Publications by authors named "Peter J Millett"

266 Publications

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.asmr.2021.01.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8220626PMC
June 2021

Posterior Glenoid Reconstruction Using a Distal Tibial Allograft.

Arthrosc Tech 2021 May 3;10(5):e1227-e1232. Epub 2021 Apr 3.

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

Posterior shoulder instability is increasingly recognized and diagnosed in young athletes. These patients often present with vague shoulder pain rather than the frank instability commonly seen with anterior instability. Three common causes of posterior shoulder instability are congenital retroversion, a single traumatic event, or repetitive microtrauma with erosive effects. The critical determination when deciding on the appropriate treatment of posterior shoulder instability is the presence and degree of glenoid bone loss. In patients without bone loss, arthroscopic procedures have a high success rate with a failure rate of less than 10% and an 89% return-to-sport rate. The determination of the critical amount of bone loss that would permit an arthroscopic procedure is controversial, but recent reports that attempt to quantify the critical bone loss value posteriorly have ranged from 13.5% to 20%. This Technical Note describes our preferred method of open surgical treatment of posterior shoulder instability with posterior glenoid bone loss using an intra-articular distal tibial allograft.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eats.2021.01.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8185618PMC
May 2021

Complex Revision Glenoid Reconstruction with Use of a Distal Tibial Allograft.

JBJS Essent Surg Tech 2021 Jan-Mar;11(1). Epub 2021 Jan 20.

The Steadman Clinic, Vail, Colorado.

Background: Coracoid transfer procedures have been increasingly utilized for anterior shoulder instability with associated glenoid bone loss. Unfortunately, in a young, high-risk patient population, these procedures can fail secondary to traumatic causes but also because of bone graft resorption or malposition or hardware prominence, among other reasons. In active patients, revision glenoid reconstruction may be indicated. Distal tibial osteoarticular allografts have been utilized to treat recurrent anterior shoulder instability for several years. Recently, this technique has been applied to cases of failed Latarjet procedures in order to reconstitute the absent glenoid bone stock, demonstrating excellent clinical outcomes at a minimum follow-up of 3 years.

Description: The procedure is performed in the beach-chair position. First, a diagnostic shoulder arthroscopy is performed to assess the cartilaginous surfaces, to examine the Hill-Sachs lesion and its engagement, and to remove any loose bodies. Next, the prior deltopectoral incision is developed, and the deltopectoral interval is utilized to visualize the subscapularis. The subscapularis is split at the junction of its upper two-thirds and lower one-third. Careful dissection is used to develop the subscapularis split from lateral to medial because the prior coracoid transfer affects the native neurovascular anatomy medially. If substantial coracoid bone remains from the previous transfer, a conjoined tendon tenotomy can be performed to further aid in visualization. Next, any associated hardware is removed, and the coracoid bone remnant is removed. The glenoid defect is sized, and the osseous glenoid bed is prepared. A fresh-frozen distal tibial allograft is then fashioned, washed of marrow elements, and enhanced with platelet-rich plasma before being fixed to the glenoid with use of 2 cortical screws in a lagged fashion. The capsule and subscapularis split are then closed to complete the repair.

Alternatives: Alternatives to revision glenoid reconstruction with distal tibial allograft include reconstruction with an iliac crest autograft, distal clavicular autograft, revision coracoid transfer, or nonoperative treatment through rehabilitation and activity modification.

Rationale: In cases of failed coracoid transfer for anterior shoulder instability with associated glenoid bone loss, distal tibial allograft is the superior revision treatment option for several reasons: it allows for an osteoarticular graft, offers flexibility in terms of graft size, and requires no donor-site morbidity. Distal tibial allograft allows active, high-risk patients to have restored and maintained stability with low complication and graft-resorption rates.

Expected Outcomes: Glenoid reconstruction with a distal tibial allograft is associated with improved patient-reported outcomes from preoperatively, as well as recurrence rates of <10% and graft-union rates of >90%.

Important Tips: Initiating the procedure with an arthroscopic evaluation allows for a complete diagnostic examination, including the Hill-Sachs lesion, articular cartilage, and rotator cuff, as well as removal of any loose bodies, which are frequently present and sometimes difficult to visualize and access during the open procedure.A subscapularis split allows for maintenance of the subscapularis insertion on the lesser tuberosity as well as minimal disruption of the muscle fibers.A conjoined tendon tenotomy can provide improved access for hardware removal if the coracoid bone graft from the prior transferred coracoid is present.A 5.5-mm arthroscopic burr is utilized to decorticate the anterior aspect of the glenoid, which facilitates graft union because the burr allows built-in suction capability during constant irrigation, minimizing the possibility of heat necrosis.The distal tibial allograft is thoroughly lavaged to remove residual marrow elements prior to insertion in order to diminish potential immunogenicity.Two solid, fully threaded 3.5-mm cortical screws are placed in a lagged fashion to fix the distal tibial allograft to the glenoid.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.ST.20.00017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8189595PMC
January 2021

Rehabilitation Following Posterior Shoulder Stabilization.

Int J Sports Phys Ther 2021 Jun 1;16(3):930-940. Epub 2021 Jun 1.

The Steadman Clinic; Steadman Philippon Research Institute.

Posterior shoulder instability has been noted in recent reports to occur at a higher prevalence than originally believed, with many cases occurring in active populations. In most cases, primary surgical treatment for posterior shoulder instability-a posterior labral repair-is indicated for those patients who have failed conservative management and demonstrate persistent functional limitations. In order to optimize surgical success and return to a prior level of function, a comprehensive and focused rehabilitation program is crucial. Currently, there is a limited amount of literature focusing on rehabilitation after surgery for posterior instability. Therefore, the purpose of this clinical commentary is to present a post-surgical rehabilitation program for patients following posterior shoulder labral repair, with recommendations based upon best medical evidence.

Level Of Evidence: 5.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.26603/001c.22501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168996PMC
June 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 Jun 8. Epub 2021 Jun 8.

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

Background: Management of massive irreparable rotator cuff tears (MIRCTs) remains controversial due 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 (ASES) 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 transfers. 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 six 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 where 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 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 eighteen scenarios and arthroscopic débridement and/or partial repair selected for two scenarios. RSA was selected as the singular Preferred treatment option in eight scenarios. Not acceptable/contraindicated treatment options reached consensus in eight scenarios, of which, four related to SCR, three to RSA, and one 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.

Level Of Evidence: Survey Study; Experts.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2021.05.012DOI Listing
June 2021

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

Am J Sports Med 2021 Jul 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/03635465211015419DOI Listing
July 2021

Patient-reported drug and latex allergies negatively affect outcomes after total and reverse shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Jun 2. Epub 2021 Jun 2.

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

Background: Patient-reported allergies (PRAs) have been identified as a risk factor for worse outcomes and less satisfaction in patients undergoing knee and hip arthroplasty. Similar associations have not been elucidated in shoulder arthroplasty patients; however, previous research is sparse. The purpose of this study was to assess the outcomes following shoulder arthroplasty surgery with respect to patient-reported drug allergies. It was hypothesized that a higher number of allergies would be associated with worse patient-reported outcomes (PROs) following shoulder arthroplasty surgery.

Methods: Consecutive patients aged 18-89 years at the time of surgery who underwent primary shoulder arthroplasty between October 2005 and March 2018 performed by a single surgeon and had a minimum follow-up period of 1 year were reviewed. PRO scores, including the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score, and 12-Item Short Form Health Survey Physical Component Summary and Mental Component Summary scores, as well as patient satisfaction, were collected preoperatively and postoperatively. Early clinical failures were reported. Subjects were categorized into a 3-level factor based on the number of PRAs (0, 1, or ≥2), and bivariate comparisons of mean postoperative PRO scores were performed using Kruskal-Wallis analyses. Additionally, multivariate regression was performed to assess the effect of PRAs on PROs while controlling for age, sex, arthroplasty type, baseline PRO scores, and Charlson Comorbidity Index.

Results: Overall, 411 shoulders were included in the final study population (367 patients, 44 of whom were treated bilaterally). The population was predominately male patients (n = 265, 64.5%), and the median age at the time of surgery was 66.5 years (first quartile-third quartile, 61.3-71.4 years). Of the patients, 253 (61.6%) underwent total shoulder arthroplasty (TSA) whereas 158 (38.4%) underwent reverse TSA. Five patients (2 TSA and 3 reverse TSA patients) experienced early clinical failure and required revision surgery. Minimum 1-year PROs were obtained for 345 of 406 patients (85.0%) with a mean follow-up period of 1.9 ± 1.2 years. Nearly all postoperative PROs reflected a trend of worse outcomes with more preoperative PRAs; however, the QuickDASH score was the only score showing a significant difference between allergy groups (P = .004). Pair-wise comparison using Nemenyi post hoc testing showed that the QuickDASH score was significantly higher (worse outcomes) for the group with ≥2 allergies compared with the group with 0 allergies. PRA was found to be a statistically significant predictor of higher postoperative QuickDASH scores (P = .043) and was more influential than the Charlson Comorbidity Index and sex. Additionally, PRA was the only statistically significant predictor of patient satisfaction (P = .016).

Conclusion: An increasing number of preoperative PRAs is associated with worse PROs and patient satisfaction following shoulder arthroplasty. The number of PRAs was the most influential predictor of patient satisfaction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2021.05.009DOI Listing
June 2021

Superior Capsule Reconstruction With a 3 mm-Thick Dermal Allograft Partially Restores Glenohumeral Stability in Massive Posterosuperior Rotator Cuff Deficiency: A Dynamic Robotic Shoulder Model.

Am J Sports Med 2021 Jul 3;49(8):2056-2063. Epub 2021 Jun 3.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: Superior capsule reconstruction (SCR) has been shown to improve shoulder function and reduce pain in patients with isolated irreparable supraspinatus tendon tears. However, the effects of SCR on biomechanics in a shoulder with an extensive posterosuperior rotator cuff tear pattern remain unknown.

Purpose/hypothesis: The purpose was to (1) establish a dynamic robotic shoulder model, (2) assess the influence of rotator cuff tear patterns, and (3) assess the effects of SCR on superior humeral head translation after a posterosuperior rotator cuff tear. It was hypothesized that a posterosuperior rotator cuff tear would increase superior humeral head translation when compared with the intact and supraspinatus tendon-deficient state and that SCR would reduce superior humeral head translation in shoulders with massive rotator cuff tears involving the supraspinatus and infraspinatus tendons.

Study Design: Controlled laboratory study.

Methods: Twelve fresh-frozen cadaveric shoulders were tested using a robotic arm. Kinematic testing was performed in 4 conditions: (1) intact, (2) simulated irreparable supraspinatus tendon tear, (3) simulated irreparable supra- and infraspinatus tendon tear, and (4) SCR using a 3 mm-thick dermal allograft (DA). Kinematic testing consisted of static 40-N superior force tests at 0°, 30°, 60°, and 90° of abduction and dynamic flexion, abduction, and scaption motions. In each test, the superior translation of the humeral head was reported.

Results: In static testing, SCR significantly reduced humeral superior translation compared with rotator cuff tear at all abduction angles. SCR restored the superior stability back to native at 60° and 90° of abduction, but the humeral head remained significantly and superiorly translated at neutral position and at 30° of abduction. The results of dynamic testing showed a significantly increased superior translation in the injured state at lower elevation angles, which diminished at higher elevation, becoming nonsignificant at elevation >75°. SCR reduced the magnitude of superior translation across all elevation angles, but translation remained significantly different from the intact state up to 60° of elevation.

Conclusion: Massive posterosuperior rotator cuff tears increased superior glenohumeral translation when compared with the intact and supraspinatus tendon-insufficient rotator cuff states. SCR using a 3-mm DA partially restored the superior stability of the glenohumeral joint even in the presence of a simulated massive posterosuperior rotator cuff tear in a static and dynamic robotic shoulder model.

Clinical Relevance: The biomechanical performance concerning glenohumeral stability after SCR in shoulders with large posterosuperior rotator cuff tears is unclear and may affect clinical outcomes in daily practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/03635465211013364DOI Listing
July 2021

Anchor Arthropathy of the Shoulder Joint After Instability Repair: Outcomes Improve With Revision Surgery.

Arthroscopy 2021 May 27. Epub 2021 May 27.

Steadman Clinic, Vail, Colorado, U.S.A.; Steadman Philippon Research Institute, Vail, Colorado, U.S.A.. Electronic address:

Purpose: To report clinical and patient-reported outcome measures (PROMs) in patients undergoing revision surgery after diagnosis of anchor-induced arthropathy.

Methods: Patients who underwent revision arthroscopic shoulder surgery and were diagnosed with post-instability glenohumeral arthropathy performed from January 2006 to May 2018 were included in the current study. Patients were excluded if they underwent prior open shoulder procedures, if glenoid bone loss was present, or if prerevision imaging and records were incomplete or not available. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, exam findings before revision surgery, and surgical intervention. PROMs were prospectively collected before surgery and at minimum 2-year follow-up.

Results: Fourteen patients were included with a mean (± standard deviation) age at presentation of 35.2 ± 12.1 years (range 16 to 59). The follow-up rate was 86%, with a mean follow-up of 3.8 years (range 1.1 to 10.6). Mean time to development of arthropathy symptoms was 48.2 months (range <1 month to 13.8 years), all presenting with pain and decreased range of motion on exam. At time of revision surgery, all patients underwent either open or arthroscopic removal of previous implants, including anchors and suture material. Six patients underwent additional revision stabilization procedures, 1 underwent total shoulder arthroplasty, and 7 underwent arthroscopic intraarticular debridement, capsular release, and chondroplasty with or without microfracture. Pain significantly improved in 79% of patients (P = .05). Significant improvements in all PROMs were observed, including 12-item Short Form (43.8 to 54.8, P < .01); Disabilities of the Arm, Shoulder, and Hand, shortened version (31.8 to 8.4, P < .01); Single Assessment Numeric Evaluation (47.0 to 84.5, P < .05); and American Shoulder and Elbow Surgeons (61.6 to 92.1, P < .01). Average external rotation significantly improved, from 31° ± 22° to 52° ± 24° (P = .02).

Conclusion: Rapid intervention after diagnosis, through either revision arthroscopic or open debridement and stabilization, can lead to significant improvement in range of motion, pain, and overall patient function and satisfaction.

Level Of Evidence: IV, retrospective case series.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2021.05.024DOI Listing
May 2021

Postoperative Stiffness and Pain After Arthroscopic Labral Stabilization: Consider Anchor Arthropathy.

Arthroscopy 2021 May 27. Epub 2021 May 27.

Steadman Clinic, Vail, Colorado, U.S.A.; Steadman Philippon Research Institute, New Orleans, Louisiana, U.S.A.. Electronic address:

Purpose: To describe the key clinical, imaging, and arthroscopic characteristics of anchor arthropathy after arthroscopic shoulder stabilization procedures and, secondarily, to define risk factors for the development of anchor-induced arthropathy.

Methods: A total of 23 patients who underwent revision arthroscopic shoulder surgery and were diagnosed with glenohumeral arthropathy were retrospectively identified from prospectively collected data registries between January 2000 and May 2018. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, and examination findings before revision surgery. Pre-revision imaging was used to assess presence of glenohumeral osteoarthritis and chondromalacia, anchors/sutures, loose bodies, and labral pathology. The same parameters were recorded intraoperatively during revision surgery. Descriptive statistics were performed for demographic data and means with standard deviations were calculated for continuous data. A McNemar-Bowker test was used to analyze marginal homogeneity between preoperative imaging and intraoperative findings.

Results: Mean age at presentation was 33.4 ± 11.7 years (range 16-59, 17 male patients; 6 female patients). More than one half (13/23) developed symptoms within 10 months after index arthroscopic procedure (mean 32.2 ± 59.9 months, range <1 to 165.2 months) with 87% presenting with pain and 100% presenting with loss of motion on examination. Plain radiographs demonstrated humeral osteoarthritis in 57% (13/23) of patients, magnetic resonance imaging (MRI) revealed recurrent labral pathology in 19 of 23 (83%) patients, potential proud implants in 12 of 23 (52%), and loose bodies in 12 of 23 (52%). Intraoperatively, all had evidence of osteoarthritis; 22 of 23 (96%) had prominent implants. Humeral head chondromalacia was present in 21 of 23 patients (91%), the majority of which was linear stripe wear, and 6 of 23 (26%) had severe global glenohumeral osteoarthritis. Statistical analysis revealed a 54.5% (95% confidence interval 0.327-0.749) sensitivity of MRI identification of proud implants with a specificity of 100% (95% confidence interval 0.055-1). The ability of MRI to accurately assess chondromalacia of the humeral head (P = .342) or glenoid (P = .685) was not statistically significant.

Conclusions: Anchor arthropathy is characterized by symptoms of pain and stiffness on examination and in many cases develops early after stabilization surgery (<10 months). Implants were implicated in the majority of cases of humeral head chondromalacia. MRI scans may produce false-negative identification of proud implants and can be a poor predictor of the severity of chondromalacia and intra-articular pathology; thus, a high index of clinical suspicion is necessary in patients with motion loss and pain postoperatively.

Level Of Evidence: Level IV, case series.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2021.05.016DOI Listing
May 2021

Mid-Term Outcomes of Arthroscopically-Assisted Anatomic Coracoclavicular Ligament Reconstruction using Tendon Allograft for High-Grade Acromioclavicular Joint Dislocations.

Arthroscopy 2021 Apr 30. Epub 2021 Apr 30.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Steadman Clinic, Vail, Colorado, U.S.A.. Electronic address:

Purpose: The purposes of this study were to assess clinical and radiographic outcomes of arthroscopically-assisted, anatomic coracoclavicular ligament reconstruction using tendon allograft (AA-ACCR) for the treatment of Rockwood type III-V injuries at minimum 2-year follow-up and to perform subgroup analyses of clinical and radiographic outcomes for acute versus chronic and type III versus type IV-V injuries.

Methods: In this retrospective study of prospectively collected data, patients who underwent primary AA-ACCR for the treatment of type III-V dislocations and had minimum 2-year follow-up were included. Preoperative and postoperative patient-reported outcome scores (PROs) were collected, including American Shoulder and Elbow Surgeons score, Single Numeric Assessment Evaluation score, Short Form-12 Physical Component Summary, Quick Disabilities of the Arm Shoulder and Hand score, and patient satisfaction. Preoperative and postoperative coracoclavicular distance (CCD) was obtained. PROs and CCD were reported for the total cohort and for the subgroups. Complication and revision rates were demonstrated.

Results: In total, 102 patients (10 women, 92 men) with a mean age of 45.0 years (range, 18-73 years) were included. There were 13 complications (12.7%) resulting in revision surgery. After exclusion of revised patients, PROs were available for 69 (77.5%). At mean follow-up of 4.7 years (range, 2.0-12.8 years), all PROs improved significantly (P < .001). Median patient satisfaction was 9.0 (interquartile range, 8.0-10.0). Median preoperative to postoperative CCD decreased significantly (P < .001). Subgroup analyses revealed significant improvements in all PROs and CCD from preoperative to postoperative for both acute and chronic, and type III and type IV-V dislocations (P < .05) with no significant differences in postoperative PROs and satisfaction between (P > .05).

Conclusion: AA-ACCR for high-grade acromioclavicular joint injuries resulted in high postoperative PROs and patient satisfaction with significant improvements from before to after surgery in those who did not undergo revision surgery. Furthermore, subgroup analyses revealed that acute and chronic, and type III and type IV-V injuries benefitted similarly from AA-ACCR.

Level Of Evidence: Level IV; therapeutic case series.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2021.04.035DOI Listing
April 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.CC.20.00833DOI Listing
April 2021

Total Shoulder Arthroplasty After Previous Arthroscopic Surgery for Glenohumeral Osteoarthritis: A Case-Control Matched Cohort Study.

Am J Sports Med 2021 06 29;49(7):1839-1846. Epub 2021 Apr 29.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: When comprehensive arthroscopic management (CAM) for glenohumeral osteoarthritis fails, total shoulder arthroplasty (TSA) may be needed, and it remains unknown whether previous CAM adversely affects outcomes after subsequent TSA.

Purpose: To compare the outcomes of patients with glenohumeral osteoarthritis who underwent TSA as a primary procedure with those who underwent TSA after CAM (CAM-TSA).

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

Methods: Patients younger than 70 years who underwent primary TSA or CAM-TSA and were at least 2 years postoperative were included. A total of 21 patients who underwent CAM-TSA were matched to 42 patients who underwent primary TSA by age, sex, and grade of osteoarthritis. Intraoperative blood loss and surgical time were assessed. Patient-reported outcome (PRO) scores were collected preoperatively and at final follow-up including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), visual analog scale, and patient satisfaction. Revision arthroplasty was defined as failure.

Results: Of 63 patients, 56 of them (19 CAM-TSA and 37 primary TSA; 88.9%) were available for follow-up. There were 16 female (28.6%) and 40 male (71.4%) patients with a mean age of 57.8 years (range, 38.8-66.7 years). There were no significant differences in intraoperative blood loss ( > .999) or surgical time ( = .127) between the groups. There were 4 patients (7.1%) who had failure, and failure rates did not differ significantly between the CAM-TSA (5.3%; n = 1) and primary TSA (8.1%; n = 3) groups ( > .999). Additionally, 2 patients underwent revision arthroplasty because of trauma. A total of 50 patients who did not experience failure (17 CAM-TSA and 33 primary TSA) completed PRO measures at a mean follow-up of 4.8 years (range, 2.0-11.5 years), with no significant difference between the CAM-TSA (4.4 years [range, 2.1-10.5 years]) and primary TSA (5.0 years [range, 2.0-11.5 years]) groups ( = .164). Both groups improved significantly from preoperatively to postoperatively in all PRO scores ( < .05). No significant differences in any median PRO scores between the CAM-TSA and primary TSA groups, respectively, were seen at final follow-up: ASES: 89.9 (interquartile range [IQR], 74.9-96.6) versus 94.1 (IQR, 74.9-98.3) ( = .545); SANE: 84.0 (IQR, 74.0-94.0) versus 91.5 (IQR, 75.3-99.0) ( = .246); QuickDASH: 9.0 (IQR, 3.4-27.3) versus 9.0 (IQR, 5.1-18.1) ( = .921); SF-12 PCS: 53.8 (IQR, 50.1-57.1) versus 49.3 (IQR, 41.2-56.5) ( = .065); and patient satisfaction: 9.5 (IQR, 7.3-10.0) versus 9.0 (IQR, 5.3-10.0) ( = .308).

Conclusion: Patients with severe glenohumeral osteoarthritis who failed previous CAM benefited similarly from TSA compared with patients who opted directly for TSA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/03635465211006479DOI Listing
June 2021

Complications Following Biologic Therapeutic Injections: A Multicenter Case Series.

Arthroscopy 2021 Apr 17. Epub 2021 Apr 17.

Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: To describe the complications that occur following biologic therapeutic injections.

Methods: We queried physician members of the Biologic Association, a multidisciplinary organization dedicated to providing a unified voice for all matters related to musculoskeletal biologics and regenerative medicine. Patients included in this study must have (1) received a biologic injection, (2) sustained an adverse reaction, and (3) had a minimum of 1-year follow-up after the injection. Patient demographic information, medical comorbidities, diagnoses, and previous treatments were recorded. The type of injection, injection setting, injection manufacturers, and specific details about the complication and outcome were collected.

Results: In total, 14 patients were identified across 6 institutions in the United States (mean age 63 years, range: 36-83 years). The most common injections in this series were intra-articular knee injections (50%), followed intra-articular shoulder injections (21.4%). The most common underlying diagnosis was osteoarthritis (78.5%). Types of injections included umbilical cord blood, platelet-rich plasma, bone marrow aspirate concentrate, placental tissue, and unspecified "stem cell" injections. Complications included infection (50%), suspected sterile inflammatory response (42.9%), and a combination of both (7.1%). The most common pathogen identified from infection cases was Escherichia coli (n = 4). All patients who had isolated infections underwent treatment with at least one subsequent surgical intervention (mean: 3.6, range: 1-12) and intravenous antibiotic therapy.

Conclusions: This study demonstrates that serious complications can occur following treatment with biologic injections, including infections requiring multiple surgical procedures and inflammatory reactions.

Level Of Evidence: Level IV, case series.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2021.03.065DOI Listing
April 2021

Quantitative and Qualitative Surgical Anatomy of the Acromioclavicular Joint Capsule and Ligament: A Cadaveric Study.

Am J Sports Med 2021 04 5;49(5):1183-1191. Epub 2021 Mar 5.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: The acromioclavicular (AC) capsule and ligament have been found to play a major role in maintaining horizontal stability. To reconstruct the AC capsule and ligament, precise knowledge of their anatomy is essential.

Purpose/hypothesis: The purposes of this study were (1) to determine the angle of the posterosuperior ligament in regard to the axis of the clavicle, (2) to determine the width of the attachment (footprint) of the AC capsule and ligament on the acromion and clavicle, (3) to determine the distance to the AC capsule from the cartilage border of the acromion and clavicle, and (4) to develop a clockface model of the insertion of the posterosuperior ligament on the acromion and clavicle. It was hypothesized that consistent angles, attachment areas, distances, and insertion sites would be identified.

Study Design: Descriptive laboratory study.

Methods: A total of 12 fresh-frozen shoulders were used (mean age, 55 years [range, 41-64 years]). All soft tissue was removed, leaving only the AC capsule and ligament intact. After a qualitative inspection, a quantitative assessment was performed. The AC joint was fixed in an anatomic position, and the attachment angle of the posterosuperior ligament was measured using a digital protractor. The capsule and ligament were removed, and a coordinate measuring device was utilized to assess the width of the AC capsule footprint and the distance from the footprint to the cartilage border of the acromion and clavicle. The AC joint was then disarticulated, and the previously marked posterosuperior ligament insertion was transferred into a clockface model. The mean values across the 12 specimens were demonstrated with 95% CIs.

Results: The mean attachment angle of the posterosuperior ligament was 51.4° (95% CI, 45.2°-57.6°) in relation to the long axis of the entire clavicle and 41.5° (95% CI, 33.8°-49.1°) in relation to the long axis of the distal third of the clavicle. The mean clavicular footprint width of the AC capsule was 6.4 mm (95% CI, 5.8-6.9 mm) at the superior clavicle and 4.4 mm (95% CI, 3.9-4.8 mm) at the inferior clavicle. The mean acromial footprint width of the AC capsule was 4.6 mm (95% CI, 4.2-4.9 mm) at the superior side and 4.0 mm (95% CI, 3.6-4.4 mm) at the inferior side. The mean distance from the lateral clavicular attachment of the AC capsule to the clavicular cartilage border was 4.3 mm (95% CI, 4.0-4.6 mm), and the mean distance from the medial acromial attachment of the AC capsule to the acromial cartilage border was 3.1 mm (95% CI, 2.9-3.4 mm). On the clockface model of the right shoulder, the clavicular attachment of the posterosuperior ligament ranged from the 9:05 (range, 8:00-9:30) to 11:20 (range, 10:00-12:30) position, and the acromial attachment ranged from the 12:20 (range, 11:00-1:30) to 2:10 (range, 13:30-14:40) position.

Conclusion: The finding that the posterosuperior ligament did not course perpendicular to the AC joint but rather was oriented obliquely to the long axis of the clavicle, in combination with the newly developed clockface model, may help surgeons to optimally reconstruct this ligament.

Clinical Relevance: Our results of a narrow inferior footprint and a short distance from the inferior AC capsule to cartilage suggest that proposed reconstruction of the AC joint capsule should focus primarily on its superior portion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0363546521995504DOI Listing
April 2021

Quantitative T2 mapping of the glenohumeral joint cartilage in asymptomatic shoulders and shoulders with increasing severity of rotator cuff pathology.

Eur J Radiol Open 2021 13;8:100329. Epub 2021 Feb 13.

Steadman Philippon Research Institute, 181 W Meadow Dr, Ste 1000, Vail, CO 81657, USA.

Purpose: To examine the relationship between glenohumeral cartilage T2 mapping values and rotator cuff pathology.

Method: Fifty-nine subjects (age 48.2 ± 13.5 years, 15 asymptomatic volunteers and 10 tendinosis, 13 partial-thickness tear, 8 full-thickness tear, and 13 massive tear patients) underwent glenohumeral cartilage T2 mapping. The humeral head cartilage was segmented in the sagittal and coronal planes. The glenoid cartilage was segmented in the coronal plane. Group means for each region were calculated and compared between the groups.

Results: Massive tear group T2 values were significantly higher than the asymptomatic group values for the humeral head cartilage included in the sagittal (45 ± 7 versus 32 ± 4 ms,  <  .001) and coronal (44 ± 6 versus 38 ± 1 ms,  =  0.01) plane images. Mean T2 was also significantly higher for massive than full-thickness tears (45 ± 7 versus 38 ± 5 ms,  =  0.02), massive than partial-thickness tears (45 ± 7 versus 34 ± 4 ms,  <  0.001), and massive tears than tendinosis (45 ± 7 versus 35 ± 4 ms,  =  0.001) in the sagittal-images humeral head region and significantly higher for massive tears than asymptomatic shoulders (44 ± 6 versus 38 ± 1 ms,  =  0.01) in the coronal-images humeral head region.

Conclusion: Humeral head cartilage T2 values were significantly positively correlated with rotator cuff pathology severity. Massive rotator cuff tear patients demonstrated significantly higher superior humeral head cartilage T2 mapping values relative to subjects with no/lesser degrees of rotator cuff pathology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejro.2021.100329DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7895706PMC
February 2021

Latarjet Procedure for the Treatment of Anterior Glenohumeral Instability in the Athlete - Key Considerations for Rehabilitation.

Int J Sports Phys Ther 2021 Feb 1;16(1):259-269. Epub 2021 Feb 1.

Steadman Philippon Research Institute; The Steadman Clinic.

The Latarjet procedure with transfer of the coracoid process and its attached conjoint tendon is a well-established surgical technique for the treatment of anterior glenohumeral instability in patients with anteroinferior bone loss and/or high risk for recurrence. Biomechanical and clinical studies have shown excellent results and high rates of return to sports. However, there is an absence of standardized, objective criteria to accurately assess an athlete's ability to progress through each phase of rehabilitation. Return to sports rehabilitation, progressed by quantitatively measured functional goals, may improve the athlete's integration back to sports participation. Therefore, the purpose of this clinical commentary is to provide a rehabilitation protocol for the Latarjet procedure, progressing through clearly defined phases, with guidance for safe and effective return to sport. Recommended criteria are highlighted which allows the clinician to progress the patient through each phase appropriately rather than purely following timeframes from surgery. This progression ensures the patient has completed a thorough rehabilitation program that addresses ROM, strength, power, neuromuscular control and a graded return to play. Level of Evidence: 5.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872454PMC
February 2021

The effect of glenosphere lateralization and inferiorization on deltoid force in reverse total shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Aug 5;30(8):1817-1826. Epub 2020 Dec 5.

Department of Biomedical Engineering, Steadman Philippon Research Institute, Vail, CO, USA; The Steadman Clinic, Vail, CO, USA. Electronic address:

Background: A medialized center of rotation (COR) in reverse total shoulder arthroplasty (RTSA) comes with limitations such as scapular notching and reduced range of motion. To mitigate these effects, lateralization and inferiorization of the COR are performed, but may adversely affect deltoid muscle force. The study purposes were to measure the effect of RTSA with varying glenosphere configurations on (1) the COR and (2) deltoid force compared with intact shoulders and shoulders with massive posterosuperior rotator cuff tears (PS-RCT). We hypothesized that the highest deltoid forces would occur in shoulders with PS-RCT, and that RTSA would lead to a decrease in required forces that is further minimized with lateralization and inferiorization of the COR but still higher compared with native shoulders with an intact rotator cuff.

Methods: In this study, 8 cadaveric shoulders were dissected leaving only the rotator cuff muscles and capsule intact. A custom apparatus incorporating motion capture and a dynamic tensile testing machine to measure the changes in COR and deltoid forces while simultaneously recording glenohumeral abduction was designed. Five consecutive testing states were tested: (1) intact shoulder, (2) PS-RCT, (3) RTSA with standard glenosphere, (4) RTSA with 4 mm lateralized glenosphere, and (5) RTSA with 2.5 mm inferiorized glenosphere. Statistical Parametric Mapping was used to analyze the deltoid force as a function of the abduction angle. One-way repeated-measures within-specimens analysis of variance was conducted, followed by post hoc t-tests for pairwise comparisons between the states.

Results: All RTSA configurations shifted the COR medially and inferiorly with respect to native (standard: 4.2 ± 2.1 mm, 19.7 ± 3.6 mm; 4 mm lateralized: 3.9 ± 1.2 mm, 16.0 ± 1.8; 2.5 mm inferiorized: 6.9 ± 0.9 mm, 18.9 ± 1.7 mm). Analysis of variance showed a significant effect of specimen state on deltoid force across all abduction angles. Of the 10 paired t-test comparisons made between states, only 3 showed significant differences: (1) intact shoulders necessitated significantly lower deltoid force than specimens with PS-RCT below 42° abduction, (2) RTSAs with standard glenospheres required significantly lower deltoid force than RTSA with 4 mm lateralized glenospheres above 34° abduction, and (3) RTSAs with 2.5 mm inferiorized glenospheres had significantly lower deltoid force than RTSA with 4 mm of glenosphere lateralization at higher abduction angles.

Conclusions: RTSA with a 2.5 mm inferiorized glenosphere and no additional lateralization resulted in less deltoid force to abduct the arm compared with 4 mm lateralized glenospheres. Therefore, when aiming to mitigate downsides of a medialized COR, an inferiorized glenosphere may be preferable in terms of its effect on deltoid force.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2020.10.038DOI Listing
August 2021

Editorial Commentary: Snapping Scapula Syndrome: Predictors of Outcomes After Arthroscopic Treatment.

Arthroscopy 2020 12;36(12):2973-2974

Vail, Colorado.

Snapping scapula syndrome and scapulothoracic bursitis are rare, often painful or functionally limiting conditions that can present owing to underlying anatomic abnormalities or can be idiopathic in nature. When there are no underlying structural abnormalities, diagnosis can be challenging and frequently patients will present with chronic pain having received multiple diagnostic and treatment modalities with no success. Injections into the scapulothoracic bursa, in conjunction with physical therapy, have been shown to be effective for the patient with snapping scapula syndrome and/or scapulothoracic bursitis, when recognized. Yet, some cases are recalcitrant to conservative treatment, and surgical intervention is required. As with any procedure, patient selection for surgical intervention is critical and based on the diagnostic workup-particularly, the response to diagnostic or therapeutic injections. The best surgical outcomes may be achieved in patients who receive bursectomy in conjunction with partial scapulectomy, and negative prognostic factors include older age, lower preoperative psychological score, and longer duration of symptoms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2020.09.010DOI Listing
December 2020

Anterior Shoulder Instability in the Professional Athlete: Return to Competition, Time to Return, and Career Length.

Orthop J Sports Med 2020 Nov 4;8(11):2325967120959728. Epub 2020 Nov 4.

United States Air Force, Eglin Air Force Base, Florida, USA.

Background: Anterior shoulder instability is a common condition in professional athletes, yet little is known about the success of surgery. Return to competition (RTC) is a metric indicative of a successful outcome for professional athletes who undergo anterior shoulder stabilization surgery.

Purpose: To determine the rate of RTC, time to RTC, recurrence rate, and length of career after surgery in professional athletes who had undergone surgical treatment for anterior shoulder instability.

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

Methods: We evaluated professional athletes who underwent surgical treatment for anterior shoulder instability by a single surgeon between 2007 and 2018. Data from patients' medical records, a patient data registry, basic search engines, sports websites, and individual team websites were used to determine length of professional play before injury, duration of career after surgery, and RTC level.

Results: Overall, 23 professional athletes (25 shoulders from 12 contact and 13 noncontact athletes) were identified. The mean age at the time of surgery was 24.3 ± 4.9 years (range, 16-35 years). Primary procedures included arthroscopic Bankart repair (76%; 19/25), open Latarjet (20%; 5/25), and bony Bankart repair (4%; 1/25). Of the 23 athletes, 22 returned to their previous level of competition (96%; 95% CI, 78%-100%). The mean time between surgery and RTC was 4.5 months (range, 3-8 months). There was no difference in time to RTC between contact and noncontact athletes (4.1 vs 4.4 months). There was no difference in RTC rates and time to return for players who received a Bankart repair versus a Latarjet procedure (4.6 vs 4.2 months). A total of 12 participants were still actively engaged in their respective sport at an average of 4.3 years since surgery, while 11 athletes went on to retire at an average of 4.8 years. Duration of play after surgery was 3.8 years for contact athletes and 5.8 years for noncontact athletes ( > .05).

Conclusion: In this series, professional athletes who underwent surgical shoulder stabilization for the treatment of anterior glenohumeral instability returned to their presurgical levels of competition at a high rate. No differences in RTC rate or time to RTC were observed for contact versus noncontact athletes or for those who received arthroscopic Bankart repair versus open Latarjet. However, contact athletes had shorter careers after surgery than did noncontact athletes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967120959728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645762PMC
November 2020

Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 10-Year Follow-up.

Am J Sports Med 2021 01 11;49(1):130-136. Epub 2020 Nov 11.

The Steadman Clinic, Vail, Colorado, USA.

Background: Few long-term outcome studies exist evaluating glenohumeral osteoarthritis (GHOA) treatment with arthroscopic management.

Purpose: To determine outcomes, risk factors for failure, and survivorship for the comprehensive arthroscopic management (CAM) procedure for the treatment of GHOA at minimum 10-year follow-up.

Study Design: Case series; Level of evidence, 3.

Methods: The CAM procedure was performed on a consecutive series of patients with advanced GHOA who opted for joint preservation surgery and otherwise met criteria for total shoulder arthroplasty. At minimum 10-year follow-up, postoperative outcome measures included change in the American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, 12-Item Short Form Health Survey (SF-12) Physical Component Summary, and visual analog scale for pain, along with the QuickDASH (shortened version of Disabilities of the Arm, Shoulder and Hand) and satisfaction score. Kaplan-Meier survivorship analysis was performed, with failure defined as progression to arthroplasty.

Results: In total, 38 CAM procedures were performed with 10-year minimum follow-up (range, 10-14 years) with a mean patient age of 53 years (range, 27-68 years) at the time of surgery. Survivorship was 75.3% at 5 years and 63.2% at minimum 10 years. Those who progressed to arthroplasty did so at a mean 4.7 years (range, 0.8-9.6 years). For those who did not undergo arthroplasty, American Shoulder and Elbow Surgeons scores significantly improved postoperatively at 5 years (63.3 to 89.6; < .001) and 10 years (63.3 to 80.6; = .007). CAM failure was associated with severe preoperative humeral head incongruity in 93.8% of failures as compared with 50.0% of patients who did not go on to arthroplasty ( = .008). Median satisfaction was 7.5 out of 10.

Conclusion: Significant improvements in patient-reported outcomes were sustained at minimum 10-year follow-up in young patients with GHOA who underwent a CAM procedure. The survivorship rate at minimum 10-year follow-up was 63.2%. Humeral head flattening and severe joint incongruity were risk factors for CAM failure. The CAM procedure is an effective joint-preserving treatment for GHOA in appropriately selected patients, with sustained positive outcomes at 10 years.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0363546520962756DOI Listing
January 2021

The Bony Bankart: Clinical and Technical Considerations.

Sports Med Arthrosc Rev 2020 Dec;28(4):146-152

The Steadman Clinic, Vail, CO.

Fractures of the anteroinferior aspect of the glenoid rim, known as a bony Bankart lesions, can occur frequently in the setting of traumatic anterior shoulder dislocation. If these lesions are large and are left untreated in active patients, then recurrent glenohumeral instability due to glenoid bone deficiency may occur. Therefore, the clinician must recognize these lesions when they occur and provide appropriate treatment to restore physiological joint stability. This article aims to provide an overview focusing on clinical and technical considerations in the diagnosis and treatment of bony Bankart lesions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JSA.0000000000000286DOI Listing
December 2020

Biologics to Improve Healing in Large and Massive Rotator Cuff Tears: A Critical Review.

Orthop Res Rev 2020 13;12:151-160. Epub 2020 Oct 13.

Steadman-Philippon Research Institute, Vail, CO 81657, USA.

Large and massive rotator cuff tears have the highest risk of retear. Common biologic modalities that can potentially reduce the retear rate and improve healing include platelet-rich plasma (PRP), scaffolds, and mesenchymal stem cells (MSCs). PRP has been studied for its role in improving rotator cuff healing and results of randomized controlled trials and meta-analyses show mixed results. Most studies in large and massivge tears show that PRP decreases the retear rate, but the connection between structural integrity and clinical outcomes is still unknown. Extracellular matrix (ECM) and synthetic scaffolds can increase healing in augmentation and bridging repair. Acellular dermal allografts have shown better healing rates and outcomes than xenografts in meta-analyses. Synthetic scaffolds augmented with bone marrow-derived stem cells have only been studied in vitro but are promising for the combination of mechanical stability and induction of a biological response. Superior capsule reconstruction is an exciting type of interposition graft reconstruction that has shown favorable early clinical outcomes for large and massive tears. Bone marrow-derived stem cells and adipose-derived stem cells improve the biomechanical characteristics of tendon repair and enhance the histological findings of the healing process in animal studies. However, evidence from human studies is lacking, especially in patients with large and massive tears. In summary, there are many biological options to augment rotator cuff repair in patients with large and massive tears. Due to mixed results and a lack of standardization in high-quality studies, we cannot recommend PRP at this time as an adjunct to rotator cuff repair. Both ECM and synthetic scaffolds, as well as SCR, can be used, especially in situations where native tendon is compromised, and additional mechanical augmentation is needed. Stem cells have been the least studied to date, so it is difficult to give recommendations for or against their use at this time.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2147/ORR.S260657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568683PMC
October 2020

Clinical Outcomes of Arthroscopic Suprascapular Nerve Decompression for Suprascapular Neuropathy.

Arthroscopy 2021 02 19;37(2):499-507. Epub 2020 Oct 19.

Steadman Clinic, Vail, Colorado, U.S.A.. Electronic address:

Purpose: To report clinical outcomes following arthroscopic suprascapular nerve (SSN) decompression for suprascapular neuropathy at the suprascapular and/or spinoglenoid notch in the absence of major concomitant pathology.

Methods: We retrospectively reviewed prospectively collected data of 19 patients who underwent SSN release at the suprascapular and/or spinoglenoid notch between April 2006 and August 2017 with ≥2 years of follow-up. Patients who underwent concomitant rotator cuff or labral repairs or had severe osteoarthritis were excluded. Pre- and postoperative strength and patient-reported outcomes were collected, including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numerical Evaluation (SANE), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), 12-item Short Form (SF-12), and satisfaction. Complications and revisions were recorded.

Results: At a mean final follow-up of 4.8 years, pre- to postoperative ASES (64.9 ± 18.7 versus 83.5 ± 23.1; P = .018), QuickDASH (28.7 ± 17.2 versus 12.7 ± 17.1; P = .028), SANE (64.3 ± 16.4 versus 80.8 ± 22.3; P = .034), and SF-12 PCS (41.1 ± 10.8 versus 52.3 ± 5.8; P = .007) scores all significantly improved. Median strength for external rotation improved significantly (4 [range 2 to 5] versus 5 [range 3 to 5]; P = .014). There was no statistically significant improvement in median strength for abduction (4 [range 3 to 5] versus 5 [5]; P = .059). Median postoperative satisfaction was 9 (range 1 to 10), with 8 patients (50%) rating satisfaction ≥9. No complications were observed, and no patients went on to revision surgery.

Conclusion: Arthroscopic SSN decompression for suprascapular neuropathy at the suprascapular and/or spinoglenoid notch in the absence of major concomitant glenohumeral pathology results in good functional outcomes with significant improvements from before to after surgery.

Level Of Evidence: IV, therapeutic case series.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2020.10.020DOI Listing
February 2021

Posterior Glenoid Augmentation With Extra-articular Iliac Crest Autograft for Recurrent Posterior Shoulder Instability.

Arthrosc Tech 2020 Sep 11;9(9):e1227-e1233. Epub 2020 Aug 11.

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

Several techniques have been described for bone block augmentation as a treatment for posterior shoulder instability, including intra-articular distal tibial allograft and extra-articular iliac crest autograft. Although indications are not yet well defined, these bone augmentation procedures are considered in patients with glenoid bone loss, increased glenoid retroversion, previous failed posterior soft-tissue repair, and insufficient posterior capsulolabral tissue. In patients with posterior glenoid bone loss, the senior author (P.J.M.) recommends intra-articular glenoid reconstruction with a fresh distal tibial osteoarticular allograft. In patients with insufficient posterior capsulolabral tissue, the senior author prefers an extra-articular iliac crest autograft to buttress the posterior soft-tissue restraints. This technique guide outlines extra-articular iliac crest autograft treatment for recurrent posterior shoulder instability in patients with insufficient posterior soft tissues due to prior failed surgery. After an open capsulolabral repair is performed using suture anchors, the bone block is placed extra-articularly on the posterior glenoid neck.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eats.2020.04.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528205PMC
September 2020

Arthroscopic Acromioclavicular Joint Treatment With Coracoclavicular Fixation and Allograft Coracoclavicular Ligament Reconstruction for Acute Acromioclavicular Dislocations.

Arthrosc Tech 2020 Sep 11;9(9):e1219-e1225. Epub 2020 Aug 11.

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

Treatment of severe acromioclavicular joint injuries remains controversial and has evolved over the past 4-plus decades. Although several variations on reconstruction exist, an ideal technique will likely use a combination of coracoclavicular ligament reconstruction with suture backup stabilization, minimal drill holes to reduce the risk of fracture, arthroscopic-assisted guidance for anatomic graft and suture placement in and around the coracoid, and fluoroscopic-aided reduction to ensure an anatomic acromioclavicular joint. The objective of this Technical Note is to describe an arthroscopic-assisted coracoclavicular ligament reconstruction with allograft using fluoroscopically guided and cerclage-controlled anatomic reduction of the acromioclavicular joint.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eats.2020.04.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528216PMC
September 2020

Arthroscopic Superior Capsular Reconstruction for Treatment of Massive Irreparable Rotator Cuff Tears: An Update of the Technique for 2020.

JBJS Essent Surg Tech 2020 Jul-Sep;10(3). Epub 2020 Aug 20.

Rothman Institute New York, New York, NY.

The treatment of massive, irreparable rotator cuff tears presents a substantial challenge to health-care professionals. Treatment options range from nonoperative to operative, including debridement, partial repair, biceps tenotomy, bridging patch grafts, muscle transfers, and reverse total shoulder arthroplasty. However, the results of such treatments are often mixed, and many carry a substantial risk of complications. Superior capsular reconstruction has been described as a surgical alternative to the aforementioned procedures. Superior capsular reconstruction is a technique that provides an anatomic reconstruction of the superior capsule of the glenohumeral joint, with the goal of restoring the normal restraint to superior translation that is lost with a deficient superior rotator cuff. The technique described in the present article highlights the pearls and pitfalls learned over the last several years of performing arthroscopic reconstruction of the superior capsule with dermal allograft.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.ST.19.00014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7494154PMC
August 2020

A Tensionable Suture-based Cerclage Is an Alternative to Stainless Steel Cerclage Fixation for Stabilization of a Humeral Osteotomy During Shoulder Arthroplasty.

J Am Acad Orthop Surg 2021 Jun;29(12):e609-e617

From Southern Oregon Orthopedics, Medford, OR (Dr. Denard), the Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR (Dr. Denard), Steadman Philippon Research Institute, Vail, CO (Dr. Nolte and Dr. Millett), BG Trauma Center Ludwigshafen at the University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwigshafen, Germany (Dr. Nolte), the The Steadman Clinic, Vail, CO (Dr. Millett), Naples Community Hospital (Dr. Adams and Mr. Rego), and Arthrex, Naples, FL (Dr. Adams, Dr. Liebler, Mr. Rego, and Dr. Higgins).

Introduction: Fixation of periprosthetic humeral fractures is most commonly obtained with steel-based wires or cables; however, disadvantages with these constructs are numerous. Suture-based cerclages offer the advantage of easy handling, less radiographic interference, and risk of metallosis, as well as decreased risk of cutting into the soft humeral bone. Therefore, the purpose of this study was to compare a suture-based cerclage to a stainless steel wire cerclage (SSWC) for stabilization of the humerus during shoulder arthroplasty.

Methods: In part I of the study, SSWC fixation was compared with single-looped tape cerclage and a double-looped tape cerclage (DLTC) fixation. In part II, a subsidence test was performed on 12 cadaveric humeri. After an osteotomy, the humeri were secured with either a SSWC or DLTC. Subsequently, a metal wedge was introduced into the humerus to simulate the stem of a shoulder arthroplasty.

Results: In part I, load to 2-mm displacement was significantly higher for the DLTC construct compared with the SSWC construct (2,401 ± 483 N versus 750 ± 33 N; P < 0.0001). Load to failure was 935 ± 143 N with the SSWC, 1,737 ± 113 N with the single-looped tape cerclage, and 4,360 ± 463 N with the DLTC constructs, and all differences were statistically significant (P < 0.05). In part II, load at 20-mm subsidence was higher for the DLTC (320 ± 274 N) compared with the SSWC (247 ± 137 N), but no significant difference was observed (P > 0.05). However, gap displacement at 20 mm subsidence was significantly lower with the DLTC construct (0.33 ± 0.31 mm versus 0.77 ± 0.23 mm; P = 0.009). Load to failure was higher with the DLTC construct compared with the SSWC construct (4,447 ± 2,325 N versus 1,880 ± 1,089 N; P = 0.032), but the final gap displacement did not differ significantly (DLTC 5.23 ± 6.63 mm versus SSWC 6.03 ± 8.82 mm; P > 0.05).

Discussion: A DLTC has higher load to failure and trends toward lower gap displacement compared with a SSWC. The DLTC construct may therefore be a viable alternative for fixation of periprosthetic fractures or osteotomies of the humeral shaft during shoulder arthroplasty.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-20-00047DOI Listing
June 2021

Total shoulder arthroplasty outcomes after noncorrective, concentric reaming of B2 glenoids.

JSES Int 2020 Sep 6;4(3):644-648. Epub 2020 May 6.

The Steadman Clinic, Vail, CO, USA.

Background: Total shoulder arthroplasty (TSA) is an effective procedure for the treatment of glenohumeral osteoarthritis (GHOA) delivering reliable pain relief and improved shoulder function. Abnormal glenoid morphologies are common, and biconcave glenoids are enigmas that have been associated with poor clinical outcomes and implant survivorship.

Purpose: To assess the clinical outcome scores of patients who underwent noncorrective, concentric reaming for TSA with biconcave glenoids (B2). We hypothesized that patients with B2 glenoids who underwent TSA with glenoid implantation using noncorrective, concentric reaming would have significant improvements in clinical outcome scores and high implant survivorship.

Methods: All patients who underwent anatomic TSA for GHOA with B2 glenoids, performed by a single surgeon, between July 2006 and December 2015 with minimum 2-year follow-up were reviewed. Walch classification was obtained from preoperative imaging (magnetic resonance imaging or computed tomography). Clinical outcome scores were prospectively collected and included American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numerical Evaluation (SANE) score, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, 12-Item Short Form Health Survey physical component summary (PCS), and patient satisfaction. Clinical failures (revision TSA surgery or conversion to reverse TSA) and complications were reported. Paired test and bivariate correlations level of significance was set at  = .05. Survivorship analysis with implant failure as an endpoint was done using Kaplan-Meier survival curves.

Results: 51 TSA in 49 patients (9 females, 40 males) with primary GHOA with B2 glenoids were performed with a mean age of 64 (range 36-81 years) at the time of surgery. The mean retroversion was 19.1° (range 5.4°-38°), and posterior decentering was 42.0% (range 19.4%-78.5%). At final evaluation, 45/51 anatomic TSAs (88% follow-up) with a mean follow-up of 4.9 years (range 2.0-10.4 years) were assessed. All clinical outcome scores improved significantly pre- to postoperatively: ASES, 52.5 to 79.6 ( < .001); SANE, 52.4 to 74.7 ( < .001); QuickDASH, 39.2 to 19.1 ( = .001); and PCS, 40.9 to 48.9 ( = .001). Median postoperative satisfaction was 9 (range 1-10). There were 2 failures and 4 that required another surgery -subscapularis repair, lysis of adhesions, irrigation and débridement, and one to explore the status of the subscapularis for persistent pain. The implant survivorship rate was 95% at a mean follow-up of 4.9 years.

Conclusion: Anatomic total shoulder replacement with minimally noncorrective, concentric reaming in patients with B2 glenoids had significant improvement in clinical outcome scores, high patient satisfaction, and high survivorship in this cohort.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jseint.2020.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7479043PMC
September 2020
-->