Nauert, Richard F.

Background: The Latarjet procedure is effective for patients with anterior glenohumeral instability with substantial glenoid bone loss due to its triple blocking effect. Indications: Indications include high-risk patients with recurrent anterior glenohumeral instability with any glenoid bone loss or low-risk patients with 15% to 30% glenoid bone loss. Technique Description: An incision is made lateral to the coracoid and the deltopectoral interval is established. The pectoralis minor is released medially off the coracoid and the coracoacromial (CA) ligament is released close to the acromion. The coracoid is cut with a right-angle saw and the inferior coracoid is decorticated with a burr. Two holes are pre-drilled in the coracoid. The subscapularis is split between the upper two-thirds and lower one-third with the arm in external rotation. The capsule is split vertically at the joint line and the humeral head is retracted. The anterior glenoid is decorticated with a burr, and a hole is drilled inferiorly. The depth is measured and added to the depth of the inferior bone block hole. A fully threaded 3.5-mm solid stainless steel screw is placed in the inferior hole. Care is taken to ensure that the lateral border of the bone block is flush with the articular margin. This is repeated for the superior hole. A 1.8-mm knotless suture anchor is placed between the screws. The repair stitch is passed through the capsule and loaded onto the anchor and tensioned. The CA ligament is laid over the capsule and repaired. The subscapularis split is repaired side to side and the wound is closed in layers. Results: High return-to-sport rates, including at the same level of play, have been observed among young competitive athletes with significant glenoid bone loss who underwent a Latarjet, with similarly favorable results in older patients. Ninety-day complication rates have been reported around 9%, 5% of which constituted graft or hardware failures. Discussion/Conclusion: The Latarjet procedure is an effective option for indicated patients with anterior glenohumeral instability and may be enhanced with solid screws, proper anatomic technique, and capsulolabral repair augmentation. 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.

Background: The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus force across the elbow during throwing. The incidence of MUCL continues to rise, and injuries are common in overhead throwing athletes often leading to elbow pain and instability. While MUCL reconstruction remains the gold standard for high-level throwing athletes with midsubstance tears, MUCL repair remains an option for select athletes and affords good functional outcomes with quicker return to sport compared with reconstruction. Indications: Indications for MUCL repair include acute injuries, proximal or distal avulsions, young and lower demand athletes, non-throwing athletes, or older athletes who may be nearing retirement. Technique Description: An incision is made over the medial elbow from the medial epicondyle to the sublime tubercle. Dissection is carried down to fascia which is split in line with its fibers. The flexor pronator muscle group is bluntly divided, and the ligament exposed. Care is taken to identify and dissect the native ligament. The avulsed portion of the ligament is secured with a 0 FiberWire suture in a running locked whipstitch fashion. The footprint of the avulsed ligament is gently debrided and prepared using a scalpel. The 0-FiberWire suture tails are then loaded onto a suture anchor preloaded with suture tape. This is then secured at the footprint of the ligament. The FiberWires are cut, and the suture tape is then pulled back over the native ligament and fixed at the other attachment site for the ligament. 0-Vicryl sutures are then used to suture the internal brace to the underlying ligament so the construct would move as a single unit. Results: Biomechanical testing has demonstrated that MUCL repair with internal brace augmentation has similar time-zero failure strength when compared with the original Jobe reconstruction technique while also having greater resistance to gapping. In addition, recent literature has shown that well-selected patients can have excellent functional outcomes and quicker return to sport with MUCL repair as opposed to reconstruction. Discussion: Medial ulnar collateral ligament repair with internal brace augmentation can be a successful treatment in the appropriately indicated athlete to allow for good functional results and quicker return to sport. 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.

Background: Prospective evaluation of clinical outcomes after posterior meniscal root repair utilizing a transtibial pullout technique is limited, and factors that may contribute to outcomes are unclear. Hypothesis: It was hypothesized that there would be an overall significant improvement in outcomes after root repair and that differences in clinical outcomes would correlate with age, body mass index (BMI), sex, and meniscal extrusion. Study Design: Case-control study; Level of evidence, 3. Methods: Consecutive patients undergoing transtibial medial or lateral meniscal root repair were enrolled prospectively at 2 orthopaedic centers between March 2017 and January 2019. Pre- and postoperative magnetic resonance imaging (MRI) were obtained to assess for meniscal healing, quantification of extrusion, articular cartilage grade, and subchondral bone changes. Patient-reported outcomes including International Knee Documentation Committee (IKDC) scores, Tegner activity scale, and visual analog scale (VAS) for pain were collected preoperatively and 2 years postoperatively. Patients were then subdivided by clinical and demographic characteristics to determine factors associated with clinical outcomes. Results: Included were 45 patients (29 female, 16 male; mean age, 42.3 ± 12.9 years; mean BMI, 31.6 kg/m 2 ) who underwent 47 meniscal root repairs (29 medial and 16 lateral; 2 had both). Significant improvements at 2-year follow-up were seen in IKDC score (41.1 vs 78.4; P < .001), Tegner activity level (3 vs 4; P < .001), and VAS pain (2.8 vs 0.7; P < .001). BMI, preoperative malalignment, cartilage status, and progressive meniscus extrusion (Δ = 0.7 mm) did not have a negative impact on IKDC and Tegner scores 2 years postoperatively. Age greater than or equal to 50 years and extrusion pre- and postoperatively were associated with decreased Tegner scores. Progressive meniscal extrusion was associated with a decreased overall improvement in Tegner scores. Conclusion: Transtibial root repair for medial and lateral posterior meniscal root tears demonstrated significantly improved clinical outcomes at 2 years postoperatively. Increased age, increased BMI, cartilage status, and meniscal extrusion did not have a negative impact on short-term functional outcomes (IKDC), but age greater than or equal to 50 years and extrusion negatively influenced patient activity level (Tegner). Registration: NCT03037242 ( ClinicalTrials.gov identifier).

Background: Athletes of all sports often have shoulder instability, most commonly as anterior shoulder instability (ASI). For overhead athletes (OHAs) and those participating in throwing sports, clinical and surgical decision making can be difficult owing to a lack of long-term outcome studies in this population of athletes. Purpose/Hypothesis: To report presentation characteristics, pathology, treatment strategies, and outcomes of ASI in OHAs and throwers in a geographic cohort. We hypothesized that OHAs and throwers would have similar presenting characteristics, management strategies, and clinical outcomes but lower rates of return to play (RTP) when compared with non-OHAs (NOHAs) and nonthrowers, respectively. Study Design: Cohort study; Level of evidence, 3. Methods: An established geographic medical record system was used to identify OHAs diagnosed with ASI in the dominant shoulder. An overall 57 OHAs with ASI were matched 1:2 with 114 NOHAs with ASI. Of the OHAs, 40 were throwers. Sports considered overhead were volleyball, swimming, racquet sports, baseball, and softball, while baseball and softball composed the thrower subgroup. Records were reviewed for patient characteristics, type of sport, imaging findings, treatment strategies, and surgical details. Patients were contacted to collect Western Ontario Shoulder Instability index (WOSI) scores and RTP data. Statistical analysis compared throwers with nonthrowers and OHAs with NOHAs. Results: Four patients, 3 NOHAs and 1 thrower, were lost to follow-up at 6 months. Clinical follow-up for the remaining 167 patients (98%) was 11.9 ± 7.2 years (mean ± SD). Of the 171 patients included, an overall 41 (36%) NOHAs, 29 (51%) OHAs, and 22 (55%) throwers were able to be contacted for WOSI scores and RTP data. OHAs were more likely to initially present with subluxations (56%; P = .030). NOHAs were more likely to have dislocations (80%; P = .018). The number of instability events at presentation was similar. OHAs were more likely to undergo initial operative management. Differences in rates of recurrent instability were not significant after initial nonoperative management (NOHAs, 37.1% vs OHAs, 28.6% [ P = .331] and throwers, 21.2% [ P = .094]) and surgery (NOHAs, 20.5% vs OHAs, 13.0% [ P = .516] and throwers, 9.1% [ P = .662]). Rates of revision surgery were similar (NOHAs, 18.0% vs OHAs, 8.7% [ P = .464] and throwers, 18.2% [ P > .999]). RTP rates were 80.5% in NOHAs, as compared with 71.4% in OHAs ( P = .381) and 63.6% in throwers ( P = .143). Median WOSI scores were 40 for NOHAs, as compared with 28 in OHAs ( P = .425) and 28 in throwers ( P = .615). Conclusion: In a 1:2 matched comparison of general population athletes, throwers and OHAs were more likely to have more subtle instability, as evidenced by higher rates of subluxations rather than frank dislocations, when compared with NOHAs. Despite differences in presentation and the unique sport demands of OHAs, rates of recurrent instability and revision surgery were similar across groups. Similar outcomes in terms of RTP, level of RTP, and WOSI scores were achieved for OHAs and NOHAs, but these results must be interpreted with caution given the limited sample size.

Objectives: There is a paucity of literature regarding outcomes of anterior shoulder instability (ASI) in throwers and overhead athletes (OHA). The purpose of this study was to report the pathology, treatment strategies, and outcomes of ASI in throwers and overhead athletes utilizing an established US geographic population-based cohort. Methods: An established geographic database of more than 500,000 patients was used to identify athletes <40 years of age with ASI between 1994 and 2016. Medical records were reviewed to obtain demographics, type of sport, surgical details, and clinical outcomes. Patients were contacted after final clinical follow-up for patient reported outcomes (PRO). The Western Ontario Shoulder Instability (WOSI) score, return to sport at previous level of performance (RPP), rate of return to play (RTP) and time to RTP were recorded. Statistical analysis was performed comparing throwers to non-throwers and OHA to non-overhead athletes (NOHA). Results: The study population consisted of 171 patients, 114 NOHA and 57 OHA. Of the OHA, 40 were throwers. The mean follow-up was 14.7 ± 5.6 years for PRO’s and 11.7 ± 7.3 years for last clinical evaluation. No difference in overall instability events was seen in either group. Throwers were more likely to present with subluxations while non-throwers were more likely to present with frank dislocations. NOHA and non-throwers were more likely than OHA and throwers to have a history of trauma related to ASI, respectively ( P = <.001, P = .002). Throwers were more likely to undergo an open surgical procedure (45%) than non-throwers (15%) ( P = .038). The rate of recurrent instability between groups was similar. Throwers returned to sport at a lower rate than non-throwers, however this did not reach significance (64% vs 83%, P = .100). Throwers and OHA reported similar WOSI scores, RPP and time to RTP grouped by surgical or conservative management compared to non-throwers and NOHA, respectively. Conclusions: In a US cohort of patients, throwers and OHA had a similar number of instability events compared to non-throwers and NOHA, respectively. Non-throwers and NOHA were more likely to present with frank dislocation which is supported by the significantly higher rates of trauma in both groups. Notably, the WOSI score, RPP, rate of RTP and time to RTP showed no difference between throwers and OHA when compared to their non-throwing and NOHA counterparts.

Background: Prospective studies evaluating second-look imaging of meniscus root repair using a transtibial pull-out technique are limited; therefore, optimal surgical indications and the technique for meniscus root repair remain uncertain. Hypothesis: It was hypothesized that there would be a high rate of healing, improvement in meniscal extrusion, and prevention of articular cartilage degeneration and subchondral bone abnormalities after meniscus root repair. Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients undergoing transtibial root repair were prospectively enrolled at 2 orthopaedic centers between March 2017 and January 2019. Pre- and postoperative magnetic resonance imaging (MRI) scans were reviewed by a musculoskeletal radiologist in a blinded fashion for meniscal healing, quantification of extrusion, articular cartilage grade, subchondral bone changes, and coronary/meniscotibial ligament abnormalities. Given persistent extrusion observed on postoperative MRI scans, an additional 10 patients gave consent and were enrolled for immediate (before weightbearing) postoperative MRI scans. Results: A total of 45 patients (16 male, 29 female; mean ± standard deviation age, 42.3 ± 12.9 years; body mass index, 31.6) were prospectively enrolled in the study; there were 47 meniscus root repairs: 29 medial and 18 lateral (2 with both). Postoperative MRI was obtained at an average of 6.3 months (range, 5.1-8 months); 98% of meniscal repairs had evidence of healing. Mean extrusion increased significantly, from 1.9 ± 1.5 mm preoperatively to 2.6 ± 1.4 mm postoperatively ( P = .03). There was no significant progression of chondromalacia grade, subchondral edema, insufficiency fracture, subchondral cysts, or subchondral collapse. In the additional 10-patient cohort, the mean preoperative extrusion (1.6 ± 1.2 mm) was not significantly different from that immediately postoperatively (2.0 ± 1.0 mm; P = .23). Conclusion: Prospective MRI analysis of transtibial meniscus root repair confirmed a high rate of meniscal healing and no observable progression of cartilage degeneration or subchondral bone abnormalities at the short-term follow-up. However, meniscal extrusion worsened in the first 6 months after surgery. Registration: NCT03037242 ( ClinicalTrials.gov identifier).