Publications by authors named "Dylan R Rakowski"

18 Publications

  • Page 1 of 1

Glenoid retroversion does not impact clinical outcomes or implant survivorship after total shoulder arthroplasty with minimal, noncorrective reaming.

JSES Int 2022 Jul 18;6(4):596-603. Epub 2022 Mar 18.

The Steadman Clinic, Vail, CO, USA.

Hypothesis: Both clinical outcomes and early rates of failure will not be associated with glenoid retroversion.

Methods: All patients who underwent an anatomic total shoulder arthroplasty with minimal, noncorrective reaming between 2006 and 2016 with minimum 2-year follow-up were reviewed. Measurements for retroversion, inclination, and posterior subluxation were obtained from magnetic resonance imaging or computerized tomography. A regression analysis was performed to assess the association between retroversion, inclination and subluxation, and their effect on patient reported outcomes (PROs). Clinical failures and complications were reported.

Results: One hundred fifty-one anatomic total shoulder arthroplasties (90% follow-up) with a mean follow-up of 4.6 years (range, 2-12 years) were assessed. The mean preoperative retroversion was 15.6° (range, 0.2-42.1), the mean posterior subluxation was 15.1% (range, -3.6 to 44.1%), and the mean glenoid inclination was 13.9° (range, -11.3 to 44.3). All median outcome scores improved significantly from pre- to post-operatively ( < .001). The median satisfaction was 10/10 (1st quartile = 7 and 3rd quartile = 10). Linear regression analysis found no significant association between retroversion and any postoperative PRO. A total of 5 (3.3%) failures occurred due to glenoid implant loosening (3 patients) and Cutibacterium acnes infection (2 patients) with no association between failure causation and increased retroversion or inclination. No correlation could be found between the Walch classification and postoperative PROs.

Conclusion: Anatomic total shoulder replacement with minimal and noncorrective glenoid reaming demonstrates reliable increases in patient satisfaction and clinical outcomes at a mean of 4.6-year follow-up in patients with up to 40° of native retroversion. Higher values of retroversion were not associated with early deterioration of clinical outcomes, revisions, or failures. Long-term studies are needed to see if survivorship and outcomes hold up over time.
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http://dx.doi.org/10.1016/j.jseint.2022.02.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9264025PMC
July 2022

Concomitant Glenolabral Articular Disruption (GLAD) Lesion is Not Associated With Inferior Clinical Outcomes After Arthroscopic Bankart Repair for Shoulder Instability: A Retrospective Comparative Study.

Arthrosc Sports Med Rehabil 2022 Jun 31;4(3):e1015-e1022. Epub 2022 Mar 31.

Steadman Philippon Research Institute, Vail, Colorado.

Purpose: The purpose of this study was to compare outcomes between anterior shoulder instability patients with and without glenolabral articular disruption (GLAD) lesions after undergoing arthroscopic Bankart repair and to evaluate potential risk factors for inferior outcomes and recurrent instability.

Methods: Prospectively collected data were retrospectively reviewed for patients who underwent arthroscopic Bankart repair with and without GLAD lesions at a minimum of 2 years follow-up. Consecutive patients were matched by age, sex, and number of anchors. Patient-reported outcomes (PROs) were evaluated before and after surgery, including American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Quick Disabilities of the Arm, Shoulder and Hand, Short Form-12 score, and satisfaction. Recurrent dislocation, subjective instability, and reoperation were analyzed. Additionally, PROs were assessed on the basis of GLAD lesion characteristics.

Results: A total of 54 patients (27 GLAD, 27 control) with a mean age of 28.9 ± 11.6 years were analyzed at mean 4.5 ± 1.9 years (range, 2-9 years) follow-up. Thirty-eight (70.3%) of the participants were male. Patients in both groups experienced significant improvements in all PROs ( ≤ .006 for all measures) and reported high median satisfaction (scale 1-10: 10 vs 10,  = .290) at final follow-up. Two patients in the GLAD cohort and 1 in the control cohort underwent reoperation ( = .588). Four (14.8%) patients in each group reported recurrent dislocation ( = 1.0). Additionally, 2 (7.4%) GLAD patients and 1 (3.7%) control patient reported subjective shoulder instability after surgery ( = 1.0). No significant differences in PROs were observed based on anchor/labral advancement or treatment with microfracture, nor were significant correlations observed between GLAD lesion size and PROs ( > .05 for all).

Conclusion: Arthroscopic Bankart repair in patients with GLAD lesions resulted in significantly improved outcomes with high satisfaction, which was no different when compared with those without GLAD lesions.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.asmr.2022.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9210388PMC
June 2022

Shoulder Arthroscopy in Conjunction With an Open Latarjet Procedure Can Identify Pathology That May Not Be Accounted for With Magnetic Resonance Imaging.

Arthrosc Sports Med Rehabil 2022 Apr 7;4(2):e301-e307. Epub 2021 Dec 7.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.

Purpose: To review arthroscopic findings at the time of open Latarjet procedures to determine whether preoperative magnetic resonance imaging reports (MRRs) correlate with arthroscopic findings, as well as whether the arthroscopic findings critically affected surgical interventions performed at the time of a Latarjet procedure.

Methods: This was a retrospective case series of all patients who received a Latarjet procedure between 2006 and 2018. Patients were excluded if they had inadequate records or underwent revision of a bony reconstruction procedure. Both primary Latarjet procedures and Latarjet procedures for revision of a failed arthroscopic procedure were included. MRRs, arthroscopic findings, and diagnoses were collected, and differences were noted. A "critical difference" was one that affected the surgical intervention in a significantly anatomic or procedural fashion or that affected rehabilitation.

Results: In total, 154 of 186 patients (83%) were included. Of these, 96 of 154 (62%) underwent revision Latarjet procedures. The average bone loss percentage reported was 20.6% (range, 0%-40%). A critical difference between MRR and arthroscopic findings was noted in 60 of 154 patients (39%), with no difference between Latarjet procedures and revision Latarjet procedures. Of 154 patients, 29 (19%) received an additional 52 intra-articular procedures for diagnoses not made on magnetic resonance imaging, with no difference between primary and revision procedures. This included biceps and/or SLAP pathology requiring a tenodesis, debridement, or repair; rotator cuff pathology requiring debridement or repair; complex (>180°) labral tears requiring repair; loose bodies; and chondral damage requiring debridement or microfracture. Patients undergoing revision Latarjet procedures were less likely to have bone loss mentioned or quantified in the MRR.

Conclusions: Diagnostic imaging may not reliably correlate with diagnostic arthroscopic findings at the time of a Latarjet procedure from both a bony perspective and a soft-tissue perspective. In this series, diagnostic arthroscopy affected the surgical plan in addition to the Latarjet procedure in 19% of cases. We recommend performing a diagnostic arthroscopy prior to all Latarjet procedures to identify and/or treat all associated intra-articular shoulder pathologies.

Level Of Evidence: Level IV, diagnostic case series.
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http://dx.doi.org/10.1016/j.asmr.2021.09.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9042768PMC
April 2022

Open Fixation of Displaced Greater Tuberosity Fractures Yields Similar Patient-Reported Outcomes to Acute Arthroscopic Rotator Cuff Repair at 2 Years: A Matched Cohort Analysis.

Arthrosc Sports Med Rehabil 2022 Apr 23;4(2):e687-e694. Epub 2022 Feb 23.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.

Purpose: To evaluate and compare patient-reported outcomes (PROs) after isolated greater tuberosity (GT) fracture fixation versus acute rotator cuff repair (RCR) at a minimum of 2 years.

Methods: Patients who underwent isolated GT fracture fixation were compared in a 1-to-3 fashion with patients who underwent arthroscopic RCR for an acute rotator cuff tear by a single surgeon from January 2006 and to July 2018. Data were prospectively collected and retrospectively reviewed. PROs were compared pre- and postoperatively as well as between groups (American Shoulder and Elbow Surgeons [ASES], General Health Short Form-12 Physical Component [SF-12 PCS], Single Assessment Numerical Evaluation [SANE], Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH], and satisfaction). Reoperation rates were analyzed.

Results: A total of 57 patients (14 with isolated GT fracture fixation, mean age 45.7 years; and 43 who underwent ARCR for acute tears, mean age 56.6 years) were evaluated ( = .050). ASES scores significantly improved from 39.7 to 94.1 ( = .018) in the isolated GT fracture fixation group and from 51.0 to 95.2 ( < .001) in acute RCR group. At final follow-up, mean QuickDASH scores were 8.9 and 7.9 ( = .677) and SANE scores were 91.1 and 87.3 ( = .616) for the GT and acute RCR groups, respectively. The median satisfaction was 10/10 for the GT group and 10/10 for the RCR group. Additional comparison of patients who underwent double-row repair for an acute rotator cuff tear or isolated GT fracture revealed no significant difference in outcomes ( > .404).

Conclusion: Minimum 2-year PROs after fixation of isolated GT fractures show relatively high outcome scores whether treated by open reduction and internal fixation or arthroscopic fixation using a double-row bridging technique. The improvements in PROs are similar to those achieved with acute rotator cuff tears that were fixed arthroscopically with RCR. Further analysis of these results suggest that the functional outcomes of tendon-to-bone healing with linked, double-row rotator cuff repairs are similar to those of bone-to-bone healing as seen with GT fractures.

Level Of Evidence: III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.asmr.2021.12.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9042898PMC
April 2022

Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up.

Am J Sports Med 2022 05 13;50(6):1512-1519. Epub 2022 Apr 13.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions can occur in recurrent anterior shoulder instability, which may lead to the labrum scarring medially to the glenoid. ALPSA lesions have also been associated with greater preoperative dislocations, larger Hill-Sachs lesions, and greater degrees of glenoid bone loss. Therefore, patients with these lesions have historically had a higher failure rate after repair, with nearly double the recurrent instability rate compared with those undergoing standard arthroscopic Bankart repair.

Purpose: To compare minimum 2-year outcomes of arthroscopic mobilization and anatomic repair of ALPSA lesions with those after standard arthroscopic Bankart repair.

Study Design: Cohort study; Level of evidence, 3.

Methods: Consecutive patients who underwent arthroscopic repair of ALPSA lesions were matched in a 1-to-3 fashion to patients who underwent standard Bankart repair by age, sex, number of previous ipsilateral shoulder instability surgical procedures, and number of anchors used. Patient-reported outcome (PRO) scores were compared preoperatively and postoperatively (American Shoulder and Elbow Surgeons [ASES]; 12-Item Short Form Health Survey [SF-12] Physical Component Summary [PCS]; Single Assessment Numeric Evaluation [SANE]; shortened version of Disabilities of the Arm, Shoulder and Hand; and satisfaction). Recurrent instability, on- versus off-track Hill-Sachs lesion, and reoperation rates were analyzed.

Results: A total of 100 shoulders (25 ALPSA and 75 Bankart) with an overall mean age of 25.7 years were evaluated. Patients in the ALPSA group demonstrated significant improvements in the ASES (preoperative, 74.8; postoperative, 89.7; = .041) and SF-12 PCS (preoperative, 46.9; postoperative, 53.4; = .021) scores but not the SANE score (preoperative, 65.2; postoperative, 75.3; = .311). Patients in the Bankart group had significant improvements in all outcome scores at final follow-up: ASES (preoperative, 67.1; postoperative, 90.3), SANE (preoperative, 58.0; postoperative, 85.7), and SF-12 PCS (preoperative, 45.3; postoperative, 52.9) (all < .001). There were no significant differences in PRO scores between the groups preoperatively or postoperatively ( > .05). The median satisfaction for the ALPSA group was 10 of 10 and for the Bankart group it was 9 of 10 ( = .094). There was a significantly higher rate of recurrent dislocation in the ALPSA group (8/25 [32.0%]) compared with the Bankart group (10/75 [13.3%]) ( = .040). Additionally, 5 patients (20.0%) in the ALPSA group underwent revision surgery at a mean of 5.6 years, and 8 patients (10.7%) in the Bankart group underwent revision surgery at a mean of 4.4 years ( = .311).

Conclusion: Despite improvements in the recognition of and surgical techniques for ALPSA lesions, they still lead to significantly higher postoperative dislocation rates; however, no differences in PRO scores were found. These findings highlight the importance of early surgical interventions in anterior shoulder instability with the hope of lessening recurrent instability and the risk of developing an ALPSA lesion, as well as careful assessment of the quality of soft tissues and other risk factors for recurrence when considering what type of shoulder stabilization procedure to perform.
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http://dx.doi.org/10.1177/03635465221090902DOI Listing
May 2022

Arthroscopic Axillary Nerve Neurolysis From the Anteroinferior Glenoid Through the Quadrilateral Space to the Terminal Deltoid Branches.

Arthrosc Tech 2022 Mar 8;11(3):e373-e377. Epub 2022 Feb 8.

Steadman Clinic, Vail, Colorado, U.S.A.

Axillary nerve compression is a rare cause of posterolateral shoulder pain. Once the diagnosis is confirmed and after failure of conservative measures, open procedures have been the mainstay of treatment for several decades. More recently, arthroscopic techniques have been proposed, which offer several advantages, including improved access to difficult locations, better visualization, and less surgical morbidity. The objective of this Technical Note is to describe an arthroscopic neurolysis of the axillary nerve from the inferior humeral pouch, through the quadrilateral space and into the subdeltoid recess.
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http://dx.doi.org/10.1016/j.eats.2021.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8897587PMC
March 2022

Arthroscopic Subcoracoid Decompression, Coracoplasty, and Subscapularis Repair for Subscapularis Tears in the Setting of Subcoracoid Impingement.

Arthrosc Tech 2022 Mar 11;11(3):e333-e338. Epub 2022 Feb 11.

The Steadman Clinic, Vail, Colorado, U.S.A.

Subscapularis tears have been found to occur in the setting of subcoracoid impingement and are related to the narrowing of the coracohumeral interval. The advancement of arthroscopic techniques has allowed for improved identification and treatment of this historically overlooked pathology. Challenges of arthroscopic subscapularis treatment include nearby neurovascular structures, tendon retraction, and adhesions, which are further complicated by diminished arthroscopic visualization, resulting from the concomitant subcoracoid impingement. The purpose of this Technical Note is to describe our preferred technique for arthroscopic management of subscapularis tears in the setting of subcoracoid impingement that is simple and reproducible, as well as cost-effective and efficient with limited additional morbidity to that of a standard diagnostic shoulder arthroscopy.
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http://dx.doi.org/10.1016/j.eats.2021.10.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8897572PMC
March 2022

Arthroscopic Characterization, Treatment, and Outcomes of Glenoid Labral Articular Disruption Lesions.

Am J Sports Med 2022 04 2;50(5):1328-1335. Epub 2022 Mar 2.

The Steadman Clinic, Vail, Colorado, USA.

Background: The pathoanatomy of glenoid labral articular disruption (GLAD) lesions has been inconsistently and poorly defined in the literature.

Purpose/hypothesis: The purpose was to characterize GLAD lesions as they pertain to the pathoanatomy of labrum, cartilage, and bony structures, and to correlate findings with patient-reported outcomes (PROs). We hypothesized that greater degrees of bony and cartilaginous involvement would correlate with worse outcomes.

Study Design: Case series; Level of evidence, 4.

Methods: All patients with a diagnosis of a GLAD lesion or a reverse GLAD (RGLAD) lesion at the time of diagnostic arthroscopy (January 2006-February 2019) were included in this study. Patients with ≥13.5% bone loss or previous ipsilateral shoulder surgery were excluded. Patient charts and operative reports/photos were used to identify the location of injury, extent of injury (labral, chondral, and bony), associated injuries, demographic factors, and treatment performed. Three injury patterns were identified: (type 1), with no chondral defect after labral repair; (type 2), with residual chondral defect after labral repair; and (type 3), with associated glenoid bone loss amenable to labral repair. Characterizations were cross-referenced to PROs at a mean follow-up of 5.5 years (range, 2.6-10.5 years): American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, shortened version of Disabilities of the Arm, Shoulder and Hand, and patient satisfaction.

Results: In total, 50 patients were included, with 40 having GLAD and 10 having RGLAD lesions (mean age, 34.7 and 33.2 years, respectively). There were 14 (35%) type 1, 22 (55%) type 2, and 4 (10%) type 3 GLAD injuries. All PROs improved without any differences in the 3 subgroups postoperatively (ASES, 95.1 vs 91.3 vs 98.8, type 1, 2, and 3, respectively). RGLAD injuries were majority type 2 (7/10; 70%) with the remainder being type 1 (3/10; 30%).

Conclusion: With GLAD and RGLAD injuries, 3 distinct injury patterns can be observed correlating with the presence/absence of chondral loss after labral repair or the presence of associated bone loss. This descriptive characterization can facilitate arthroscopic treatment decisions. Future large studies are needed to determine if this is prognostic in nature.
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http://dx.doi.org/10.1177/03635465221076854DOI Listing
April 2022

High rate of return to sport and excellent patient-reported outcomes after an open Latarjet procedure.

J Shoulder Elbow Surg 2022 Aug 18;31(8):1704-1712. Epub 2022 Feb 18.

Steadman Philippon Research Institute, Vail, CO, USA; The Steadman Clinic, Vail, CO, USA. Electronic address:

Hypothesis: The purpose of this study was to report return to sport, patient-reported outcomes (PROs), subjective outcomes, and complications or failures in patients who underwent open Latarjet surgery.

Methods: Patients who underwent open Latarjet surgery performed by 2 fellowship-trained surgeons between August 2006 and November 2018 were included. Prospectively collected data were reviewed. Recurrent instability and revision surgical procedures were recorded. Subjective outcomes included return to sport and fear of reinjury or activity modification as a result of patients' instability history. PROs included the American Shoulder and Elbow Surgeons (ASES) score, Short Form 12 Physical Component Summary score, Single Assessment Numeric Evaluation score, Quick Disabilities of the Arm, Shoulder and Hand score, and satisfaction. Age, sex, sports participation, pain, primary vs. revision surgery (prior failed arthroscopic or open Bankart repair), dislocation number, glenoid bone loss, glenoid track concept, and projected glenoid track were evaluated. Failure was defined as an ASES score <70, recurrent dislocation, or revision instability surgery.

Results: A total of 126 shoulders (125 patients) met the inclusion criteria, with a mean age of 28.1 years (range, 15-57 years). Of 126 shoulders, 7 (5.5%) underwent additional procedures prior to final follow-up and were excluded from outcome analyses; failure occurred in 6 of these shoulders. Mean follow-up data at 3.7 years (range, 2-9.3 years) were attained in 86.6% of patients (103 of 119). All PROs significantly improved from preoperative baseline (ASES score, from 69.7 to 90.2; Single Assessment Numeric Evaluation score, from 55.8 to 85.9; and Quick Disabilities of the Arm, Shoulder and Hand score, from 28.4 to 10.5). PROs did not differ based on sex, sports participation type, dislocation with or without sports, primary vs. revision procedure, and preoperative dislocation number. No correlations existed between PROs and age, glenoid bone loss, or number of previous surgical procedures. On-track lesions (50 of 105, 47.6%) and projected on-track lesions (90 of 105, 85.7%) correlated with better patient satisfaction but not PROs. Despite not having recurrences, 63 of 99 patients (63.6%) reported activity modifications and 44 of 99 patients (44.4%) feared reinjury. These groups had statistically worse PROs, although the minimal clinically important difference was not met. Return to sport was reported by 97% of patients (86 of 89), with 74% (66 of 89) returning at the same level or slightly below the preinjury level. Revision stabilization surgery was required 6 of 126 cases (4.8%), and 6 of 103 shoulders (5.8%) had ASES scores <70.

Conclusion: The open Latarjet procedure led to significant improvements in all PROs, and overall, 97% of patients returned to sport. Fear of reinjury and activity modifications were common after open Latarjet procedures but did not appear to affect clinical outcomes. On-track and projected on-track measurements correlated with better patient satisfaction but not improved PROs.
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http://dx.doi.org/10.1016/j.jse.2022.01.139DOI Listing
August 2022

The Evolution of Arthroscopic Rotator Cuff Repair.

Orthop J Sports Med 2021 Dec 6;9(12):23259671211050899. Epub 2021 Dec 6.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Over the past 30 years, arthroscopic rotator cuff repair (ARCR) has evolved to become the gold standard in treating rotator cuff pathology. As procedural concepts of ARCR continue to improve, it is also continually compared with the open rotator cuff repair as the historical standard of care. This review highlights the evolution of ARCR, including a historical perspective; the anatomic, clinical, and surgical implications of the development of an arthroscopic approach; how arthroscopy improved some of the problems of the open approach; adaptations in techniques and technologies associated with ARCR; future perspectives in orthobiologics as they pertain to ARCR; and lastly, the clinical improvements, or lack of improvements, with all of these adaptations.
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http://dx.doi.org/10.1177/23259671211050899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8652190PMC
December 2021

Combined Arthroscopic Superior and Anterior Capsular Reconstruction of the Glenohumeral Joint: A Case Report.

JBJS Case Connect 2021 08 4;11(3). Epub 2021 Aug 4.

Steadman Philippon Research Institute, Vail, Colorado.

Case: A 57-year-old male automobile mechanic presented with 1 year of atraumatic, bilateral shoulder pain and progressive loss of motion. Three months of physical therapy and nonsteroidal anti-inflammatory medications did not offer pain relief or increase his motion. He opted for right-sided dermal allograft superior capsular reconstruction (SCR) and anterior capsular reconstruction (ACR) with subsequent left-sided SCR and subscapularis repair 3 months later.

Conclusion: At the 18 months follow-up, combined SCR/ACR was effective in restoring motion and relieving pain. Although promising, additional studies are needed to determine the efficacy of this combined procedure.
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http://dx.doi.org/10.2106/JBJS.CC.20.00943DOI Listing
August 2021

Results of arthroscopic rotator cuff repair for calcific tendonitis: a comparative analysis.

J Shoulder Elbow Surg 2022 Mar 1;31(3):616-622. Epub 2021 Sep 1.

Steadman Philippon Research Institute, Vail, CO, USA; The Steadman Clinic, Vail, CO, USA. Electronic address:

Background: Outcomes following arthroscopic excision of calcific tendonitis and arthroscopic rotator cuff repair (CT-ARCR) are relatively limited without comparison analysis to standard arthroscopic rotator cuff repair (ARCR). The purpose of this study was to evaluate patient-reported outcomes (PROs) after CT-ARCR compared against a matched cohort who received standard ARCR.

Methods: An institutional review board-approved retrospective review was performed for patients aged 18-80 years receiving CT-ARCR by a single surgeon from 2006-2018. These were matched 1:3 with patients receiving ARCR. Patients with concurrent labral repair, subscapularis repair, or glenohumeral joint arthritis procedures; refusal to participate; deceased; inadequate contact information; or those with inadequate records were excluded. PROs included Short Form-12 Physical Component Summary (SF-12 PCS) score; American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES); Single Assessment Numeric Evaluation (SANE); Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH); patient satisfaction; activity level/symptoms; and sport participation scores.

Results: 21 CT-ARCR patients (mean age 50 years, range 36-62) and 54 ARCR patients (mean age 52 years, range 19-77) were included. Minimum 2-year follow-up was obtained in 18 of 21 (86%) CT-ARCR (mean 5.9 years) and 45 of 54 (83%) ARCR patients (mean 5.6 years). CT-ARCR patients improved pre- to postoperation in mean SF-12 PCS (41.1 to 50.0), ASES (54.2 to 94.0), and QuickDASH (54.2 to 94.0). SANE score improvements (57.6 to 82.8) were not significant. ARCR controls improved pre- to postoperation in mean SF-12 PCS (41.4 to 49.0), ASES (59.4 to 88.0), QuickDASH (35.1 to 13.8), and SANE scores (52.6 to 80.8). Pre- to postoperative pain during recreation and sport participation similarly improved in both groups. The only postoperative difference observed between CT-ARCR and ARCR was better patient satisfaction with CT-ARCR (9.7 vs. 8.3).

Conclusion: CT-ARCR results in excellent PROs, activity symptoms, and sports participation at final follow-up. CT-ARCR results were comparable to patients who received conventional ARCR for similar-sized rotator cuff tears that did not have calcific tendonitis.
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http://dx.doi.org/10.1016/j.jse.2021.08.007DOI Listing
March 2022

Single-Stage Anterior Cruciate Ligament Revision Reconstruction Using an Allograft Bone Dowel for a Malpositioned and Widened Femoral Tunnel.

Arthrosc Tech 2021 Jul 20;10(7):e1793-e1797. Epub 2021 Jun 20.

Steadman Clinic, Vail, Colorado, U.S.A.

Tunnel widening, osteolysis, and/or malposition can be a cause of anterior cruciate ligament (ACL) reconstruction failure and a challenging problem to treat when performing revision ACL reconstruction (RACLR). Traditionally, problematic tunnels that interfere with bony stability and incorporation of the new graft at the time of revision have been treated with staged procedures-bone grafting first, followed by a return several months later for the revision reconstruction after bony incorporation has occurred. Multiple staged procedures increase the level of risk the patient may encounter and increase cost and resource utilization. In addition, they prolong the recovery period for the patient. In recent years, several studies have evaluated the clinical outcomes of performing bone grafting of tunnels and concomitant RACLR in a single-stage setting in an effort to mitigate these issues. We describe a technique by which a malpositioned and widened femoral tunnel from a primary ACL failure is treated with bone grafting using an allograft dowel, as well as immediate RACLR using a bone-patellar tendon-bone allograft.
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http://dx.doi.org/10.1016/j.eats.2021.03.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8322569PMC
July 2021

Consensus statement on the treatment of massive irreparable rotator cuff tears: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons.

J Shoulder Elbow Surg 2021 Sep 9;30(9):1977-1989. Epub 2021 Jun 9.

Department of Orthopedic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA.

Background: Management of massive irreparable rotator cuff tears (MIRCTs) remains controversial owing to variability in patient features and outcomes contributing to a lack of unanimity in treatment recommendations. The purpose of this study was to implement the Delphi process using experts from the Neer Circle of the American Shoulder and Elbow Surgeons to determine areas of consensus regarding treatment options for a variety of MIRCTs.

Methods: A panel of 120 shoulder surgeons were sent a survey regarding MIRCT treatments including arthroscopic débridement and partial cuff repair, graft augmentation, reverse shoulder arthroplasty (RSA), superior capsular reconstruction (SCR), and tendon transfer. An iterative Delphi process was then conducted with a first-round questionnaire consisting of 13 patient factors with the option for open-ended responses to identify important features influencing the treatment of MIRCTs. The second-round survey sought to determine the importance of patient factors related to the 6 included treatment options. A third-round survey asked participants to classify treatment options for 60 MIRCT patient scenarios as either preferred treatment, acceptable treatment, not acceptable/contraindicated, or unsure/no opinion. Patient scenarios were declared to achieve consensus for the preferred and not acceptable/contraindicated categories when at least 80% of the survey respondents agreed on a response, and a 90% threshold was required for the acceptable treatment category, defined by an acceptable treatment or preferred treatment response.

Results: Seventy-two members agreed to participate and were deemed to have the requisite expertise to contribute based on their survey responses regarding clinical practice and patient volume. There were 20 clinical scenarios that reached 90% consensus as an acceptable treatment, with RSA selected for 18 scenarios and arthroscopic débridement and/or partial repair selected for 2. RSA was selected as the singular preferred treatment option in 8 scenarios. Not acceptable/contraindicated treatment options reached consensus in 8 scenarios, of which, 4 related to SCR, 3 related to RSA, and 1 related to partial repair with graft augmentation.

Conclusion: This Delphi process exhibited significant consensus regarding RSA as a preferred treatment strategy in older patients with pseudoparesis, an irreparable subscapularis, and dynamic instability. In addition, the process identified certain unacceptable treatments for MIRCTs such as SCR in older patients with pseudoparesis and an irreparable subscapularis or RSA in young patients with an intact or reparable subscapularis without pseudoparesis or dynamic instability. The publication of these scenarios and areas of consensus may serve as a useful guide for practitioners in the management of MIRCTs.
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http://dx.doi.org/10.1016/j.jse.2021.05.012DOI Listing
September 2021

Minimum 10-Year Outcomes of Primary Arthroscopic Transosseous-Equivalent Double-Row Rotator Cuff Repair.

Am J Sports Med 2021 07 8;49(8):2035-2041. Epub 2021 Jun 8.

The Steadman Clinic, Vail, Colorado, USA.

Background: Modern rotator cuff repair techniques demonstrate favorable early and midterm outcomes, but long-term results have yet to be reported.

Purpose: To determine 10-year outcomes and survivorship after arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair.

Study Design: Case series; Level of evidence 4.

Methods: The primary TOE rotator cuff repair procedure was performed using either a knotted suture bridge or knotless tape bridge technique on a series of patients with 1 to 3 tendon full-thickness rotator cuff tears involving the supraspinatus. Only patients who were 10 years postsurgery were included. Patient-reported outcomes were collected pre- and postoperatively, including American Shoulder and Elbow Surgeons (ASES), 12-Item Short Form Health Survey (SF-12), Single Assessment Numeric Evaluation (SANE), shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and satisfaction. Kaplan-Meier survivorship analysis was performed. Failure was defined as progression to revision surgery.

Results: A total of 91 shoulders (56 men, 31 women) were included between October 2005 and December 2009. Mean follow-up was 11.5 years (range, 10.0-14.1 years). Of 91 shoulders, 5 (5.5%) failed and required revision surgery. Patient-reported outcomes for patients who survived were known for 80% (69/86). Outcomes scores at final follow-up were as follows: ASES, 93.1 ± 10.8; SANE, 87.5 ± 14.2; QuickDASH, 11.1 ± 13.5; and SF-12 physical component summary (PCS), 49.2 ± 10.1. There were statistically significant declines in ASES, SANE, and SF-12 PCS from the 5-year to 10-year follow-up, but none of these changes met the minimally clinically important difference threshold. Median satisfaction at final follow-up was 10 (range, 3-10). From this cohort, Kaplan-Meier survivorship demonstrated a 94.4% survival rate at a minimum of 10 years.

Conclusion: Arthroscopic TOE rotator cuff repair demonstrates high patient satisfaction and low revision rates at a mean follow-up of 11.5 years. This information may be directly utilized in surgical decision making and preoperative patient counseling regarding the longevity of modern double-row rotator cuff repair.
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http://dx.doi.org/10.1177/03635465211015419DOI Listing
July 2021

Comprehensive Arthroscopic Management for Severe Glenohumeral Arthritis in an Ultimate Fighting Championship Fighter: A Case Report.

JBJS Case Connect 2021 04 29;11(2). Epub 2021 Apr 29.

Steadman Philippon Research Institute, Vail, Colorado.

Case: A 41-year-old, former world-champion, mixed martial arts fighter presented with debilitating pain and loss of motion because of severe glenohumeral osteoarthritis (GHOA) in the setting of a previous shoulder instability stabilization procedure. Multiple conservative treatments failed to provide permanent relief, and he elected to undergo a comprehensive arthroscopic management (CAM) procedure for his GHOA.

Conclusion: At 2-year follow-up, the CAM procedure was effective in returning them to fighting at a professional level. The CAM procedure can be considered in young and highly active patients to restore function, preserve anatomy, and delay progression to prosthetic arthroplasty.
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http://dx.doi.org/10.2106/JBJS.CC.20.00833DOI Listing
April 2021

A transient dopamine signal encodes subjective value and causally influences demand in an economic context.

Proc Natl Acad Sci U S A 2017 12 6;114(52):E11303-E11312. Epub 2017 Nov 6.

Psychology Department, University of Colorado Denver, Denver, CO 80217

The mesolimbic dopamine system is strongly implicated in motivational processes. Currently accepted theories suggest that transient mesolimbic dopamine release events energize reward seeking and encode reward value. During the pursuit of reward, critical associations are formed between the reward and cues that predict its availability. Conditioned by these experiences, dopamine neurons begin to fire upon the earliest presentation of a cue, and again at the receipt of reward. The resulting dopamine concentration scales proportionally to the value of the reward. In this study, we used a behavioral economics approach to quantify how transient dopamine release events scale with price and causally alter price sensitivity. We presented sucrose to rats across a range of prices and modeled the resulting demand curves to estimate price sensitivity. Using fast-scan cyclic voltammetry, we determined that the concentration of accumbal dopamine time-locked to cue presentation decreased with price. These data confirm and extend the notion that dopamine release events originating in the ventral tegmental area encode subjective value. Using optogenetics to augment dopamine concentration, we found that enhancing dopamine release at cue made demand more sensitive to price and decreased dopamine concentration at reward delivery. From these observations, we infer that value is decreased because of a negative reward prediction error (i.e., the animal receives less than expected). Conversely, enhancing dopamine at reward made demand less sensitive to price. We attribute this finding to a positive reward prediction error, whereby the animal perceives they received a better value than anticipated.
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http://dx.doi.org/10.1073/pnas.1706969114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5748169PMC
December 2017

Diazepam Concurrently Increases the Frequency and Decreases the Amplitude of Transient Dopamine Release Events in the Nucleus Accumbens.

J Pharmacol Exp Ther 2018 01 20;364(1):145-155. Epub 2017 Oct 20.

University of Colorado Denver, Department of Psychology, Denver, Colorado (S.A.S., D.R.R., K.J.P., A.T.S., E.B.O.) and Drexel University College of Medicine, Department of Neurobiology and Anatomy, Philadelphia, Pennsylvania (Z.D.R., R.A.E.)

Benzodiazepines are commonly prescribed anxiolytics that pose abuse liability in susceptible individuals. Although it is well established that all drugs of abuse increase brain dopamine levels, and benzodiazepines are allosteric modulators of the GABA receptor, it remains unclear how they alter dopamine release. Using in vivo fast-scan cyclic voltammetry, we measured diazepam-induced changes in the frequency and amplitude of transient dopamine release events. We found that diazepam concurrently increases the frequency and decreases the amplitude of transient dopamine release events in the awake and freely moving rat. The time course during which diazepam altered the frequency and amplitude of dopamine release events diverged, with the decreased amplitude effect being shorter lived than the increase in frequency, but both showing similar rates of onset. We conclude that diazepam increases the frequency of accumbal dopamine release events by disinhibiting dopamine neurons, but also decreases their amplitude. We speculate that the modest abuse liability of benzodiazepines is due to their ability to decrease the amplitude of dopamine release events in addition to increasing their frequency.
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http://dx.doi.org/10.1124/jpet.117.241802DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741045PMC
January 2018
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