidence (22%), low cost (17%), and availability (11%). The top 5 reasons for choosing an FBB procedure were less anatomic disruption (58%), lower complication rate (21%), restoration of articular cartilage interface (16%), graft versatility (11%), and technical ease (11%). Only 20% of surgeons indicated always performing a bony glenoid reconstruction procedure in the noncontact athlete with less than 20% glenoid bone loss. However, that percentage rose to 62% when considering a contact athlete with the same amount of bone loss.Although open Latarjet continues to be the most popular glenoid bony primary reconstruction procedure in shoulder instability, nearly 30% of shoulder surgeons in the western United States have adopted FBB techniques as their preferred treatment modality--with DTA being the most frequently used graft. High-quality comparative clinical effectiveness research is needed to reduce decisional conflict and refine current evidence-based treatment algorithms.

Purpose The purpose of this study was to perform a Delphi consensus for the treatment of patients with shoulder impingement with intact rotator cuff tendons, comparing North American to European shoulder surgeon preferences. Methods Nineteen surgeons from North America [NAP] and 18 surgeons from Europe [EP] agreed to participate and answered 10 open-ended questions in rounds 1 and 2. The results of the first two rounds were used to develop a Likert style questionnaire for round 3. If agreement at round 3 was 60% for an item, the results were carried forward into round 4. For round 4 the panel members outside consensus >60%, Results There was agreement on the following items: impingement is a clinical diagnosis; a combination of clinical tests should be used; other pain generators must be excluded; radiographs must be part of the work up; MR imaging is helpful; the first line of treatment should always be physiotherapy; a corticosteroid injection is helpful in reducing symptoms; indication for surgery is failure of non-operative treatment for a minimum of 6 months. The NAP were likely to routinely prescribe NSAIDs [NA 89%; EU 35%] and consider steroids for impingement [NA 89%. EU 65%]. Conclusion Consensus was achieved for 16 of the 71 Likert items: impingement is a clinical diagnosis and a combination of clinical tests should be used. The first line of treatment should always be physiotherapy, and a corticosteroid injection can be helpful in reducing symptoms. The indication for surgery is failure of non-operative treatment for a minimum of 6 months. The panel also agreed that SAD is a good choice for shoulder impingement if there is evidence of mechanical impingement with pain not responding to non-surgical measures.

Arthroscopic shoulder stabilization is the most commonly used technique to treat shoulder instability; however, recurrence rates have been shown to be high in our literature. Optimizing treating of glenohumeral instability is crucial to improve patient outcomes. This chapter will provide a basic review of the key steps in the evaluation and management of patients with shoulder instability with minimal bone loss.

To determine the inter-rater reliability (IRR) of a procedure-specific checklist scored in a binary fashion for the evaluation of surgical skill and whether it meets a minimum level of agreement (≥0.8 between 2 raters) required for high-stakes assessment.In a prospective randomized and blinded fashion, and after detailed assessment training, 10 Arthroscopy Association of North America Master/Associate Master faculty arthroscopic surgeons (in 5 pairs) with an average of 21 years of surgical experience assessed the video-recorded 3-anchor arthroscopic Bankart repair performance of 44 postgraduate year 4 or 5 residents from 21 Accreditation Council for Graduate Medical Education orthopaedic residency training programs from across the United States.No paired scores of resident surgeon performance evaluated by the 5 teams of faculty assessors dropped below the 0.8 IRR level (mean = 0.93; range 0.84-0.99; standard deviation = 0.035). A comparison between the 5 assessor groups with 1 factor analysis of variance showed that there was no significant difference between the groups (P = .205). Pearson's product-moment correlation coefficient revealed a strong and statistically significant negative correlation, that is, -0.856 (P.000), indicating that as intra-operative error rate scores increased, the IRR decreased.Arthroscopy Association of North America shoulder faculty raters from across the United States showed high levels of IRR in the assessment of an arthroscopic 3-anchor Bankart repair procedure. All paired assessments were above the 0.8 level and the mean IRR of all resident assessments was 0.93, indicating that they could be used for high-stakes decisions.With the move toward outcomes-based performance evaluation for graduate medical education, high-stakes assessments of surgical skill will require robust, reliable measurement tools that are able to withstand challenge. Surgical checklists employing metrics scored in a binary fashion meet the need and can show a high (80%) IRR.

Purpose To create and determine face validity and content validity of arthroscopic rotator cuff repair (ARCR) performance metrics, to confirm construct validity of the metrics coupled with a cadaveric shoulder, and to establish a performance benchmark for the procedure on a cadaveric shoulder. Methods Five experienced arthroscopic shoulder surgeons created step, error, and sentinel error metrics for an ARCR. Fourteen shoulder arthroscopy faculty members from the Arthroscopy Association of North America formed the modified Delphi panel to assess face and content validity. Eight Arthroscopy Association of North America shoulder arthroscopy faculty members (experienced group) were compared with 9 postgraduate year 4 or 5 orthopaedic residents (novice group) in their ability to perform an ARCR. Instructions were given to perform a diagnostic arthroscopy and a 2-anchor, 4–simple suture repair of a 2-cm supraspinatus tear. The procedure was videotaped in its entirety and independently scored in blinded fashion by trained, paired reviewers. Results Delphi panel consensus for 42 steps and 66 potential errors was obtained. Overall performance assessment showed a mean inter-rater reliability of 0.93. Novice surgeons completed 17% fewer steps (32.1 vs 37.5, P = .001) and enacted 2.5 times more errors than the experienced group (6.21 vs 2.5, P = .012). Fifty percent of the experienced group members and none of the novice group members achieved the proficiency benchmark of a minimum of 37 steps completed with 3 or fewer errors. Conclusions Face validity and content validity for the ARCR metrics, along with construct validity for the metrics and cadaveric shoulder, were verified. A proficiency benchmark was established based on the mean performance of an experienced group of arthroscopic shoulder surgeons. Clinical Relevance Validated procedural metrics combined with the use of a cadaveric shoulder can be used to accurately assess the performance of an ARCR.

Purpose: To determine if previously validated performance metrics for an arthroscopic Bankart repair (ABR) coupled with a cadaveric shoulder are a valid assessment tool with the ability to discriminate between the performances of experienced and novice surgeons and to establish a proficiency benchmark for an ABR using a cadaveric shoulder. Methods: Ten master/associate master faculty from an Arthroscopy Association of North America Resident Course (experienced group) were compared with 12 postgraduate year 4 and postgraduate year 5 orthopaedic residents (novice group). Each group was instructed to perform a diagnostic arthroscopy and a 3 suture anchor Bankart repair on a cadaveric shoulder. The procedure was videotaped in its entirety and independently scored in blinded fashion by a pair of trained reviewers. Scoring was based on defined and previously validated metrics for an ABR and included steps, errors, “sentinel” (more serious) errors, and time. Results: The inter-rater reliability was 0.92. Novice surgeons made 50% more errors (5.86 v 2.95, P ¼ .013), showed more performance variability (SD, 1.86 v 0.55), and took longer to perform the procedure (45.5 minutes v 25.9 minutes, P < .001). The greatest difference in errors related to suture delivery and management (exclusive of knot tying) (1.95 v 0.45, P ¼ .024). Conclusions: The assessment tool composed of validated arthroscopic Bankart metrics coupled with a cadaveric shoulder accurately distinguishes the performance of experienced from novice orthopaedic surgeons. A benchmark based on the mean performance of the experienced group includes completion of a 3-anchor Bankart repair, and enacting no more than 3 total errors and 1 sentinel error. Clinical Relevance: Validated procedural metrics combined with the use of a cadaveric shoulder can be used to assess the performance of an ABR. The methodology used may serve as a template for outcomes-based procedural skills training in general.

Purpose To determine if a dry shoulder model simulator coupled with previously validated performance metrics for an arthroscopic Bankart repair (ABR) would be a valid tool with the ability to discriminate between the performance of experienced and novice surgeons, and to establish a proficiency benchmark for an ABR using a model simulator. Methods We compared an experienced group of arthroscopic shoulder surgeons (Arthroscopy Association of North America faculty) (n = 12) with a novice group (n = 7) (postgraduate year 4 or 5 orthopaedic residents). All surgeons were instructed to perform a diagnostic arthroscopy and a 3 suture anchor Bankart repair on a dry shoulder model. Each procedure was videotaped in its entirety and scored in blinded fashion independently by 2 trained reviewers. Scoring used previously validated metrics for an ABR and included steps, errors, and "sentinel" (more serious) errors. Results The inter-rater reliability among pairs of raters averaged 0.93. The experienced group made 63% fewer errors, committed 79% fewer sentinel errors, and performed the procedure in 42% less time than the novice group (all significant differences). The greatest difference in errors between the groups involved anchor preparation and insertion, suture delivery and management, and knot tying. Conclusions The tool comprised by validated ABR metrics coupled with a dry shoulder model simulator is able to accurately distinguish between the performance of experienced and novice orthopaedic surgeons. A performance benchmark based on the mean performance of the experienced group includes completion of a 3 anchor Bankart repair, enacting no more than 4 total errors and 1 sentinel error. Clinical Relevance The combination of performance metrics and an arthroscopic shoulder model simulator can be used to improve the effectiveness of surgical skills training for an ABR. The methodology used may serve as a template for outcomes-based procedural skills training in general.

Rotator cuff integrity after repair is the basis for a better patient outcome, and the use of adjunctive graft material may result in a demonstrable benefit toward achieving that end.

SLAP (superior labrum, anterior and posterior) lesions have been identified as a cause of instability and pain in the shoulder. This review describes clinical features, mechanism of injury, physical examination, classification and associated lesions, normal and pathologic anatomy, as well as a treatment algorithm for SLAP lesions.

When stabilization surgery fails, both patient and treating physician face disappointment as well as additional stress in attempting to solve this difficult clinical challenge. The treating physician must: (1) review the basics of what constitutes stability, (2) confirm the correct diagnosis by performing a thorough examination supplemented by appropriate imaging, (3) determine the reason for failure, (4) determine the expectations and needs of the patient, and (5) decide which operative or nonoperative approach provides the best potential result for the patient. This review article will provide a basic review of the key principles in the evaluation and management of patients with recurrent instability after a failed arthroscopic anterior stabilization.

The treatment of articular-sided partial rotator cuff tears remains a challenge to the treating orthopaedic surgeon. Treatment algorithms have included nonoperative management, debridement alone, and debridement and subacromial decompression, as well as articular-sided rotator cuff repair and completion of the tear on the bursal side followed by a traditional arthroscopic rotator cuff repair. Implantation of a bio-inductive collagen scaffold on the bursal side of the rotator cuff to potentially heal an articular-sided tear represents a novel approach to this difficult clinical entity.

Partial rotator cuff tears can be a natural consequence of aging or can be caused by anatomic impingement or trauma. These tears can be asymptomatic or a potential source of shoulder dysfunction. We know very little about their natural history and whether they progress to full-thickness tears. With the advent of magnetic resonance imaging and shoulder arthroscopy, a more precise characterization of these tears is now possible. At the present time, there is no accepted classification system of partial-thickness rotator cuff tears. The optimal clinical approach to treating these tears is also controversial and ranges from simple debridement to open repair. The purpose of this article is to review partial-thickness rotator cuff tears, including the pathogenesis, diagnosis, nonoperative, and operative treatment options, and to create a rational treatment algorithm.

For decades, clinicians have been in search of the technically simple, highly effective, reproducible procedure for recurrent anterior shoulder instability, complemented by a facilitated rehabilitation, minimal motion loss, and an acceptable complication rate. What ensued is a wide array of open procedures in which the recurrence rates are acceptable, but in which rotation is commonly sacrificed, late arthrosis engendered, and the rehabilitation grueling. With the advent of arthroscopy, and with rapid technical advances and improved implant choices, arthroscopic stabilization quickly became the “panacea” for traumatic shoulder instability. Early reports were encouraging, 1-4 citing the many virtues of the arthroscopic approach, including minimal surgical trauma and a facilitated rehabilitation with much less perioperative morbidity. The arthroscopic approach also offered the additional advantages of recognizing and treating associated pathology, such as SLAP lesions, sparing the subscapularis, and providing a desirable cosmetic outcome. However, with longer-term follow-up, the initial success rates plummeted, with recurrence rates approaching 50% 5-7 in the hands of skilled and experienced arthroscopic surgeons. Numerous factors 6-9 were identified as potential high-risk factors for recurrent instability including short postoperative immobilization, bony Bankart lesions, associated generalized ligamentous laxity, Hill-Sachs lesions, contact or collision sports, younger age, “inverted pear” glenoid configurations as well as poor glenohumeral ligament quality. Clearly a dilemma exists for those of us trying to decide if arthroscopic stabilization for traumatic anterior shoulder instability is a reasonable alternative to the traditional open approach. This presentation provides a historical perspective of arthroscopic stabilization, the pathoanatomy of instability, state-of-the-art techniques, and the current recommendations for treating the patient with traumatic anterior shoulder instability.

Subacromial impingement is typically diagnosed in the older throwing athlete who has a stable shoulder. Often these overhand athletes will have a loss of internal rotation that may be refractory to stretching. Some have postulated bony adaptive changes in the thrower leading to internal rotation loss.1,2 These patients have a painful arc, positive impingement maneuvers, and respond affirmatively to a subacromial injection. Radiographs usually show some form of an acquired or congenitally prominent anterior acromion that predisposes to outlet stenosis. Some may also exhibit lateral downsloping of the acromion. Many of these patients will improve with anti-inflammatory medication combined with a well-supervised physical therapy program focusing not only on cuff rehabilitation, but also on scapular dynamics. There is no conclusive data supporting acromioclavicular (AC) joint spurring as a cause of subacromial impingement.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 2 (February, Suppl 1), 2002: pp 51–64

Purpose: To assess a new method for biomechanical assessment of arthroscopic knots and to establish proficiency benchmarks using the Fundamentals of Arthroscopic Surgery Training (FAST) Program workstation and knot tester. Methods: The first study group included 20 faculty at an Arthroscopy Association of North America resident arthroscopy course (19.9 � 8.25 years in practice). The second group comprised 30 experienced surgeons attending an Arthroscopy Association of North America fall course (17.1 � 19.3 years in practice). The training group included 44 postgraduate year 4 or 5 orthopaedic residents in a randomized, prospective study of proficiency-based training, with 3 subgroups: group A, standard training (n ¼ 14); group B, workstation practice (n ¼ 14); and group C, proficiency-based progression using the knot tester (n ¼ 16). Each subject tied 5 arthroscopic knots backed up by 3 reversed hitches on alternating posts. Knots were tied under video control around a metal mandrel through a cannula within an opaque dome (FAST workstation). Each suture loop was stressed statically at 15 lb for 15 seconds. A calibrated sizer measured loop expansion. Knot failure was defined as 3 mm of loop expansion or greater. Results: In the faculty group, 24% of knots “failed” under load. Performance was inconsistent: 12 faculty had all knots pass, whereas 2 had all knots fail. In the second group of practicing surgeons, 21% of the knots failed under load. Overall, 56 of 250 knots (22%) tied by experienced surgeons failed. For the postgraduate year 4 or 5 residents, the aggregate knot failure rate was 26% for the 220 knots tied. Group C residents had an 11% knot failure rate (half the overall faculty rate, P ¼ .013). Conclusions: The FAST workstation and knot tester offer a simple and reproducible educational approach for enhancement of arthroscopic knot-tying skills. Our data suggest that there is significant room for improvement in the quality and consistency of these important arthroscopic skills, even for experienced arthroscopic surgeons. Level of Evidence: Level II, prospective comparative study.

Purpose To determine the effectiveness of proficiency-based progression (PBP) training using simulation both compared with the same training without proficiency requirements and compared with a traditional resident course for learning to perform an arthroscopic Bankart repair (ABR). Methods In a prospective, randomized, blinded study, 44 postgraduate year 4 or 5 orthopaedic residents from 21 Accreditation Council for Graduate Medical Education–approved US orthopaedic residency programs were randomly assigned to 1 of 3 skills training protocols for learning to perform an ABR: group A, traditional (routine Arthroscopy Association of North America Resident Course) (control, n = 14); group B, simulator (modified curriculum adding a shoulder model simulator) (n = 14); or group C, PBP (PBP plus the simulator) (n = 16). At the completion of training, all subjects performed a 3 suture anchor ABR on a cadaveric shoulder, which was videotaped and scored in blinded fashion with the use of previously validated metrics. Results The PBP-trained group (group C) made 56% fewer objectively assessed errors than the traditionally trained group (group A) ( P = .011) and 41% fewer than group B ( P = .049) (both comparisons were statistically significant). The proficiency benchmark was achieved on the final repair by 68.7% of participants in group C compared with 36.7% in group B and 28.6% in group A. When compared with group A, group B participants were 1.4 times, group C participants were 5.5 times, and group C PBP participants (who met all intermediate proficiency benchmarks) were 7.5 times as likely to achieve the final proficiency benchmark. Conclusions A PBP training curriculum and protocol coupled with the use of a shoulder model simulator and previously validated metrics produces a superior arthroscopic Bankart skill set when compared with traditional and simulator-enhanced training methods. Clinical Relevance Surgical training combining PBP and a simulator is efficient and effective. Patient safety could be improved if surgical trainees participated in PBP training using a simulator before treating surgical patients.

The diagnosis and management of SLAP lesions in the overhead athlete remains a challenge for the sports medicine specialist due to variable anatomy, changes with aging, concomitant pathology, lack of dependable physical findings on examination, and lack of sensitivity and specificity with imaging studies. This article presents a comprehensive review of the epidemiology, relevant anatomy, proposed pathogenesis, diagnostic approach, and outcomes of nonoperative and operative management of SLAP lesions in the overhead athlete.

Os acromiale is an uncommon condition of the shoulder. When symptomatic, os acromiale may cause impingement pain, rotator cuff tears, or pain through abnormal motion at the unfused apophysis. Treatment of symptomatic os acromiale is controversial. This article reports on four patients with symptomatic mesoacromions who were treated with open reduction and internal fixation. All four patients recovered full function postoperatively with UCLA shoulder rating scores improving from 19 preoperatively to 35 postoperatively. Open reduction and internal fixation of a symptomatic meso-acromion is a reliable and reproducible technique in which the deltoid attachment and lever arm are minimally affected.

Purpose: To establish the metrics (operational definitions) necessary to characterize a reference arthroscopic Bankart procedure, and to seek consensus from experienced shoulder arthroscopists on the appropriateness of the steps, as well as errors identified. Methods: Three experienced arthroscopic shoulder surgeons and an experimental psychologist (comprising the Metrics Group) deconstructed an arthroscopic Bankart procedure. Fourteen full-length videos were analyzed to identify the essential steps and potential errors. Sentinel (i.e., more serious) errors were defined as either (1) potentially jeopardizing the procedure outcome or (2) creating iatrogenic damage to the shoulder. The metrics were stress tested for clarity and the ability to be scored in binary fashion during a video review as either occurring or not occurring. The metrics were subjected to analysis by a panel of 27 experienced arthroscopic shoulder surgeons to obtain face and content validity using a modified Delphi Panel methodology (consensus opinion of experienced surgeons rendered by cyclical deliberations). Results: Forty-five steps and 13 phases characterizing an arthroscopic Bankart procedure were identified. Seventy-seven procedural errors were specified, with 20 designated as sentinel errors. The modified Delphi Panel deliberation created the following changes: 2 metrics were deleted, 1 was added, and 5 were modified. Consensus on the resulting Bankart metrics was obtained and face and content validity verified. Conclusions: This study confirms that a core group of experienced arthroscopic surgeons is able to perform task deconstruction of an arthroscopic Bankart repair and create unambiguous step and error definitions (metrics) that accurately characterize the essential components of the procedure. Analysis and revision by a larger panel of experienced arthroscopists were able to validate the Bankart metrics. Clinical Relevance: The ability to perform task deconstruction and validate the resulting metrics will play a key role in improving surgical skills training and assessing trainee progression toward proficiency.

Arthroscopic subacromial decompression is an effective treatment for impingement syndrome, with published success rates between 77% and 90%. Failure of subacromial decompression is defined as persistent pain and disability after surgery despite adequate postoperative rehabilitation. Potential causes of failure after subacromial decompression are varied and may include technical error, incorrect diagnosis, inadequate rehabilitation, or unrealistic postoperative expectations. A methodical approach to the patient with persistent symptoms after subacromial decompression will allow for accurate diagnosis and treatment of the underlying problem in the majority of cases.

Arthroscopic subacromial decompression has become a popular technique supplanting the open Neer acromioplasty in many instances of chronic rotator cuff disease. A review of 61 consecutive decompressions with a minimum follow-up of 12 months was undertaken to evaluate preoperative criteria and surgical outcomes. Of the 61 patients, 53 patients with an average follow-up of 23 months were available for review. Thirty-four men and 19 women with an average age of 47 years comprised the study group. Eleven (21%) had full-thickness tears, 35 (66%) had partial-thickness injuries, and 7 (13%) had normal-appearing rotator cuffs at the time of arthroscopy. The UCLA shoulder rating system was used to evaluate outcome. Eighty-one percent of the patients had an excellent (32%) or good (49%) result whereas 19% (15% fair and 4% poor) were considered unsatisfactory. Those with early impingement findings and partial rotator cuff tears were likely to experience a satisfactory outcome. Patients with full-thickness rotator cuff tears were less likely to experience a successful result (55%). Workmen's compensation cases had a satisfactory outcome in 74%, with a predominance of good over excellent results. Excluding those with full-thickness tears and work-related injuries, a satisfactory outcome was achieved in 90%. Arthroscopic subacromial decompression for mechanical impingement of the rotator cuff is a technically demanding procedure requiring appropriate skills as well as careful preoperative treatment and evaluation. For individuals in whom conservative measures fail and who meet stringent criteria, namely, a largely intact rotator cuff and a non-work-related injury, a highly reliable and satisfying outcome can be anticipated by both patient and surgeon.

As arthroscopic rotator cuff repair techniques become ubiquitous, mastering basic surgical steps is of paramount importance if satisfactory results are to be achieved on a consistent basis. We have learned that the critical steps in an arthroscopic rotator cuff repair consist of (1) appropriate portal placement for optimal viewing and for manipulation of tissue and equipment;1,2 (2) tear pattern recognition, such that appropriate mobilization techniques are utilized to complete an anatomical repair without undue tension;2 (3) rotator cuff mobilization, including supraglenoid release, subacromial space release, possible anterior interval release, or double interval release, to include the infraspinatus and supraspinatus junction;3, 4, 5 (4) greater tuberosity preparation, in which the subchondral bone is not violated, accompanied by anchor insertion oriented at 45° to the long axis of the humerus, to maximize pullout strength;6 (5) suture management and passage, either retrograde or antegrade, through the free edge of the tear or in a side-to-side pattern, in which tissue is captured and coapted without sacrificing pullout strength;7,8 (6) deft knot tying such that loop and knot security are achieved while re-attaching the edge of the cuff tear to the anatomical footprint.6

The biceps tendon originates from the labrum and the supraglenoid tubercle of the scapula. The structure is intraarticular yet extrasynovial. It is widest at its origin and progressively narrows as it exits the bicipital groove. The proximal one-third of the biceps tendon has a high degree of innervation, with substance P and calcitonin gene-related peptides present, suggesting a rich sympathetic network1. There is a spectrum of pathological conditions of the proximal part of the biceps, including tendinitis, SLAP (superior labrum anterior and posterior) lesions, biceps instability, and partial or complete ruptures. The origin of the long head of the biceps is variable and is approximately 9 cm long2. The proximal portion of the long head receives its blood supply primarily from the anterior circumflex humeral artery3. The biceps tendon passes posterior to the coracohumeral ligament and beneath the transverse humeral ligament as it courses distally. The capsuloligamentous structures of the rotator interval are responsible for restraining the biceps tendon within its proper anatomic location as it passes into the bicipital groove4,5. The coracohumeral ligament and the superior glenohumeral ligament are the two most important structures within the rotator interval for securing the biceps tendon2. The superior glenohumeral ligament forms an anterior sling about the biceps. The more distal transverse humeral ligament is not believed to play a primary role in securing the biceps tendon5. The exact function of the long head of the biceps tendon in the shoulder is controversial. The angular orientation of the biceps relative to the humeral head appears to be adaptive in nature, and it diminishes the capacity for arm elevation, perhaps placing the biceps at risk for instability. The proximal part of the biceps tendon probably has at least a passive …

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 3 (March), 2003: pp 305–309

Purpose: Progressive degenerative arthritis leading to premature pain and functional loss in the postmeniscectomy state is a well-recognized and debilitating condition. Meniscal allograft replacement may be a suitable, early treatment alternative for this population at risk. The purpose of this study was to examine the potential benefits of meniscal allograft replacement on relieving pain and restoring function. Type of Study: Retrospective clinical review. Methods: From 1993 to 1999, 29 menisci were implanted in 28 patients. Of these, 25 patients (26 menisci) were available for review. All patients had a minimum of 12 months of follow-up, with an average of 33 months. Study participants included 17 men and 8 women with primary symptoms of pain or instability at study onset. Eighteen patients had grades I through III Outerbridge chondromalacia changes and 7 demonstrated grade IV changes in the affected compartment. Data were collected using the International Knee Documentation Committee (IKDC), Lysholm II, and Tegner scoring systems as well as a visual analogue scale (VAS) for pain measurement. Results: Our findings revealed that following meniscal allograft replacement, pain was significantly reduced and function was improved (P .001). In addition, IKDC scores for activity were reported as normal or nearly normal in 17 subjects and abnormal in 8 participants. Outerbridge grade had a significant impact on final outcome; only 3 of 7 with grade IV changes achieved normal or nearly normal scores versus 14 of 18 in those with lesser Outerbridge changes. Isolated implants fared the same as those combined with an ACL reconstruction. Overall satisfaction reported by the subjects averaged 83%. Ten second-look procedures revealed 5 normal menisci, 3 with shrinkage, and 2 with recurrent tears. Conclusions: Earlier results from this population of patients indicated substantial pain relief and improved function. The durability of these early results has not met the test of time for those with exposed subchondral bone. However, statistically significant early and midterm improvements in pain, symptoms, and functional status continue to be noteworthy in the properly selected patient. Key Words: Meniscus—Allograft—Transplant.

Rather than a scholarly treatise debating the advantages of arthroscopic versus open stabilization in adolescents with shoulder instability, this article provides a concise and useful reference for practicing pediatricians whose care includes young athletes. With the ever-increasing number of boys and girls participating in organized sports, specific injury patterns, often dependent on sport and gender, have been identified. This article identifies the most common sports injuries, focusing on mechanism of injury, pathoanatomy, the history and physical findings, as well as recommendations for initial diagnostic studies and treatment. For injuries requiring a timely referral, a clear imperative is noted. Special consideration is given to skeletally immature patients whereas those who are skeletally mature may be treated as adults.

Shoulder injuries in tennis players are common because of the repetitive, high-magnitude forces generated around the shoulder during the various tennis strokes. An understanding of the complex sequences of muscle activity in this area may help reduce injury, enhance performance, and assist the rapid rehabilitation of the injured athlete. The supraspinatus, infraspinatus, subscapularis, mid dle deltoid, pectoralis major, latissimus dorsi, biceps brachii, and serratus anterior muscles were studied in six uninjured male Division II collegiate tennis players using dynamic electromyography (EMG) and synchro nized high-speed photography. Each subject performed the tennis serve and the forehand and backhand groundstrokes, and each stroke was divided into stages. The tennis serve contains four stages. Three stages characterize the forehand and backhand ground strokes. Our results indicate that the subscapularis, pectoralis major, and serratus anterior display the greatest activity during the serve and forehand. The middle deltoid, supraspinatus, and infraspinatus are most active in the acceleration and follow-through stages of the backhand. The biceps brachii increases its activity during cocking and follow-through in the serve with a similar pattern noted in the acceleration and follow-through stages of the forehand and back hand. The serratus anterior demonstrates intense activ ity in the serve and forehand, thus providing a stable platform for the humeral head and assisting in gleno humeral-scapulothoracic synchrony. The tennis serve and forehand and backhand ground strokes are accomplished by complex sequences of muscle activity that incorporate contributions from the lower extremities and trunk into smooth, coordinated patterns. Although our study focused on shoulder function in the uninjured tennis player, it may provide a basis for understanding abnormal shoulder biomechanics that contribute to pain and dysfunction. The serratus anterior deserves special emphasis, for our study showed that its activity is essential to each of the three tennis strokes. Because of the similarities between the tennis serve and overhead throw, a conditioning program comparable to one pitchers use many be appropriate for tennis players.

Summary The potential for healing of meniscal tissue has been historically underappreciated, but is currently more widely acknowledged. We have reviewed our experience with arthroscopic meniscal repair in 29 patients who had had a minimum of 2 years' follow-up. Between September 1983 and November 1986, 31 patients who had undergone arthroscopic meniscal repair with a minimum of 2-years' follow-up were identified. Of the 31 patients, 29 were available for additional follow-up. The patient population averaged 31 years of age, with 15 men and 14 women. Utilizing a closed arthroscopic cannulated technique, 16 lateral and 15 medial menisci were repaired. The majority of lesions were vertical bucket-handle tears involving the posterior horn and averaged 2.5 cm in length. Of the 31 tears, 29 were in the red-red or red-white zones. Clinical healing was present in 27 (87%) of the 31 repaired menisci. Nine patients underwent relook arthroscopy at which time healing was confirmed in eight, and a retear noted in one. Four reruptures occurred and the menisci required removal. Of the 29 patients, 16 had concomitant anterior cruciate ligament injuries ranging from partial tears to complete disruptions. Seven patients underwent immediate or delayed anterior cruciate ligament stabilization. Healing occurred in six of the seven patients whose anterior cruciate ligaments had been reconstructed. Among those patients with reruptures, chronic anterolateral rotatory instability was identified as a significant risk factor for rerupture. A complication rate of 13% was noted. Three patients underwent manipulation under anesthesia for postoperative ankylosis and one patient experienced a transient saphenous nerve neuropraxia. Arthroscopic anterior cruciate ligaments repair remains a desirable alternative to meniscal excision and has excellent results when proper selection and technique are implemented.

Malignant tumors around fracture fixation implants have been reported sporadically for many years. Recently, however, reports of sarcomatous degeneration around a standard cemented hip arthroplasty and around cobalt-chromium-bearing hip arthroplasties raise new questions of the malignant potential of metallic ends prostheses. Sarcomatous changes around aluminum oxide ceramics seem not to have been reported in the literature. The present report may be the first documented case of an aggressive soft tissue sarcoma detected 15 months after the patient had an uncemented ceramic total hip arthroplasty. If a causal relationship exists, the incidence of this phenomenon in the United States is 250 times greater than would be expected from statistics on soft tissue sarcoma at the hip. Because of the similarity on plane roentgenograms of this tumor to lesions known to be caused by wear debris, tumors should be included in the differential diagnosis of cases of total hip loosening.