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Purpose: To perform a Delphi consensus for the treatment of patients with shoulder impingement with intact rotator cuff tendons, comparing North American with European shoulder surgeon preferences., Methods: Nineteen surgeons from North America (North American panel [NAP]) and 18 surgeons from Europe (European panel [EP]) agreed to participate and answered 10 open-ended questions in rounds 1 and 2. The results of the first 2 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%, <80%) were contacted and asked to review their response. The level of agreement and consensus was defined as 80%., 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 workup; magnetic resonance 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 nonoperative treatment for a minimum of 6 months. The NAP was likely to routinely prescribe nonsteroidal anti-inflammatory drugs (NAP 89%; EP 35%) and consider steroids for impingement (NAP 89%; EP 65%)., Conclusions: 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 no-operative treatment for a minimum of 6 months. The panel also agreed that subacromial decompression is a good choice for shoulder impingement if there is evidence of mechanical impingement with pain not responding to nonsurgical measures., Level of Evidence: Level V, expert opinion., (Copyright © 2021 Arthroscopy Association of North America. All rights reserved.)

Since the introduction of acromioplasty by Neer in 1971 and arthroscopic subacromial decompression (SAD) by Ellman in 1987, the outcomes have been reported to be consistently good. Recently it was suggested that supervised physical therapy is comparable with SAD, which was contested by other studies claiming that SAD is clearly superior to nonoperative treatment. Before consideration for treatment, the diagnosis of impingement with an intact rotator cuff must be determined by clinical history, a detailed and structured clinical examination, and appropriate imaging. In favor of SAD are published long-term studies with a minimum of 10 years outlining significant functional and clinical improvement. The main factor for failure reported was workers compensation, calcific tendinopathy, and high-grade partial-thickness tears. Studies nonsupportive of SAD suffer from bias, crossover from the nonoperative group to the operative group following failure of conservative treatment, and loss of follow-up. Recently, lateral acromion resection has been suggested as a viable alternative, effectively reducing the critical shoulder angle. Following nonoperative treatment for at least 6 weeks, SAD is a viable and good surgical option for the treatment of shoulder impingement with an intact rotator cuff. Care should be taken to avoid resection of the acromioclavicular ligament. Five millimeters of lateral acromion resection is the recommended amount of resection. Patients with chronic calcific tendinitis, workers compensation, and partial-thickness tears should not be treated by SAD alone., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to perform a systematic review and meta-analysis comparing single- and double-row biomechanical studies to evaluate load to failure, mode of failure and gap formation., Materials and Methods: A systematic review of MEDLINE, Embase, Scopus and Google Scholar was performed from 1990 through 2016. The inclusion criteria were: documentation of ultimate load to failure, failure modes and documentation of elongation or gap formation. Studies were excluded if the study protocol did not use human specimens. Publication bias was assessed by funnel plot and Egger's test. The risk of bias was established using the Cochrane Collaboration's risk of bias tool. Heterogeneity was assessed using χ 2 and I 2 statistic., Results: Eight studies were included. The funnel plot was asymmetric suggesting publication bias, which was confirmed by Egger's test (p = 0.04). The pooled estimate for load to failure demonstrated significant differences (SMD 1.228, 95% CI: 0.55-5.226, p = 0.006, I 2  = 60.47%), favouring double-row repair. There were no differences for failure modes. The pooled estimate for elongation/gap formation demonstrated significant differences (SMD 0.783, 95% CI: 0.169-1.398, p = 0.012, I 2  = 58.8%), favouring double-row repair., Conclusion: The results of this systematic review and meta-analysis suggest that double-row repair is able to tolerate a significantly greater load to failure. Gap formation was also significantly lower in the double-row repair group, but both of these findings should be interpreted with caution because of the inherent interstudy heterogeneity., Level of Evidence: Systematic review and meta-analysis.

Purpose: To use magnetic resonance imaging to determine the influence of the labrum on both the osseous version and effective diameter of the glenoid., Methods: This was a retrospective, cross-sectional study of patients with shoulder pain who underwent MRI between February 2014 and February 2015. The morphology of the glenoid labrum and glenoid was scanned with a 3-T magnetic resonance imaging scanner, and variables were measured by use of IntelliSpace PACS Enterprise. Patients were included if they were aged between 18 and 40 years and the radiologist reported a normal glenohumeral joint or if they were young patients aged less than 30 years with acute traumatic isolated partial- or full-thickness tears of the rotator cuff with a history of symptoms of less than 3 months. A pilot study was conducted with 3 observers and 3 repeated measurements at intervals to determine the interobserver and intraobserver reliability. Data analysis included descriptive statistics of measured variables, as well as paired Student t tests to determine the relative difference between labral and osseous morphometric variables., Results: Excellent inter-rater reliability (0.95-0.96) and intrarater reliability (0.93-0.98) were obtained in the pilot study of 20 patients. The study population was composed of 100 patients with a mean age of 37.3 years (standard deviation [SD], 11.8 years), having a gender distribution of 56 male and 44 female patients; there were 53 right and 47 left shoulders. The glenoid osseous version measured -5.7° (SD, 5.3°), and the labral version measured -10° (SD, 5.5°); the glenoid osseous diameter measured 28.0 mm (SD, 3.3 mm), and the labral diameter measured 31.9 mm (SD, 3.2 mm). The labrum significantly increased the version by 4.3° (P = .001) and significantly increased the diameter by 3.9 mm (P = .001)., Conclusions: The results of this study showed that the labrum increased the effective glenoid version by 75% (4.3° of retroversion) and the effective glenoid diameter by 14% (3.9 mm)., Level of Evidence: Level IV, prognostic case series., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)