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Full-thickness rotator cuff tears (FTRCTs) represent a common shoulder injury that, if untreated, can progress in size, become increasingly painful, and inhibit function. These lesions are often surgically repaired, with double-row arthroscopic repair often preferred for larger tears. Biological augmentation technologies have been developed to improve rates of postoperative radiographic retear and enhance patient-reported outcomes after surgical FTRCT repair. This study sought to confirm that augmented repair with a bioinductive bovine collagen implant results in favorable retear rates and patient outcomes with follow-up to 2 years.A prospective multicenter cohort study was undertaken to determine the efficacy and safety of augmenting single- or double-row arthroscopic repair of FTRCTs with a bioinductive bovine collagen implant. Of 115 adult patients participating, 66 (57.4%) had medium (1-3-cm) tears and 49 (42.6%) had large (3-5-cm) tears. Magnetic resonance imaging and patient-reported outcomes (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant-Murley Score [CMS]) were performed and recorded at baseline, 3 months, 1 year, and 2 years.Mean duration of follow-up was 2.1 years (range, 1.5-2.9 years). Between baseline and 2-year follow-up, mean total thickness of the supraspinatus tendon increased by 12.5% for medium tears and by 17.1% for large tears. Radiographic retear was noted in 7 of 61 available patients (11.5%) with medium tears, and in 14 of 40 patients (35.0%) with large tears. In both groups, these tears primarily occurred before the 3-month follow-up visit (13 of 21 [61.9%]). Radiographic retear with the supplemented double-row (DR) repair technique was 13.2% overall (12 of 91 DR patients; 11.3% for medium tears and 15.8% for large tears). The minimal clinically important difference was achieved by90% of patients with both medium and large tears for both ASES and CMS. There were 2 serious adverse events classified by the treating surgeon as being possibly related to the device and/or procedure (1 case of swelling/drainage and 1 case of intermittent pain). Nine patients (7.8%; 4 medium tears and 5 large tears) required reoperation of the index rotator cuff surgery.Final 2-year data from this study confirm that using this implant in augmentation of arthroscopic double-row repair of FTRCTs provides favorable rates of radiographic retear and substantial functional recovery. The relative safety of the device is also further supported.

Opiate-based regimens have been used as a foundation of postoperative analgesia in orthopedic surgery for decades, and the vast majority of orthopedic patients in the United States receive postoperative opioid prescriptions. Both the safety and efficacy of opioid use in orthopedic patients have been questioned because of mounting evidence that postoperative opioid use can be detrimental to outcomes and patient satisfaction. The purpose of this study is to compare a new, opioid-free pain management pathway with a traditional opioid-containing, multimodal pathway in patients undergoing shoulder arthroplasty.This is a single-center randomized clinical trial in which 67 patients who underwent shoulder arthroplasty were allocated into 2 treatment arms: either a completely opioid-free, multimodal perioperative pain management pathway (OF), or a traditional opioid-containing perioperative pain management pathway (OC). Pain was measured on a numeric rating scale from 0 to 10 at 6-, 12-, 24-hour, 2-week, and 6-week time points. Deviations from the OF pathway, morphine milligram equivalents, readmissions, and opioid-related side effects were analyzed.Pain levels were significantly lower in the OF group at 12 hours, 24 hours, and 2 weeks. At 12 hours, the median pain rating was 0 compared with a median pain rating of 3 in the OC group (P = .003). At 24 hours, the OF group reported a median pain rating of 1 and the OC group reported a median pain rating of 4 (P .001). The median pain rating at the 2-week time point in the OF group was 2 compared with 4 in the OC group (P = .006). Median pain ratings were similar between the OF group and the OC group at the 6-week time point. The median pain rating in the OF group at 6 weeks was 1, compared with 1.5 in the OC group. Of the 35 patients in the OF pathway, 1 required a rescue opioid medication for left cervical radiculopathy that ultimately necessitated cervical spine fusion after recovery from right shoulder arthroplasty, and 1 was noted to have taken an opioid medication, diverted from a prior prescription, at the 2-week visit. The morphine milliequivalents received in the OF group was 20 compared with 4936.25 in the OC group. There were no readmissions in the OF pathway, and no differences between the groups with regard to constipation, falls, or delirium.A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively.

The purpose of this study was to compare outcomes of patients who underwent posterior labral repair with and without concomitant glenohumeral chondral pathology.A retrospective review was performed on patients aged ≥18 years who underwent primary posterior labral repair over 5 years. Charts were reviewed to determine the presence and location of high-grade (Outerbridge grade III or IV) pathology. Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Western Ontario Stability Index (WOSI), visual analog scale (VAS), and Simple Shoulder Test (SST) scores were collected at median 71.5-month follow-up and compared between patients with and without concomitant chondral pathology during the index procedure.Of 100 patients who underwent primary posterior labral repair, 43% had glenoid and/or humeral-sided high-grade chondral pathology. Patients with chondral pathology were older than those without (P.001). A higher proportion of patients with chondral pathology underwent concomitant biceps tenodesis (19.3% vs. 37.2%, P = .046). The type of anchor (all-suture or solid body, P = .010) used was different between patients with and without chondral pathology at time of posterior labrum repair. There was no difference in reoperation rates at final follow-up between patients with and without chondral damage at time of index procedure (P = .200). All outcome scores were similar between all comer patients with and without chondral pathology. Isolated glenoid pathology was significantly associated with lower QuickDASH (P = .018), higher SST (P = .013), lower VAS (P = .016), and lower WOSI scores (P = .046) compared to patients with bipolar lesions. After stratifying by age, there was an association between chondral pathology and lower VAS and WOSI scores in patients aged35 years, and there was an association between chondral pathology and lower SST scores in patients aged ≥35 years.Based on median QuickDASH, SST, WOSI, and VAS scores, subjective and functional outcomes after primary arthroscopic posterior labral repair were not negatively influenced by the presence of concomitant chondral damage at the time of surgery for patients aged35 years at minimum 2-year follow-up. Although our primary outcome score, the QuickDASH, was not significantly associated with the presence of chondral damage in patients aged35 years, SST scores were negatively influenced by concomitant chondral damage in this older cohort, but this may not be adequately powered. It appeared that patients with chondral damage localized to the glenoid tended to have better outcomes scores that those with bipolar damage.

Background: In response to the opioid epidemic, the use of multimodal pain management in orthopaedic surgery is increasing. Efforts to decrease opioid prescribing and opioid consumption among foot and ankle surgical patients are needed. The purpose of this study was to compare the efficacy and adverse events between 2 multimodal pain management pathways for forefoot surgical patients: standard opioid-containing (OC) and opioid-free (OF). Methods: This is a single-center noninferior randomized controlled trial of 51 patients undergoing forefoot surgery allocated to one of 2 perioperative pain management treatments: opioid-free, multimodal (OF, n=27 patients), or traditional opioid-containing (OC, n=24 patients). Patient characteristics, creatine markers, pain (numeric rating scale [NRS]), general health (Veterans Rand 12-Item Health Survey [VR-12]), and depression were measured preoperatively. Postoperatively, pain was measured at 24-hour, 2-week, and 6-week time points. Satisfaction with pain control, complications, and general health were measured at 2 and 6 weeks. Results: The OF group is statistically noninferior to the OC group and reported lower median pain scores at 24 hours (2 [IQR 0, 3] vs 6 [IQR 3.5, 7]; p90% at 6 weeks. The VR-12 scores were similar between groups across all time points. At 2 weeks, 8 patients in each group reported constipation. By 6 weeks, all but 2 OC patients reported resolution. No other adverse events of postoperative wound complications, readmissions, medication reactions, thrombosis, or persistent pain were documented. Conclusion: In forefoot surgery, the opioid-free pain management protocol was statistically noninferior to the opioid-containing protocol in reducing postoperative pain. Level of Evidence: Level II, prospective cohort study.

Background Ulnar collateral ligament reconstruction (UCLR) is the gold standard for treating ulnar collateral ligament injuries in throwing athletes who have failed conservative treatment. There are several described techniques that produce successful and reproducible outcomes. In addition, there is biomechanical evidence that supports hybrid fixation of the graft with a docking technique on the humeral side and suspensory fixation on the ulnar side. However, as of this writing there are no clinical studies that have reported results. This retrospective case series is the first of its kind to report on clinical outcomes following UCLR with hybrid suspensory fixation. Methods Fifty throwing athletes who underwent ULCR with hybrid suspensory fixation from 2010-2017 by one of 5 surgeons at a single institution were available at a median follow-up of 7 years. Return to sport, level of sport, and postoperative complications were recorded at final follow-up. Results A total of 50 patients were included in final analysis. Nearly all were able to return to sport at the same level or higher (48/50, 96%). One of these 50 athletes (2%) played professionally, 27 (54%) played collegiately, and 21 (42%) played at the high school level. Seven patients (14%) underwent reoperation following the index procedure. The median (interquartile range) Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score was 0.098 (0-4.5) at final follow-up. Conclusion Hybrid suspensory fixation is a safe and effective technique for UCLR in the throwing athlete. Throwers can expect to return to sport at a very high rate with low risks for postoperative complications.

Background: Distal biceps repair is a commonly reported procedure in male patients, with reliable outcomes and minimal long-term complications. Information on female patients, however, is limited, and variation in presentation and clinical outcomes is unknown. Questions/Purpose: We sought to report on the presentation, treatment algorithm, and outcomes of a case series of female patients with distal biceps pathology. Methods: A retrospective evaluation was performed from a large, single specialty orthopedic group from 2005 to 2017. Inclusion criteria were surgical treatment of the distal biceps in female patients, with minimum 3 months of follow-up. The primary outcome variable was the Mayo Elbow Performance Score (MEPS). Results: Of 26 patients who met inclusion criteria, 18 (70%) were available for follow-up with patient-reported outcomes. Median age at time of injury was 56.1 years; 46.2% of patients presented with a complete tear of the distal biceps, and the remaining 53.8% presented with a partial tear that failed nonoperative treatment. Six patients had lateral antebrachial cutaneous neuritis in early follow-up, which ultimately resolved. Median MEPS score was 100 (interquartile range: 20). Conclusion: This study represents the largest case series to date describing the presentation, treatment, and outcomes of female patients with distal biceps repair. Women tend to be older than men, have more insidious onset of pain, present with partial tearing, and may benefit from nonoperative treatment. Ultimately, based on this case series we believe distal biceps repair in female patients is a successful operation with minimal complications and high patient satisfaction.

Background: Biologic technologies can potentially augment existing arthroscopic rotator cuff repair to improve retear rates and postoperative outcomes. The purpose of this study was to evaluate healing rates and clinical outcomes of full-thickness rotator cuff repairs augmented with a bioinductive bovine collagen implant. Methods: In this prospective multicenter study, investigators enrolled 115 patients (mean age, 60.4 years) with full-thickness rotator cuff tears. There were 66 (57.4%) medium (1-3 cm) tears and 49 (42.6%) large (3-5 cm) tears. Eligible patients consisted of those ≥21 years of age with chronic shoulder pain lasting longer than 3 months and unresponsive to conservative therapy. Patients underwent single- or double-row repair augmented with a bioinductive bovine collagen implant. At the baseline, 3 months, and 1 year, magnetic resonance imaging was performed and patients were assessed for American Shoulder and Elbow Surgeons (ASES) Shoulder Score and Constant-Murley Score (CMS). The primary failure end point was retear, classified as any new full-thickness defect observed on magnetic resonance imaging. Results: There were 13 retears (11.3%) at 3 months, with an additional 6 (19 total [16.5%]) found at 1 year. In large tears, double-row repair had a significantly lower rate of retear at 3 months (P = .0004) and 1 year (P = .0001) compared with single-row repair. ASES and CMS scores significantly improved between the baseline and 1 year for medium and large tears. At 1 year, the minimally clinically important difference for ASES and CMS was met by 91.7% (95% CI: 84.9-96.1) and 86.4% (95% CI: 78.2-92.4) of patients, respectively. Patients without retear and those

Background The purpose of this study was to identify and report on the rate at which leaders in orthopaedic surgery are encountering GTM, their treatment methods and to identify whether these clinicians’ demographics or techniques correlate with their GTM incidence and/or treatment algorithms. Methods A survey was sent to identify the rate at which member orthopaedic surgeons of the American Orthopaedic Society for Sports Medicine (AOSSM), the National Football League Physicians Society (NFLPS), and the Herodicus Society are encountering GTM in ACL reconstruction with BTB graft and to establish what methods are most commonly utilized. Results In total, 260 orthopaedic surgeons completed the survey. Respondents most frequently reported GTM in 1–5% of cases, with GTM most often between 5 and 10 mm. For lower levels of GTM, surgeons are most frequently recessing the femoral bone plug and adding a cortical suspensory device or outside–in fixation. Higher degrees of GTM are most commonly supplemented with a screw/post on the tibia. Those with > 15 years of experience were more commonly using a transtibial femoral drilling with lower tibial tunnel angulation, and lower incidences of GTM than their less experienced counterparts. Conclusion There is tremendous variability in the incidence and management of GTM in ACL reconstruction with BTB graft with no clear consensus among experts. Differences are seen in ACL reconstruction techniques and means of correcting GTM when evaluating based on years of surgical experience and Sports Medicine Fellowship completion.

Background: The purpose of this study was to evaluate the clinical outcomes and cost of shoulder arthroplasty (SA) performed in ambulatory surgery centers (ASCs) compared with SA performed in hospital-based surgery settings. Methods: The State Inpatient Databases and the State Ambulatory Surgery Databases were queried for patients undergoing primary or reverse SA between 2010 and 2014 in 5 states in either the inpatient (IP), hospital outpatient department (HOPD), or ASC setting. Outcomes included all-cause readmissions, emergency department visits within the 90-day postoperative period, and charges. Covariates included patient demographic data and procedure details. Risk factors for readmission were calculated using logistic regression analysis. Results: We identified 795 ASC (2%), 183 HOPD (0.5%), 38,114 (97.5%) SA procedures. The outpatient cohort was overall younger and healthier with a lower percentage of diabetes (14.1% vs. 20.2%), cardiopulmonary disease (11.4% vs. 20.4%), and obesity (10.7% vs. 15.6%). The US state and obesity were factors significantly (P < .0001) associated with readmission. The median IP charge was $62,905 (range, $41,327-$87,881) vs. $37,395 (range, $21,976-$61,775) for combined outpatient cases. When outpatient SA was stratified into ASC and HOPD cases, the median charges were $31,790 for ASC cases vs. $55,990 for HOPD cases (P < .0001). After adjustment for multiple covariates, the charges for combined outpatient SA surgery were 40% lower than those for IP SA surgery (P < .0001). Conclusion: As the current health care climate shifts toward lower-cost and higher-quality care, this study demonstrates that SAs performed in ASCs have a comparable safety profile to and significant financial advantage over SAs performed in the hospital-based setting.

Rotator cuff pathology is a very common source of shoulder pain. Similarly, osteoarthritis of the glenohumeral joint can cause shoulder pain and produce similar symptoms. Surgical management can be indicated for both pathologies, however, outcomes data is limited when examining rotator cuff repair (RCR) in the setting of glenohumeral arthritis (GHOA). Thus, this study sought to determine outcomes for patients who undergo RCR in the setting of GHOA.To evaluate if a relationship exists between outcomes of RCR in the setting of GHOA.This was a retrospective analysis of patients who underwent arthroscopic rotator cuff repair with concurrent glenohumeral osteoarthritis between 2010-2017. Patients were stratified based on rotator cuff tear size and glenohumeral osteoarthritis severity. Cohorts were paired 1:1 with patients without glenohumeral osteoarthritis. Patients included had a minimum two year follow-up. Rate of conversion to total shoulder arthroplasty, complication rates following initial surgery, and patient-reported outcome measures were collected.A total of 142 patients were included. The number of patients that required total shoulder arthroplasty within two years after index surgery was low. 2/71 (2.8%) patients with GHOA, and 1/71 (1.4%) without GHOA. Following rotator cuff repair, both groups showed favorable patient-reported outcomes.Patients with glenohumeral osteoarthritis who underwent arthroscopic rotator cuff repair showed comparable outcomes to patients without glenohumeral osteoarthritis.

Background The purpose of this cadaveric study was to describe the characteristics of the “A-frame” morphology of the distal clavicle via computed tomography (CT) to determine if it can be used as a reliable intraoperative guide for arthroscopic distal clavicle excision. Methods Twenty-eight fresh-frozen human cadaveric clavicles underwent a three-dimensional CT scan utilizing 1.0 mm cuts. The distance from the most lateral aspect of the clavicle to the point in which the superior cortex of the clavicle paralleled the inferior cortex was measured. Measurements were performed in a blinded fashion by a single author on two separate occasions. Results The “A-frame” was present in all specimens (28/28). Upon first measurement, the mean distance from distal clavicle to the point in which the “A-frame” disappeared was 1.00 cm (range: 0.90-1.08 cm; standard deviation: 0.5 mm). Upon second measurement, the mean distance was 1.02 cm (range: 0.90-1.11 cm; standard deviation: 0.6 mm). The intra-rater reliability between measurement occasions was 0.65 [p Conclusions This study demonstrated that the cross-sectional “A-frame” morphology of the distal clavicle was consistently visualized on CT scan. The “A-frame” disappeared 1.00-1.02 cm medial to the most lateral extent of the clavicle on CT scan. The disappearance of the “A-frame” morphology of the distal clavicle can serve as a reliable intraoperative guide for arthroscopic distal clavicle excision.

Background: The anteromedial (AM) portal and transtibial (TT) approaches are 2 common anterior cruciate ligament (ACL) femoral tunnel drilling techniques, each with unique benefits and disadvantages. A hybrid TT (HTT) technique using medial portal guidance of a flexible TT guide wire has recently been described that may combine the strengths of both the AM portal and the TT approaches. Hypothesis: The HTT technique will achieve anatomic femoral tunnel apertures similar to the AM portal technique, with improved femoral tunnel length and orientation. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 30 consecutive patients with primary ACL tears were randomized to undergo the TT, AM portal, or HTT technique for femoral tunnel positioning at the time of reconstruction. All patients underwent 3-dimensional computed tomography of the operative knee at 6 weeks postoperatively. Femoral and tibial tunnel aperture positions and tunnel lengths, as well as graft bending angles in the sagittal and coronal planes, were measured. Results: Tibial tunnel lengths and aperture positions were identical between the 3 groups. The AM portal and HTT techniques achieved identical femoral aperture positions in regard to both height ( P = .629) and depth ( P = .582). By contrast, compared with the AM portal and HTT techniques, femoral apertures created with the TT technique were significantly higher ( P < .001 and P < .001, respectively) and shallower ( P = .014 and P = .022, respectively) in the notch. The mean femoral tunnel length varied significantly between the groups, measuring 35.2, 41.6, and 54.1 mm for the AM portal, HTT, and TT groups, respectively ( P < .001). Last, there was no difference between the mean coronal ( P = .190) and sagittal ( P = .358) graft bending angles between the TT and HTT groups. By contrast, compared with the TT and HTT techniques, femoral tunnels created with the AM portal technique were significantly more angulated in the coronal plane (17.7° [ P < .001] and 12.5° [ P = .006], respectively) and sagittal plane (13.5° [ P < .001] and 10.5° [ P = .013], respectively). Conclusion: This prospective randomized controlled trial found that the HTT technique achieved femoral aperture positions equally as anatomic as the AM portal technique but produced longer, less angulated femoral tunnels, which may help reduce graft strain and mismatch. As such, this hybrid approach may represent a beneficial combination of both the TT and the AM portal techniques. Registration: NCT02795247 (ClinicalTrials.gov identifier)

Objectives: Improved biomechanical and clinical outcomes have been reported when femoral anterior cruciate ligament (ACL) tunnels are centered on the native footprint. The anteromedial (AM) portal technique achieves improved aperture position when compared to a transtibial (TT) approach but sacrifices technical ease and creates a shorter more acutely angulated tunnel. A hybrid transtibial technique (HTT) technique using medial portal guidance of a flexible transtibial guide wire without the need for knee hyperflexion may combine the strengths of both the AM and TT approaches. The authors hypothesized that this HTT technique would achieve anatomic femoral tunnel apertures similar to the AM technique, but with longer and less angulated femoral tunnels similar to a TT technique. Methods: A prospective randomized controlled trial was implemented where 30 consecutive patients with acute, primary ACL tears were randomized to receive a TT, AM or HTT technique for their reconstruction. A total of 46 patients were assessed for eligibility in the investigation (Figure 1). All patients underwent 3D CT scans of the operative knee 6 weeks postoperatively to characterize tunnel positions. Femoral and tibial tunnel aperture positions and tunnel lengths, as well as the graft bending angle in the sagittal and coronal plane were measured. Results: There were no significant differences between the patient demographics of the three groups. Tibial tunnel lengths and aperture positions were identical between the three groups. The AM portal and HTT techniques achieved identical femoral aperture positions in regards to both height (p=0.75) and depth (p=0.72). On the other hand, compared to the AM portal and HTT techniques, respectively, femoral apertures created by the TT technique were significantly higher (pConclusion: The HTT technique achieves femoral aperture positions equally as anatomic as an AM portal technique, but with longer and less acutely oriented grafts similar to a transtibial approach. These advantages will decrease the incidence of graft tunnel mismatch as well as reduce the amount of stress imparted onto the graft by avoiding an acute graft bending angle. As such, this hybrid approach may represent a beneficial combination of both transtibial and AM portal techniques.

The role of intramedullary (IM) fixation of displaced mid-shaft clavicle fractures in adolescents has not been described. This study analyzes characteristics and outcomes of IM fixation in adolescent clavicle fractures. Patients18 years with acute, mid-shaft clavicle fractures treated with IM clavicle pins between March 2007 and August 2013 were reviewed. Outcomes of interest were activity level, fracture pattern, time to union, return to sports and complications. Twenty-nine patients (14.8 years (range 11.4-17.9)) underwent IM pin fixation for a displaced, mid-shaft clavicle fracture, including 7 (24.1%) that were multi-fragmentary (length unstable). Complete displacement (100%) occurred in 27/29 (93.1%), with average preoperative shortening length of 18 mm. Union occurred in 100% of patients, at a mean duration of 8 weeks. Among student-athletes (25/29, 86.2%), average return to sport was at 18 weeks post-injury. IM pinning offers stable fixation of clavicle fractures in the active adolescent population.(Journal of Surgical Orthopaedic Advances 29(2):81-87, 2020).

Background: Anterior cruciate ligament (ACL) injuries are common in American football players. The risk of subsequent ACL reinjury to either the ipsilateral or the contralateral knee in National Football League (NFL) draftees with a history of successful ACL reconstruction before entering the NFL remains unknown. Hypothesis: NFL athletes with a history of successful ACL reconstruction before being drafted will likely demonstrate increased risk of subsequent ACL injury when compared with a control cohort consisting of players of similar positions and draft class. Study Design: Cohort study; Level of evidence, 3. Methods: Detailed orthopaedic evaluations of NFL Combine participants from 2006 to 2012 were obtained to identify players entering the NFL draft with a history of successful ACL reconstruction. A control cohort was created in a 2:1 ratio, consisting of players matched by position and draft class. Results: Of the 2016 players invited to the NFL Combine during the study period, 100 met the inclusion criteria. A total of 26 subsequent ACL reinjuries (12 ipsilateral, 14 contralateral) occurred in 25 players (25%) while playing in the NFL, with injuries occurring at a mean of 22.1 months after the NFL draft. In comparison, 18 of the 200 (9%) carefully matched cohort players without history of prior ACL injury sustained a new ACL injury during this time period ( P < .001). Conclusion: NFL athletes with a history of successful ACL reconstruction before being drafted into the NFL have a significantly higher rate of subsequent ACL reinjury while playing in the NFL when compared with a carefully matched cohort of players without a history of prior ACL injury.

Background Latissimus dorsi (LD) and teres major (TM) tendon transfers have been performed concurrently with reverse shoulder arthroplasty (RSA) to address combined loss of elevation and external rotation (CLEER) at the shoulder. The purpose of this prospective, randomized study was to compare RSA with and without LD-TM tendon transfer in patients with rotator cuff tear arthropathy and CLEER. Methods Patients undergoing RSA for rotator cuff tear arthropathy who also had CLEER were randomized into the group undergoing RSA with tendon transfer or the group undergoing RSA without tendon transfer. The primary outcome measure was the Activities of Daily Living and External Rotation (ADLER) score 2 years after surgery. Secondary outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score, and Simple Shoulder Test (SST) score. Results Both the treatment and control groups showed significant improvements in the ability to perform activities of daily living requiring active external rotation measured by the ADLER score postoperatively. No significant difference in the ADLER, DASH, ASES, or SST score was found between the 2 groups at final follow-up. Resolution of the Hornblower sign occurred postoperatively in 58.3% of patients in the control group and 73.3% of those in the treatment group. Conclusion No differences in the ADLER, DASH, ASES, and SST results were found between patients treated with RSA alone and those treated with RSA with LD-TM transfer for rotator cuff tear arthropathy and CLEER. Both groups showed significant improvements in all clinical outcome assessments including functional tasks that require active external rotation.

Background Opioid therapy has been a cornerstone of perioperative pain control for decades in the United States, despite our increased understanding of the morbidity and mortality linked to opioids. The purpose of this study is to explore the safety, efficacy, and feasibility of an entirely opioid-free perioperative pathway in patients undergoing elective shoulder arthroplasty. Methods Thirty-five patients undergoing elective total shoulder arthroplasty with a mean age of 71 (range, 50-87) years elected into a comprehensive opioid-free, multimodal pain management protocol. Opioid use was completely eliminated for all points in the perioperative period including during regional and general anesthesia. Data were collected regarding patient-reported pain, opioid consumption in the perioperative period, postoperative delirium, nausea, constipation, and falls. Results Pain level at the primary outcome point of 24 hours or discharge was rated at 2.5 on the numeric rating scale. Stable, low pain scores were demonstrated at all time points postoperatively. Low rates of nausea, falls, and constipation were reported. Only 1 patient required “rescue” opioid medications during the in-patient stay, and an additional patient was given a low-dose opioid prescription at the 2-week postoperative appointment. Conclusions An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids. This study is the first such study to present a surgical protocol entirely free of opioids at all portions of the patient care pathway.

Introduction: Early reports of outpatient shoulder arthroplasty are promising, although a paucity of outcome data exists, particularly for the outpatient shoulder arthroplasty performed at a freestanding ambulatory surgery center (ASC). Methods: A retrospective analysis of 61 shoulder arthroplasty procedures (21 consecutive outpatients and 40 inpatients) was performed. Outpatient shoulder arthroplasties were conducted at a freestanding ASC using a multimodal pain regimen without the use of regional anesthesia. The primary outcome was 90-day postoperative complication rate. Secondary outcomes included 90-day hospital admissions or readmissions, emergency department and urgent care visits, revision surgeries, mortality, postoperative pain, and functional scores. Results: No major complications, readmissions, revision surgeries, or deaths occurred in the outpatient cohort. The rate of 90-day complications was 9.5% and 17.5% for the outpatient and inpatient cohorts, respectively. All patients who had their shoulder arthroplasty as an outpatient were discharged home the day of surgery. No complications related to the outpatient protocol were observed. However, 4.8% of those who had outpatient surgery visited an emergency department or urgent care within 90 days compared with 5.0% of those who had surgery as an inpatient. Discussion: Outpatient shoulder arthroplasty can be performed safely and predictably in select patients at an ASC using a multimodal pain regimen without regional nerve block.

Background The major complication and reoperation rates after distal biceps repair are poorly defined. The purpose of this large retrospective cohort study of distal biceps repairs performed by multiple surgeons within a large orthopedic group was to more clearly define the rates and risk factors of clinically impactful major complications and reoperations. Methods All distal biceps tendon repairs performed from January 2005 through April 2017 with a minimum 2-month follow-up were identified using Current Procedural Terminology code 24342. We included 970 patients. The primary outcome measure was the total major complication rate. Reoperations, minor complications, and risk factors were also tracked. Results Repairs were performed via a single anterior incision in 652 cases and a 2-incision exposure in 318 cases. A 7.5% major complication rate and 4.5% reoperation rate were observed overall. Major complications occurred at the following rates: proximal radioulnar synostosis, 1.0%; heterotopic ossification or loss of range of motion with reoperation, 0.9%; tendon rerupture, 1.6%; deep infection, 0.5%; posterior interosseous nerve palsy, 1.9%; and complex regional pain syndrome, 0.6%. The 2-incision exposure was identified as a significant risk factor for the development of proximal radioulnar synostosis when compared with single-incision repair techniques (P = .0003; odds ratio, 19), occurring in 2.8% of 2-incision exposure cases. Lateral antebrachial cutaneous nerve neuritis or numbness and radial sensory nerve neuritis or numbness were documented more frequently in the postoperative period among patients treated with a single-incision exposure (P Conclusions Distal biceps repair is associated with a 7.5% major complication rate and 4.5% reoperation rate. The use of a 2-incision technique for repair increases the risk of radioulnar synostosis.

Background The prevalence and severity of concomitant rotator cuff pathology in the setting of proximal biceps tendon ruptures are poorly understood. Concomitant rotator cuff disease may have important implications in the prognosis and natural history of this shoulder condition. Therefore, an observational cohort of patients with an acute rupture of the long head of the biceps tendon (LHBT) was evaluated to determine the prevalence and severity of concomitant rotator cuff disease. Methods Thirty consecutive patients diagnosed with acute proximal biceps tendon rupture were prospectively enrolled. Magnetic resonance imaging of the affected shoulder was obtained in 27 patients and reviewed by a fellowship-trained orthopedic surgeon. Results The cohort consisted of 20 men (74%) and 7 women (26%) (mean age, 61.0 years [range, 42-78 years]). The dominant side was involved in 20 injuries (74%), and a low-energy trauma mechanism of injury was involved in 23 (85%). Of the patients, 11 (41%) reported a history of antecedent shoulder pain. Magnetic resonance imaging assessment revealed that 93% of patients had evidence of rotator cuff disease, including 13 full-thickness tears. Of the full-thickness tears, 3 were small, 6 medium, 2 large, and 2 massive. Pathology of the subscapularis tendon was identified in 7 patients (26%). Conclusion In this cohort, we found LHBT rupture to be highly correlated with the presence of rotator cuff disease, with the majority of patients presenting with full-thickness tears of the supraspinatus. These findings may have important implications in the treatment and prognosis of patients who present with acute LHBT ruptures.

Background The purpose of this study was to evaluate wear debris in periprosthetic tissues at the time of revision total elbow arthroplasty. Polyethylene, metallic, and bone cement debris were characterized, and the tissue response was quantified. Materials and methods Capsular and medullary tissue samples were collected during revision surgery. Polyethylene debris was characterized by scanning electron microscopy after tissue digestion. The concentrations of metal and cement debris were quantified by inductively coupled plasma mass spectrometry. Tissue response was graded with a semiquantitative histologic method. Results Polyethylene particle size varied from the submicron range to over 100 μm. The mean diameter ranged from 0.6 μm to about 1 μm. Particles in the synovial tissues were larger and less abundant than those in tissues from the medullary canal. Cement, titanium alloy, and low levels of cobalt-chrome debris were also present, with cement predominating over metal debris. Histiocyte response was associated with small polyethylene particles (0.5-2 μm), and giant cells were associated with large polyethylene particles (>2 μm). Histiocyte scores positively correlated with the polyethylene particle number and the presence of metal. Discussion We have shown that periprosthetic tissues of total elbow patients who have undergone revision for loosening and osteolysis contain polyethylene, cement, and metal debris. Although the polyethylene particles were of a size and shape that have been previously shown to result in activation of phagocytic cells, osteolysis after total elbow arthroplasty is a multimodal process. Because of the presence of multiple wear particle sources, a cause-and-effect relationship between polyethylene debris and osteolysis cannot be established with certainty.

Rotator cuff pathology causes substantial pain/disability and health care costs. Cell-based tissue engineering offers promise for improved outcomes in tendon to bone healing. Cells from the tendon-bone interface were used here to amplify surgical defect healing in a rat model. Cells from tendon-to-bone interface of the rotator cuff were seeded in sponges and implanted into critical rotator cuff defects: Group I, control; II, surgical defect only; III, suture-repaired defect; IV, surgical defect, repair with sponge only; V, surgical defect, repair with sponge with cells. Three, 6-, and 12-week results were assessed for histologic features. At 3 weeks, histologic indices in Group V were significantly increased versus other treatment groups. Group V (12 weeks) showed significantly improved collagen organization versus other treatment groups; there was no difference in collagen organization in Group I versus V. In summary, increased cellularity, inflammation, vascularity, and collagen organization were present at 3 weeks; increased collagen organization at 12 weeks in Group V provides evidence for improved healing with cells. Data further support the utility of tendon-bone interface cells in rotator cuff healing. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31: 407–412, 2013

Background: Heterotopic ossification around the elbow can result in pain, loss of motion, and impaired function. We hypothesized that a single dose of radiation therapy could be administered safely and acutely after elbow trauma, could decrease the number of elbows that would require surgical excision of heterotopic ossification, and might improve clinical results. Methods: A prospective randomized study was conducted at three medical centers. Patients with an intra-articular distal humeral fracture or a fracture-dislocation of the elbow with proximal radial and/or ulnar fractures were enrolled. Patients were randomized to receive either single-fraction radiation therapy of 700 cGy immediately postoperatively (within seventy-two hours) or nothing (the control group). Clinical and radiographic assessment was performed at six weeks, three months, and six months postoperatively. All adverse events and complications were documented prospectively. Results: This study was terminated prior to completion because of an unacceptably high number of adverse events reported in the treatment group. Data were available on forty-five of the forty-eight patients enrolled in this study. When the rate of complications was investigated, a significant difference was detected in the frequency of nonunion between the groups. Of the nine patients who had a nonunion, eight were in the treatment group. The nonunion rate was 38% (eight) of twenty-one patients in the treatment group, which was significantly different from the rate of 4% (one) of twenty-four patients in the control group (p = 0.007). There were no significant differences between the groups with regard to the prevalence of heterotopic ossification, postoperative range of motion, or Mayo Elbow Performance Score noted at the time of study termination. Conclusions: This study demonstrated that postoperative single-fraction radiation therapy, when used acutely after elbow trauma for prophylaxis against heterotopic ossification, may play a role in increasing the rate of nonunion at the site of the fracture or an olecranon osteotomy. The clinical efficacy of radiation therapy could not be determined on the basis of the sample size. Further research is needed to determine the role of limited-field radiation for prophylaxis against heterotopic ossification after elbow trauma. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Background Clavicle fractures have historically been managed nonoperatively. Recent literature suggests a subset of clavicle fractures may be best treated with primary surgical treatment. Purpose To review the National Football League (NFL) experience in the management of middle-third clavicle fractures over a 5-year period. Study Design Case series; Level of evidence, 4. Methods A retrospective review of clavicle fractures that occurred during a 5-season period was obtained from the NFL Injury Surveillance System. A detailed questionnaire was also sent to the medical staff of all 32 NFL teams. Results Nineteen players sustained a middle-third clavicle fracture over the 5-year period. Six fractures were nondisplaced or minimally displaced. All 6 healed at an average time of 7.3 weeks. Thirteen fractures were 100% displaced. Six of the 13 underwent acute surgical fixation that resulted in fracture healing without complication at an average of 8.8 weeks. The remaining 7 players with a completely displaced fracture were initially treated nonoperatively. Three of these 7 healed clinically without sequela at an average of 13.3 weeks after injury; however, 4 players sustained a refracture within 1 year of the initial injury. Conclusion Over the past 5 years, nearly 50% of NFL players with a completely displaced middle-third clavicle fracture were treated successfully with acute surgical fixation without sequela and healed at an average of 8.8 weeks. Three of these players were able to return to play during the same season. In addition, 4 of 7 players initially treated nonoperatively for a completely displaced middle-third clavicle fracture refractured their clavicle within a 1-year period from their initial injury. The 4 players missed an average of 1.5 seasons because of their clavicle injury and subsequent clinical course. Based on this review, it may be reasonable to consider acute surgical treatment of this injury in the NFL player to enable a successful clinical outcome in a predictable time frame.

Background Reverse shoulder arthroplasty has become more prevalent for the treatment of complex shoulder issues. Prosthetic designs vary in both the number and orientation of screws recommended for securing the glenoid base plate. This study examined the contribution of the posterior glenoid screw for stabilizing the glenosphere by comparing constructs with no posterior screw, a standard posterior screw directed into the glenoid neck, and a long posterior screw (LPS) into the scapular spine. Material and methods The Tornier RTSA glenoid implant was fixed into 2 groups of matched cadaveric scapulae. In both groups, the controls were fixed with a standard posterior screw (SPS). Matching scapulae had a screw configuration that omitted the posterior screw (NPS) in group I or utilized an LPS in group II. Specimens were tested using a “rocking-horse” protocol. During cyclic loading (50,000 cycles), the vertical displacement of the glenoid component was monitored using a digital caliper. Results In group I, NPS constructs demonstrated a significantly higher mean rate of loosening than SPS constructs. In group II, the LPS constructs demonstrated lower loosening rates than SPS constructs. Mean initial displacements were greater for NPS than SPS in group I and similar for SPS and LPS in group II Discussion The posterior glenoid screw contributes significantly to stability of the reverse glenoid base plate. If an SPS does not obtain good purchase into the scapula, glenoid component fixation will be enhanced by the addition of an LPS into the scapular spine.

We conducted a study to biomechanically compare 4 tibial hamstring tendon fixation devices commonly used in anterior cruciate ligament reconstruction. Quadrupled human semitendinosus-gracilis tendon grafts were fixed into porcine tibias using 4 separate fixation devices. For each device, 10 specimens were tested (1500-cycle loading test at 50-200 N). Specimens surviving the cyclic loading then underwent a single load-to-failure test. Failure mode, stiffness, ultimate load, and residual displacement were recorded. Eight of 10 Delta screw (Arthrex), 2 of 10 Retroscrew (Arthrex), 10 of 10 WasherLoc (Arthrotek), and 10 of 10 Intrafix (Depuy Mitek) devices completed the 1500-cycle loading test. Residual displacement was significantly (P.001) lower for Intrafix (2.9 mm), WasherLoc (5.6 mm), and Delta (6.4 mm) than for Retroscrew (25.5 mm). Mean stiffness was significantly (P.05) higher for Intrafix (129 N/mm) than for the other devices. Mean load to failure was highest for Intrafix (656 N), then WasherLoc (630 N), Delta (430 N), and Retroscrew (285 N). The Intrafix device demonstrated superior strength in the fixation of hamstring grafts in the tibia. WasherLoc was close behind.

We conducted a study to biomechanically compare 5 femoral hamstring tendon fixation devices commonly used in anterior cruciate ligament reconstruction. Quadrupled human semitendinosus-gracilis tendon grafts were fixed into porcine femurs using 5 separate fixation devices. For each device, 10 specimens were tested (1500-cycle loading test at 50-200 N). Specimens surviving the cyclic loading then underwent a single load-to-failure (LTF) test. Failure mode, stiffness, ultimate load, and rigidity were recorded. Two of 10 Delta screw (Arthrex), 10 of 10 Bio-TransFix (Arthrex), 10 of 10 Bone Mulch screw (Arthrotek), 10 of 10 EZLoc (Arthrotek), and 10 of 10 Zip Loop (Arthrotek) devices completed the 1500-cycle loading test. Residual displacement was lowest for Bio-TransFix (4.1 mm) followed by Bone Mulch (5.2 mm), EZLoc (6.4 mm), Zip Loop (6.8 mm), and Delta (8.2 mm). Mean stiffness was significantly (P.001) higher for Bone Mulch (218 N/mm) than for Bio-TransFix (171 N/mm), EZLoc (122 N/mm), Zip Loop (105 N/mm), or Delta (84 N/mm). Mean LTF was significantly ( P.001) higher for Bone Mulch (867 N) than for Zip Loop (615 N), Bio-TransFix (552 N), EZLoc (476 N), or Delta (410 N). The Bone Mulch screw demonstrated superior strength in the fixation of hamstring grafts in the femur. Bio-TransFix was close behind. The Delta screw demonstrated poor displacement, stiffness, and LTF. When used as the sole femoral fixation device, a device with low LTF, decreased stiffness, and high residual displacement should be used cautiously in patients undergoing aggressive rehabilitation.

To compare the mechanical stability of a fixed-angle blade plate with that of a locking plate in a cadaveric proximal humerus fracture-fixation model subjected to cyclic loading. A secondary objective was to evaluate whether the use of synthetic humerus specimens would replicate significant differences found during cadaveric tests.Mechanical evaluation of constructs in bending and torsion.Biomechanical laboratory in an academic medical center.Simulated humeral neck fractures (Orthopaedic Trauma Association (OTA) classification 11A3), in matched-pair cadaveric and synthetic specimens underwent fixation using either a 3.5-mm, 90-degree cannulated LC-Angled Blade Plate or a 3.5-mm LCP Proximal Humerus Locking Plate. Cadaveric specimen constructs were cyclically loaded in bending and torsion; synthetic specimens were tested in torsion.Humeral shaft-bending displacements and angular rotations for respective cyclic bending loads and axial torques were recorded and compared at repeated cyclic intervals to evaluate construct loosening.Locking-plate constructs exhibited significantly less loosening than blade-plate constructs for torsional loading in cadaveric specimens (P = 0.036). The two types of constructs performed similarly for torsional loading in synthetic specimens (P = 0.100). Under cyclic, closed-bending load conditions in which the plates served as tension members, both types of constructs performed similarly in cadaveric specimens (P = 0.079).For simulated humeral neck fractures subjected to cyclic loading, locking-plate constructs demonstrated significantly greater torsional stability and similar bending stability to blade plates in a cadaveric specimen model. In contrast, these same constructs performed similarly with torsional loading when using synthetic humerus specimens. These results indicate potential advantages for locking-plate fixation. They also indicate that the synthetic specimens tested may not be appropriate for evaluating fixation stability in the humeral head, where cancellous bone fixation predominates.

Background Although several studies have described magnetic resonance imaging findings in shoulders of asymptomatic volunteers, no such investigation has been performed on asymptomatic dominant and nondominant shoulders of elite overhead athletes. Hypothesis Asymptomatic dominant shoulders of elite overhead athletes may have a higher incidence of magnetic resonance imaging abnormalities than either their nondominant shoulder or shoulders of asymptomatic volunteers. Study Design Prospective cohort study. Methods Detailed magnetic resonance imaging scans of asymptomatic dominant and nondominant shoulders of elite overhead athletes were obtained. Three experienced musculoskeletal radiologists interpreted each scan for multiple variables, including rotator cuff appearance. Images from a surgical control group were intermixed to assess accuracy and control for observer bias. A 5-year follow-up interview was performed to determine whether magnetic resonance imaging abnormalities found in the initial stage of the study represented truly clinical false-positive findings or symptomatic shoulders in evolution. Results Eight of 20 (40%) dominant shoulders had findings consistent with partial- or full-thickness tears of the rotator cuff as compared with none (0%) of the nondominant shoulders. Five of 20 (25%) dominant shoulders had magnetic resonance imaging evidence of Bennett's lesions compared with none (0%) of the nondominant shoulders. None of the athletes interviewed 5 years later had any subjective symptoms or had required any evaluation or treatment for shoulder-related problems during the study period. Conclusions Magnetic resonance imaging alone should not be used as a basis for operative intervention in this patient population.

Thirty-six consecutive patients who underwent revision decompression for refractory subacromial impingement were studied retrospectively. Average interval from the primary decompression procedure to revision was 29 months. Eighteen patients underwent arthroscopic and 18 underwent open revision. Six (33%) patients in the arthroscopic group and 12 (67%) patients in the open group were workers' compensation cases. At an average follow-up of 26 months, 17 (94%) patients in the arthroscopic group and 8 (44%) in the open group were satisfied with their procedure. Comparing workers' compensation patients, 5 of 6 in the arthroscopic group and 4 of 12 in the open group were satisfied. For nonworkers' compensation patients, all 12 patients in the arthroscopic group and 4 of 6 in the open group were satisfied. Average pain scores and postoperative range of motion was improved in both groups. Dense subacromial scarring with thick, fibrous adhesions was present in all patients. Residual, prominent bone, or an acromial spur was found in 20 (56%) patients. Overall, revision arthroscopic subacromial decompression was superior to open revision. However, there were more workers' compensation patients in the open group. Workers' compensation patients fared worse for both groups, but a significant proportion (83%) of the arthroscopic group was satisfied. Since subacromial scarring may be the most important pathology, arthroscopy is less invasive, allowing earlier, unrestricted postoperative rehabilitation and proving more effective.

Although open anterior acromioplasty and rotator cuff repair has reliably provided satisfactory results for several decades, efforts are continually being made to improve on these results. Arthroscopically assisted mini-open rotator cuff repair provides the advantages of arthroscopic glenohumeral inspection and identification and treatment of any concomitant lesions, deltoid origin preservation (with the arthroscopic subacromial decompression), decreased surgical morbidity, and improved cosmesis. In addition, this procedure can reliably be performed as an outpatient procedure and may allow accelerated postoperative rehabilitation. This report outlines the rationale and technique for this surgical approach, which may be used for the repair of significant partial-thickness tears and small to medium-sized full-thickness tears. Also, it requires experience and expertise in shoulder arthroscopy and arthroscopic subacromial decompression.

In this article, we report on our experience with patients who sustained a fracture of the acromion after reverse shoulder arthroplasty (RSA), and on the results of a comprehensive survey regarding this complication- a survey of American Shoulder and Elbow Surgeons (ASES) members. Patients were assessed with radiographs and validated functional outcome measures. Eight (4.9%) of the 162 patients that underwent RSA had radiographic evidence of postoperative fracture of the acromion. Mean active forward elevation was 71°, and mean ASES score was 70. Four patients reported no pain; 2 had mild pain; 1 had moderate pain; and 1 patient had severe pain. Six of the 8 fractures did not unite. Survey results showed that 74% of ASES respondents treated these patients nonoperatively and that 53% of respondents thought that acromial fractures after RSA led to reduced shoulder function, but without persistent pain. The natural history of nonoperative management is characterized by reduced global shoulder function and a high rate of nonunion. However, most of the patients who experienced this complication did not report chronic pain. Given these patients' outcomes, and the surveyed opinions of ASES members, conservative management is a reasonable option for this complication.

The purpose of this study was to compare the incidence of presumed rotator cuff pathology based on radiologist and surgeon interpretation of preoperative magnetic resonance images (MRIs) with actual rotator cuff pathology found intraoperatively in patients undergoing arthroscopic capsular release for adhesive capsulitis. The medical records of 38 consecutive patients who underwent arthroscopic glenohumeral capsular release for adhesive capsulitis between September 2001 and May 2007 were retrospectively reviewed. Radiologist and surgeon predicted status of the rotator cuff by prospective MRI interpretation was compared to the actual status of the rotator cuff intraoperatively. Radiologists’ preoperative MRI interpretations predicted a 57.9% incidence of rotator cuff pathology, while operative findings revealed a true incidence of only 13.2% ( P Interpretations of shoulder MRIs in patients with adhesive capsulitis may provide misleading information regarding rotator cuff pathology. The actual findings of shoulder MRI scans may lead to the appearance of false rotator cuff pathology in this population, and a high percentage of false positive MRI reports of rotator cuff tears was observed in these patients. If MRI is chosen as a diagnostic adjunct in this patient population, careful consideration should be given to its interpretation to avoid unnecessary or possibly aggravating surgical intervention.

Background: Techniques for ulnar collateral ligament (UCL) reconstruction have evolved since its original description.Hypothesis: Ulnar collateral ligament reconstruction using the ZipLoop for ulnar-sided fixation, as combined with the humeral docking technique supplemented with an interference screw, will restore valgus stability similar to that of the Jobe technique and the native ligament.Study Design: Controlled laboratory study.Methods: Kinematic testing was performed on 8 matched pairs of cadaver elbows with an electromagnetic tracking system through an arc of motion for the intact, disrupted, and reconstructed states of the UCL in an unloaded and loaded condition. From each pair, the docking technique using the ZipLoop for ulnar fixation and humeral docking technique supplemented with an interference screw and the traditional Jobe technique were performed with matched gracilis allograft tendons. After kinematic testing, both reconstruction groups were tested to failure at 70° of flexion.Results: Kinematic results for the unloaded condition showed that both reconstruction techniques significantly overcorrected (less valgus angulation) the specimens between 40° and 120° of flexion when compared with the intact ligament (all P values < .027). Under loaded conditions, the ulnar trajectories for both reconstruction techniques exhibited significantly greater valgus angulation (undercorrection) at 20° of flexion (Jobe, P = .0084; ZipLoop, P = .0289) when compared with the intact ligament but were not significantly different over the remaining arc of motion. Failure testing resulted in no significant statistical difference between the 2 reconstruction groups. Failure testing demonstrated that humeral tunnel egress, midsubstance elongation, and ulnar tunnel egress of the ligament were similar between the reconstruction techniques.Conclusion: The docking technique using the ZipLoop for ulnar-sided fixation is biomechanically equivalent to the Jobe technique for UCL reconstruction. Both reconstruction techniques restore valgus stability similar to that of the native UCL ligament.Clinical Relevance: This modification in the docking technique restores elbow kinematics while eliminating the risk of ulnar bone bridge fracture, and it allows for retensioning of the graft after cortical fixation.