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Brandon T Goldenberg,1 Lucca Lacheta,1,2 Travis J Dekker,3 James D Spratt,1 Philip C Nolte,1 Peter J Millett1,4 1Steadman-Philippon Research Institute, Vail, CO 81657, USA; 2Center for Musculoskeletal Surgery, Charitè Universitaetsmedizin Berlin, Berlin, Germany; 3Department of Orthopaedic Surgery, Eglin Air Force Base, Elgin, FL, USA; 4The Steadman Clinic, Vail, CO 81657, USACorrespondence: Peter J Millett 181 West Meadow Drive Suite 1000, Vail, CO 81657, USATel +19704795876Fax +19704799753Email drmillett@thesteadmanclinic.comAbstract: Large and massive rotator cuff tears have the highest risk of retear. Common biologic modalities that can potentially reduce the retear rate and improve healing include platelet-rich plasma (PRP), scaffolds, and mesenchymal stem cells (MSCs). PRP has been studied for its role in improving rotator cuff healing and results of randomized controlled trials and meta-analyses show mixed results. Most studies in large and massivge tears show that PRP decreases the retear rate, but the connection between structural integrity and clinical outcomes is still unknown. Extracellular matrix (ECM) and synthetic scaffolds can increase healing in augmentation and bridging repair. Acellular dermal allografts have shown better healing rates and outcomes than xenografts in meta-analyses. Synthetic scaffolds augmented with bone marrow-derived stem cells have only been studied in vitro but are promising for the combination of mechanical stability and induction of a biological response. Superior capsule reconstruction is an exciting type of interposition graft reconstruction that has shown favorable early clinical outcomes for large and massive tears. Bone marrow-derived stem cells and adipose-derived stem cells improve the biomechanical characteristics of tendon repair and enhance the histological findings of the healing process in animal studies. However, evidence from human studies is lacking, especially in patients with large and massive tears. In summary, there are many biological options to augment rotator cuff repair in patients with large and massive tears. Due to mixed results and a lack of standardization in high-quality studies, we cannot recommend PRP at this time as an adjunct to rotator cuff repair. Both ECM and synthetic scaffolds, as well as SCR, can be used, especially in situations where native tendon is compromised, and additional mechanical augmentation is needed. Stem cells have been the least studied to date, so it is difficult to give recommendations for or against their use at this time.Keywords: biologics, large rotator cuff tears, massive rotator cuff tears, platelet-rich plasma, scaffolds, mesenchymal stem cells

Philip C Nolte,1,2 Lucca Lacheta,1,3 Travis J Dekker,1,4 Bryant P Elrick,1 Peter J Millett1,5 1Steadman Philippon Research Institute, Vail, CO, USA; 2Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany; 3Center for Musculoskeletal Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany; 4Eglin Air Force Base, 96th Medical Group, United States Air Force, Eglin, FL, USA; 5The Steadman Clinic, Vail, CO, USACorrespondence: Peter J MillettSteadman Philippon Research Institute, 181 W Meadow Dr, Ste 400, Vail, CO 81657, USATel +1 970 479-5871Email drmillett@thesteadmanclinic.comAbstract: Injuries to the acromioclavicular (AC) joint are common and mostly involve younger, male individuals. Whereas the majority of AC joint dislocations can be treated nonoperatively with a trial of immobilization, pain medication, cryotherapy, and physiotherapy, there are patients that do not respond well to conservative management and may require surgical treatment. Identifying and treating these patients according to the type and chronicity of AC joint dislocation is paramount. To date, a myriad of surgical techniques have been proposed to address unstable AC joint dislocations and are indicative of the uncertainty that exists in optimal management of these injuries. Historically research has focused on the restoration of the coracoclavicular ligament complex. However, recently the importance of the acromioclavicular capsule and ligaments has been emphasized. This review aims to provide the reader with an overview of current treatment strategies and research, as well as future perspectives.Keywords: AC capsule, AC joint, coracoclavicular, reconstruction, stabilization, shoulder surgery

Ulrich J Spiegl,1 Peter J Millett,2 Christoph Josten,1 Pierre Hepp1 1Department of Orthopedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Leipzig, Germany; 2The Steadman Clinic, Vail, CO, USA Abstract: The majority of os acromiale is asymptomatic and requires no treatment. In patients with shoulder pain, os acromiale is a possibility in the differential diagnosis and may imitate shoulder impingement. The diagnosis of symptomatic os acromiale can be proven by combining physical examination, conventional radiographs, magnetic resonance imaging, and selective injections. Surgical treatment is indicated in those patients with failed conservative therapy, in those with highly painful and unstable os acromiale, or in those with associated shoulder pathologies such as rotator cuff tears. Open or arthroscopic excision is indicated in patients with pre-type os acromiale. In meso-type acromiale, arthroscopic excision, acromioplasty, or open reduction and internal fixation have all been used, but fixation is usually preferred. Internal fixation should be done either with cannulated screws alone or in combination with tension band, which has biomechanical advantages. Keywords: os acromiale, nonoperative treatment, surgical treatment, open or arthroscopic excision, osteosynthesis techniques

Background: Infections after shoulder surgery are potentially devastating complications. Propionibacterium acnes is recognized as a causal agent in shoulder infections. The clinical presentation is usually insidious and nonspecific, but a P. acnes infection could be an occult cause of postoperative shoulder pain.Questions/purposes: What are the clinical and microbiologic characteristics of a postsurgical P. acnes shoulder infection and how should it be addressed?Patients and Methods: Ten patients with an average age of 57 years presented with P. acnes postsurgical shoulder infection. Clinical infection signs and surgical history were assessed and joint aspirates and tissue biopsy specimens were obtained. Diagnosis was confirmed by microbiologic cultures.Results: At the time of confirmation of the diagnosis, clinical signs of infection were absent. C-reactive protein and erythrocyte sedimentation rates were inconsistently elevated. Cultures took a mean 7 days to confirm organism growth. The average time from surgery to diagnosis of infection was 1.8 years (range, 0.07-8.0 years). All patients underwent irrigation and débridement and were treated with antibiotics for 6 weeks.Conclusions: P. acnes shoulder infections should be considered as a cause for persistent, unexplained shoulder pain. Shoulder aspirations and tissue samples should be obtained. Surgical débridement and intravenous antibiotics are necessary treatment modalities.Level Of Evidence: Level IV, Prognostic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

BACKGROUND: The triceps tendon has been described as a single unit with contribution from each of the 3 heads of the muscle. An observation at the time of surgical repair of a triceps tendon injury led to an anatomical study to further define the anatomy of this tendon as it inserts on the olecranon. HYPOTHESIS: The medial head of the triceps has a tendon that is distinct from, and deep to, the common tendon of the long and lateral heads. STUDY DESIGN: Descriptive laboratory study and case report. METHODS: Eight cadaveric elbows were dissected to examine the triceps tendon. None of the specimens had any evidence of prior injury or surgery to the elbow. All specimens were fresh-frozen and stored at -4 degrees C until they were thawed for use. Skin and subcutaneous tissue were removed, and the tendon of each head of the triceps was explored from the muscle to its bony insertion. RESULTS: In all 8 specimens, on gross inspection, the medial head had a separate insertion deep to the common insertion of the lateral and long heads. The muscle of the medial head extended further distally than did the long and lateral heads. The medial head was muscular to its deep insertion, with a small amount of tendon blended with the muscle distally. Histologic analysis demonstrated that the tendon of the medial head and that of the other 2 heads are confluent distally at their olecranon insertion. CONCLUSION: The medial head of the triceps has a tendon that is distinct from, and deep to, the common tendon of the long and lateral heads on gross inspection. Histologic studies show the insertion of these 2 tendons is confluent. CLINICAL RELEVANCE: This anatomy has important implications for surgical repair of these tendon injuries. Rupture of the deep triceps insertion alone can occur and lead to weakness of elbow extension with the elbow flexed beyond 90 degrees . Triceps strength should be tested with the elbow fully flexed when injury to the tendinous insertion is suspected. [ABSTRACT FROM AUTHOR]

Background: Recurrent defects after open and arthroscopic rotator cuff repair are common. Double-row repair techniques may improve initial fixation and quality of rotator cuff repair.Purpose: To evaluate the load to failure, cyclic displacement, and anatomical footprint of 4 arthroscopic rotator cuff repair techniques.Hypothesis: Double-row suture anchor repair would have superior structural properties and would create a larger footprint compared to single-row repair.Study Design: Controlled laboratory study.Methods: Twenty fresh-frozen cadaveric shoulders were randomly assigned to 4 arthroscopic repair techniques. The repair was performed as either a single-row technique or 1 of 3 double-row techniques: diamond, mattress double anchor, or modified mattress double anchor. Angle of loading, anchor type, bone mineral density, anchor distribution, angle of anchor insertion, arthroscopic technique, and suture type and size were all controlled. Footprint length and width were quantified before and after repair. Displacement with cyclic loading and load to failure were determined.Results: There were no differences in load to failure and displacement with cyclic loading between the single-row repair and each double-row repair. All repair groups demonstrated load to failure greater than 250 N. A significantly greater supraspinatus footprint width was seen with double-row techniques compared to single-row repair.Conclusions: The single-row repair technique was similar to the double-row techniques in load to failure, cyclic displacement, and gap formation. The double-row anchor repairs consistently restored a larger footprint than did the single-row method.Clinical Relevance: The arthroscopic techniques studied have strong structural properties that approached the reported performance of open repair techniques. Double-row techniques provide a larger footprint width; although not addressed by this study, such a factor may improve the biological quality of repair. [ABSTRACT FROM AUTHOR]

Background: Bioabsorbable interference screw fixation has superior biomechanical properties compared to suture anchor fixation for biceps tenodesis. However, it is unknown whether fixation technique influences clinical results.Hypothesis: We hypothesize that subpectoral interference screw fixation offers relevant clinical advantages over suture anchor fixation for biceps tenodesis.Study Design: Case Series.Methods: We performed a retrospective review of a consecutive series of 88 patients receiving open subpectoral biceps tenodesis with either interference screw fixation (34 patients) or suture anchor fixation (54 patients). Average follow up was 13 months. Outcomes included Visual Analogue Pain Scale (0-10), ASES score, modified Constant score, pain at the tenodesis site, failure of fixation, cosmesis, deformity (popeye) and complications.Results: There were no failures of fixation in this study. All patients showed significant improvement between their preoperative and postoperative status with regard to pain, ASES score, and abbreviated modified Constant scores. When comparing IF screw versus anchor outcomes, there was no statistical significance difference for VAS (p = 0.4), ASES score (p = 0.2), and modified Constant score (P = 0.09). One patient (3%) treated with IF screw complained of persistent bicipital groove tenderness, versus four patients (7%) in the SA group (nonsignificant).Conclusion: Subpectoral biceps tenodesis reliably relieves pain and improves function. There was no statistically significant difference in the outcomes studied between the two fixation techniques. Residual pain at the site of tenodesis may be an issue when suture anchors are used in the subpectoral location. [ABSTRACT FROM AUTHOR]

Background: A labral injury contributes to glenohumeral instability. The Anterior Labral Circumferential Onlay Technique (ALCOT) reconstructs the labrum using the long head of the biceps tendon., Hypothesis: The ALCOT would restore glenohumeral joint stability in a cadaveric model without glenoid bone loss (1) comparable to the native state and (2) comparable to the Latarjet procedure., Study Design: Controlled laboratory study., Methods: A total of 10 fresh-frozen cadaveric shoulders were tested using a 6 degrees of freedom robotic arm in 5 consecutive states: (1) native, (2) capsular repair, (3) labral tear, (4) ALCOT, and (5) Latarjet procedure. Biomechanical testing consisted of 80 N of anteroinferior force and 50 N of compression in 90° of humerothoracic abduction. Lateral displacement of the humeral head and the force ratio during a dislocation were measured., Results: The mean lateral translation of the humeral head during a dislocation in the native state was 6.5 ± 2.2 mm and decreased to 5.4 ± 2.4 mm in the labral tear state ( P < .001). The mean lateral translation of the humeral head was restored to 6.4 ± 2.2 mm ( P > .99) with the ALCOT, showing no difference from the native state. The Latarjet procedure restored the mean force ratio during a dislocation to 1.3 ± 0.6 but failed to restore lateral translation, with a value of 5.6 ± 2.8 mm ( P = .003 vs native; P = .94 vs labral tear). The mean force ratio was 1.8 ± 0.1 in the native state, decreased to 1.1 ± 0.4 in the labral tear state, and was 1.4 ± 0.4 ( P < .27) with the ALCOT, showing no difference from the native state., Conclusion: The ALCOT is a novel technique for labral reconstruction that may have a role in the treatment of anterior glenohumeral instability in the setting of a deficient labrum without bone loss. In this study, the ALCOT restored the force ratio and lateral translation of the humeral head compared to the native state. The Latarjet procedure restored the force ratio but not lateral translation of the humeral head compared to the native state., Clinical Relevance: This study proposes and biomechanically validates the ALCOT as a surgical technique for labral reconstruction that may have a role in treating patients with chronic anterior shoulder instability in the setting of a deficient labrum., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study received partial support from Arthrex for in-kind products supplied. P.J.M. has received a royalty or license from Arthrex, consulting fees from Arthrex, and nonconsulting fees from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

Objectives: The purpose of this study was to determine the correlation between microscopic degeneration in the long head of the biceps tendon (LHBT) and the apoptotic process. Methods: This study included 26 consecutive patients who had undergone arthroscopic biceps tenodesis or tenotomy for symptomatic LHBT with or without concomitant rotator cuff tears (RCTs). Histological examination of the specimens under a light microscope was conducted after staining with hematoxylin, eosin, and the Alcian blue. Histopathological changes were assessed using the original Bonar score and the modified Bonar score and then correlated with the expression of the subsequent apoptosis markers: activated caspase-3 (casp3), tumor protein p53 (p53), and B-cell lymphoma 2 (BCL-2). Results: The mean original Bonar score was 8.65 (range 5-11), while the modified Bonar score was 7.61. There was no correlation between the original Bonar score and the age of the patients, but a positive correlation was found between the modified Bonar score and the age of the patients ( p = 0.0022). There was no correlation between the age of patients and the expression indexes of BCL-2 and casp3. However, the expression of the p53 index showed a positive correlation with patient aging ( p = 0.0441). Furthermore, there was no correlation observed between the expression of apoptotic indexes and both the original and modified Bonar scale. Conclusions: In LHB tendinopathy, the expression of apoptosis does not seem to directly correlate with the extent of degeneration, particularly in the late stages of tendinopathy. However, the transformations observed in collagen and ground substance were significantly associated with age, as well as tendinous tissue degeneration quantified according to modified Bonar score. The age of patients was also linked with the expression of the p53 index, as an increased apoptosis in the studied population.

Background: The purpose of this study is to report clinical outcomes, return to activity, redislocation rate, and rate of conversion to arthroplasty for active patients over age 40 undergoing primary arthroscopic shoulder stabilization., Methods: Patients over 40 years of age who underwent arthroscopic capsulolabral repair for shoulder instability between December 2005 and January 2018 with a minimum of 2-year postoperative follow-up were enrolled in this retrospective, monocentric study. Clinical outcome scores including the 12-Item Short-Form Survey, American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder, and Hand, Single-Assessment Numeric Evaluation, and visual analog scale pain were collected. Additionally, it was determined which patients reached the minimal clinically important difference and the patient-acceptable symptom state for the ASES score. Bivariate analysis was utilized to determine if there was any association between baseline demographic and clinical factors with the outcome scores., Results: Of a total of 814 patients assessed for eligibility, an aggregate of 40 patients were included and 33 patients (8 females) were available for follow-up. The average age was 49.4 ± 7.6 years. At an average follow-up of 7.0 ± 3.6 years, all the outcome scores significantly improved compared to baseline. These included ASES (69.9 ± 19 to 95.8 ± 7.6, P  < .001); the Quick Disabilities of the Arm, Shoulder, and Hand score (29.7 ± 17.7 to 3.9 ± 5.4, P  < .002); Single Assessment Numeric Evaluation score (53.5 ± 29.3 to 91.6 ± 14.3, P  < .003); the 12-Item Short-Form Survey (45.6 ± 8.8 to 55.2 ± 5.7, P  < .001); and the visual analog scale (2.1 ± 2.1 to 0.3 ± 1, P  < .002). The minimal clinically important difference was reached by 72.7% of the patients and 81.8% reached the patient-acceptable symptom state threshold for the ASES score. Postoperative shoulder stability improved substantially and significantly. Median postoperative satisfaction was 10/10 (range 1-10). Ninety-five-point-six percent of the patients returned to sport, with 91.0% of the patients able to return to preinjury level. One patient (3%) underwent revision surgery for osteoarthritis, in the form of comprehensive arthroscopic management procedure. The presence of cartilage defects cartilage defects Outerbridge grade >2 ( P  = .020) and posterior labral lesions ( P  = .03) at index surgery were significantly associated with inferior outcomes in the ASES score., Conclusion: Active patients aged 40 years and older undergoing arthroscopic shoulder stabilization experienced favorable functional outcomes at a mean follow-up of 7 years, with low rates of revision surgery or of progression to clinically relevant osteoarthritis. However, the presence of high-grade cartilage lesions and the presence of a posterior labral tear were associated with inferior clinical outcomes., (© 2024 The Author(s).)

Background: Shoulder arthroplasty (SA) has been shown to improve quality of life, though outcomes may vary between individuals. Multiple factors may affect outcomes, including preoperative mental health conditions (MHCs). The goal of this systematic review was to evaluate the clinical and functional outcomes after SA in patients with MHC compared to patients without MHC., Methods: This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines outlined by Cochrane Collaboration. A search of PubMed, the Medline Library, and EMBASE was conducted from inception until September 2023 to obtain studies reporting outcomes after total shoulder arthroplasty and reverse total shoulder arthroplasty in patients with and without MHC. Study characteristics and information on clinical and functional outcomes were collected. All included studies were case-control studies. The methodological quality of the included primary studies was appraised using the methodological index for nonrandomized studies scoring., Results: Eleven articles published between 2016 and 2023 met inclusion criteria. In total, 49,187 patients, 49,289 shoulders, and five different MHC were included. 8134 patients in the cohort had a diagnosed MHC. The mean patient age was 67.8 years (range, 63.5-71.6 years), and 52.6% of the patients were female. The mean follow-up time was 35.5 months (range, 16.2-58.3 months). Reverse total shoulder arthroplasty was the most common type of procedure (25,543 shoulders, 51.8%). Depression and anxiety were the most reported psychiatric diagnoses (7990 patients, 98.2%). Patients with versus without MHC reported mean improvements of 38 and 42 in American Shoulder and Elbow Surgeons shoulder score and mean Visual Analog Scale pain improvements of 4.7 and 4.9, respectively. Mean complication rates of 31.4% and 14.2% were observed in patients with versus without MHC, respectively. The most prevalent surgical complication in patients with MHC was infection (1.8%), followed by prosthetic complication (1.7%), and adhesive capsulitis (1.6%)., Conclusions: Patients with MHC may have lower preoperative range of motion, worse postoperative shoulder function, and higher postoperative pain levels than patients without MHC. Patients with MHC demonstrated improvements in range of motion and functional outcomes after SA but had higher reported complication and revision rates when compared to patients without MHC. Depression and anxiety were the leading conditions correlated with lower outcomes in patients with MHC after SA. Preoperative physical therapy, mental health counseling, and expectation setting may help these patients reach the maximal achievable benefit from SA., (© 2024 The Authors.)

Background: To report clinical and activity-specific outcomes after arthroscopic rotator cuff repair (ARCR) for full-thickness supraspinatus tears in active individuals aged less than or equal to 45 years. The pre hoc hypothesis was that patients in this age group would demonstrate significant improvements in clinical outcomes following ARCR along with a significant improvement of athletic abilities., Methods: Patients were included in this study if they were (1) active individuals aged between 18 and 45 years at the time of surgery, (2) had a full-thickness rotator cuff tear of the supraspinatus tendon with or without anterior or posterior extension, and (3) underwent ARCR. Preoperative and postoperative patient-reported outcomes scores including the American Shoulder and Elbow Surgeons (ASES) score; Disabilities of Arm, Shoulder and Hand; Single Assessment Numeric Evaluation; and Short Form-12 Physical Component Summary were prospectively collected and postoperative patient satisfaction (scale of 1-10) was recorded at a minimum of 2 years postoperatively. Attainment of the minimal clinically important difference and patient acceptable symptom state for the ASES was calculated. Athletic activity-specific outcomes and return to activity were investigated prospectively via a custom-made comprehensive questionnaire., Results: Between November 2005 and June 2020, of 1149 RCRs performed by the senior author, 54 patients (mean age 40.9 years, 13 female; follow-up 69.7 ± 35.2 months in a range of 24.6-179.6 months) were included into the outcomes analysis. Of those, 4 patients (7.4%) had progressed to revision RCR. At a follow-up of 5.8 years, outcome scores had significantly improved compared to preoperative baselines (ASES 55.6 ± 13.8 to 90.1 + 15.8; P  < .001; Disabilities of Arm, Shoulder and Hand 38.9 ± 18.4 to 11.9 ± 17.1; P  < .001, Single Assessment Numeric Evaluation 60.7 ± 22.7 to 79.3 ± 27.6; P  = .001, Short Form-12 Physical Component Summary 41.6 ± 8.3 to 51.9 ± 9.0; P ≤ .001). Ninety three point six percent of the patients reached the minimal clinically important difference and 72.6% reached the patient acceptable symptom state. Median satisfaction was 9.5/10. Eighty six percent of the patients returned to sports, while 67% of the patients returned to a similar level compared to preoperatively. All sport-specific metrics such as shoulder strength and endurance ( P  < .001), intensity ( P  < .001), and impairments from pain affecting speed ( P  = .002), endurance ( P  = .002), and competition ( P  < .001) significantly improved postoperatively., Conclusion: ARCR of full-thickness rotator cuff tear in active individuals aged 45 years or less results in a clinically relevant improvement of outcomes, function, and quality of life at a minimum of 2 years and mean 5.8-year follow-up with a low rate of revision. While 86% of patients were able to return to activity and sport-specific outcome metrics significantly and substantially improved compared to preoperatively, a return to preinjury levels was not reliably achieved in all patients, with particular limitations observed in overhead active individuals. The data support the hypothesis that patients in this age group demonstrate significant improvements in clinical outcomes following ARCR along with significant improvements in athletic abilities., (© 2024 The Author(s).)

Background: The substances present in cigarette smoke have a negative impact on cellular integrity and metabolism, can reduce blood flow to tissues, and can disrupt collagen synthesis. Ultimately this can lead to cell death, which clinically may result in impaired tendon healing and the onset of chronic tendinopathy. Within the shoulder, the exact association between the extent of apoptosis in the long head of the biceps (LHB) tendon and harmful factors like cigarette smoke remains unclear., Objectives: The purpose of this study was to investigate the connection between smoking, the degree of apoptosis in LHB tendinopathy, and the long-term outcomes of surgical treatment., Design: Observational, retrospective study., Methods: This study included 22 consecutive patients who had undergone arthroscopic biceps tenodesis or tenotomy for symptomatic LHB tendinopathy with or without concomitant rotator cuff tears (RCT). The intra-articular LHB tendon remnants were histologically examined by measuring the level of expression of apoptotic cell markers such as BCL2, cleaved caspase 3, and p53. Pre- and postoperative clinical outcomes were analyzed by collecting patient report outcome measures such as the American Shoulder and Elbow Surgeons (ASES) score and the Visual Analogue Scale (VAS) for pain., Results: The smokers group had a mean pack-year history of 13.12 (SD = 9.94), mean number of cigarettes per day of 14.77 (SD = 4.64), and a mean smoking duration of 16.38 (SD = 10.1) years. Among the smoking indexes, the number of cigarettes per day showed a positive correlation with Snyder classification ( p = 0.0459, rho = 0.3682). Non-smokers and smokers did not show a statistically significant difference in the expression indexes of BCL2, cleaved caspase 3, or p53 ( p = 0.4216, p = 0.5449, p = 0.5613, respectively). However, the cleaved caspase 3 expression index showed a negative correlation with the severity of rotator cuff lesions in the total population ( p = 0.0193, rho = -0.4651)., Conclusions: While apoptotic processes in the LHB tendon were observed, no significant association was found between tobacco smoking, the extent of apoptosis, and clinical outcomes. However, the expression of the apoptotic marker cleaved caspase 3 correlated with the severity of rotator cuff pathology. Furthermore, active smoker status was associated with worse clinical outcomes in terms of pain following LHB tenodesis or tenotomy.

Background: In the Latarjet procedure, the ideal placement of the coracoid graft in the medial-lateral position is flush with the anterior glenoid rim. However, the ideal position of the graft in the superior-inferior position (sagittal plane) for restoring glenohumeral joint stability is still controversial., Purpose: To compare coracoid graft clockface positions between the traditional 3 to 5 o'clock and a more inferior (for the right shoulder) 4 to 6 o'clock with regard to glenohumeral joint stability in the Latarjet procedure., Study Design: Controlled laboratory study., Methods: A total of 10 fresh-frozen cadaveric shoulders were tested in a dynamic, custom-built robotic shoulder model. Each shoulder was loaded with a 50-N compressive load while an 80-N force was applied in the anteroinferior axes at 90° of abduction and 60° of shoulder external rotation. Four conditions were tested: (1) intact, (2) 6-mm glenoid bone loss (GBL), (3) Latarjet procedure fixed at 3- to 5-o'clock position, and (4) Latarjet procedure fixed at 4- to 6-o'clock position. The stability ratio (SR) and degree of lateral humeral displacement (LHD) were recorded. A 1-factor random-intercepts linear mixed-effects model and Tukey method were used for statistical analysis., Results: Compared with the intact state (1.77 ± 0.11), the SR was significantly lower after creating a 6-mm GBL (1.14 ± 0.61, P  = .009), with no significant difference in SR after Latarjet 3 to 5 o'clock (1.51 ± 0.70, P  = .51) or 4 to 6 o'clock (1.55 ± 0.68, P  = .52). Compared with the intact state (6.48 ± 2.24 mm), LHD decreased significantly after GBL (3.16 ± 1.56 mm, P  < .001) and Latarjet 4 to 6 o'clock (5.48 ± 3.39 mm, P  < .001). Displacement decreased significantly after Latarjet 3 to 5 o'clock (4.78 ± 2.50 mm, P  = .04) compared with the intact state but not after Latarjet 4 to 6 o'clock ( P  = .71)., Conclusion: The Latarjet procedure in both coracoid graft positions (3-5 and 4-6 o'clock) restored the SR to the values measured in the intact state. A more inferior graft position (fixed at 4-6 o'clock) may improve shoulder biomechanics, but additional work is needed to establish clinical relevance., Clinical Relevance: An inferior coracoid graft fixation, the 4- to 6-o'clock position, may benefit in restoring normal shoulder biomechanics after the Latarjet procedure., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: this research was supported by the Steadman Philippon Research Institute. R.-O.D.H. and M.-C.R. have received grant support from AGA. P.J.M. has received consulting and nonconsulting fees from Arthrex; research support from Arthrex, Ossur, Siemens, and Smith & Nephew; royalties from Arthrex, Medbridge, and Springer; and stock or stock options from VuMed. M.T.P. has received royalties from Anika Therapeutics, Arthrex, and Arthrosurface; consulting fees from Arthrex, Zimmer Biomet Holdings, and JRF Ortho; nonconsulting fees from Arthrex and Arthrosurface; and honoraria from Flexion Therapeutics and JRF Ortho. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Objectives: The purpose of this study is to systematically review the comparative studies in the literature to compare the outcomes of the Latarjet procedure in the setting of a previously failed Bankart repair versus those undergoing the Latarjet procedure as a primary surgery for anterior shoulder instability., Methods: A systematic search in Pubmed, EMBASE, and The Cochrane Library databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Cohort studies comparing outcomes in the Latarjet procedure as a primary surgery versus the Latarjet procedure in the setting of a previously failed Bankart repair were included., Results: Ten studies with 1913 patients were included. There was a significantly lower rate of recurrent instability in those with a Latarjet procedure as a primary surgery (4.8% vs 12.1%, p ​= ​0.007). There was also a significantly lower rate of complications with the Latarjet procedure as a primary surgery (6.2% vs 10.2%, p ​= ​0.03). Furthermore, there was a significant difference in the rate of revision surgery in favour of the Latarjet procedure as a primary surgery (4.8% vs 10.9%, p ​= ​0.02). However, there were similar rates of redislocations (2.8% vs 3.4%, p ​= ​0.82) and return to play (67.7% vs 78.5%, p ​= ​0.30) between the two cohorts., Conclusion: This study found that the Latarjet procedure as a revision procedure for a previously failed Bankart repair resulted in higher rates of complications, recurrent instability, and revisions than the Latarjet procedure performed as a primary procedure., Level of Evidence: Level III, Systematic Review & Meta-Analysis of Level III studies., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Fisetin has been shown to be beneficial for brain injury and age-related brain disease via different mechanisms. The purpose of this study was to determine the presence of senescent cells and the effects of fisetin on cellular senescence in the brain and other vital organs in old sheep, a more translational model. Female sheep 6-7 years old (N = 6) were treated with 100 mg/kg fisetin or vehicle alone on two consecutive days a week for 8 weeks. All vital organs were harvested at the time of sacrifice. Histology, immunofluorescence staining, and RT-Q-PCR were performed on different regions of brain tissues and other organs. Our results indicated that fisetin treatment at the current regimen did not affect the general morphology of the brain. The presence of senescent cells in both the cerebral brain cortex and cerebellum and non-Cornu Ammonis (CA) area of the hippocampus was detected by senescent-associated β-galactosidase (SA-β-Gal) staining and GL13 (lipofuscin) staining. The senescent cells detected were mainly neurons in both gray and white matter of either the cerebral brain cortex, cerebellum, or non-CA area of the hippocampus. Very few senescent cells were detected in the neurons of the CA1-4 area of the hippocampus, as revealed by GL13 staining and GLB1 colocalization with NEUN. Fisetin treatment significantly decreased the number of SA-β-Gal + cells in brain cortex white matter and GL13 + cells in the non-CA area of the hippocampus, and showed a decreasing trend of SA-β-Gal + cells in the gray matter of both the cerebral brain cortex and cerebellum. Furthermore, fisetin treatment significantly decreased P16 + and GLB1 + cells in neuronal nuclear protein (NEUN) + neurons, glial fibrillary acidic protein (GFAP) + astrocytes, and ionized calcium binding adaptor molecule 1 (IBA1) + microglia cells in both gray and white matter of cerebral brain cortex. Fisetin treatment significantly decreased GLB1 + cells in microglia cells, astrocytes, and NEUN + neurons in the non-CA area of the hippocampus. Fisetin treatment significantly decreased plasma S100B. At the mRNA level, fisetin significantly downregulated GLB1 in the liver, showed a decreasing trend in GLB1 in the lung, heart, and spleen tissues, and significantly decreased P21 expression in the liver and lung. Fisetin treatment significantly decreased TREM2 in the lung tissues and showed a trend of downregulation in the liver, spleen, and heart. A significant decrease in NRLP3 in the liver was observed after fisetin treatment. Finally, fisetin treatment significantly downregulated SOD1 in the liver and spleen while upregulating CAT in the spleen. In conclusion, we found that senescent cells were widely present in the cerebral brain cortex and cerebellum and non-CA area of the hippocampus of old sheep. Fisetin treatment significantly decreased senescent neurons, astrocytes, and microglia in both gray and white matter of the cerebral brain cortex and non-CA area of the hippocampus. In addition, fisetin treatment decreased senescent gene expressions and inflammasomes in other organs, such as the lung and the liver. Fisetin treatment represents a promising therapeutic strategy for age-related diseases.

In the management of multidirectional type of shoulder instability (MDI), arthroscopic surgical stabilization is a preferred treatment option after failed conservative therapy regimens because of the ability to easily access all aspects of the capsule with one surgical procedure. As arthroscopic techniques have evolved, factors critical to postoperative success have been elucidated. Currently, optimal arthroscopic treatment of MDI involves circumferentially restoring labral integrity, a tailored, patient-specific surgical reduction of capsular volume, and adequately managing potential lesions of the biceps anchor. The purpose of this article and accompanying video is to present our technique for arthroscopic circumferential labral repair and pancapsular shift using knotless all-suture anchors in the setting of MDI with a concurrent type II SLAP lesion., (© 2023 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.)

Clinical instability of the sternoclavicular (SC) joint is a challenging problem. Recurrent subluxation and pain can lead to significant functional limitations. Although many patients respond positively to conservative treatment, chronic dislocations often require operative intervention. The complex anatomy of the diarthrodial SC joint and the existence of concomitant SC joint degenerative changes compounded with close-by neurovascular structures present a surgical challenge. The purpose of this Technical Note is to describe a technique for the open management of symptomatic sternoclavicular joint instability using a figure-of-8 reconstruction with a gracilis autograft. The present authors believe this technique provides a technically safe and reproducible method for reconstructing the SC joint without compromising biomechanical strength., (© 2023 The Authors.)

Background: Rotator cuff tears are common in the elderly population and are associated with increased pain, decreased function, and decreased enjoyment of recreational activities., Purpose: To evaluate clinical outcomes at a minimum of 5 years after arthroscopic repair of full-thickness rotator cuff tears in recreational athletes aged ≥70 years at the time of surgery., Study Design: Case series; Level of evidence, 4., Methods: Included were recreational athletes aged ≥70 years who underwent arthroscopic rotator cuff repair (RCR) from December 2005 to January 2016. Patient and surgery characteristics were collected prospectively and retrospectively reviewed. Patient-reported outcome (PRO) scores utilized were the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), the shortened version of Disabilities of the Arm, Shoulder and Hand score (QuickDASH), 12-Item Short Form Health survey (SF-12) questionnaire (Physical Component Summary and Mental Component Summary), and patient satisfaction. Kaplan Meier survivorship analysis was performed, with failure defined as revision RCR or retear on magnetic resonance imaging (MRI)., Results: Overall, 71 shoulders (n = 67 patients [44 men, 23 women]; mean age, 73.4 years [range, 70.1-81.3 years]) were included in this study. Follow-up data was obtained for 65 of the 69 available shoulders (94%) at a mean of 7.8 years (range, 5-15.3 years). Mean age at follow-up was 81.2 years (range, 75.7-91.0). One RCR was revised after a traumatic accident, and another had a symptomatic, MRI-confirmed retear. One patient had lysis of adhesions for stiffness 3 months postoperatively. All PRO scores improved from pre- to postoperatively-ASES, from 55.3 to 93.6; SANE, from 62 to 89.6; QuickDASH, from 32.9 to 7.3; and SF-12 Physical Component Summary, from 43.3 to 53 ( P < .001 for all)-and the median satisfaction score was 10 out of 10. Postoperatively, 63% of the patients returned to their original fitness program and 33% of patients modified their recreational activity. Survivorship analysis showed a 98% survival rate at 5 years and a 92% rate at 10 years., Conclusion: Sustained improvement in function, reduced pain, and return to activities was seen after arthroscopic RCR in active patients ≥70 years old. Despite one-third of patients modifying their recreational activity, the cohort reported high levels of satisfaction and general health., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Grant support for this study was received from Arthrex (grant IIRR-01051). This study was supported by the Steadman Philippon Research Institute (SPRI), which is a 501(k) nonprofit institution. During the past calendar year, the SPRI has received grant funding or in-kind donations from Arthrex, DJO, Ossur, Siemens, Smith & Nephew, and XTRE. R.B.P. has received research support from Arthrex; education payments from Medical Device Business Services, Pinnacle, and Smith & Nephew; and hospitality payments from Exactech. L.B.V. has received education payments from Arthrex and consulting and nonconsulting fees from Smith & Nephew. P.J.M. has received research support from Arthrex, Ossur, Siemens, and Smith & Nephew; consulting fees and nonconsulting fees from Arthrex; and royalties from Arthrex, Medbridge, and Springer; and has stock/stock options in VuMedi. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Background: Arthroscopic superior capsular reconstruction (SCR) has been introduced as a successful alternative to latissimus dorsi tendon transfer (LDTT) for irreparable posterosuperior rotator cuff tears., Purpose: To compare minimum 5-year clinical outcomes of SCR and LDTT for the treatment of irreparable posterosuperior rotator cuff tears in patients with minimal evidence of arthritis and intact or reparable subscapularis tears., Study Design: Cohort study; Level of evidence, 3., Methods: Patients who underwent SCR or LDTT and had undergone surgery ≥5 years earlier were included. The SCR technique used a dermal allograft customized to the defect. Surgical, demographic, and subjective data were collected prospectively and reviewed retrospectively. Patient-reported outcome (PRO) scores utilized were the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), the short version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), and patient satisfaction. Further surgical procedures were documented, and treatment that progressed to reverse total shoulder arthroplasty (RTSA) or revision rotator cuff surgery was considered a failure. Kaplan-Meier survivorship analysis was performed., Results: Thirty patients (n = 20 men; n = 10 women) with a mean follow-up of 6.3 years (range, 5-10.5 years) were included. A total of 13 patients underwent SCR and 17 patients underwent LDTT. The mean age of the SCR group was 56 years (range, 41.2-63.9 years), and the mean age of the LDTT group was 49 years (range, 34.7-57 years) ( P = .006). One patient in the SCR group and 2 patients in the LDTT group progressed to RTSA. Two additional (11.8%) patients in the LDTT group had further surgery-1 had arthroscopic cuff repair and 1 had hardware removal with biopsies. The SCR group demonstrated significantly better ASES (94.1 ± 6.3 vs 72.3 ± 16.4; P = .001), SANE (85.6 ± 8 vs 48.7 ± 19.4; P = .001), QuickDASH (8.8 ± 8.7 vs 24.3 ± 16.5; P = .012), and SF-12 PCS (56.1 ± 2.3 vs 46.5 ± 6; P = .001) PROs at the final follow-up. There was no significant difference between groups in median satisfaction (SCR, 9; LDTT, 8 [ P = .379]). At 5 years, survivorship rates were 91.7% and 81.3% for the SCR and LDTT groups, respectively ( P = .421)., Conclusion: At the final follow-up, SCR yielded superior PROs compared with LDTT for the treatment of massive, irreparable posterosuperior rotator cuff tears despite similar patient satisfaction and survivorship between procedures., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This work was partially funded directly by a private grant from Paul and Lee Schmidt. This research was supported by the Steadman Philippon Research Institute (SPRI), which is a 501(c)(3) nonprofit institution supported financially by private donations and corporate support. The SPRI exercises special care to identify any financial interests or relationships related to the research conducted. During the past calendar year, the SPRI has received grant funding or in-kind donations from Arthrex, DJO, MLB, Ossur, Siemens, Smith & Nephew, and XTRE. S.L. has received grant support from Arthrex and education payments from Arthrex and Smith & Nephew. P.J.M. has received research support from Arthrex, Ossur, Siemens, and Smith & Nephew; consulting fees from Arthrex; and royalties from Arthrex, MedBridge, and Springer; and has stock/stock options in VuMedi. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Purpose of Review: Shoulder instability in patients with underlying joint hyperlaxity can be challenging to treat. Poorly defined terminology, heterogeneous treatments, and sparse reports on clinical outcomes impair the development of best practices in this patient population. This article provides a review of the current literature regarding optimal management of patients suffering from shoulder instability with concomitant hyperlaxity of the shoulder, from isolated shoulder joint hyperlaxity to congenital hypermobility spectrum disorders (HSD)., Recent Findings: Current research shows specialized physiotherapy protocols focused on strengthening of periscapular muscles and improvement of sensorimotor control are a promising non-surgical therapeutic avenue in certain patients, which can be augmented by device-based intervention in select cases. If surgical treatment is warranted, arthroscopic techniques such as pancapsular shift or plication continue to demonstrate favorable outcomes and are currently considered the benchmark for success. The long-term success of more recent innovations such as coracoid process transfers, conjoint tendon transfers, subscapularis tendon augmentation, and capsular reconstruction remains unproven. For patients affected by connective tissue disorders, treatment success is generally less predictable, and the entire array of non-operative and operative interventions needs to be considered to achieve the best patient-specific treatment results. In the treatment of shoulder instability and concomitant hyperlaxity, specialized physiotherapy protocols augmented by device-based interventions have emerged as powerful, non-operative treatment options for select patients. Successful surgical approaches have been demonstrated to comprehensively address capsular redundancy, labral lesions, and incompetence of additional passive stabilizers in a patient-specific fashion, respective of the underlying connective tissue constitution., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

While functional reconstruction of massive irreparable rotator cuff tears remains a challenge, current techniques aimed at recentering and preventing superior migration of the humeral head allow for clinical and biomechanical improvements in shoulder pain and function. Recentering of the glenohumeral joint reduces the moment arm and helps the deltoid to recruit more fibers, which compensates for insufficient rotator cuff function and reduces joint pressure. In the past, the concept of a superior capsular reconstruction with a patch secured by suture anchors has been used. However, several innovative arthroscopic treatment options have also been developed. The purpose of this article is to present an overview of new strategies and surgical techniques and if existing present initial clinical results. Techniques that will be covered include rerouting the long head of the biceps tendon, utilization of the biceps tendon as an autograft to reconstruct the superior capsule, utilization of a semitendinosus tendon allograft to reconstruct the superior capsule, superior capsular reconstruction with dermal allografts, and subacromial spacers.

Background: Surgical pectoralis major (PM) repair can offer improved functional outcomes over nonoperative treatment. However, there is a lack of literature on consensus of the anatomical site of the humeral attachment., Purpose: To provide qualitative and quantitative anatomic analysis of the PM by focusing on humeral insertion and relevant structures at risk., Study Design: Descriptive laboratory study., Methods: Eight fresh-frozen male cadavers were dissected. The relevant landmarks that were collected and measured included (1) PM footprint length at the humeral insertion (total, sternal head, and clavicular head insertions); (2) PM tendon length from the humeral insertion to the musculotendinous junction; (3) distance from the PM humeral insertion to the lateral (LPN) and medial (MPN) pectoral nerves; and (4) distance from the coracoid process to the musculocutaneous nerve (MCN) in anatomical position., Results: The total PM footprint length was 81.4 mm (95% CI, 71.4-91.3). The sternal and clavicular heads that make up the PM had footprint lengths of 42.1 mm (95% CI, 32.9-51.4) and 56.6 mm (95% CI, 46.5-66.7), respectively. The PM tendon was wider at the clavicular head (74.7 mm; 95% CI, 67.5-81.7) than the sternal head insertions (43.0 mm; 95% CI, 40.1-45.9). The distances from the PM humeral insertion to LPN and MPN were 93.2 mm (95% CI, 83.1-103.3) and 103.8 mm (95% CI, 98.3-109.4), respectively. The coracoid process to MCN distance was 68.5 mm (95% CI, 60.2-76.8)., Conclusion: This study successfully quantifies anatomic dimensions of the PM tendon, its sternal and clavicular head insertions, and its location relative to nearby vital structures. Such knowledge can provide surgeons with a better understanding of the PM in relation to nearby neurovascular structures during anatomic PM repair and reconstruction to avoid debilitating complications., Clinical Relevance: Knowledge of the quantitative anatomy of the PM at the humeral footprint along structures at risk may aid surgeons with identifying the injured part of the PM and improve outcomes for anatomic repair and reconstruction., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Specimens were donated for medical research and subsequently purchased by the Steadman Philippon Research Institute (SPRI) from corresponding tissue banks. P.J.M. has received research support from Arthrex, Ossur, Siemens, and Smith & Nephew; consulting fees from Arthrex; royalties from Arthrex, Medbridge, and Springer; hospitality payments from Arthrosurface, Merz Pharmaceuticals, Sanofi-Aventis, and Stryker; and stock/stock options from VuMedi. M.T.P. has received consulting fees from Arthrex, JRF Ortho, and SLACK; royalties from Arthrex and Elsevier; and honoraria from Arthrosurface. The SPRI, a 501(c)(3) nonprofit institution supported financially by private donations and corporate support, exercises special care to identify any financial interests or relationships related to research conducted. During the past calendar year, SPRI has received grant funding or in-kind donations from Arthrex, Ossur, Siemens, Smith & Nephew, and DJO. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: Anterior shoulder instability (ASI) is a frequently encountered pathology. Patients with a history of ASI have an increased rate of developing glenohumeral osteoarthritis and becoming candidates for shoulder arthroplasty. This systematic review aims to synthesize outcomes for patients undergoing shoulder arthroplasty with a history of ASI., Methods: A comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, OVID Medline, Scopus, CINAHL, Web of Science, and Cochrane databases for studies evaluating the impact of prior ASI on total shoulder arthroplasty (TSA), reverse TSA, and/or hemiarthroplasty outcomes, with a minimum follow-up of 12 months. Studies were graded by level of evidence and data concerning patient demographics and outcomes were extracted., Results: Sixteen articles met the inclusion criteria, including 596 patients (413 male, 181 female). The average age of the control and prior ASI groups were 57.5 and 57.0 years, respectively. Overall, 251 patients were treated operatively, 132 nonoperatively, and 213 were controls without a history of prior ASI. Shoulder arthroplasty techniques included TSA (436 shoulders), reverse TSA (130 shoulders), and hemiarthroplasty (14 shoulders). Prior anterior stabilization management included soft tissue repair, bony augmentation, and nonoperative treatment. Almost all studies reported no significant difference in subjective and functional arthroplasty outcomes between control and prior ASI groups, or between patients with prior ASI treated nonoperatively vs. surgically., Conclusion: Shoulder arthroplasty in the setting of prior ASI results in improved subjective and functional outcome scores that are comparable to patients without a history of instability., (© 2022 The Authors.)

Purpose: To assess clinical outcomes following pectoralis major tendon (PMT) repairs and to compare outcomes of PMT repairs augmented with and without leukocyte-poor platelet-rich plasma (LP-PRP)., Methods: A retrospective review of prospectively collected data was performed of patients who underwent a PMT repair from May 2007 to June 2019 with a minimum of 2-year follow-up. Exclusion criteria included revision PMT repair, PMT reconstruction, and concomitant repair of another glenohumeral tendon/ligament. LP-PRP was injected surrounding the PMT repair before wound closure. Patient-reported outcome (PRO) data were collected preoperatively and evaluated at final follow-up using the American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numeric Evaluation Score (SANE), Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), and Short Form 12 physical component summary (SF-12 PCS), patient satisfaction with outcomes., Results: Twenty-three men (mean age, 38.6 years; range, 20.5-64.3 years) were included in the final analysis. Mean time from injury to surgery was 30 days (range, 3-123 days). Follow-up was obtained for 16 of 23 patients (70%) at a mean of 5.1 years (range 2.0-13.0 years). Significant improvement in PROs was observed (ASES: 59.0 → 92.4, P  = .008; SANE: 44.4 → 85.9, P  = .018; QuickDASH: 44.4 → 8.5, P  = .018; and SF-12 PCS: 42.5 → 52.6, P  = .008). Median satisfaction was 9 of 10 (range, 6-10). Patients receiving LP-PRP had superior ASES (99.6 vs 83.0, P  = .001), SANE (94.8 vs 74.6, P  = .005), QuickDASH (0.24 vs 19.1, P  = .001), and patient satisfaction (10 vs 9, P  = .037) scores compared with those without PRP. PROs were unchanged based on chronicity, mechanism of injury, or tear location. One patient had revision surgery at 3.4 years due to adhesions., Conclusions: PMT repair produces improved PROs at final follow-up when compared with preoperative values., Level of Evidence: Level III, retrospective comparative therapeutic trial., (© 2022 The Authors.)

Posterior shoulder instability (PSI) is a relatively less common form of instability that frequently affects young overhead or contact athletes. The etiology of PSI may be traumatic or atraumatic, with establishment of the diagnosis being more difficult in cases of atraumatic instability. Surgical management of PSI has evolved from open techniques to arthroscopic techniques. Posterior stabilization has commonly been performed with 2 posterior working portals with the patient in the lateral decubitus position. The objective of this Technical Note is to describe a technique for posterior labral repair using all-suture anchors with the patient in the beach-chair position via 1 working portal with capsular closure., (© 2022 The Authors.)

Background: It remains unclear if young overhead athletes with isolated superior labrum anterior-posterior (SLAP) type 2 lesions benefit more from SLAP repair or subpectoral biceps tenodesis., Purpose: To evaluate clinical outcomes and return to sport in overhead athletes with symptomatic SLAP type 2 lesions who underwent either biceps tenodesis or SLAP repair., Study Design: Cohort study; Level of evidence, 3., Methods: A retrospective analysis of prospectively collected data was performed in patients who underwent subpectoral biceps tenodesis (n = 14) or SLAP repair (n = 24) for the treatment of isolated type 2 SLAP lesions. All patients were aged <35 years at time of surgery, participated in overhead sports, and were at least 2 years out from surgery. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numerical Evaluation (SANE) score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; and the 12-Item Short Form (SF-12) physical component score. Return to sport and patient satisfaction were documented. Clinical failures requiring revision surgery and complications were reported., Results: Preoperative baseline scores in both the tenodesis and SLAP repair groups were similar. There were no significant differences between the groups on any postoperative outcome measure: For biceps tenodesis versus SLAP repair, the ASES score was 92.7 ± 10.4 versus 89.1 ± 16.7, the SANE score was 86.2 ± 13.7 versus 83.0 ± 24.1, the QuickDASH score was 10.0 ± 12.7 versus 9.0 ± 14.3, and SF-12 was 51.2 ± 7.5 versus 52.8 ± 7.7. No group difference in return-to-sports rate (85% vs 79%; P = .640) was noted. More patients in the tenodesis group (80%) reported modifying their sporting/recreational activity postoperatively because of weakness compared with patients in the SLAP repair group (15%; P = .022). One patient in each group progressed to surgery for persistent postoperative stiffness, and 1 patient in the tenodesis group had a postoperative complication related to the index surgery., Conclusion: Both subpectoral biceps tenodesis and SLAP repair provided excellent clinical results for the treatment of isolated SLAP type 2 lesions, with a high rate of return to overhead sports and a low failure rate, in a young and high-demanding patient cohort. More patients reported modifying their sporting/recreational activity because of weakness after subpectoral tenodesis., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The positions of L.L. and P.C.N. at the Steadman Philippon Research Institute were supported by AGA, via Arthrex, for 1 calendar year. T.J.D. has received educational or grant support from Smith & Nephew, CGG Medical, and DJO. P.J.M. has received research support from Arthrex, Ossur, Siemens, and Smith & Nephew; consulting fees from Arthrex; royalties from Arthrex, Medbridge, and Springer; and hospitality payments from Arthrosurface, Merz Pharmaceuticals, Sanofi-Aventis, and Stryker; and has stock/stock options in VuMedi. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Snapping scapula syndrome (SSS) is a painful and debilitating condition that occurs as a result of disruption of normal scapulothoracic articulation and inflammation of numerous soft tissue and bursal structures that function to facilitate scapulothoracic motion. Historically, when nonoperative management of SSS failed, patients progressed to open surgical management. However, as arthroscopic techniques have evolved, the condition has been increasingly treated arthroscopically because of the minimally invasive nature, periscapular muscle-preserving approach with decreased risk to surrounding neurovascular structures, better intraoperative visualization, and quicker patient recovery and rehabilitation. The objective of this Technical Note is to describe our arthroscopic approach for the management of SSS using two portals to complete a scapulothoracic bursectomy and partial scapulectomy of the superomedial scapula. Level of Evidence: Level I: shoulder., (© 2022 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.)

Purpose: To elucidate the clinical outcomes of patients who underwent anterior capsular reconstruction (ACR) with dermal allograft for irreparable subscapularis tears in native shoulders at a minimum of 2-year follow-up., Methods: This study included patients who underwent ACR by a single surgeon between March 2015 and September 2018. Clinical and intraoperative findings were recorded. Patient-reported outcomes were evaluated pre- and postoperatively, including American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, General Health Short-Form 12 Physical Component Summary and patient satisfaction (on a 1-10 scale, with 10 = best). Failure was defined as revision subscapularis surgery or conversion to reverse total shoulder arthroplasty., Results: Seven patients who underwent ACR at a mean age of 53 ± 7.3 years at the time of surgery were included. Median time from injury to surgery was 13.8 months (range 13.8-32.0 months). Two patients had concomitant superior capsular reconstruction. One patient progressed to a reverse total shoulder arthroplasty at 6.8 months. Minimum 2-year follow-up was obtained in the remaining 6 of 6 (100%) patients, with a mean follow-up of 3.4 years (range 2.0-6.2). There was significant improvement in the Quick Disabilities of the Arm, Shoulder and Hand score (preoperative: 32.7, postoperative: 9.5, P  = .04), whereas the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, and SF-12 PCS scores demonstrated nonsignificant improvement. Median patient satisfaction was 9.5 (range 7-10)., Conclusions: This small cohort of patients had a significant improvement in Quick Disabilities of the Arm, Shoulder and Hand score, high patient satisfaction, and relatively low conversion rate to reverse total shoulder arthroplasty. These clinical outcomes demonstrate that ACR with a dermal allograft may be a viable salvage operation for irreparable subscapularis tears in the short-term., Level of Evidence: Level IV, therapeutic case series., (© 2022 The Authors.)

Background: Excellent results have been reported for anatomic total shoulder arthroplasty (TSA) for the treatment of primary glenohumeral osteoarthritis (GHOA). We aim to assess the recovery curve and longitudinal effects of time, age, sex, and glenoid morphology on patient-reported outcomes (PROs) after primary anatomic TSA for primary GHOA., Methods: Patients who underwent primary anatomic TSA over 5 years ago were included: Short-Form 12 Physical Component Summary, American Shoulder and Elbow Surgeons scores, Quick Disabilities of the Arm Shoulder and Hand Score, Single Assessment Numeric Evaluation, and patient satisfaction were assessed. Linear mixed-effects models were used to model progression in PROs longitudinally. Unadjusted models and models controlling for sex and age were constructed., Results: Eighty-one patients (91 shoulders) were included. Significant improvements from the preoperative period to 1 year postoperatively in the median American Shoulder and Elbow Surgeons (48 to 93; P  < .001), Quick Disabilities of the Arm Shoulder and Hand Score (42 to 11; P  < .001), Single Assessment Numeric Evaluation (50 to 91; P  < .001), and Short-Form 12 Physical Component Summary (35 to 53; P  = .004) scores were noted. No significant decrease was observed for any of the outcome scores. Median satisfaction at the final follow-up was 10 out of 10. At 1, 2, 3, 4, 5, 6, and 7 years postoperatively, 77%, 64%, 79%, 57%, 86%, 56%, and 78% of patients, respectively, reported sports participation equal to or slightly below preinjury level. There was no association between the glenoid morphology and functional outcomes., Conclusion: Patients undergoing anatomic TSA for primary GHOA showed excellent improvement in PROs and satisfaction in the first year, and these results were maintained postoperatively for a minimum of 5 years. Age- and sex-adjusted models or glenoid morphology did not substantially alter any trends in PROs postoperatively., (© 2022 The Author(s).)

Purpose: The purpose of this study was to compare outcomes between anterior shoulder instability patients with and without glenolabral articular disruption (GLAD) lesions after undergoing arthroscopic Bankart repair and to evaluate potential risk factors for inferior outcomes and recurrent instability., Methods: Prospectively collected data were retrospectively reviewed for patients who underwent arthroscopic Bankart repair with and without GLAD lesions at a minimum of 2 years follow-up. Consecutive patients were matched by age, sex, and number of anchors. Patient-reported outcomes (PROs) were evaluated before and after surgery, including American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Quick Disabilities of the Arm, Shoulder and Hand, Short Form-12 score, and satisfaction. Recurrent dislocation, subjective instability, and reoperation were analyzed. Additionally, PROs were assessed on the basis of GLAD lesion characteristics., Results: A total of 54 patients (27 GLAD, 27 control) with a mean age of 28.9 ± 11.6 years were analyzed at mean 4.5 ± 1.9 years (range, 2-9 years) follow-up. Thirty-eight (70.3%) of the participants were male. Patients in both groups experienced significant improvements in all PROs ( P ≤ .006 for all measures) and reported high median satisfaction (scale 1-10: 10 vs 10, P  = .290) at final follow-up. Two patients in the GLAD cohort and 1 in the control cohort underwent reoperation ( P  = .588). Four (14.8%) patients in each group reported recurrent dislocation ( P  = 1.0). Additionally, 2 (7.4%) GLAD patients and 1 (3.7%) control patient reported subjective shoulder instability after surgery ( P  = 1.0). No significant differences in PROs were observed based on anchor/labral advancement or treatment with microfracture, nor were significant correlations observed between GLAD lesion size and PROs ( P > .05 for all)., Conclusion: Arthroscopic Bankart repair in patients with GLAD lesions resulted in significantly improved outcomes with high satisfaction, which was no different when compared with those without GLAD lesions., Level of Evidence: Level III, retrospective comparative study., (© 2022 The Authors.)

Hypothesis: Both clinical outcomes and early rates of failure will not be associated with glenoid retroversion., Methods: All patients who underwent an anatomic total shoulder arthroplasty with minimal, noncorrective reaming between 2006 and 2016 with minimum 2-year follow-up were reviewed. Measurements for retroversion, inclination, and posterior subluxation were obtained from magnetic resonance imaging or computerized tomography. A regression analysis was performed to assess the association between retroversion, inclination and subluxation, and their effect on patient reported outcomes (PROs). Clinical failures and complications were reported., Results: One hundred fifty-one anatomic total shoulder arthroplasties (90% follow-up) with a mean follow-up of 4.6 years (range, 2-12 years) were assessed. The mean preoperative retroversion was 15.6° (range, 0.2-42.1), the mean posterior subluxation was 15.1% (range, -3.6 to 44.1%), and the mean glenoid inclination was 13.9° (range, -11.3 to 44.3). All median outcome scores improved significantly from pre- to post-operatively ( P  < .001). The median satisfaction was 10/10 (1st quartile = 7 and 3rd quartile = 10). Linear regression analysis found no significant association between retroversion and any postoperative PRO. A total of 5 (3.3%) failures occurred due to glenoid implant loosening (3 patients) and Cutibacterium acnes infection (2 patients) with no association between failure causation and increased retroversion or inclination. No correlation could be found between the Walch classification and postoperative PROs., Conclusion: Anatomic total shoulder replacement with minimal and noncorrective glenoid reaming demonstrates reliable increases in patient satisfaction and clinical outcomes at a mean of 4.6-year follow-up in patients with up to 40° of native retroversion. Higher values of retroversion were not associated with early deterioration of clinical outcomes, revisions, or failures. Long-term studies are needed to see if survivorship and outcomes hold up over time., (© 2022 The Author(s).)

Purpose: To evaluate and compare patient-reported outcomes (PROs) after isolated greater tuberosity (GT) fracture fixation versus acute rotator cuff repair (RCR) at a minimum of 2 years., Methods: Patients who underwent isolated GT fracture fixation were compared in a 1-to-3 fashion with patients who underwent arthroscopic RCR for an acute rotator cuff tear by a single surgeon from January 2006 and to July 2018. Data were prospectively collected and retrospectively reviewed. PROs were compared pre- and postoperatively as well as between groups (American Shoulder and Elbow Surgeons [ASES], General Health Short Form-12 Physical Component [SF-12 PCS], Single Assessment Numerical Evaluation [SANE], Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH], and satisfaction). Reoperation rates were analyzed., Results: A total of 57 patients (14 with isolated GT fracture fixation, mean age 45.7 years; and 43 who underwent ARCR for acute tears, mean age 56.6 years) were evaluated ( P  = .050). ASES scores significantly improved from 39.7 to 94.1 ( P  = .018) in the isolated GT fracture fixation group and from 51.0 to 95.2 ( P < .001) in acute RCR group. At final follow-up, mean QuickDASH scores were 8.9 and 7.9 ( P  = .677) and SANE scores were 91.1 and 87.3 ( P  = .616) for the GT and acute RCR groups, respectively. The median satisfaction was 10/10 for the GT group and 10/10 for the RCR group. Additional comparison of patients who underwent double-row repair for an acute rotator cuff tear or isolated GT fracture revealed no significant difference in outcomes ( P > .404)., Conclusion: Minimum 2-year PROs after fixation of isolated GT fractures show relatively high outcome scores whether treated by open reduction and internal fixation or arthroscopic fixation using a double-row bridging technique. The improvements in PROs are similar to those achieved with acute rotator cuff tears that were fixed arthroscopically with RCR. Further analysis of these results suggest that the functional outcomes of tendon-to-bone healing with linked, double-row rotator cuff repairs are similar to those of bone-to-bone healing as seen with GT fractures., Level of Evidence: III, retrospective comparative study., (© 2022 The Authors.)

Subscapularis tears have been found to occur in the setting of subcoracoid impingement and are related to the narrowing of the coracohumeral interval. The advancement of arthroscopic techniques has allowed for improved identification and treatment of this historically overlooked pathology. Challenges of arthroscopic subscapularis treatment include nearby neurovascular structures, tendon retraction, and adhesions, which are further complicated by diminished arthroscopic visualization, resulting from the concomitant subcoracoid impingement. The purpose of this Technical Note is to describe our preferred technique for arthroscopic management of subscapularis tears in the setting of subcoracoid impingement that is simple and reproducible, as well as cost-effective and efficient with limited additional morbidity to that of a standard diagnostic shoulder arthroscopy., (© 2021 The Authors.)

Axillary nerve compression is a rare cause of posterolateral shoulder pain. Once the diagnosis is confirmed and after failure of conservative measures, open procedures have been the mainstay of treatment for several decades. More recently, arthroscopic techniques have been proposed, which offer several advantages, including improved access to difficult locations, better visualization, and less surgical morbidity. The objective of this Technical Note is to describe an arthroscopic neurolysis of the axillary nerve from the inferior humeral pouch, through the quadrilateral space and into the subdeltoid recess., (© 2021 The Authors.)

Purpose: To review arthroscopic findings at the time of open Latarjet procedures to determine whether preoperative magnetic resonance imaging reports (MRRs) correlate with arthroscopic findings, as well as whether the arthroscopic findings critically affected surgical interventions performed at the time of a Latarjet procedure., Methods: This was a retrospective case series of all patients who received a Latarjet procedure between 2006 and 2018. Patients were excluded if they had inadequate records or underwent revision of a bony reconstruction procedure. Both primary Latarjet procedures and Latarjet procedures for revision of a failed arthroscopic procedure were included. MRRs, arthroscopic findings, and diagnoses were collected, and differences were noted. A "critical difference" was one that affected the surgical intervention in a significantly anatomic or procedural fashion or that affected rehabilitation., Results: In total, 154 of 186 patients (83%) were included. Of these, 96 of 154 (62%) underwent revision Latarjet procedures. The average bone loss percentage reported was 20.6% (range, 0%-40%). A critical difference between MRR and arthroscopic findings was noted in 60 of 154 patients (39%), with no difference between Latarjet procedures and revision Latarjet procedures. Of 154 patients, 29 (19%) received an additional 52 intra-articular procedures for diagnoses not made on magnetic resonance imaging, with no difference between primary and revision procedures. This included biceps and/or SLAP pathology requiring a tenodesis, debridement, or repair; rotator cuff pathology requiring debridement or repair; complex (>180°) labral tears requiring repair; loose bodies; and chondral damage requiring debridement or microfracture. Patients undergoing revision Latarjet procedures were less likely to have bone loss mentioned or quantified in the MRR., Conclusions: Diagnostic imaging may not reliably correlate with diagnostic arthroscopic findings at the time of a Latarjet procedure from both a bony perspective and a soft-tissue perspective. In this series, diagnostic arthroscopy affected the surgical plan in addition to the Latarjet procedure in 19% of cases. We recommend performing a diagnostic arthroscopy prior to all Latarjet procedures to identify and/or treat all associated intra-articular shoulder pathologies., Level of Evidence: Level IV, diagnostic case series., (© 2021 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.)

Background: The therapeutic efficacy of orthobiologic therapies for rotator cuff repair is difficult to evaluate owing to reporting inconsistences. In response, the Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO) guidelines were developed to ensure standard reporting on orthobiologic therapies., Purpose: To systematically review clinical studies evaluating platelet-rich plasma (PRP) for full-thickness rotator cuff repair and adherence to MIBO guidelines., Study Design: Scoping review; Level of evidence, 4., Methods: A search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed, EMBASE, and the Cochrane Library databases. Inclusion criteria were clinical studies reporting on rotator cuff tears (≥1 cm) surgically repaired with PRP. Patient demographics, biologic intervention, and adherence to the MIBO guidelines were systematically reviewed., Results: A total of 19 studies (1005 patients) were included in this review. Across all studies, 58.5% of the MIBO checklist items for PRP were reported. Out of 47 checklist items, 19 were reported in over 85% of studies, whereas 22 were reported in less than half of studies. Details of whole-blood processing and characteristics, as well as PRP processing and characteristics, were reported inconsistently, and no study provided adequate information to enable the precise replication of preparation protocols for PRP., Conclusion: This systematic review highlights the current reporting deficiencies within the scientific literature of important variables for evaluating PRP for full-thickness rotator cuff repair. There was widespread variability among published studies that evaluate PRP for this application and, more specifically, studies were limited by inconsistent universal reporting of whole-blood and PRP processing and postprocessing characteristics. To improve our understanding of biologic efficacy and to promote repeatability, stricter adherence to the MIBO guidelines is necessary. We propose that the checklist limitations be addressed and that modification of the MIBO guidelines be considered to improve the reporting of individual components within certain categories., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.J.R. has received financial support from ProofPoint Biologics and hospitality payments from Smith & Nephew. P.J.M. has received financial support from ProofPoint Biologics, royalties from Arthrex, Medbridge, and Springer; consulting fees from Arthrex; research support from Arthrex, Ossur, Siemens, VuMedi, and Smith & Nephew; and hospitality payments from Arthrosurface, Gemini Mountain Medical, Stryker, and Sanofi-Aventis; and holds stock in Vu Medi. J.H. has received financial support from ProofPoint Biologics and royalties from CookMyosite. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Over the past 30 years, arthroscopic rotator cuff repair (ARCR) has evolved to become the gold standard in treating rotator cuff pathology. As procedural concepts of ARCR continue to improve, it is also continually compared with the open rotator cuff repair as the historical standard of care. This review highlights the evolution of ARCR, including a historical perspective; the anatomic, clinical, and surgical implications of the development of an arthroscopic approach; how arthroscopy improved some of the problems of the open approach; adaptations in techniques and technologies associated with ARCR; future perspectives in orthobiologics as they pertain to ARCR; and lastly, the clinical improvements, or lack of improvements, with all of these adaptations., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This research was supported by the Steadman Philippon Research Institute (SPRI), which is a 501(c)(3) nonprofit institution supported financially by private donations and corporate support. SPRI exercises special care to identify any financial interests or relationships related to research conducted here. During the past calendar year, SPRI has received grant funding or in-kind donations from Arthrex, Ossur, Siemens, Smith & Nephew, DoD, DJO, MLB, and XTRE. R.O.D.H.’s position at SPRI was supported by AGA via Arthrex for 1 calendar year. J.J.E. has received consulting fees from Medical Device Business Services. R.E.B. has received consulting fees from Smith & Nephew, nonconsulting fees from Arthrex and Smith & Nephew, and hospitality payments from Exactech. P.J.M. has received consulting fees from Arthrex and royalties from MedBridge and Springer and has stock/stock options in VuMedi. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)