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Purpose: To investigate if patients younger than 50 years old had improved functional outcomes after subpectoral biceps tenodesis (BT) for the treatment of biceps reflection pulley (BRP) lesions at minimum 2-year postoperative follow-up., Methods: Patients who had arthroscopically confirmed BRP tears that were treated with subpectoral BT and were at least 2 years out from surgery were included; patients were excluded if they had concomitant reconstructive or reparative procedures at index surgery. Patient-centered outcomes including return to activity, American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Short Form-12 Physical Component Summary (SF-12 PCS) scores, and patient satisfaction were collected. The pre- and postoperative scores were compared with a Wilcoxon test. Failure was defined as revision BT., Results: Between January 2006 and July 2014, of 1,184 patients who underwent open subpectoral BT, 14 patients (6 male, 8 female) with mean age 37 (range, 16-49 years) met the inclusion criteria. Minimum 2-year outcomes data were available for all 14 patients (100% follow-up). The mean follow-up was 3.6 ± 1.3 years. There were significant improvements postoperatively for all outcome scores (P = .017 ASES, P = .002 QuickDASH, P = .003 SF-12 PCS). There was no correlation between age and outcome scores (P > .05). Median patient satisfaction was 9 of 10. Five patients (36%) reported return to recreational activity with no modifications; 9 (64%) indicated a return to activity with modifications. The 5 patients who returned to recreational activity with no modification had significantly less time from initial injury/onset of symptoms until surgery in comparison with the 9 patients who modified their activity (P = .028). No complications or reoperations were reported., Conclusions: Patients younger than 50 years old with a symptomatic isolated BRP lesion experienced excellent results, high return to recreational activity, little postoperative pain, and high degrees of satisfaction when treated with subpectoral BT., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: Varus failure is one of the most common failure modes following surgical treatment of proximal humeral fractures. Straight antegrade nails (SAN) theoretically provide increased stability by anchoring to the densest zone of the proximal humerus (subchondral zone) with the end of the nail. The aim of this study was to biomechanically investigate the characteristics of this "proximal anchoring point" (PAP). We hypothesized that the PAP would improve stability compared to the same construct without the PAP., Methods: Straight antegrade humeral nailing was performed in 20 matched pairs of human cadaveric humeri for a simulated unstable two-part fracture., Results: Biomechanical testing, with stepwise increasing cyclic axial loading (50-N increments each 100 cycles) at an angle of 20° abduction revealed significantly higher median loads to failure for SAN constructs with the PAP (median, 450 N; range, 200-1.000 N) compared to those without the PAP (median, 325 N; range, 100-500 N; p = 0.009). SAN constructs with press-fit proximal extensions (endcaps) showed similar median loads to failure (median, 400 N; range, 200-650 N), when compared to the undersized, commercially available SAN endcaps (median, 450 N; range, 200-600 N; p = 0.240)., Conclusions: The PAP provided significantly increased stability in SAN constructs compared to the same setup without this additional proximal anchoring point. Varus-displacing forces to the humeral head were superiorly reduced in this setting. This study provides biomechanical evidence for the "proximal anchoring point's" rationale. Straight antegrade humeral nailing may be beneficial for patients undergoing surgical treatment for unstable proximal humeral fractures to decrease secondary varus displacement and thus potentially reduce revision rates.

Purpose: The purpose of this study was to identify the risk of concomitant glenohumeral pathologies with acromioclavicular joint injuries grade III and V., Methods: Patients who underwent arthroscopically-assisted stabilization of acromioclavicular joint injuries grade III or grade V between 01/2007 and 12/2015 were identified in the patient databases of two surgical centres. Gender, age at index surgery, grade of acromioclavicular joint injury (Rockwood III or Rockwood V), and duration between injury and index surgery (classified as acute or chronic) were of interest. Concomitant glenohumeral pathologies were noted and their treatment was classified as debridement or reconstructive procedure., Results: A total of 376 patients (336 male, 40 female) were included. Mean age at time of arthroscopic acromioclavicular joint reconstruction surgery was 42.1 ± 14.0 years. Overall, 201 patients (53%) had one or more concomitant glenohumeral pathologies. Lesions of the biceps tendon complex and rotator cuff were the most common. Forty-five patients (12.0%) had concomitant glenohumeral pathologies that required an additional repair. The remaining 156 patients (41.5%) received a debridement of their concomitant pathologies. Rockwood grade V compared to Rockwood grade III (p = 0.013; odds ratio 1.7), and chronic compared to acute injury were significantly associated with having a concomitant glenohumeral pathology (p = 0.019; odds ratio 1.7). The probability of having a concomitant glenohumeral pathology was also significantly associated with increasing age (p < 0.0001)., Conclusions: Concomitant glenohumeral pathologies were observed in 53% of surgically treated patients with an acute or chronic acromioclavicular joint injury of either grade III or V. Twenty-two percent of these patients with concomitant glenohumeral pathologies received an additional dedicated repair procedure. Although a significant difference in occurrence of concomitant glenohumeral pathologies was seen between Rockwood grades III and V, and between acute and chronic lesions, increasing age was identified as the most dominant predictor., Level of Evidence: Level IV, case series.

Clavicle fractures are among the most common fractures occurring in the general population, and the vast majority are localized in the midshaft portion of the bone. Management of midshaft clavicle fractures remains controversial. Although many can be managed nonoperatively, certain patient populations and fracture patterns, such as completely displaced and shortened fractures, are at risk of less optimal outcomes with nonoperative management; surgical intervention should be considered in such cases. The purpose of this article is to demonstrate our technique of midshaft clavicle fixation using minimally invasive intramedullary fixation.

Humeral avulsion of the glenohumeral ligament (HAGL) is a lesion associated with anterior shoulder instability. Although uncommon, HAGL lesions are a significant contributor to shoulder pain and dysfunction and, if missed, can even be a cause of failed Bankart repair. HAGL lesions should generally be repaired surgically; however, given their low prevalence, there is no consensus on the optimal surgical approach. The purpose of this Technical Note is to describe our preferred surgical technique for the fixation of an HAGL lesion using an all-arthroscopic approach and a knotless suture anchor construct.

Although uncommon, rotator cuff tears that occur medially at the musculotendinous junction can result from acute trauma, anatomic force imbalance, or medial row cuff failure following a previous rotator cuff repair. The quality of the torn muscle and tendon along with the length of the remnant tendon stump should be considered before deciding on the most appropriate repair technique. When muscle and tendon quality are sufficient, the tear can often be repaired directly to the remnant tendon stump and compressed onto the greater tuberosity. If the remnant tendon stump is degenerative, of insufficient length, or lacks tendon in which to place sutures, an allograft patch can be used to augment the repair. When the quality of the remaining muscle and tendon are poor or when the muscle is retracted too far medially and is nonmobile, a bridging technique such as superior capsule reconstruction is preferable. The purpose of this report is to (1) highlight that medial cuff failure can occur both primarily and after previous repair; (2) define and classify the 3 major tear patterns that are encountered, and (3) describe the authors' preferred techniques for medial cuff repair that specifically address each of the major tear patterns.

Initial treatment of shoulder multidirectional instability (MDI) consists of nonoperative modalities of physical therapy and rehabilitation; if this fails, surgical treatment can become necessary. MDI of the shoulder can be challenging to manage in individuals who fail conservative management. Historically, surgical treatment for MDI has been open capsular plication; however, arthroscopic capsular plication has now become the standard of care, with outcomes similar to the open procedure. The purpose of this article and Video 1 is to describe our arthroscopic technique for pancapsular shift with labral repair.

Os acromiale occur frequently in the population and can be a cause of significant shoulder dysfunction and rotator cuff impingement. When symptomatic os acromiale fail conservative management, surgical intervention may become necessary. The purpose of this article is to describe our preferred surgical technique for osteosynthesis of os acromiale using cannulated screws and tension-band wiring.

Chronic anterior shoulder instability due to structural failure of the subscapularis muscle and the anterior capsule is a rare and challenging diagnosis for surgeons to manage because poor-quality capsular, labral, and rotator cuff tissue often limits effective treatment options. If primary repair is not possible because of retraction and poor tissue quality, reconstruction with an allograft or autograft may be the only joint-preserving option. The purpose of this article is to describe a surgical technique for anterior capsular reconstruction using a human acellular dermal allograft for the treatment of irreparable subscapularis tears.

Purpose: To investigate outcomes of arthroscopic single-anchor repair and biceps tenodesis of partial- and full-thickness tears of the upper third subscapularis (SSC)., Methods: Thirty-three patients with arthroscopically confirmed isolated SSC tears, Lafosse type I (>50% of the tendon thickness involved), or type II were included. All patients underwent arthroscopic subcoracoid decompression, coracoplasty if the coracohumeral distance was narrowed, biceps tenodesis, and a single-anchor repair of the upper third SSC. No other reconstructive procedures were performed. Subjective evaluations included American Shoulder and Elbow Surgeons, Short-Form 12, Quick Disabilities of the Arm, Shoulder and Hand, Single Assessment Numeric Evaluation, and visual analog scale pain scores preoperatively and at minimum 2 years postoperatively., Results: Thirty-one patients (n = 25 male, n = 6 female) were included in the final collective, because 2 patients refused participation. Minimum 2-year follow-up data were available for 28 of the 31 patients (90.3%). The mean age at the time of surgery was 54.8 (range, 36-71) years. The mean follow-up was 4.1 (range, 2.0-8.0) years. The results of all outcome measures improved significantly postoperatively compared with preoperative scores (P < .05). Patients with single-anchor repair of type II SSC tears (n = 17) had a significantly higher mean postoperative American Shoulder and Elbow Surgeons score (93.7 ± 10.8) than patients with single-anchor repair of type I SSC tears (n = 11; 86.7 ± 10.9; P = .027)., Conclusions: Arthroscopic single-anchor repair of upper third SSC tendon tears led to improved function and decreased pain with high patient satisfaction. Outcomes of full-thickness upper third SSC tears were more favorable compared with outcomes of high grade partial-thickness upper third SSC tears., Level of Evidence: Level IV, retrospective therapeutic case series., (Copyright © 2017. Published by Elsevier Inc.)

Isolated fractures of the greater tuberosity of the humerus are an uncommon and frequently missed diagnosis. Mistreated and unrecognized, these fractures can cause chronic pain and diminished shoulder range of motion and function. Operative treatment options include open reduction and internal fixation, as well as arthroscopic-assisted reduction and internal fixation. The purpose of this Technical Note is to describe a bridging arthroscopic technique for the treatment of bony avulsions of the supraspinatus tendon.

Superior capsule reconstruction is a recently-developed surgical technique for the treatment of massive, irreparable rotator cuff tears. So far, biomechanical cadaveric studies and clinical outcomes results have been promising concerning integrity, stability, and ROM after superior capsule reconstruction. As this technique has only been recently developed, an evidence-based rehabilitation protocol has not been previously designed. Thus, the purpose of this clinical commentary is to provide an overview of superior capsule reconstruction and to propose a rehabilitation program based on the available scientific evidence. The existing evidence is supplemented by the experience of the senior author who has performed more than forty superior capsule reconstruction procedures to date. This proposed rehabilitation protocol consists of four distinct phases, focusing on maximal protection, range of motion and muscular endurance, muscular strength and return to activity., Level of Evidence: 5.

Purpose: The objective of this study was to assess the outcomes after subpectoral biceps tenodesis (BT) for long head of the biceps (LHB) tenosynovitis in active patients <45 years old., Methods: This was an Institutional Review Board-approved, retrospective outcomes study with prospectively collected data. Patients treated with subpectoral BT were included if they met the following criteria: age <45 years, anterior shoulder pain with arthroscopically confirmed LHB tenosynovitis, no concomitant procedures other than debridement and decompression procedures, and minimum 2 years out from surgery. Patients were excluded from analysis if they refused participation. The American Shoulder and Elbow Surgeons (ASES), Short Form-12, Quick Disabilities of the Arm, Shoulder and Hand, Single Assessment Numeric Evaluation, and pain scores as well as sports participation preoperatively and at a minimum of 2 years postoperatively were obtained. Pre- and postoperative scores were compared using paired samples t-test and Wilcoxon signed-rank test., Results: Thirty patients met the inclusion criteria. Two of these patients refused to participate in follow-up and were excluded from analysis. Of the remaining 28 patients (17 male, 11 female; 37.0 ± 8.0 years), minimum 2-year outcomes were available for 24 (13 males, 11 females: 37.7 ± 8.2 years; 85.7%). Mean follow-up was 3.1 years (range, 2.0 to 7.3 years). There were significant improvements in all outcome measures including ASES score (P < .001), with a postoperative mean of 95.8 ± 7.8, visual analog scale "pain today" (P < .001), and pain affecting activities of daily living (P < .001). Seventeen of 20 (85%) patients who answered the question about postoperative sport participation were able to return to sport. Mean patient satisfaction was 9.2/10 (standard deviation, +1.7). There were no postoperative complications such as Popeye deformity or cramping. There were no clinical failures., Conclusions: Subpectoral BT is an excellent treatment option for active patients <45 years old with LHB tenosynovitis and chronic anterior shoulder pain, resulting in decreased pain, improved function, high satisfaction, and improved quality of life., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate glenoid fixation for superior capsule reconstruction (SCR) and evaluate anchor positions, intraosseous trajectories, and proximity to the suprascapular nerve (SSN) and glenoid fossa. The secondary purpose was to provide technical pearls and pitfalls for anchor insertion on the superior glenoid during SCR., Methods: Three beath pins were arthroscopically inserted into 12 (n = 12) nonpaired human cadaveric shoulders through Neviaser, anterior, and posterior portals to simulate anchor placement on the superior glenoid during SCR. Computed tomography scans were performed to evaluate anchor positioning and insertion trajectories. Specimens were then dissected to delineate the anatomic relations of the beath pins to the SSN and glenoid fossa., Results: The superior glenoid anchor position was a mean 15.0 ± 4.0 mm to the SSN and 6.5 ± 1.7 mm to the glenoid fossa. The posterior glenoid anchor position was a mean 11.8 ± 2.1 mm to the SSN and 2.9 ± 2.9 mm to the glenoid fossa. On average, the superior pin was placed at 12:30 ± 0:30 (left-sided glenoid clock face) and inserted at 19° ± 9° with respect to the sagittal plane of the glenoid, the anterior pin was placed at 11:00 ± 0:30 and inserted 40° ± 17° off the glenoid, and the posterior pin was placed at 3:00 ± 1:00 and inserted at 52° ± 12° off the glenoid., Conclusions: The results of the present cadaveric study showed that glenoid fixation was safe with respect to the SSN and delineated technical guidelines and trajectories for inserting 3 anchors into the glenoid., Clinical Relevance: This study shows that 3 anchors can be inserted into the glenoid without a risk of SSN damage and delineates technical guidelines for anchor insertion., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Snapping scapula syndrome (SSS) is caused by bony and/or soft tissue impingement in the scapulothoracic articulation. Surgical resection of the superomedial angle (SMA) plus bursectomy can provide relief in most cases; however, the amount needed to achieve adequate scapulothoracic space decompression (SSD) is unknown., Purpose: The aim of this study was to evaluate the effectiveness of partial scapulectomy and the influence of bony anatomy on SSD. It was hypothesized that the anterior offset and costomedial angle would correlate with the amount of bony resection needed to achieve adequate SSD., Study Design: Controlled laboratory study., Methods: Twenty pairs (n = 40) of shoulder specimens (mean age, 58 years [range, 41-64 years]; 10 male and 10 female specimens) were included. The scapula shape, medial scapula corpus angle (MSCA), anterior offset, and costomedial angle were obtained from computed tomography scans. Specimens were dissected, and each bare bony scapula was rigidly mounted. Points were collected using a 3-dimensional measuring arm. An SMA point and theoretical resection points (incremental 1-cm points up to 3 cm) proceeding laterally and medially were collected. The scapular plane was interpolated using points from the posterior scapular body. The horizontal distances of the anterior offset and each resection point to the scapular plane were calculated. The difference between the native anterior offset and the offset after resection represented the SSD. Adequate SSD was set at 5 mm. One-way analyses of variance and Pearson correlations were used with statistical significance set at P < .05., Results: The maximum SSD with 3-cm resection was significantly correlated with the anterior offset ( R = 0.83, P < .001) as well as the costomedial angle ( R = -0.43, P = .006) but not the MSCA ( R = -0.11, P = .495) or scapula shape ( F 2,37 = 0.39, P = .681). For the 5 scapulae with an anterior offset of less than 20 mm, a 5-mm SSD was not achieved. For 18 of 30 (60%) scapulae with an anterior offset between 20 mm and 35 mm, 3-cm resection provided at least a 5-mm SSD. For the 5 scapulae with an anterior offset of greater than 35 mm, 2-cm resection resulted in at least a 5-mm SSD in all cases., Conclusion: The anterior offset of the scapula appeared to be the most important bony parameter to consider during preoperative planning and the evaluation of SSD with partial scapulectomy., Clinical Relevance: The results of this study may help surgeons with preoperative planning of surgical decompression of the scapulothoracic space for patients with symptomatic SSS.

Background: The Latarjet procedure is commonly performed using either the classic or the congruent-arc technique. Each technique has potential clinical advantages and disadvantages. However, data on the anatomic and biomechanical effects, benefits, and limitations of each technique are limited. Hypothesis/Purpose: To compare the anatomy and biomechanical fixation strength (failure load) between the 2 techniques. It was hypothesized that the classic technique would have superior initial fixation when compared with the congruent-arc technique and that this would be affected by sex and coracoid size., Study Design: Controlled laboratory study., Methods: A biomechanical cadaver study was performed with 20 pairs of male and female shoulders. One of each pair of shoulders was randomly assigned to receive the classic or congruent-arc technique. Coracoid and glenoid anatomic measurements were collected before biomechanical testing. A tensile force was applied through the conjoined tendon to replicate forces experienced by the coracoid graft in the early postoperative period, and the failure load was determined for each specimen., Results: The mean ± SD surface area available for fixation was 263 ± 63 mm 2 in the classic technique compared with 177 ± 63 mm 2 in the congruent-arc group ( P < .001). 36% of the glenoid width was recreated in the classic group and 50% in the congruent-arc group ( P < .001). The congruent-arc technique resulted in a significantly lower ( P = .005) mean failure load (239 ± 91 N) compared with the classic technique (303 ± 114 N). Failure load was significantly higher in males ( P = .037); male specimens had a mean failure load of 344 ± 122 N for the classic technique and 289 ± 73 N for the congruent-arc technique, and females had a mean failure load of 266 ± 98 N and 194 ± 84 N, respectively., Conclusion: In this biomechanical model, the classic technique of the Latarjet procedure provided a greater surface area for healing to the glenoid and superior initial fixation when compared with the congruent-arc technique. The congruent-arc technique allowed restoration of a larger glenoid defect., Clinical Relevance: The classic and congruent-arc techniques of coracoid transfer have anatomic and biomechanical advantages and disadvantages that should be considered when choosing between the 2 techniques.

Background: Straight antegrade intramedullary nailing of proximal humerus fractures has shown promising clinical results. However, up to 36% of all humeri seem to be "critical types" in terms of the potential violation of the supraspinatus (SSP) tendon footprint by the nail's insertion zone. The aims of this study were to evaluate if a computed tomography (CT) scan could reliably predict the nail's entry point on the humeral head and if it would be possible to preoperatively estimate the individual risk of iatrogenic violation of the SSP tendon footprint by evaluating the uninjured contralateral humerus., Methods: Twenty matched pairs of human cadaveric shoulders underwent CT scans, and the entry point for an antegrade nail as well as measurements regarding critical distances between the entry point and the rotator cuff were determined. Next, gross anatomic measurements of the same data were performed and compared. Furthermore, specimens were reviewed for critical types., Results: Overall, 42.5% of all specimens were found to be critical types. The CT measurements exhibited excellent intra-rater and inter-rater reliability (intraclass correlation coefficients >0.90). Similarly, excellent agreement between the CT scan and gross anatomic measurements in contralateral shoulders (intraclass correlation coefficients >0.88) was found., Conclusion: Assessing the uninjured contralateral side, CT can reliably predict the entry point in antegrade humeral nailing and preoperatively identify critical types of humeral heads at risk of iatrogenic implantation damage to the SSP tendon footprint. This study may help surgeons in the decision-making processon which surgical technique should be used without putting the patient at risk for iatrogenic, implant-related damage to the rotator cuff., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Case: Hemiarthroplasty of the shoulder is commonly indicated for younger patients with osteoarthritis who desire to continue recreational and employment activities. In patients who have undergone prior shoulder surgery, metallic suture anchors may be present in the glenoid. We present a case of bilateral shoulder metallosis following bilateral resurfacing hemiarthroplasty for arthropathy in the setting of previous shoulder instability; the prostheses caused eventual glenoid erosion, leading to contact with the retained metal anchors., Conclusion: Because glenoid erosion is a common complication after shoulder hemiarthroplasty, patients with retained metal anchors are at risk for secondary metallosis due to medial protrusion of the prosthesis in the glenoid, with subsequent erosion of the metal anchors.

Purpose: To determine the most cost-effective treatment strategy for patients with massive rotator cuff tears and pseudoparalysis of the shoulder without osteoarthritis of the glenohumeral joint (PP without OA). Specifically, we aimed to compare arthroscopic rotator cuff repair (ARCR) versus reverse total shoulder arthroplasty (RTSA) and investigate the effect of patient age on this decision., Methods: A Markov decision model was used to compare 3 treatment strategies for addressing PP without OA: (1) ARCR with option to arthroscopically revise once, (2) ARCR with immediate conversion to RTSA on potential failure, and (3) primary RTSA. Hypothetical patients were cycled through the model according to transition probabilities, meanwhile accruing financial costs, utility for time in health states, and disutilities for surgical procedures. Utilities were derived from the Short Form-6D scale and expressed as quality-adjusted life-years. Model parameters were derived from the literature and from expert opinion, and thorough sensitivity analyses were conducted. TreeAge Pro 2015 software was used to construct and assess the Markov model., Results: For the base-case scenario (60-year-old patient), ARCR with conversion to RTSA on potential failure was the most cost-effective strategy when we assumed equal utility for the ARCR and RTSA health states. Primary RTSA became cost-effective when the utility of RTSA exceeded that of ARCR by 0.04 quality-adjusted life-years per year. Age at decision did not substantially change this result., Conclusions: Primary ARCR with conversion to RTSA on potential failure was found to be the most cost-effective strategy for PP without OA. This result was independent of age. Primary ARCR with revision ARCR on potential failure was a less cost-effective strategy., Level of Evidence: Level IV, economic and decision analysis., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate clinical outcomes after primary and revision arthroscopic treatment for snapping scapula syndrome (SSS) and identify predictive factors associated with outcomes., Methods: Patients who underwent arthroscopic treatment for SSS between October 2005 and December 2013 were identified in a prospectively collected database. The inclusion criteria were patients with a diagnosis of symptomatic SSS, in whom extensive nonoperative modalities failed, who underwent arthroscopic surgery for SSS, and who had undergone surgery a minimum of 2 years earlier. Postoperative clinical outcomes were assessed with the American Shoulder and Elbow Surgeons score; short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; and general health Short Form 12 (SF-12) scores, including both physical component summary and mental component summary. Patient satisfaction was recorded on a 10-point visual analog scale. Scapular bony morphology was determined on preoperative magnetic resonance imaging., Results: Ninety-two scapulae underwent arthroscopic treatment for SSS. There were 74 scapulae that met the inclusion criteria, including having undergone surgery a minimum of 2 years earlier. An outcome questionnaire was completed for 60 of 74 (81%). The mean age was 33 years (range, 12-65 years), and the mean duration of symptoms before surgery was 4 years (range, 90 days to 20.4 years). The mean follow-up period was 3.4 years (range, 2-7 years). Eight scapulae failed initial surgical management (10.9%) because of recurrent pain and underwent revision surgery at a mean of 309 days (range, 120-917 days). After surgery, there was a significant improvement in all outcome scores, including SF-12 physical component summary score, from 39.2 to 45.4 (P = .002); SF-12 mental component summary score, from 45.0 to 49.6 (P = .023); American Shoulder and Elbow Surgeons score, from 52.6 to 75.8 (P < .001); and score on the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire, from 40.2 to 24.2 (P = .001). The median patient satisfaction rating was 7 of 10. Greater age, lower preoperative psychological score, and longer duration of symptoms before surgery correlated with lower postoperative outcome scores., Conclusions: Arthroscopic surgery is an effective treatment for SSS in both primary and revision cases, showing significant improvements in all postoperative outcome scores at a mean of 3.4 years. Lower preoperative mental status score, longer duration of symptoms, and greater age were associated with poorer outcomes., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine whether a 5-mm and/or 10-mm arthroscopic lateral acromioplasty (ALA) would weaken the structural and mechanical integrity of the lateral deltoid., Methods: The acromion and lateral deltoid origin were harvested from 15 pairs (n = 30) of fresh-frozen human cadaveric shoulder specimens. One side of each specimen pair (left or right) was randomly assigned to either a 5-mm (n = 7) or 10-mm (n = 8) ALA group, and the contralateral sides (n = 15) were used as matched controls. Acromion thickness and width were measured pre- and postoperatively. After ALA, specimens were inspected for damage to the lateral deltoid origin. Each specimen was secured within a dynamic testing machine, and the deltoid muscle was pulled to failure. Statistical analysis was performed to determine whether ALA reduced the lateral deltoid's failure load., Results: There was no significant difference in failure load between the 5-mm ALA group (661 ± 207 N) and its matched control group (744 ± 212 N; mean difference = 83 N; 95% confidence interval [CI], -91 to 258; P = .285) nor between the 10-mm ALA group (544 ± 210 N) and its matched control group (598 ± 157 N; mean difference = 54 N; 95% CI, -141 to 250; P = .532). There was no correlation found between the amount of bone resected (measured by percent thickness and width of the acromion after ALA) and the failure load of the deltoid. Visual evaluation of the acromion after ALA revealed the lateral deltoid origin had no damage in any case., Conclusions: ALA did not weaken the structural or mechanical integrity of the lateral deltoid origin. Neither a 5-mm nor a 10-mm ALA significantly reduced the deltoid's failure load. The lateral deltoid origin was not macroscopically damaged in any case., Clinical Relevance: ALA can be performed without the potential risk of macroscopically damaging the lateral deltoid origin or reducing its failure load., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Patient selection is critical when choosing between arthroscopic joint preservation and total shoulder arthroplasty in young patients with glenohumeral osteoarthritis (GHOA)., Purpose: To identify prognostic factors predictive of early failure in patients undergoing comprehensive arthroscopic management (CAM) for GHOA., Study Design: Case-control study; Level of evidence, 3., Methods: A total of 107 shoulders in 98 patients with minimum 2-year follow-up who underwent CAM were identified and evaluated. All shoulders met clinical and radiographic criteria for total shoulder arthroplasty (TSA), but the patients opted for joint preservation with arthroscopic management. Radiographic and preoperative factors were analyzed to determine predictors of early failure, defined as progression to TSA within the study period., Results: There were 72 men and 26 women with a mean age of 52 years (range, 29-77 years). Seventeen (15.8%) of 107 shoulders progressed to TSA at a mean of 2 years (range, 0.46-8.2 years). Shoulder status for the rest had a mean follow-up of 3.9 years (range, 2-9.4 years). There were a number of radiographic features that were correlated with early failure. Patients who failed had significantly less preoperative joint space than did those who succeeded (1.3 vs 2.6 mm; P = .004). Higher Kellgren-Lawrence grades for osteoarthritis and age older than 50 were also associated with failure. Shoulders with Walch type B2 and C glenoid were significantly more likely to fail than were Walch types A1, A2, and B1 ( P < .05)., Conclusion: The CAM procedure has been shown to reliably improve pain and function in active patients with advanced GHOA; however, it is important to inform patients about the limitations of the procedure. Patients with less joint space and abnormal posterior glenoid shape were significantly more likely to progress to early failure.

Purpose: To compare glenoid retroversion and functional outcomes between patients with traumatic onset of posterior shoulder instability (PSI) and patients with atraumatic onset of PSI., Methods: Patients with PSI who underwent arthroscopic posterior capsulolabral anchor repair, were active in sports, and had undergone surgery a minimum of 2 years earlier were included. Traumatic onset was defined as PSI that occurred after a trauma with the shoulder in adduction, flexion, and internal rotation in patients with no history of instability. Subjective evaluations were obtained with the American Shoulder and Elbow Surgeons (ASES); Quick Disabilities of the Arm, Shoulder and Hand; Single Assessment Numeric Evaluation (SANE); and Short Form 12 Physical Component Summary scores preoperatively and after a minimum 2-year follow-up postoperatively. Additional questions assessed return to sport and shoulder stability. Glenoid version was measured with a 2-dimensional glenoid vault method on magnetic resonance imaging., Results: A total of 41 shoulders in 38 patients were eligible for inclusion (3 female and 35 male patients; mean age, 27.6 years; age range, 13 to 66 years). Three patients refused participation, and 2 patients required subsequent surgery for failure. Postoperative outcomes were available for 32 of the remaining 36 shoulders (89%) with a mean follow-up of 4.1 years (range, 2.0 to 7.8 years; 20 atraumatic and 12 traumatic). The ASES score improved significantly in both groups (P < .03), whereas the SANE; Quick Disabilities of the Arm, Shoulder and Hand; and Short Form 12 Physical Component Summary scores only significantly improved for patients with traumatic PSI (P < .02). Baseline score-adjusted comparison between groups showed that the postoperative median ASES scores (atraumatic, 95.8; traumatic, 99.9) and SANE scores (atraumatic, 86.5; traumatic, 98.0) were significantly more improved in patients with traumatic PSI (P = .01 and P = .012, respectively). Atraumatic PSI was associated with significantly higher glenoid retroversion (-21.8° ± 4.2° vs -17.7° ± 5.5°, P = .032). There was no significant difference regarding return to sport (P = .375) or postoperative re-dislocations (P = .99) between the groups., Conclusions: Atraumatic onset of PSI was associated with higher degrees of glenoid retroversion and less favorable functional outcomes of arthroscopic posterior capsulolabral anchor repair than traumatic PSI., Level of Evidence: Level III, retrospective case-control study., (Copyright © 2016. Published by Elsevier Inc.)

Hypothesis: The aim of this study was to assess the effect of open resection arthroplasty for osteoarthritis of the sternoclavicular (SC) joint on pain levels, functional outcomes, and return to sport., Methods: Patients from a single surgeon's practice who underwent open resection arthroplasty (maximum 10-mm resection) for SC osteoarthritis or prearthritic changes between November 2006 and November 2013 were retrospectively reviewed. This was an outcomes study with prospectively collected data. Preoperative and postoperative American Shoulder and Elbow Surgeons score, Quick Disabilities of the Arm, Shoulder, and Hand score, Single Assessment Numeric Evaluation score, several pain scores, and level of sport intensity were assessed., Results: Seventeen SC joints in 16 patients (9 female, 7 male) met inclusion criteria. Mean age at time of surgery way 41.1 years (range, 12-66 years). One patient refused participation in the study. Three SC joint resections (17.7%) required SC joint revision surgery. Minimum 2-year outcomes data were available for 11 of the remaining 13 SC joints (84.6%). The mean time to follow-up was 3.3 years (range, 2.0-8.8 years). Pain at its worst (P = .026), pain at competition (P = .041), the Quick Disabilities of the Arm, Shoulder, and Hand score (P = .034), and the ability to sleep on the affected shoulder (P = .038) showed significant improvement postoperatively. The average postoperative American Shoulder and Elbow Surgeons score was 83.3. The level of sports participation (P = .042) as well as strength and endurance when participating in sport (P = .039) significantly increased postoperatively., Conclusion: Resection arthroplasty of the medial end of the clavicle in patients with osteoarthritis of the SC joint without instability results in pain reduction, functional improvement, and a high rate of return to sport at midterm follow-up., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Acromioclavicular joint injuries are one of the most common shoulder injuries, and there are a variety of treatment options. Recently, there have been newer arthroscopic techniques that have addressed coracoid and clavicle fracture risk by using a knotted suture-button fixation through a single, small bone tunnel with additional looped soft-tissue graft stabilization. Although clinical outcomes have been good to excellent, there have still been instances of knot and hardware irritation. The described technique builds on the latest advances and achieves an anatomic coracoclavicular (CC) reconstruction through a single knotless CC fixation device with additional soft-tissue allograft reconstruction of the CC ligaments. This technique minimizes the risks of coracoid and clavicle fractures and knot and hardware irritation while maintaining excellent stability.

Background: Outcomes after arthroscopic pancapsular capsulorrhaphy (APC) with suture anchors for multidirectional instability (MDI) of the shoulder are not widely reported., Purpose: To compare intraoperative findings and midterm outcomes of APC with suture anchors for MDI between female and male athletes and between a classic, atraumatic onset versus clinical onset of MDI after a traumatic event., Study Design: Cohort study; Level of evidence, 3., Methods: Patients who underwent APC with suture anchors for MDI and were at least 2 years out from surgery were included. Data were prospectively collected and retrospectively reviewed and included the onset of MDI, intraoperative pathoanatomic findings, level of sports participation, and patient satisfaction as well as the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Short Form-12 Physical Component Summary (SF-12 PCS) scores. Information regarding shoulder instability and return to sport was collected, and Kaplan-Meier survivorship analysis was performed., Results: Forty-one patients (45 shoulders; 25 male, 20 female), consecutively treated between October 2006 and January 2013, were included. The onset of MDI was atraumatic in 22 shoulders and traumatic in 23 shoulders. At surgery, 29 of 45 (64.4%) had labral detachment. Seven shoulders (16.7%) experienced instability episodes postoperatively, and 3 of these underwent revision surgery. The mean follow-up was 3.3 years (range, 2.0-6.6 years). All subjective outcome scores improved significantly from preoperative levels (P < .005). At final follow-up, the mean ASES score was 92.0, and 76.7% (23/30) indicated that they had returned to sports participation equal to or slightly below their preinjury level. Kaplan-Meier analysis showed a survivorship rate of 87% at 3 years. Male patients were 2.3 times more likely to have a traumatic onset of instability (68% vs 30%, respectively; P = .017) and were 2.1 times more likely to have concomitant lesions (84% vs 40%, respectively; P = .004) than female patients. Furthermore, male patients demonstrated a higher mean postoperative ASES score than female patients (97.0 ± 4.7 vs 85.5 ± 16.4, respectively; P = .023). Female patients were 6.9 times more likely to undergo an additional rotator interval closure (RIC) procedure (58% vs 4.7%, respectively; P < .001) and to experience postoperative subluxations (40% vs 22%, respectively; P = .035) than male patients. A traumatic onset of MDI was associated with a higher mean postoperative ASES score (96.4 ± 6.9 vs 87.0 ± 15.7, respectively; P = .048), higher median satisfaction score (10 vs 9, respectively; P = .029), and higher return-to-sport rate (83% vs 44%, respectively; P = .030) than an atraumatic onset., Conclusion: APC with suture anchors can be an effective and safe treatment for patients with MDI. Labral tears were commonly found, even in patients with a classic, atraumatic onset. Male patients and patients with a traumatic onset of MDI had more favorable outcomes. Female patients may be more challenging to treat as they were more likely to undergo an additional RIC procedure and experience postoperative subluxations., (© 2016 The Author(s).)

Background: There are little data on midterm outcomes after the arthroscopic management of glenohumeral osteoarthritis (GHOA) in young active patients., Purpose: To report outcomes and survivorship for the comprehensive arthroscopic management (CAM) procedure for the treatment of GHOA at a minimum of 5 years postoperatively., Study Design: Case series; Level of evidence, 4., Methods: The CAM procedure was performed on a consecutive series of 46 patients (49 shoulders) with advanced GHOA who met criteria for shoulder arthroplasty but instead opted for a joint-preserving, arthroscopic surgical option. The procedure included glenohumeral chondroplasty, capsular release, synovectomy, humeral osteoplasty, axillary nerve neurolysis, subacromial decompression, loose body removal, microfracture, and biceps tenodesis. Outcome measures included the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Short Form-12 (SF-12) Physical Component Summary (PCS), visual analog scale for pain, and satisfaction scores. Kaplan-Meier survivorship analysis was performed with failure defined as progression to total shoulder arthroplasty (TSA)., Results: Forty-six consecutive patients (49 shoulders) who underwent a CAM procedure at a minimum of 5 years from surgery were included. Two patients were excluded for refusing to participate before study initiation. The mean age at surgery was 52 years (range, 27-68 years) in 15 women and 29 men. All patients were recreational athletes with 7 former collegiate or professional athletes. Twelve shoulders (26%) progressed to TSA at a mean of 2.6 years (range, 0.5-8.2 years). For survivorship analysis, the status of the shoulder (preservation of the native joint or progression to TSA) at a minimum of 5 years was known for 45 of 47 (96%) shoulders. Survivorship was 95.6% at 1 year, 86.7% at 3 years, and 76.9% at 5 years. For surviving shoulders, minimum 5-year subjective outcome data were available for 28 of 32 (87.5%) shoulders at a mean of 5.7 years (range, 5-8 years). The mean (±SD) ASES score was 84.5 ± 17, the mean SANE score was 82 ± 18, the mean QuickDASH score was 15 ± 13, the mean SF-12 PCS score was 51.0 ± 9.1, and median patient satisfaction was 9 of a possible 10 points., Conclusion: This study demonstrates significant improvements in midterm clinical outcomes and high patient satisfaction after the arthroscopic CAM procedure for GHOA, with a 76.9% survivorship rate at a minimum of 5 years postoperatively. For patients looking for an alternative to TSA, the CAM procedure can provide reasonable outcomes and should be considered an effective procedure in appropriately selected, young active patients. Further studies are warranted to evaluate long-term outcomes and durability after this procedure., (© 2016 The Author(s).)

Bipolar bone loss in patients with anterior glenohumeral instability is challenging to treat. The goal of the treatment is to restore stability by ensuring that the humeral head remains within the glenoid vault. This can be achieved either with the combination of an arthroscopic Bankart procedure and remplissage (glenoid bone loss <25%), or with a Latarjet procedure (glenoid bone loss >25%). In cases with more severe bipolar bone loss of both the glenoid and the humeral head, the conventional approach has been to lengthen the articular arc of the glenoid and to ignore the Hill-Sachs lesion. However, it has recently been shown that this can still lead to an "off-track" situation with persistent shoulder instability from engagement of the Hill-Sachs on the anterior glenoid. In these cases, the combination of a Hill-Sachs remplissage and the Latarjet procedure can be effective in preventing persistent instability. In this technical note, the surgical technique of an arthroscopic Hill-Sachs remplissage in combination with an open Latarjet procedure is presented.

Purpose: To assess minimum 2-year clinical outcomes after open revision biologic patch augmentation in patients with massive rotator cuff retears who had deficient rotator cuff tendons with healthy rotator cuff muscles., Methods: Patients with massive posterosuperior rotator cuff retears who underwent open revision rotator cuff repair with patch augmentation were identified from a surgical registry. Outcomes data collected included American Shoulder and Elbow Surgeons; Quick Disabilities of the Arm, Shoulder and Hand; Single Assessment Numeric Evaluation; and Short Form-12 Physical Component Summary scores along with postoperative patient satisfaction, and activity modification., Results: There were 10 men and 2 women (13 shoulders, 1 bilateral) with a mean age of 57 years (range, 26 to 68 years). All patients had at least one prior arthroscopic rotator cuff repair. After patch augmentation, there were no complications, no adverse reactions to the patch, and no patients required further surgery. One patient (7.7%) with 4 prior cuff repairs had a documented posterosuperior retear on magnetic resonance imaging 2 months after repair. Minimum 2-year outcome scores were available for 12 of 13 (92.3%) shoulders after a mean follow-up period of 2.5 years (range, 2.0 to 4.0 years). The ASES score improved by 21.5 points. Although the pain component of the ASES score and the total ASES score did not improve significantly, the function component of the ASES score improved significantly when compared with their preoperative baselines (P < .05). Median patient satisfaction at final follow-up was 9/10 (range, 2 to 10)., Conclusions: Biologic patch augmentation with human acellular dermal allograft was a safe and effective treatment method for patients with massive rotator cuff retears with deficient posterosuperior rotator cuff tendons in the presence of healthy rotator cuff muscles., Level of Evidence: Level IV, therapeutic study., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Rehabilitation after rotator cuff repair surgery has been the focus of several clinical trials in the past decade. Many illuminate new evidence with regard to the prognosis of structural and functional success after surgery., Methods: A selective literature search was performed and personal physiotherapeutic and surgical experiences are reported., Results: Post-operative rehabilitation parameters, namely the decision to delay or allow early range of motion after surgery, play a large role in the overall success after surgery. Using a prognosis driven rehabilitation program offers clinicians a means of prescribing optimal rehabilitation parameters while ensuring structural and functional success. This commentary aims to synthesize the evidence in a spectrum of prognostic factors to guide post-operative rehabilitation., Conclusion: The optimal rehabilitation program after rotator cuff repair surgery is debatable; therefore, we suggest using a spectrum of prognostic factors to determine a rehabilitation program suited to ensure structural and functional success, quickly and safely.

Background: Tendon transfers can be a surgical treatment option in managing younger, active patients with massive irreparable rotator cuff tears. The purpose of this article is to provide an overview of the use of tendon transfers to treat massive irreparable rotator cuff tears and to summarize clinical outcomes., Methods: A selective literature search was performed and personal surgical experiences are reported., Results: Latissimus dorsi transfers have been used for many years in the management of posterosuperior rotator cuff tears with good reported clinical outcomes. It can be transferred without or with the teres major (L'Episcopo technique). Many surgical techniques have been described for latissimus dorsi transfer including single incision, double incision, and arthroscopically assisted transfer. Transfer of the pectoralis major tendon is the most common tendon transfer procedure performed for anterosuperior rotator cuff deficiencies. Several surgical techniques have been described, however transfer of the pectoralis major beneath the coracoid process has been found to most closely replicate the force vector that is normally provided by the intact subscapularis., Conclusion: Tendon transfers can be used successfully in the management of younger patients with massive irreparable rotator cuff tears and minimal glenohumeral arthritis. Improvements in clinical outcomes scores and range of motion have been demonstrated. This can delay arthroplasty, which is of particular importance for younger patients with high functional demands.

Background: Several meta-analyses of randomized clinical trials have been performed to analyze whether double-row (DR) rotator cuff repair (RCR) provides superior clinical outcomes and structural healing compared to single-row (SR) repair. The purpose of this study was to sum up the results of meta-analysis comparing SR and DR repair with respect on clinical outcomes and re-tear rates., Methods: A literature search was undertaken to identify all meta-analyses dealing with randomized controlled trials comparing clinical und structural outcomes after SR versus DR RCR., Results: Eight meta-analyses met the eligibility criteria: two including Level I studies only, five including both Level I and Level II studies, and one including additional Level III studies. Four meta-analyses found no differences between SR and DR RCR for patient outcomes, whereas four favored DR RCR for tears greater than 3 cm. Two meta-analyses found no structural healing differences between SR and DR RCR, whereas six found DR repair to be superior for tears greater than 3 cm tears., Conclusion: No clinical differences are seen between single-row and double-row repair for small and medium rotator cuff tears after a short-term follow-up period with a higher re-tear rate following single-row repairs. There seems to be a trend to superior results with double-row repair in large to massive tear sizes.

Background: Surgical treatment of rotator cuff tears has consistently demonstrated good clinical and functional outcomes. However, in some cases, the rotator cuff fails to heal. While improvements in rotator cuff constructs and biomechanics have been made, the role of biologics to aid healing is currently being investigated., Methods: A selective literature search was performed and personal surgical experiences are reported., Results: Biologic augmentation of rotator cuff repairs can for example be performed wtableith platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs). Clinical results on PRP application have been controversial. Application of MSCs has shown promise in animal studies, but clinical data on its effectiveness is presently lacking. The role of Matrix Metalloproteinase (MMP) inhibitors is another interesting field for potential targeted drug therapy after rotator cuff repair., Conclusions: Large randomized clinical studies need to confirm the benefit of these approaches, in order to eventually lower retear rates and improve clinical outcomes after rotator cuff repair.

Background: It is important to appreciate the risk factors for the development of rotator cuff tears and specific physical examination maneuvers., Methods: A selective literature search was performed., Results: Numerous well-designed studies have demonstrated that common risk factors include age, occupation, and anatomic considerations such as the critical shoulder angle. Recently, research has also reported a genetic component as well. The rotator cuff axially compresses the humeral head in the glenohumeral joint and provides rotational motion and abduction. Forces are grouped into coronal and axial force couples. Rotator cuff tears are thought to occur when the force couples become imbalanced., Conclusion: Physical examination is essential to determining whether a patient has an anterosuperior or posterosuperior tear. Diagnostic accuracy increases when combining a series of examination maneuvers.

Background: Massive rotator cuff tears in active patients with minimal glenohumeral arthritis remain a particular challenge for the treating surgeon., Methods: A selective literature search was performed and personal surgical experiences are reported., Results: For patients with irreparable rotator cuff tears, a reverse shoulder arthroplasty or a tendon transfer are often performed. However, both procedures have rather high complication rates and debatable long-term results, particularly in younger patients. Therefore, patch-augmented rotator cuff repair or superior capsule reconstruction (SCR) have been recently developed as arthroscopically applicable treatment options, with promising biomechanical and early clinical results., Conclusion: For younger patients with irreparable rotator cuff tears wishing to avoid tendon transfers or reverse total shoulder arthroplasty, both patch-augmentation and SCR represent treatment options that may delay the need for more invasive surgery.

Background: Rotator cuff tears are a significant cause of shoulder morbidity. Surgical techniques for repair have evolved to optimize the biologic and mechanical variables critical to tendon healing. Double-row repairs have demonstrated superior biomechanical advantages to a single-row., Methods: The preferred technique for rotator cuff repair of the senior author was reviewed and described in a step by step fashion. The final construct is a knotless double row transosseous equivalent construct., Results: The described technique includes the advantages of a double-row construct while also offering self reinforcement, decreased risk of suture cut through, decreased risk of medial row overtensioning and tissue strangulation, improved vascularity, the efficiency of a knotless system, and no increased risk for subacromial impingement from the burden of suture knots., Conclusion: Arthroscopic knotless double row rotator cuff repair is a safe and effective method to repair rotator cuff tears.

Purpose: The purpose of this study was to determine whether there is an association between the critical shoulder angle (CSA) and rotator cuff tears (RCT) as well as osteoarthritis (OA), and to compare the reproducibility and accuracy of CSA values as measured with radiograph and MRI., Methods: Based on a pre hoc power analysis, three independent reviewers measured CSAs for three groups of 10 age-matched patients each (RCT group, OA group, and non-RCT/non-OA group) using radiographs and MRIs. Inter- and intra-observer agreements of CSAs were determined with intraclass correlation coefficients. ANOVA analysis was performed., Results: Interobserver and intra-observer agreements on radiographs were 0.87 (95 % CI 0.78-0.93) and 0.91 (95 % CI 0.82-0.96), respectively. Significant differences in mean CSAs by radiographs were found between the groups (RCT 37.3° ± 2.6°; OA 28.7° ± 2.2°; non-RCT/non-OA 32.7° ± 2.5°; p < 0.001). CSAs obtained from MRI scans had interobserver agreement of 0.62 (95 % CI 0.43-0.78) and intra-observer agreement of 0.68 (95 % CI 0.50-0.80). There was a significant correlation between the patients' pathologies and CSAs measured by radiographs (r = 0.44; p = 0.02) and MRI (r = 0.50; p = 0.01). A significant difference in mean CSAs measured on radiograph versus MRI was seen in the OA group (28.7° ± 2.2° vs. 31.3° ± 4.4°; p = 0.01)., Conclusion: CSA measurements obtained from radiographs demonstrated excellent interobserver agreement with less variability than CSAs from MRI, especially in OA patients. This study confirms an association between the CSA and RCTs as well as OA pathology. Assessing the CSA may be helpful during diagnostic evaluation of patients with shoulder pain and can help predict pathology., Level of Evidence: Retrospective cohort study, Level IV.

Purpose: Quantitative MRI T2 mapping is a non-invasive imaging technique sensitive to biochemical changes, but no studies have evaluated T2 mapping in pathologic rotator cuff tendons. It was sought to evaluate the efficacy of T2 mapping in detecting differences in the supraspinatus tendon (SST) among patients with tendinosis, partial tears and minimally retracted full-thickness tears, relative to asymptomatic volunteers., Methods: The pathologic cohort consisted of two arthroscopically verified groups: tendinosis and a tear group of partial tears or minimally retracted full-thickness tears, and was compared to an asymptomatic cohort with no prior history of shoulder pathology. The SST was manually segmented from the footprint to the medial humeral head in the coronal and sagittal planes and divided into six clinically relevant subregions. Mean T2 values and inter- and intra-rater reliability were assessed., Results: In the anterolateral subregion, the tear group exhibited significantly higher mean T2 values (43.9 ± 12.7 ms) than the tendinosis (34.9 ± 3.9 ms; p = 0.006) and asymptomatic (33.6 ± 5.3 ms; p = 0.015) groups. In the posterolateral subregion, the tear group had higher mean T2 values (45.2 ± 13.7) than the asymptomatic group (34.7 ± 6.7; p = 0.012). Inter- and intra-rater reliability was mostly excellent (ICC > 0.75)., Conclusion: T2 mapping is an accurate non-invasive method to identify quantitatively early rotator cuff pathology. The lateral region in the coronal plane in particular may differentiate partial and small minimally retracted full-thickness tears from tendinosis and asymptomatic tendons. Understanding and being able to measure quantitatively the process of tendon degeneration and subsequent tearing may help clinicians to better predict at-risk groups and to stratify treatment options., Level of Evidence: III.

Background: The optimal location and extent of medial clavicle resection for sternoclavicular (SC) joint resection arthroplasty are unknown., Hypothesis: Resection of the intra-articular disc alone cannot reliably decompress the SC joint, and a parallel resection technique will decompress the SC joint significantly more compared with the same amount with an oblique resection technique., Study Design: Controlled laboratory study., Methods: Force transmission through the SC joint was measured in 7 matched-pair human cadaveric SC joints in a dynamic tensile testing machine. The specimens were randomized to either a parallel or an oblique resection technique. An 80-N axial load was applied on the lateral clavicle toward the SC joint in each of the following 4 conditions: (1) intact joint, (2) after resecting the intra-articular disc, (3) after resecting 5 mm of the medial clavicle, and (4) after 10-mm resection., Results: Complete discectomy of all SC joints resulted in a significant reduction of force transmitted through the SC joint (P = .002). However, the varying anatomy of the disc was accompanied by a varying amount of joint decompression (95% CI, 29.8%-65.4%). Resecting 5 mm of the SC joint with the parallel technique decompressed the SC joint by a mean (±SD) of 76.7 ± 22.1 N compared with 37.8 ± 24.8 N with the oblique technique (P = .02). Decompression did not significantly differ between the groups after 10-mm resection (P = .18) using the parallel technique (89.4 ± 24.1 N) compared with the oblique technique (68.2 ± 31.6 N). Furthermore, 5-mm resection of the medial end of the clavicle with the parallel technique decompressed the SC joint by an amount similar to 10-mm resection with the oblique technique., Conclusion: Resection of the disc alone did not reliably decompress each SC joint. Resection of 5 mm of the medial end of the clavicle with the parallel resection technique reliably decompressed the SC joint better than with the oblique resection technique., Clinical Relevance: This study provides baseline data on SC joint resection techniques and their mechanical effects. This knowledge can be implemented in clinical practice to treat patients with symptomatic posttraumatic arthritis of the SC joint., (© 2016 The Author(s).)

Background: The Latarjet procedure for the treatment of recurrent anterior shoulder instability is highly successful, but reasons for failure are often unclear. Measurements of the "glenoid track" have not previously been evaluated as potential predictors of postoperative stability., Hypothesis: There are clinical and anatomic characteristics, including the glenoid track, that are predictive of outcomes after the Latarjet procedure., Study Design: Case series; Level of evidence, 4., Methods: Patients who underwent the Latarjet procedure for anterior shoulder instability with glenoid bone loss before October 2012 were assessed for eligibility. Patient-reported subjective data that were prospectively collected and retrospectively reviewed included demographic information, patient satisfaction, pain measured on a visual analog scale (VAS), questions regarding instability, Single Assessment Numeric Evaluation (SANE) scores, American Shoulder and Elbow Surgeons (ASES) scores, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores, and Short Form-12 Physical Component Summary (SF-12 PCS) scores. Anatomic measurements were performed of the coracoid size (surface area and width), width of the conjoined tendon and subscapularis tendon, estimated glenoid defect surface area, Hill-Sachs interval (HSI), and projected postoperative glenoid track engagement. Failure was defined as the necessity for revision stabilization or continued instability (dislocation or subjective subluxation) at a minimum of 2 years postoperatively., Results: A total of 38 shoulders in 38 patients (33 men, 5 women) with a mean age of 26 years (range, 16-43 years) were included. The mean follow-up for 35 of 38 patients (92%) was 3.2 years (range, 2.0-7.9 years); 25 of 38 had undergone prior stabilization surgery, and 6 had workers' compensation claims. All mean subjective outcome scores significantly improved (P < .05), with a high median satisfaction score of 9 of 10. Eight patients had failures because of continued instability. Patients with moderate or higher preoperative pain scores (VAS ≥3) had a negative correlation with postoperative SF-12 PCS scores (ρ = 0.474, P = .022). Patients with outside-and-engaged (Out-E) or "off-track" lesions were 4.0 times more likely to experience postoperative instability (relative risk, 4.0; 95% CI, 1.32-12.2; P = .33). The width of patients' coracoid processes was also directly associated with postoperative stability (P = .014). Moreover, 50% (4/8) of failures demonstrated Out-E glenoid tracks (off-track lesions) versus 16% (4/25) of those without recurrent instability (P = .033). Five of 8 failures were considered as such because of subjective subluxation events, not frank dislocations. Four of the 6 patients with workers' compensation claims had failed results (P = .016)., Conclusion: Workers' compensation claims were associated with continued instability, and patients with higher preoperative pain levels demonstrated lower SF-12 PCS scores postoperatively. The concept of the glenoid track may be predictive of stability after the Latarjet procedure and may be helpful in surgical decision making regarding the treatment of Hill-Sachs lesions at risk for persistent engagement. Although stability and patient satisfaction are high after the Latarjet procedure, subjective complaints of subluxation may be more common than previously estimated., (© 2016 The Author(s).)

Introduction: The use of total shoulder arthroplasty (TSA) to treat primary glenohumeral osteoarthritis (GHOA) is increasing. Factors influencing patient satisfaction after surgery have not been well documented. The aim of this study was to determine demographic, radiologic, and surgical, factors predictive for satisfaction after TSA for GHOA., Materials and Methods: Between 2005 and 2012, 95 shoulders undergoing TSA for GHOA by a single surgeon were eligible for inclusion in the study. Age, gender, previous surgeries, American Society of Anesthesiologists (ASA) score, and Walch glenoid morphology were analyzed as satisfaction predictors. Patients with Walch glenoid type C were excluded., Results: Data on 80/92(87 %) shoulders were available at a mean of 3 years (range 2-9). Three complications (3 %) and 2 failures (2 %) occurred. The outcome scores collected significantly improved from preoperative values (p < 0.05). Median patient satisfaction was 10/10. Gender, age, previous surgery, ASA score, and Walch morphology were not associated with patient satisfaction., Conclusions: TSA provided excellent results for patients with idiopathic GHOA with low complication and failure rates. Outcomes after TSA for type B glenoid morphology with posterior subluxation were similar to outcomes after TSA for centered type A morphology. Overall patient satisfaction was high and was not influenced by the demographic, anatomic, and surgical variables investigated., Level of Evidence: III, Therapeutic study, Retrospective Cohort Study.

Purpose: To compare the clinical outcomes in patients with grade III acromioclavicular (AC) joint injuries in whom nonoperative therapy was successfully completed and those who had nonoperative therapy failure and who proceeded to undergo surgical reconstruction., Methods: Forty-nine patients were initially treated nonoperatively for grade III AC joint injuries with physical therapy. Patients completed questionnaires at initial presentation and after a follow-up period of 2 years. Outcome measures included the Short Form 12 Physical Component Score; American Shoulder and Elbow Surgeons score; Quick Disabilities of the Arm, Shoulder and Hand score; and Single Assessment Numeric Evaluation score. Failure of nonoperative treatment occurred when a patient underwent AC reconstruction before final follow-up., Results: Forty-one patients with a mean age of 39 years (range, 18 to 79 years) were included. In this cohort, 29 of 41 patients (71%) successfully completed nonoperative therapy whereas 12 of 41 (30%) had nonoperative therapy failure at a median of 42 days (range, 6 days to 17.0 months). Of the 41 patients, 39 (95.3%) were contacted to determine treatment success. Of the 12 patients who had nonoperative therapy failure, 11 (92%) had sought treatment more than 30 days after the injury. Subjective follow-up data were available for 10 of 12 patients (83.3%) who had nonoperative therapy failure and for 23 of 29 patients (79.3%) who were successfully treated nonoperatively. The mean length of follow-up was 3.3 years (range, 1.8 to 5.9 years). Although there were no statistically significant differences in outcome scores between groups, those who sought treatment more than 30 days after their injury showed decreased postoperative Single Assessment Numeric Evaluation scores (P = .002) and Short Form 12 Physical Component Scores (P = .037)., Conclusions: According to our results, (1) a trial of nonoperative treatment is warranted because successful outcomes can be expected even in patients who eventually opt for surgery and (2) patients who presented more than 30 days after their injury were less likely to complete nonoperative treatment successfully., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Introduction: The purpose of this study was to evaluate the clinical results of surgical repair for proximal long head of the biceps (LHB) tendon ruptures comparing chronic primary and postsurgical revision LHB tendon ruptures., Materials and Methods: Patients who underwent subpectoral LHB tenodesis for chronic ruptures with a minimum of 2 years from surgery were identified. ASES and SF-12 PCS scores and surgical and demographic data were collected prospectively. At final follow-up, patients were interviewed regarding symptoms related to their biceps. Symptoms were converted into a Subjective Proximal Biceps Score (SPBS)., Results: Twenty-seven patients (22 males, 5 females) with a mean age of 61 years (range 40-76 years) underwent LHB tenodeses. Twenty patients (74.1 %) were primary repairs for chronic ruptures and seven patients (25.9 %) were revision repairs after failed prior LHB tenodesis. Twenty-five patients (92.6 %; n = 18 primary; n = 7 revision) were available for follow-up a mean of 3.8 years (range 2-6.1). The overall median postoperative SPBS showed significant improvement over the preoperative baseline (p < 0.001). Individual components of the SPBS showed substantial improvements. The SPBS significantly correlated with the postoperative ASES score (r = -0.478; p = 0.038). There were no differences in postoperative SPBSs between the primary and revision tenodesis groups. The mean postoperative ASES score was 90.3 and SF-12 PCS was 52.6., Conclusions: Open subpectoral LHB tenodesis was a safe and effective method for the treatment of chronic LHB tendon ruptures and for the revision of failed post-surgical LHB ruptures. Patients had less pain, cramping, and deformity after LHB tenodesis. The SPBS, ASES, and SF-12 PCS scores significantly improved among this group of patients., Level of Evidence: Level III; Retrospective comparative study.

Purpose: To investigate if (1) an anterolateral acromioplasty and (2) a lateral acromion resection alter the critical shoulder angle (CSA) without affecting the deltoid origin., Methods: First, the native CSAs of 10 human cadaveric shoulders (6 male and 4 female specimens; mean age, 54.2 years) were determined with the use of fluoroscopy. Setup allowed for consistent repetitive measurements. Next, a standard arthroscopic anterolateral acromioplasty was performed to create a type 1 acromion, and the CSA was reassessed fluoroscopically. Afterward, a lateral acromioplasty was performed with a 5-mm lateral acromion resection using a 5-mm burr, and the CSA was measured again. The native CSA was compared with (1) the CSA after acromioplasty and (2) the CSA after acromioplasty and lateral acromion resection using a paired t test. Finally, the acromial deltoid attachment was evaluated anatomically for damage to the anterolateral origin., Results: The mean native CSA (34.3° ± 2.1°) was reduced significantly by acromioplasty (33.1° ± 2.0°, P < .001) and further reduced by lateral acromion resection (31.5° ± 1.7°, P < .001). Anterolateral acromioplasty reduced the CSA by a mean of 1.4° (95% confidence interval boundaries, 0.8° and 1.9°), and in combination with lateral acromion resection, the CSA was reduced by a mean of 2.8° (95% confidence interval boundaries, 2.1° and 3.5°). In all specimens (5 of 5) with a presurgery CSA of 35° or greater, the CSA was reduced to the range of 30° to 35° by the combination of both techniques. However, in 2 specimens with a CSA of approximately 32°, the CSA was reduced to less than 30°. The acromial deltoid attachment was found to be well preserved in all specimens., Conclusions: Arthroscopic anterolateral acromioplasty and a 5-mm lateral acromion resection each reduced the CSA significantly and did not damage the deltoid origin., Clinical Relevance: The combination of both techniques could potentially be used in clinical practice to reduce a CSA greater than 35° to the desired range of 30° to 35°., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Instability of the sternoclavicular (SC) joint is a rare condition. However, in some cases, SC joint instability may lead to persistent pain and impairment of shoulder function that requires surgical management. This study evaluated clinical outcomes after SC joint reconstruction with hamstring tendon autograft in patients with SC joint instability., Methods: From December 2010 to January 2014, 21 reconstructions of the SC joint with hamstring tendon autograft were performed. Outcomes data were prospectively collected and retrospectively reviewed. Data analyzed included American Shoulder and Elbow Surgeons score, Quick Disability of the Arm, Shoulder and Hand, physical component of the Short Form 12, and Single Assessment Numeric Evaluation scores. Pain with activities of daily living, work, and sleep were separately analyzed along with painless use of arm for activities. Patients were also questioned regarding postoperative satisfaction., Results: Nine women and 10 men (2 bilaterals), with a mean age of 30 years (range, 15-56 years), were monitored for a mean of 2 years (range, 12-36 months) postoperatively. Mean American Shoulder and Elbow Surgeons, Quick Disability of the Arm, Shoulder and Hand, and Single Assessment Numeric Evaluation scores significantly improved (P < .001). Pain scores also improved over preoperative baselines, including pain with activities of daily living, work, and sleep (P < .001). Median satisfaction at final follow-up was 8.5 (range, 7-10). There were no intraoperative or postoperative complications and no cases of recurrent instability., Conclusion: Free hamstring tendon autograft reconstruction for SC joint instability resulted in significantly improved clinical outcomes with high patient satisfaction and no intraoperative or postoperative complications., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To quantitatively measure the 3-dimensional (3D) glenohumeral translations during dynamic shoulder abduction in the scapular plane, using a biplane fluoroscopy system, in patients with supraspinatus rotator cuff tears., Methods: A custom biplane fluoroscopy system was used to measure the 3D position and orientation of the scapula and humerus of 14 patients with full-thickness supraspinatus or supraspinatus and infraspinatus rotator cuff tears and 10 controls as they performed shoulder abduction over their full range of motion. The 3D geometries of the scapula and humerus were extracted from a computed tomography scan of each shoulder. For each frame, the 3D bone position and orientation were estimated using a contour-based matching algorithm, and the 3D position of the humeral head center was determined relative to the glenoid. For each subject the superior-inferior and anterior-posterior translation curves were determined from 20° through 150° of arm elevation., Results: The humeral head in shoulders with rotator cuff tears was positioned significantly inferior compared with controls for higher elevation angles of 80° to 140° (P < .05). For both groups the humeral head translated inferiorly during shoulder abduction from 80° (P = .044; rotator cuff tear v controls: -0.2 ± 1.3 v 1.2 ± 1.4 mm) up to 140° (P = .047; rotator cuff tear v controls: -1.3 ± 2.2 v 0.44 ± 1.4 mm). There was no significant translation in the anterior- posterior direction., Conclusions: Patients with well-compensated single or 2-tendon rotator cuff tears show no dynamic superior humeral head migration but unexpectedly show an inferior shift during active elevation. It is unclear whether the size of the translational differences found in this study, while statistically significant, are also of clinical significance., Level of Evidence: Level III, comparative study., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

The management of massive rotator cuff tears remains a challenge for physicians, with failure rates being higher when compared with smaller tears. Many surgical treatment options exist including debridement with biceps tenodesis, complete repair, partial repair, repair with augmentation devices, superior capsule reconstruction, tendon transfer, and reverse total shoulder arthroplasty. The purpose of this article is to describe our preferred surgical technique for a complete arthroscopic repair using an extended linked, knotless, double-row construct.

The ideal treatment for massive rotator cuff tears is influenced by the morphology and chronicity of the tear, tissue quality, the degree of concomitant osteoarthritis, and patient-specific factors. Traditionally, massive rotator cuff tears have wrongly been equated with irreparable tears. A variety of improvements in surgical technique and materials now permit successful arthroscopic management of many massive rotator cuff tears when non-operative management has failed. This study provides an overview of the current treatment options for large and massive rotator cuff tears, including their expected outcomes. Finally, a possible treatment algorithm is suggested., (Georg Thieme Verlag KG Stuttgart · New York.)