Publications by authors named "Peter J Millett"

294 Publications

Arthroscopic Treatment of Snapping Scapula Syndrome With Scapulothoracic Bursectomy and Partial Scapulectomy.

Arthrosc Tech 2022 Jul 14;11(7):e1175-e1180. Epub 2022 Jun 14.

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

Snapping scapula syndrome (SSS) is a painful and debilitating condition that occurs as a result of disruption of normal scapulothoracic articulation and inflammation of numerous soft tissue and bursal structures that function to facilitate scapulothoracic motion. Historically, when nonoperative management of SSS failed, patients progressed to open surgical management. However, as arthroscopic techniques have evolved, the condition has been increasingly treated arthroscopically because of the minimally invasive nature, periscapular muscle-preserving approach with decreased risk to surrounding neurovascular structures, better intraoperative visualization, and quicker patient recovery and rehabilitation. The objective of this Technical Note is to describe our arthroscopic approach for the management of SSS using two portals to complete a scapulothoracic bursectomy and partial scapulectomy of the superomedial scapula. Level of Evidence: Level I: shoulder.
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http://dx.doi.org/10.1016/j.eats.2022.02.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9353079PMC
July 2022

Current State of Platelet-Rich Plasma and Cell-Based Therapies for the Treatment of Osteoarthritis and Tendon and Ligament Injuries.

J Bone Joint Surg Am 2022 08 24;104(15):1406-1414. Epub 2022 Mar 24.

Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado.

: Orthobiologics encompass numerous substances that are naturally found in the human body including platelet-rich plasma (PRP), isolated growth factors, and cell therapy approaches to theoretically optimize and improve the healing of cartilage, fractures, and injured muscles, tendons, and ligaments.

: PRP is an autologous derivative of whole blood generated by centrifugation and is perhaps the most widely used orthobiologic treatment modality. Despite a vast amount of literature on its use in osteoarthritis as well as in tendon and ligament pathology, clinical efficacy results remain mixed, partly as a result of insufficient reporting of experimental details or exact compositions of PRP formulations used.

: Mesenchymal stromal cells (MSCs) can be isolated from a variety of tissues, with the most common being bone marrow aspirate concentrate. Similar to PRP, clinical results in orthopaedics with MSCs have been highly variable, with the quality and concentration of MSCs being highly contingent on the site of procurement and the techniques of harvesting and preparation.

: Advances in novel orthobiologics, therapeutic targets, and customized orthobiologic therapy will undoubtedly continue to burgeon, with some early promising results from studies targeting fibrosis and senescence.
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http://dx.doi.org/10.2106/JBJS.21.01112DOI Listing
August 2022

The recovery curve of anatomic total shoulder arthroplasty for primary glenohumeral osteoarthritis: midterm results at a minimum of 5 years.

JSES Int 2022 Jul 13;6(4):587-595. Epub 2022 May 13.

Steadman Philippon Research Institute, Vail, CO, USA.

Background: Excellent results have been reported for anatomic total shoulder arthroplasty (TSA) for the treatment of primary glenohumeral osteoarthritis (GHOA). We aim to assess the recovery curve and longitudinal effects of time, age, sex, and glenoid morphology on patient-reported outcomes (PROs) after primary anatomic TSA for primary GHOA.

Methods: Patients who underwent primary anatomic TSA over 5 years ago were included: Short-Form 12 Physical Component Summary, American Shoulder and Elbow Surgeons scores, Quick Disabilities of the Arm Shoulder and Hand Score, Single Assessment Numeric Evaluation, and patient satisfaction were assessed. Linear mixed-effects models were used to model progression in PROs longitudinally. Unadjusted models and models controlling for sex and age were constructed.

Results: Eighty-one patients (91 shoulders) were included. Significant improvements from the preoperative period to 1 year postoperatively in the median American Shoulder and Elbow Surgeons (48 to 93;  < .001), Quick Disabilities of the Arm Shoulder and Hand Score (42 to 11;  < .001), Single Assessment Numeric Evaluation (50 to 91;  < .001), and Short-Form 12 Physical Component Summary (35 to 53;  = .004) scores were noted. No significant decrease was observed for any of the outcome scores. Median satisfaction at the final follow-up was 10 out of 10. At 1, 2, 3, 4, 5, 6, and 7 years postoperatively, 77%, 64%, 79%, 57%, 86%, 56%, and 78% of patients, respectively, reported sports participation equal to or slightly below preinjury level. There was no association between the glenoid morphology and functional outcomes.

Conclusion: Patients undergoing anatomic TSA for primary GHOA showed excellent improvement in PROs and satisfaction in the first year, and these results were maintained postoperatively for a minimum of 5 years. Age- and sex-adjusted models or glenoid morphology did not substantially alter any trends in PROs postoperatively.
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http://dx.doi.org/10.1016/j.jseint.2022.04.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9264145PMC
July 2022

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

SLAP Repair Versus Subpectoral Biceps Tenodesis for Isolated SLAP Type 2 Lesions in Overhead Athletes Younger Than 35 Years: Comparison of Minimum 2-Year Outcomes.

Orthop J Sports Med 2022 Jun 21;10(6):23259671221105239. Epub 2022 Jun 21.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: It remains unclear if young overhead athletes with isolated superior labrum anterior-posterior (SLAP) type 2 lesions benefit more from SLAP repair or subpectoral biceps tenodesis.

Purpose: To evaluate clinical outcomes and return to sport in overhead athletes with symptomatic SLAP type 2 lesions who underwent either biceps tenodesis or SLAP repair.

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

Methods: A retrospective analysis of prospectively collected data was performed in patients who underwent subpectoral biceps tenodesis (n = 14) or SLAP repair (n = 24) for the treatment of isolated type 2 SLAP lesions. All patients were aged <35 years at time of surgery, participated in overhead sports, and were at least 2 years out from surgery. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numerical Evaluation (SANE) score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; and the 12-Item Short Form (SF-12) physical component score. Return to sport and patient satisfaction were documented. Clinical failures requiring revision surgery and complications were reported.

Results: Preoperative baseline scores in both the tenodesis and SLAP repair groups were similar. There were no significant differences between the groups on any postoperative outcome measure: For biceps tenodesis versus SLAP repair, the ASES score was 92.7 ± 10.4 versus 89.1 ± 16.7, the SANE score was 86.2 ± 13.7 versus 83.0 ± 24.1, the QuickDASH score was 10.0 ± 12.7 versus 9.0 ± 14.3, and SF-12 was 51.2 ± 7.5 versus 52.8 ± 7.7. No group difference in return-to-sports rate (85% vs 79%; = .640) was noted. More patients in the tenodesis group (80%) reported modifying their sporting/recreational activity postoperatively because of weakness compared with patients in the SLAP repair group (15%; = .022). One patient in each group progressed to surgery for persistent postoperative stiffness, and 1 patient in the tenodesis group had a postoperative complication related to the index surgery.

Conclusion: Both subpectoral biceps tenodesis and SLAP repair provided excellent clinical results for the treatment of isolated SLAP type 2 lesions, with a high rate of return to overhead sports and a low failure rate, in a young and high-demanding patient cohort. More patients reported modifying their sporting/recreational activity because of weakness after subpectoral tenodesis.
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http://dx.doi.org/10.1177/23259671221105239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9218463PMC
June 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

Anatomic safe zones for arthroscopic snapping scapula surgery: quantitative anatomy of the superomedial scapula and associated neurovascular structures and the effects of arm positioning on safety.

J Shoulder Elbow Surg 2022 May 9. Epub 2022 May 9.

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

Background: Neurovascular anatomy has not been previously quantified for the arthroscopic snapping scapula approach with the patient in the most frequent patient position ("chicken-wing" position). The purposes of this study were (1) to determine anatomic relationships of the superomedial scapula and neurovascular structures at risk during arthroscopic surgical treatment of snapping scapula syndrome (SSS), (2) to compare these measurements between the arm in the neutral position and the arm in the chicken-wing position, and (3) to establish safe zones for arthroscopic treatment of SSS.

Methods: Eight fresh-frozen cadaveric hemi-torsos (mean age, 55.8 years; range, 52-66 years) were dissected to ascertain relevant anatomic structure locations including the (1) spinal accessory nerve, (2) dorsal scapular nerve, and (3) suprascapular nerve. A coordinate measuring device was used to collect data on the relationships of anatomic landmarks and at-risk structures during the surgical approach.

Results: The dorsal scapular nerve was a mean of 24.4 mm medial to the superomedial scapula in the neutral position and 33.1 mm medial in the chicken-wing position (P < .001); the dorsal scapular nerve was 21.7 mm medial to the medial border of the scapular spine in the neutral position and 35.5 mm medial in the chicken-wing position (P < .001). The mean distance from the superomedial angle to the spinal accessory nerve intersection at the superior scapular border was 16.5 mm in the neutral position and 15.0 mm in the chicken-wing position (P = .031). The average distance from the superomedial angle to the closest point of the spinal accessory nerve was 11.6 mm and 10.4 mm in the neutral position and chicken-wing position, respectively (P = .039).

Conclusion: Neurologic structures around the scapula vary significantly between the neutral arm position and the chicken-wing position commonly used in the arthroscopic treatment of SSS. The chicken-wing position improves safe distances for the dorsal scapular nerve during medial-portal placement and should be considered as a primary position for arthroscopic management of SSS.
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http://dx.doi.org/10.1016/j.jse.2022.03.029DOI Listing
May 2022

Sternoclavicular Joint Instability and Reconstruction.

J Am Acad Orthop Surg 2022 May 2. Epub 2022 May 2.

From the Steadman Philippon Research Institute, Vail, CO (Provencher, Bernholt, Peebles, and Millett), and The Steadman Clinic, Vail, CO (Provencher and Millett).

Chronic instability or degenerative arthritis of the sternoclavicular (SC) joint may occur after traumatic or spontaneous dislocation of the SC joint. Most commonly, chronic instability of the SC joint occurs anteriorly; however, posterior instability has an increased risk of serious complications because of proximity to mediastinal structures. Although chronic anterior instability of the SC joint does not resolve with nonsurgical treatment, patients often have mild symptoms that do not impair activities of daily living; however, chronic anterior SC joint instability may be functionally limiting in more active individuals. In these cases, surgical treatment with either (1) SC joint reconstruction or (2) medial clavicle resection, or both, can be done. Recurrent posterior instability of the SC joint also requires surgical treatment due to risk of injury to mediastinal structures. Recent literature describes various reconstruction techniques which generally show improved patient-reported outcomes and low complication rates.
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http://dx.doi.org/10.5435/JAAOS-D-19-00611DOI Listing
May 2022

Editorial Commentary: Shoulder Superior Capsular Reconstruction Graft Tensioning Between 30° and 40° of Glenohumeral Abduction Is Recommended: The Balance Beam of Superior Capsular Reconstruction.

Arthroscopy 2022 05;38(5):1408-1410

Vail, Colorado.

Massive irreparable rotator cuff tears in young, active patients pose a challenging treatment dilemma. Since the relatively recent development of the superior capsular reconstruction (SCR) procedure, the technique has been increasingly used to stave off reverse total shoulder arthroplasty in this demographic. As a result of continued output of supportive literature, both biomechanically and clinically, SCR has been adopted by surgeons despite some technical aspects of the procedure not being fully elucidated. One notable topic of study is the ideal glenohumeral position in which to determine graft length and therefore graft tension. Tensioning inevitably affects glenohumeral joint kinematics, including superior humeral head translation, subacromial contact pressure, and graft healing potential. Although it is currently known that some degree of glenohumeral abduction is necessary for appropriate graft tensioning, and there are some biomechanical studies from our group and other groups that have looked at this, there is not a clinically supported position in which to measure graft length and therefore set graft tension. Well-designed biomechanical studies will serve as the foundation for what is performed clinically. On the basis of the best available evidence, tensioning the graft between 30° and 40° of glenohumeral abduction is recommended and has yielded encouraging clinical outcomes for SCR in our patients.
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http://dx.doi.org/10.1016/j.arthro.2021.12.022DOI Listing
May 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

Comprehensive Arthroscopic Management of Shoulder Arthritis.

Arthroscopy 2022 04;38(4):1035-1036

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

Glenohumeral arthritis is a challenging problem, especially in the young, active patient. After nonoperative treatment, including activity modification, anti-inflammatory medications, physical therapy, and injections, is exhausted, surgical treatment ranging from simple debridement to arthroplasty is commonly offered. Given concerns regarding arthroplasty implant longevity, there is an interest in joint-preserving procedures. In this difficult population, the authors recommend a systematic, inclusive approach to the array of pathologies encountered in the setting of early glenohumeral arthritis: the Comprehensive Arthroscopic Management (CAM) procedure. CAM consists of the combination of arthroscopy, glenohumeral chondroplasty, synovectomy, loose body removal, microfracture, capsular release, humeral osteoplasty, axillary nerve neurolysis, subacromial decompression, and biceps tenodesis. Key perioperative care includes the use of regional nerve blocks to allow immediate physical therapy with the goal of restoring range of motion by 4 to 6 weeks with strengthening beginning at 6 to 12 weeks and return to full activities at 4 to 6 months. Although this is still considered a bridging procedure, the literature has reported 92% survival at 1 year, 85% survival at 2 years, 77% survival at 5 years, and 63% survival at 10 years. Predictors of failure of the CAM procedure include joint space <2 mm, flattening of the humeral head, and abnormal posterior glenoid morphology. Patient selection and education is therefore essential for optimizing outcomes.
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http://dx.doi.org/10.1016/j.arthro.2022.01.033DOI Listing
April 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

Editorial Commentary: Current Indications for Lateral Acromioplasty Include Patients With Elevated Critical Shoulder Angle Plus Subacromial Impingement With Rotator Cuff Pathology or Previous Rotator Cuff Repair.

Arthroscopy 2022 03;38(3):716-718

Vail, Colorado.

The critical shoulder angle (CSA) reflects the lateral extent of the acromion and the inclination of the glenoid. In 2013, CSA was first introduced and its association with rotator cuff (RC) tears and glenohumeral osteoarthritis (GHOA) was shown. It was speculated that with a high CSA, there was an increased superior force vector from the deltoid and that this superior force led to RC tears. Conversely, when the CSA was low, there was a greater compressive force from the deltoid and that this compressive force led to GHOA. CSA serves as a further development of 2 previously reported measurements (glenoid inclination and acromial index). A key potential therapeutic aspect of the CSA is the ability to modify it surgically, which theoretically could protect RC repairs or prevent progression. In our current clinical practice, we perform lateral acromioplasty (LA) in patients undergoing treatment of subacromial impingement with an "at-risk" rotator cuff (partial rotator cuff tear and severe tendinopathy on magnetic resonance imaging) with a CSA > 38° or all patients with a CSA >35° after an RC repair to protect the RC repair construct. The relationships of high and low CSA, the anatomic safe zone, and thus clinical applicability of LA are well established and performed in our daily surgical practice. However, we do not yet have widespread clear clinical evidence on potential benefits regarding the clinical outcome after LA. Finally, at this time, the downsides seem minimal, so we continue to use LA as an adjunct in patients with RC tears and RC tendons that are at risk.
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http://dx.doi.org/10.1016/j.arthro.2021.11.002DOI Listing
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

Evaluation and Management of the Contact Athlete's Shoulder.

J Am Acad Orthop Surg 2022 Mar;30(6):e584-e594

From the Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA (Arner and Bradley), and The Steadman Clinic and Steadman Philippon Research Institute, Vail, CO (Provencher and Millett).

Shoulder injuries are common in contact athletes and vary in severity because of the required complex interplay of shoulder stability and range of motion for proper function. Pathology varies based on sport but most commonly includes shoulder instability, acromioclavicular injuries, traumatic rotator cuff tears, and brachial plexus injuries. Acute management ranges from reduction of shoulder dislocations to physical examination to determine the severity of injury. Appropriate radiographs should be obtained to evaluate for alignment and fracture, with magnetic resonance imaging commonly being necessary for accurate diagnosis and management. Treatments range from surgical stabilization in shoulder instability to repeat examinations and physical therapy. Return-to-play decision making can be complex with avoidance of reinjury and player safety being of utmost concern. Appropriate evaluation and treatment are vital because repeat injury can lead to long-term effects due to the relatively high effectsometimes seen in contact sports.
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http://dx.doi.org/10.5435/JAAOS-D-20-01374DOI Listing
March 2022

Concomitant Biceps Tenodesis Improves Outcomes for SLAP Repair: Minimum 2-Year Clinical Outcomes after SLAP II-IV Repair Versus Tenodesis Versus Both.

Arthrosc Sports Med Rehabil 2021 Dec 23;3(6):e2007-e2014. Epub 2021 Nov 23.

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

Purpose: To investigate clinical outcomes, return to sport, and complication rate in patients with an isolated SLAP II-IV tear treated with biceps tenodesis (BT), SLAP-repair (SLAP-R), or both (SLAP-R+BT).

Methods: A retrospective analysis of prospectively collected data was performed in patients who underwent surgery between February 2006 and February 2018 for isolated SLAP II-IV lesions with either BT, SLAP-R, or SLAP-R+BT and had minimum 2-year follow-up. Patients were excluded if they were older than 45 years of age, had anterior shoulder instability, rotator cuff tears, glenohumeral osteoarthritis, or concomitant fractures about the shoulder. Clinical outcomes were assessed by the use of the American Shoulder and Elbow Society Score, Single Assessment Numerical Evaluation Score, Quick Disabilities of the Arm, and Shoulder and Hand Score, the General Health Short Form-12 Physical Component, and patient satisfaction.

Results: There were 38 shoulders in the isolated BT group with 1 (2.6%) shoulder requiring revision, 13 in the SLAP-R group with no patient requiring revision, and 21 in the SLAP-R+BT group with 2 (9.5%) shoulders requiring revision. Minimum 2-year follow-up was obtained in >85% of each group. Mean age at time of surgery was significantly different between the groups (36.5 years BT vs 27.7 years SLAP-R vs 36.5 years SLAP-R+BT;  = .003). While patient-reported outcomes improved significantly from pre- to postoperatively for the BT ( < .001) and SLAP-R+BT groups ( < .001), they did not significantly improve for the isolated SLAP-R group ( values ranging .635 to .123). The BT and SLAP-R+BT groups showed significant improvement in return to sport pre- to postoperatively whereas the SLAP-R group did not. The SLAP-R+BT group had the most patients reaching minimal clinical important difference, substantial clinical benefit, and patient acceptable symptom state American Shoulder and Elbow Society Score scores; however, this was not statistically significant.

Conclusions: SLAP II-IV lesions treated with BT or both SLAP-R+BT demonstrated improved outcomes compared with isolated SLAP-R at minimum 2-year follow-up. Concomitant biceps tenodesis should be considered when performing repair of SLAP II-IV tears.

Level Of Evidence: III; Retrospective comparative study.
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http://dx.doi.org/10.1016/j.asmr.2021.10.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8689264PMC
December 2021

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

Systematic Review of Platelet-Rich Plasma for Rotator Cuff Repair: Are We Adhering to the Minimum Information for Studies Evaluating Biologics in Orthopaedics?

Orthop J Sports Med 2021 Dec 7;9(12):23259671211041971. Epub 2021 Dec 7.

Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: The therapeutic efficacy of orthobiologic therapies for rotator cuff repair is difficult to evaluate owing to reporting inconsistences. In response, the Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO) guidelines were developed to ensure standard reporting on orthobiologic therapies.

Purpose: To systematically review clinical studies evaluating platelet-rich plasma (PRP) for full-thickness rotator cuff repair and adherence to MIBO guidelines.

Study Design: Scoping review; Level of evidence, 4.

Methods: A search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed, EMBASE, and the Cochrane Library databases. Inclusion criteria were clinical studies reporting on rotator cuff tears (≥1 cm) surgically repaired with PRP. Patient demographics, biologic intervention, and adherence to the MIBO guidelines were systematically reviewed.

Results: A total of 19 studies (1005 patients) were included in this review. Across all studies, 58.5% of the MIBO checklist items for PRP were reported. Out of 47 checklist items, 19 were reported in over 85% of studies, whereas 22 were reported in less than half of studies. Details of whole-blood processing and characteristics, as well as PRP processing and characteristics, were reported inconsistently, and no study provided adequate information to enable the precise replication of preparation protocols for PRP.

Conclusion: This systematic review highlights the current reporting deficiencies within the scientific literature of important variables for evaluating PRP for full-thickness rotator cuff repair. There was widespread variability among published studies that evaluate PRP for this application and, more specifically, studies were limited by inconsistent universal reporting of whole-blood and PRP processing and postprocessing characteristics. To improve our understanding of biologic efficacy and to promote repeatability, stricter adherence to the MIBO guidelines is necessary. We propose that the checklist limitations be addressed and that modification of the MIBO guidelines be considered to improve the reporting of individual components within certain categories.
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http://dx.doi.org/10.1177/23259671211041971DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8655472PMC
December 2021

Outcomes After Arthroscopic Rotator Cuff Repair Using Margin Convergence Versus Superior Capsular Reconstruction: Should Candidates for Margin Convergence Be Treated With Superior Capsular Reconstruction?

Orthop J Sports Med 2021 Nov 3;9(11):23259671211050624. Epub 2021 Nov 3.

The Steadman Clinic, Vail, Colorado, USA.

Background: Both margin convergence rotator cuff repair (MC-RCR) and superior capsular reconstruction (SCR) result in improved clinical outcomes in the treatment of massive rotator cuff tears (RCTs). The question remains whether it is better to perform MC-RCR using native, albeit occasionally deficient, tissues or to perform primary SCR.

Purpose/hypothesis: To compare the clinical results of MC-RCR versus SCR for the treatment of massive RCTs. It was hypothesized that SCR would yield better outcomes.

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

Methods: Included were patients who underwent arthroscopic MC-RCR or SCR for massive RCTs performed by a single surgeon between 2014 and 2019. MC-RCR was performed if it was technically possible to close the defect; otherwise, SCR was performed. Outcomes were assessed at 6 months and then annually using American Shoulder and Elbow Surgeons; Single Assessment Numerical Evaluation; shortened version of Disabilities of the Arm, Shoulder and Hand; 12-Item Short Form Health Survey Physical Component Summary; and patient satisfaction scores. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) were compared between groups. Revision surgeries and complications were reported.

Results: Included were 46 patients in the MC-RCR group (mean age, 59 ± 8 years) and 46 patients in the SCR group (mean age, 57 ± 7 years); 29 patients in each group were available at 2-year follow-up. Preoperative outcome scores were not significantly different between groups. Within groups, all outcome scores improved from pre- to postoperatively ( < .05), with no significant differences in postoperative scores or patient satisfaction between groups. No significant between-group differences were noted in the percentage of patients who reached the MCID, SCB, and PASS (MCID, 92.3% vs 84.6%; SCB, 80.8% vs 80.8%; and PASS, 66.7% vs 66.7%). SCR had a significantly lower survivorship rate compared with MC-RCR (84.7% vs 100%) ( = .026).

Conclusion: Both MC-RCR and SCR provided similar improvement in outcomes; however, SCR resulted in a significantly lower survivorship rate at 2 years postoperatively. If an RCT is technically repairable, we recommend that it be repaired primarily, even if MC techniques are needed to close the defect. SCR remains a good option for massive RCTs that are not technically repairable.
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http://dx.doi.org/10.1177/23259671211050624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8573497PMC
November 2021

Immunologic Contributions Following Rotator Cuff Injury and Development of Cuff Tear Arthropathy.

JBJS Rev 2021 11 10;9(11). Epub 2021 Nov 10.

Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.

»: Rotator cuff tear arthropathy (RCTA) describes a pattern of glenohumeral degenerative changes following chronic rotator cuff tears that is characterized by superior humeral head migration, erosion of the greater tuberosity of the humeral head, contouring of the coracoacromial arch to create a socket for the humeral head, and eventual glenohumeral arthritis.

»: Acute and chronic inflammatory changes following rotator cuff tears are thought to contribute to cartilage damage, muscle fibrosis, and fatty infiltration in the glenohumeral joint.

»: In vitro animal studies targeting various inflammatory modulators, including macrophages, insulin-like growth factor-I, and transforming growth factor-beta pathways, provide promising therapeutic targets to improve healing after rotator cuff tears.

»: The role of platelet-rich plasma in the treatment and prevention of RCTA has been investigated, with conflicting results.
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http://dx.doi.org/10.2106/JBJS.RVW.21.00126DOI Listing
November 2021

Grade III Acromioclavicular Separations Treated With Suspensory Fixation Techniques: A Systematic Review of Level I Through IV Studies.

Arthrosc Sports Med Rehabil 2021 Oct 5;3(5):e1535-e1545. Epub 2021 Aug 5.

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

Purpose: To perform a systematic review comparing clinical outcomes, radiographic outcomes, and complication rates after acute (surgery ≤6 weeks from injury) versus chronic (surgery >6 weeks from injury) acromioclavicular joint reconstructions for grade III injuries using modern suspensory fixation techniques.

Methods: We performed a systematic review of the literature examining acute versus chronic surgical treatment of Rockwood grade III acromioclavicular joint separations using the Cochrane registry, MEDLINE database, and Embase database over the past 10 years according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria included techniques using suspensory fixation, a minimum study size of 3 patients, a minimum follow-up period of 6 months, human studies, and English-language studies. The methodology of each study was evaluated using the Methodological Index for Non-randomized Studies (MINORS) tool for nonrandomized studies and the revised Cochrane risk-of-bias (RoB 2) tool for randomized controlled trials.

Results: The systematic review search yielded 20 studies with a total of 253 patients. There were 2 prospective randomized controlled trials, but most of the included studies were retrospective. On comparison of acute surgery (≤6 weeks) and chronic surgery (>6 weeks), individual studies reported a range of Constant scores of 84.4 to 98.2 and 80.8 to 94.1, respectively. The ranges of radiographic coracoclavicular distances reported at final follow-up also favored acute reconstructions, which showed improved reduction (9.2-15.7 mm and 11.7-18.6 mm, respectively). The reported complication rates ranged from 7% to 67% for acute reconstructions and from 0% to 30% for chronic reconstructions.

Conclusions: The ranges in the Constant score may favor acute reconstructions, but because of the heterogeneity in the surgical techniques in the literature, no definitive recommendations can be made regarding optimal timing.

Level Of Evidence: Level IV, systematic review of Level I through IV studies.
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http://dx.doi.org/10.1016/j.asmr.2021.04.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8527265PMC
October 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

Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies.

J Shoulder Elbow Surg 2022 Jan 3;31(1):209-216. Epub 2021 Aug 3.

Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA.

Background: The purpose of this study was to review the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following revision arthroscopic Bankart repair.

Methods: Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the Embase, MEDLINE, and Cochrane Library databases. Studies in which arthroscopic Bankart repair was performed as a revision procedure were included. The clinical outcomes extracted and analyzed were functional outcomes, return to play, and recurrent instability.

Results: Fourteen studies with 433 patients met the inclusion criteria. The majority of patients were male patients (63.7%); the average age was 26.1 years (range, 14-58 years), and the mean follow-up period was 37.6 months (range, 10-144 months). The mean Rowe score was 84.2, and 79.7% of patients had good to excellent outcomes. The rate of return to play was 78.5%, with 47.5% of patients returning to their preinjury level of play across 10 studies. The rate of recurrent instability was reported in 12 studies, with 328 shoulders demonstrating 86 instability events (26.2%). The rate of recurrent instability due to dislocation was reported in 7 studies (n = 176), with 19 events (10.8%), whereas the rate of subluxation was reported in 4 studies (n = 76), with 6 events (7.9%).

Conclusions: Revision arthroscopic Bankart repair for anterior shoulder instability was shown to result in a high rate of recurrent shoulder instability. There was a relatively poor rate of return to sport among athletes, and only about half of the patients were able to return at or above their preoperative level of ability.
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http://dx.doi.org/10.1016/j.jse.2021.06.021DOI Listing
January 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

Influence of Radiographic Parameters on Reduction of the Critical Shoulder Angle With Arthroscopic Lateral Acromioplasty-A Mathematical Model.

Arthrosc Sports Med Rehabil 2021 Jun 2;3(3):e799-e805. Epub 2021 Apr 2.

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

Objectives: To develop a mathematical model for the preoperative planning of arthroscopic lateral acromioplasty (ALA) and to evaluate the role of radiographic parameters with regards to the critical shoulder angle (CSA).

Methods: Anteroposterior (AP) radiographs of patients who underwent rotator cuff surgery were screened to identify true AP radiographs. Radiographs were assessed for (1) native CSA, (2) CSA after simulated resection of a spur if present, (3) amount of ALA necessary to achieve a CSA of 34°, (4) CSA after 5-mm ALA, (5) lateral acromion angle, (6) acromion index, and (7) sclerosis of the greater tuberosity.

Results: A total of 1191 radiographs were screened. Of the 124 patients included, the native CSA was large (≥35°) in 56 patients (45%). In 30 patients (24%), a subacromial spur was detected and resection reduced the CSA by a median of 2°. Spur resection alone reduced the CSA to ≤34° in 19 patients (15.3%). Mean amount of ALA to achieve a CSA of 34° was 3.9 ± 1.8 mm, and this value strongly correlated with the CSA before ALA (R = 0.88, < .001). The linear regression model to determine the amount of ALA to achieve a CSA of 34° was as follows: The multiple R for this model was 0.777. Mean reduction of CSA by 5-mm ALA was 3.8 ± 0.8° and 75% of large CSAs were reduced to a CSA of 30-34°. The acromion index had no significant independent influence on the model ( = .427), whereas lateral acromion angle was an independently significant predictor of required ALA to achieve a CSA of 34° ( = .019). Sclerosis of the greater tuberosity was significantly associated with a CSA of 35° or greater ( = .003).

Conclusions: The amount of ALA needed to reduce a large CSA to 34° correlates with the CSA before ALA and can preoperatively be planned with the use of a simple equation.

Level Of Evidence: Level III; cross-sectional design; epidemiology study.
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http://dx.doi.org/10.1016/j.asmr.2021.01.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8220626PMC
June 2021
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