Background: Arthroscopic remplissage is an effective adjunct for anterior shoulder stabilization in patients with large engaging Hill-Sachs lesions (HSLs) and without significant glenoid bone loss or ...on-track HSLs with high risk of recurrence. Indications: The arthroscopic remplissage shown was performed in a patient with a high-risk profile for recurrence (age <25, near track) following a first-time traumatic anterior dislocation event. In this specific case, the remplissage was used to fill a near-track HSL, a significant risk factor for recurrence. Technique Description: Following diagnostic shoulder arthroscopy, the anterior labral repair is started with placement of the most inferior anchor and passage of the suture around the labrum and capsule. This anchor is not tightened to allow visualization and access to the posterior humeral head. Posterior labral work is then performed if there is a posterior labral tear extension. Next, for the remplissage, 2 double loaded suture anchors are placed spanning the HSL and passed through the capsule/infraspinatus without tightening. The prior placed anterior inferior anchor is then tightened. The remaining anterior labrum is then completed with capsulorraphy using additional 3 knotless suture anchors. Finally, the remplissage is completed using a double pulley method to pull the posterior capsule into fill the HSL. Results: Based on literature and the author's experience, addition of a remplissage for arthroscopic anterior stabilization in patients with anterior glenohumeral instability and either off-track HSL, or on-track HSL with high risk of recurrence can significantly reduce rates of recurrent instability when compared to arthroscopic Bankart repair alone. Discussion/Conclusion: Arthroscopic remplissage is an effective adjunct for arthroscopic anterior instability in patients with off-track HSLs or on-track HSLs with high risk of recurrence that is efficient with low surgical complication risk when performed with proper technique. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
The purpose of this study was to compare recurrent instability and return to play (RTP) in young athletes who underwent clearance to full activity based on a validated return-to-sport (RTS) test to ...those who underwent time-based clearance following primary posterior labral repair.
This was a retrospective review of athletes with posterior shoulder instability who underwent primary arthroscopic posterior labral repair from 2012 to 2021 with minimum 1-year follow-up. Patients who underwent RTS testing at a minimum of 5 months postoperatively were compared to a historic control cohort of patients who underwent time-based clearance.
There were 30 patients in the RTS cohort and 67 patients in the control cohort (mean follow-up 32.1 and 38.6 months, respectively). Of the 30 patients who underwent RTS testing, 11 passed without failing any sections, 10 passed while failing 1 section, and 9 failed the RTS test by failing 2+ sections. No differences were found between the RTS and control cohort in the incidence of recurrent instability (6.7% vs. 9.0%), overall RTP (94.7% vs. 94.3%), RTP at the same level as before injury (84.2% vs. 80.0%), recurrent pain/weakness (23.3% vs. 25.4%), or revision surgery (0% vs. 3.0%), respectively.
While RTS testing in young athletes after posterior labral repair did not reduce recurrence or improve return to play compared to time-based clearance, two-thirds of athletes who underwent testing failed at least 1 section, indicating some functional deficit. Thus, RTS testing may help guide postoperative rehabilitation following posterior stabilization.
Posterior shoulder instability is of particular therapeutic interest, as it typically affects patients with high functional demands such as young athletes and active adults. Although posterior ...capsulolabral repair has high return-to-sport rates, it is associated with recurrent instability of up to 11%. Posterior glenoid bone loss and significant glenoid retroversion have been identified as risk factors for recurrent instability and failure after primary arthroscopic soft-tissue repair. Therefore, posterior glenoid bone block reconstruction may be indicated for glenoid bone loss 20% or greater (as measured by the perfect circle technique) or greater than 10% in the setting of pathologic glenoid, failed primary posterior labral repair, incompetent posterior capsular tissue, or significant risk factors for failure of soft-tissue repair. This procedure may be performed arthroscopically or with a posterior open approach using distal tibial allograft, iliac crest autograft, or scapular spine autograft. Although short-term to midterm outcomes have been promising, there remain concerns regarding long-term outcomes, with potentially high rates of late recurrence, revision, and secondary osteoarthritis.
The primary purpose of this study was to identify demographic, anatomic, and radiographic risk factors for active forward elevation (AFE) <90° in the setting of massive, irreparable rotator cuff tear ...(miRCT). The secondary purpose was to identify characteristics differentiating between patients with pseudoparalysis (AFE <45°) and pseudoparesis (AFE >45° but <90°).
This was a retrospective case-control study reviewing patients with miRCTs at a single institution between January 12, 2016 and November 26, 2020. Patients were separated into 2 cohorts based on presence or absence of preoperative AFE <90° with maintained passive range of motion. Demographics, RCT pattern, and radiographic parameters were assessed as risk factors for AFE <90°. A secondary analysis was conducted to compare patients with pseudoparalysis and pseudoparesis.
There were 79 patients in the AFE <90° cohort and 50 patients in the control cohort. Univariate analysis confirmed significant differences between the AFE <90° and control cohort in age (71.9 ± 11.0 vs. 65.9 ± 9.1 years), arthritis severity (34.2% vs. 16.0% grade 3 Samilson-Prieto), acromiohumeral distance (AHD; 4.8 ± 2.7 vs. 7.6 ± 2.6 mm), fatty infiltration of the supraspinatus (3.3 ± 0.9 vs. 2.8 ± 0.8) and subscapularis (2.0 ± 1.2 vs. 1.5 ± 1.0), and proportion of subscapularis tears (55.7% vs. 34.0%). On multivariate analysis, age (odds ratio OR 1.08, P = .014), decreased AHD (OR 0.67, P < .001), severe arthritis (OR 2.84, P = .041), and subscapularis tear (OR 6.29, P = .015) were independent factors predictive of AFE <90°. Secondary analysis revealed tobacco use (OR 3.54, P = .026) and grade 4 fatty infiltration of the supraspinatus (OR 2.22, P = .015) and subscapularis (OR 3.12, P = .042) as significant predictors for pseudoparalysis compared to pseudoparesis.
In patients with miRCT, increased age, decreased AHD, severe arthritis, and subscapularis tear are associated with AFE <90°. Furthermore, patients with AFE <90° tend to have greater supraspinatus and subscapularis fatty infiltration. Lastly, among patients with AFE <90°, tobacco use and grade 4 fatty infiltration of the supraspinatus and subscapularis are associated with pseudoparalysis compared with pseudoparesis.
With the COVID-19 pandemic placing an increased burden on health care systems, shoulder arthroplasties are more commonly being performed as outpatient procedures. The purpose of this study was to ...characterize the 90-day episode-of-care complications of consecutive shoulder arthroplasties defaulted for outpatient surgery without using a prior algorithm for patient selection and to assess for their risk factors. We hypothesized that outpatient shoulder arthroplasty would be a safe procedure for all patients, regardless of patient demographics and comorbidities.
A retrospective review of consecutive patients who underwent planned outpatient anatomic or reverse total shoulder arthroplasty between March 2020 and January 2022 with 3-month follow-up was performed. All patients were scheduled for outpatient surgery regardless of medical comorbidities. Patient demographics; pre/postoperative patient-reported outcomes including visual analog scale, subjective shoulder value, and American Shoulder and Elbow Surgeons score; pre/postoperative range of motion; and complications were collected from medical chart review. Multivariate logistic regression was used to identify predictors of the following outcomes: 1. Unplanned overnight hospital stay, 2. 90-day unplanned emergency department (ED)/clinic visit, 3. 90-day hospital readmission, 4. 90-day complications requiring revision.
One hundred twenty-seven patients (47% male, 17% tobacco users, 18% diabetics) with a mean age 69 ± 9 years were identified, of whom 92 underwent reverse total shoulder arthroplasty and 35 underwent anatomic total shoulder arthroplasty. All patient-reported outcomes and range of motion were significantly improved at 3 months. There were 15 unplanned overnight hospital stays (11.8%) after the procedure. Within 90 days postoperatively, there were 17 unplanned ED/clinic visits (13.4%), 7 hospital readmissions (5.5%), and 4 complications requiring revision (3.1%). Factors predictive of unplanned overnight stay included age above 70 years (odds ratio OR, 36.80 95% confidence interval CI, 2.20-615.49; P = .012), tobacco use (OR, 12.90 95% CI, 1.23-135.31; P = .033), and American Society of Anesthesiologists status of 3 (OR, 13.84 95% CI, 1.22-156.57; P = .034). The only factor predictive of unplanned ED/clinic visit was age over 70 years old (OR, 7.52 95% CI, 1.26-45.45; P = .027). No factors were predictive of 90-day hospital readmission or revision.
Outpatient shoulder arthroplasty is a safe procedure with excellent outcomes and low rates of readmissions and can be considered as the default plan for all patient undergoing shoulder arthroplasty. Patients who are above 70 years of age, use tobacco, and have ASA score of 3, however, may be less suitable for outpatient arthroplasty and should be counseled regarding the higher risk of unplanned overnight hospitalization.
Management of patients with recurrent anterior glenohumeral instability in the setting of subcritical glenoid bone loss (GBL), defined in this study as 20% GBL or less, remains controversial. This ...study aimed to compare arthroscopic Bankart with remplissage (ABR+R) to open Latarjet for subcritical GBL in primary or revision procedures. We hypothesized that ABR+R would yield higher rates of recurrent instability and reoperation compared to Latarjet in both primary and revision settings.
A retrospective study was conducted on patients undergoing either arthroscopic ABR+R or an open Latarjet procedure. Patients with connective tissue disorders, critical GBL (>20%), < 2 year follow-up, or insufficient data were excluded. Recurrent instability and revision were the primary outcomes of interest. Additional outcomes of interest included subjective shoulder value (SSV), strength and range of motion (ROM)
108 patients (70 ABR+R, 38 Latarjet) were included with an average follow-up of 4.3 ±2.1 years. In the primary and revision settings, similar rates of recurrent instability (Primary: p=0.60; Revision: p=0.28) and reoperation (Primary: p=0.06; Revision: p=1.00) were observed between Latarjet and ABR+R. Primary ABR+R exhibited better SSV, active ROM, and internal rotation strength compared to primary open Latarjet. However, no differences were observed in the revision setting.
Similar rates of recurrent instability and reoperation in addition to comparable outcomes with no differences in ROM were found for ABR+R and Latarjet in patients with subcritical GBL in both the primary and revision settings. ABR+R can be a safe and effective procedure in appropriately selected patients with less than 20% GBL for both primary and revision stabilization.
Margin convergence (MC) and superior capsular reconstruction (SCR) are common treatment options for irreparable rotator cuff tears in younger patients, although they differ in associated costs and ...operative times. The purpose of this study was to compare range of motion, patient-reported outcomes (PROs), and reoperation rates following MC and SCR. We hypothesized superior outcomes after SCR relative to MC regarding functional outcomes, subjective measures, and reoperation rates.
This was a multicenter retrospective review of 59 patients from 3 surgeons treating irreparable rotator cuff tears with either MC (n = 28) or SCR (n = 31) and minimum 1-year follow-up from 2014-2019. Visual analog scale (VAS) for pain, Subjective Shoulder Value (SSV), active forward flexion (FF), external rotation (ER), retear rate, and conversion rate to reverse shoulder arthroplasty were evaluated. t tests and χ2 tests were used for continuous and categorical variables, respectively (P < .05).
Baseline demographics, range of motion, and magnetic resonance imaging findings were similar between groups. Average follow-up was 31.5 months and 17.8 months for the MC and SCR groups, respectively (P < .001). The MC and SCR groups had similar postoperative FF (151° ± 26° vs. 142° ± 38°; P = .325) and ER (48° ± 12° vs. 46° ± 11°; P = .284), with both groups not improving significantly from their preoperative baselines. However, both cohorts demonstrated significant improvements in VAS score (MC: 7.3 to 2.5; SCR: 6.4 to 1.0) and SSV (MC: 54% to 82%; SCR: 38% to 87%). There were no significant differences in postoperative VAS scores, SSV, and rates of retear or rates of conversion to arthroplasty between the MC and SCR groups. In patients with preoperative pseudoparesis (FF < 90°), SCR (n = 9) resulted in greater postoperative FF than MC (n = 5) (141° ± 38° vs. 67° ± 24°; P = .002).
Both MC and SCR demonstrated excellent postoperative outcomes in the setting of massive irreparable rotator cuff tear, with significant improvements in PROs and no significant differences in range of motion. Specifically for patients with preoperative pseudoparesis, SCR was more effective in restoring forward elevation. Further long-term studies are needed to compare outcomes and establish appropriate indications.
To determine the comparative accuracy and precision of routine magnetic resonance imaging (MRI) versus magnetic resonance (MR) arthrogram in measuring labral tear size as a function of time from a ...shoulder dislocation.
We retrospectively evaluated consecutive patients who underwent primary arthroscopic stabilization between 2012 and 2021 in a single academic center. All patients completed a preoperative MRI or MR arthrogram of the shoulder within 60 days of injury and subsequently underwent arthroscopic repair within 6 months of imaging. Intraoperative labral tear size and location were used as standards for comparison. Three musculoskeletal radiologists independently interpreted tear extent using a clock-face convention. Accuracy and precision of MR labral tear measurements were defined based on location and size of the tear, respectively. Accuracy and precision were compared between MRI and MR arthrogram as a function of time from dislocation.
In total, 32 MRIs and 65 MR arthrograms (total n = 97) were assessed. Multivariate analysis demonstrated that intraoperative tear size, early imaging, and arthrogram status were associated with increased MR accuracy and precision (P < .05). Ordering surgeons preferred arthrogram for delayed imaging (P = .018). For routine MRI, error in accuracy increased by 3.4° per day and error in precision increased by 2.3° per day (P < .001) from time of injury. MR arthrogram, however, was not temporally influenced. Significant loss of accuracy and precision of MRI compared with MR arthrogram occurred at 2 weeks after an acute shoulder dislocation.
Compared with MR arthrogram, conventional MRI demonstrates time-dependent loss of accuracy and precision in determining shoulder labral tear extent after dislocation, with statistical divergence occurring at 2 weeks.
Level II, retrospective radiographic diagnostic study.
Large, circumferential glenoid labral tears are an uncommon injury affecting young, athletic patients. There are limited data describing the clinical presentation of patients with larger tears, ...especially 270° and 360° labral tears. Additionally, examination and imaging findings have poor reliability in diagnosing these tears. The purpose of this study was to determine the clinical presentation among patients presenting with small (less than 180°), medium (180°-270°), and large (270°-360°) labral tears.
This is a retrospective comparative study of consecutive patients surgically managed by a single shoulder surgeon for all glenoid labral tears from 2018-2022. The primary outcome was demographic and preoperative clinical risk factors. Demographic data including age, sex, hand dominance, body mass index, as well as clinical presentation (subluxation vs. dislocation, instability history, and participation in contact sports) were recorded.
A total of 188 patients met the inclusion criteria: 101 of 188 (53.70%) patients with small tears, 43 of 188 (22.90%) patients with medium tears, and 44 of 188 (23.40%) patients with large tears. Individuals with large and medium-sized labral tears were more likely to have participated in contact sports compared to those with smaller labral tears (P = .003). Medium and smaller tears were more likely to present as dominant-side injury (P = .02). Furthermore, medium and large tears were more likely to present with anterior instability symptoms compared with smaller tears, which more frequently presented with posterior instability and pain (P = .003).
Males participating in contact sports were the most common demographic population presenting with large, 270°-360° labral tears. Instability was the primary complaint rather than pain, and compared with small tears, medium and large tears were more likely to present with primary anterior instability. Although arthroscopic repair of 270°-360° labral tears can yield excellent clinical outcomes similar to smaller tears, identifying factors associated with larger glenoid labral tears may help in surgical planning and patient counseling.
Indications for reverse total shoulder arthroplasty (RSA) have expanded to include individuals with intact rotator cuffs such as patients with severe glenoid deformity or with concern of future ...rotator cuff insufficiency. The purpose of this study was to compare outcomes of RSA with an intact rotator cuff to RSA for cuff arthropathy and anatomic total shoulder arthroplasty (TSA). We hypothesized that outcomes of RSA with an intact rotator cuff would be comparable to RSA for cuff arthropathy and TSA but with diminished range of motion (ROM) compared with TSA.
Patients at one institution who underwent RSA and TSA between 2015 and 2020 with minimum 12-month follow-up were identified. RSA with preservation of the rotator cuff (+rcRSA) was compared to RSA for cuff arthropathy (–rcRSA) and anatomic TSA (TSA). Demographics and glenoid version/inclination were obtained. Pre- and postoperative ROM; patient-reported outcomes including visual analog scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores; and complications were obtained.
Twenty-four patients underwent +rcRSA, 69 underwent –rcRSA, and 93 underwent TSA. There were more women in the +rcRSA cohort (75.8%) than in the –rcRSA (37.7%, P = .001) and TSA (37.6%, P = .001) cohorts. Mean age of the +rcRSA cohort (71.1) was greater than that of TSA (66.0, P = .021) but similar to that of –rcRSA (72.4, P = .237). Glenoid retroversion was greater in +rcRSA (18.2°) compared with –rcRSA (10.5°, P = .011) but was similar to TSA (14.7°; P = .244). Postoperatively, there were no differences in VAS or ASES between +rcRSA vs. –rcRSA and +rcRSA vs. TSA. SSV was lower in +rcRSA (83.9) compared with –rcRSA (91.8, P = .021), but was similar to TSA (90.5, P = .073). Similar ROM was achieved in forward flexion, external rotation, and internal rotation at final follow-up between +rcRSA and –rcRSA, but TSA had greater external rotation (44° vs. 38°, P = .041) and internal rotation (6.5° vs. 5.0°, P = .001) compared with +rcRSA. There were no differences in complication rates.
At short-term follow-up, preservation of the rotator cuff in RSA demonstrated similarly excellent outcomes and low complication rates compared with RSA with a deficient rotator cuff and TSA, except for slightly lower internal and external rotation compared with TSA. Although multiple factors deserve consideration when choosing between RSA and TSA, RSA with preservation of the posterosuperior cuff is a viable treatment option for glenohumeral osteoarthritis, particularly in patients with severe glenoid deformity or those at risk for future rotator cuff insufficiency.
