Woodmass, Jarret Murray

Background: Diagnosis and treatment of posterior shoulder instability (PSI) has improved with advances in imaging and surgical technique. However, the relationship between PSI and osteoarthritis (OA) remains unclear. Purpose: To evaluate a population-based cohort to (1) determine the rate of symptomatic OA, (2) identify patient characteristic risk factors for OA, and (3) evaluate the effect of posterior capsulolabral repair on OA progression. Study Design: Case-control study; Level of evidence, 3. Methods: After review of 324 patient records, we included 115 patients (14 female, 101 male) diagnosed with PSI between January 1994 and July 2012 with an average follow-up of 12.5 years (range, 5-23 years). Medical records were reviewed for patient characteristics, injury characteristics, surgical details (if any), and radiographic progression of OA. Kaplan-Meier survival was used to estimate survival free of OA; characteristics associated with OA progression were determined via univariate Cox regression models, and associated 95% CIs and hazard ratios (HRs) are presented. Results: Overall, 14% (16/115) of patients had radiographic progression of symptomatic glenohumeral arthritis, with 5-year survival of 88.3% (95% CI, 79.7%-97.3%). Older age at the time of instability diagnosis was associated with arthritis progression (10-year unit HR, 1.95; 95% CI, 1.26-3.03). Patients who underwent surgery demonstrated increased radiographic progression of OA (HR, 4.03; 95% CI, 1.23-13.23). There was a trend of increased OA in patients treated with labral debridement compared with repair despite lower baseline levels of OA; however, this difference was not statistically significant ( P = .09). Conclusion: Symptomatic glenohumeral arthritis is not seen routinely in patients with PSI. Although uncommon, an age of at least 30 years at the time of diagnosis and surgical intervention were identified as risk factors for developing symptomatic arthritis at long-term follow-up.

Objective: To report the injury characteristics, radiographic findings, and long-term outcomes of nonoperative management for posterior shoulder instability (PSI). Design: A retrospective review of 143 patients with PSI using a large geographic database. Setting: Single county between January 1994 and July 2012. Patients: A clinical history and diagnosis of PSI, one confirmatory imaging study to support the diagnosis, and a minimum of 5 years follow-up were required for inclusion. Patients with seizure disorders, anterior-only instability, multidirectional instability, and superior labrum from anterior to posterior diagnosis were excluded. Interventions: Patients with PSI were managed nonoperatively or operatively. Main Outcome Measures: Pain, recurrent instability, and progression into glenohumeral osteoarthritis at long-term follow-up. Results: One hundred fifteen patients were identified. Thirty-seven (32%) underwent nonoperative management. Twenty (54%) patients were diagnosed with posterior subluxation, 3 (8%) with a single dislocation, and 7 (19%) with multiple dislocations. Symptomatic progression of glenohumeral arthritis was observed in 8% (3) of patients. Pain improved in 46% (17) of patients and worsened in 19% (7). Recurrent instability and progression to osteoarthritis occurred in 15% (3/20) of patients with a traumatic instability event compared with 0% of atraumatic patients after nonoperative management ( P = 0.234). Pain at follow-up was more common in nonoperative than operative patients ( P = 0.017). Conclusions: Nonoperative management is a viable option for many patients with posterior shoulder instability; however, many may continue to have posterior shoulder pain.

AbstractFailed multiligament knee reconstruction is a challenging problem due to recurrent pathologic laxity that is often associated with limb malalignment, meniscus deficiency, articular cartilage insufficiency, decreased motion, compromised bone stock, and a paucity of graft sources. Revision surgical indications and techniques require a comprehensive evaluation of the patient, injury and treatment factors along with a focused physical examination and advanced imaging. A stepwise treatment approach can be effective in the evaluation of revision surgery and also in setting realistic patient goals.

Objectives: Recurrent anterior glenohumeral instability is a disabling pathology that can be successfully treated by arthroscopic Bankart repair or an open Latarjet procedure. Long-term outcomes have shown lower rates of apprehension, recurrent dislocation and operative revision following Latarjet when compared to Bankart repair. However, there is a paucity of studies comparing the short-term post-operative recovery of arthroscopic Bankart versus open Latarjet. The purpose of this study is to evaluate the post-operative recovery following Bankart and the open Latarjet procedure. Methods: The surgical outcomes system (SOS) database (Arthrex Inc., Naples, FL) was used to compare the post-operative recovery outcomes after either a primary or revision arthroscopic Bankart and an open Latarjet procedure. Patients were included who had a minimum of 1 year follow-up. Preoperative and postoperative (2 weeks, 6 weeks, 3 months, 6 months, 1 year and 2 year) time points were evaluated. Outcomes measures included Visual Analog Pain Scale (VAS), American Shoulder and Elbow Surgeons (ASES) Shoulder Function Score, ASES Shoulder Index Score, and SANE Score. Overall, 787 patients underwent primary Bankart (518 male, 240 female, 4 not recorded), 36 underwent revision Bankart (24 male, 10 female, 2 not recorded) and 75 underwent an open Latarjet procedure (59 male, 12 female, 4 not recorded). The mean age for primary Bankart, revision Bankart, and open Latarjet was 40.8, 38.6 and 32.8 respectively. Additionally, the average BMI for primary Bankart, revision Bankart, and open Latarjet was 27.2, 28.13, and 25.6, respectively. Results: The postoperative recovery curves are displayed in Figure 1. When compared to primary Bankart, open Latarjet demonstrated significantly lower VAS scores at six weeks (p=0.0272) and at three months (p=0.0094). Medium term outcomes for ASES Shoulder Index Score, ASES Shoulder Function Score, and SANE Score, at 1- and 2-years showed no difference between primary Bankart and Latarjet. For the revision Bankart and open Latarjet procedures, the open Latarjet cohort demonstrated significantly higher ASES Shoulder Index Scores at the 3-months (p= 0.0017), 1-year (p= 0.0021), and 2-years (p= 0.0006) timepoints. Open Latarjet patients also had significantly higher ASES Shoulder Function Scores than revision Bankart at 3-months (p= 0.0162), 1-year (p= 0.0083), and 2-years (p= 0.0013). Revision Bankart repair resulted in significantly higher VAS scores than open Latarjet at 2-weeks (p= 0.0025), 6-weeks (p=0.0114), 3-months (p= 0.0024), 1-year (p= 0.0039), and 2-years (p= 0.0007). Conclusion: When compared to Bankart repair, open Latarjet provides improved pain and functional outcomes during the early recovery phase, 2-weeks, 6-weeks, 3-months, and 6-months, with equivalent medium-term outcomes at 1-2-years. Furthermore, when compared to revision Bankart reconstruction, open Latarjet provides improved ASES Shoulder Index Scores, ASES Shoulder Function Scores and VAS Scores at nearly all timepoints. In the treatment of recurrent anterior glenohumeral instability, open Latarjet is reasonable option in the primary setting and should be favored over Bankart repair for revision cases with improved pain relief and functional scores.

Purpose To (1) define the rate of delayed surgery, between 1 and 10 years after injury, in a population‐based study of patients with posterior shoulder instability (PSI), (2) evaluate predictive factors associated with delayed repair, and (3) identify differences between the nonoperative and operative groups at long‐term follow‐up. Methods A population‐based retrospectively reviewed study of all patients with PSI from January 1, 1994, to December 31, 2015, was performed. Inclusion required a clinical diagnosis of PSI combined with supporting imaging. Complete medical records were reviewed for 2,091 potential cases. Kaplan‐Meier estimates were used to calculate survival. Landmark survival analysis was performed to identify predictors of conversion to surgery. Results The study included 143 patients with PSI, 79 of whom were managed nonoperatively for at least 1 year after diagnosis. After the first year, survival free of surgery was 78.3% at 1 year, 63.1% at 5 years, and 51.5% at 10 years. There was a trend toward increased surgery in patients with a body mass index > 35 ( P = .10; hazard ratio = 2.32; confidence interval, 0.8‐6.8). Nonthrowing athletes (including contact/weight‐lifting athletes) showed a trend toward an increased risk for surgery ( P = . 07). Patients who underwent surgery were significantly more likely to have progression in arthritis ( P = . 02; hazard ratio = 4.0; confidence interval, 1.2‐13.2). Conclusions Nonoperative management was performed for at least 1 year in over half of patients diagnosed with PSI. Overall, long‐term follow‐up demonstrates that 46% of these patients converted to surgery between 1 and 10 years after initial diagnosis. Ultimately, 70% of patients diagnosed with PSI go on to surgical intervention. Patients who underwent surgery at any time point were at an increased risk of radiographic progression of arthritis at a minimum of 5 years of follow‐up. Level of Evidence Level III, cohort study.

* Massive rotator cuff tears that are treated nonoperatively demonstrate increases in tear size, fatty infiltration, muscular atrophy, and arthritis. * The pooled retear rate following complete repair of massive rotator cuff tears is 79%. * Absorbable and nonabsorbable graft augmentation following rotator cuff repair can reduce the retear rate and improve functional outcomes. * Irreparable tears can be predicted preoperatively by evaluating the degree of fatty infiltration, muscular atrophy, and tendon length. * Latissimus dorsi transfer, lower trapezius transfer, and superior capsular reconstruction provide improvements in terms of pain, range of motion, and function in patients with irreparable tears.

Objectives: Diagnosis of and treatment for posterior shoulder instability (PSI) has improved with advances in surgical technique and radiographic imaging. It is unknown if PSI, or surgical measures to correct PSI, affect the progression of osteoarthritis in the glenohumeral joint. The purpose of this study is to evaluate the effect of posterior capsulolabral reconstruction (PCLR) and demographic risk factors on the rate of radiographic progression of osteoarthritis in shoulders with PSI. Methods: The study population included 115 patients (14 females, 101 males) diagnosed with PSI between January 1994 and July 2012 with an average follow up of 12.5years (range 5-23). Medical records were reviewed to evaluate patient demographics, surgical intervention, and radiographic progression of osteoarthritis. Kaplan Meier survival was used to estimate survival and Cox models were used to examine associations with osteoarthritis progression. Results: Overall, 16/115 (14%) patients had radiographic progression of glenohumeral arthritis with 5-year survival at 88.3% (95% CI 79.7%-97.3%). Age ≥30 at the time of instability was associated with arthritis progression (p<0.05). The number of previous dislocations, sport, and gender each did not affect progression (p>0.05). PCLR with at least one anchor along the posterior glenoid rim was performed in 56/115 (48%) of patients. There was no difference in the rate of radiographic arthritic progression in those who underwent PCLR and those who did not (7/56, 13% vs 10/59, 17%, p>0.05). One male patient who underwent PCLR progressed to end-stage arthritis, necessitating a shoulder arthroplasty at age 53. Conclusion: Radiographic progression of glenohumeral arthritis occurred 14% of patients with PSI. Age ≥30 at the time of initial instability was associated with radiographic progression of glenohumeral arthritis.

Objectives: Among patients treated non-operatively for 1 year following a diagnosis of posterior shoulder instability (PSI), little is known about the the incidence of surgery between 1-13 years after injury. The purpose of this study is to define the frequency and evaluate the factors predictive for late surgical intervention of symptomatic PSI. Methods: This study included a population-based cohort of 115 patients (14 females, 101 males) diagnosed with PSI between January 1994 and July 2012 with a minimum 5-years follow-up (mean:13.9 years; range: 5-23 years). Landmark survival analysis was performed to evaluate incidence of surgery after 1 year. Survival was estimated using Kaplan Meier method and predictors of late surgical intervention were analyzed using Cox proportional hazards regression. Results: A total of 61/115 (53%) patients were treated non-operatively for 1 year following diagnosis of PSI. Of these, 24/61 (39%) converted to surgery for symptomatic PSI. The overall survival free of surgery at 1 and 5 years was 53.0% (95% CI 434.7-63.0) and 37.1% (95% CI 29.1-47.1), respectively. BMI >35 (p=0.04, HR 3.3) was predictive for late conversion to surgery. Age, gender, occupation, or history of glenohumeral dislocation were not significant. Assessing surgery as a time dependent covariate, a patient undergoing surgery was at an increased risk for radiographic progression of osteoarthritis (p=0.02, HR=4.0, 95% CI 1.2-13.2). Conclusion: Conservative management was performed for at least one year in over half of patients diagnosed with PSI. However, long-term follow-up demonstrates that nearly 40% of these patients eventually require surgery. Increased BMI was predictive for late failure of while age, gender, history of dislocation and occupation did not show an effect. Patients who underwent surgery were at an increased risk of radiographic progression of arthritis.

Background: Massive irreparable rotator cuff tears in both the primary and the revision setting are challenging problems. There remains controversy over the ideal treatment methods for these patients. In the case of an irreparable posterosuperior rotator cuff tear, tendon transfers 1–12 have emerged as a reliable option, with a durable outcome. The most commonly used tendon transfer options are the latissimus dorsi (LD) 1–6 and the lower trapezius (LT) 12 . Description: The LD transfer is performed by first harvesting the LT tendon from the humeral shaft. It is critical to release the many adhesions to the muscle belly as well as to separate it from the teres major muscle. The tendon is then transferred intra-articularly, in an interval between the deltoid and the teres minor. The tendon is anchored arthroscopically after preparation of the anterolateral aspect of the tuberosity. The LT transfer is performed by harvesting the LT muscle and tendon off its insertion on the medial aspect of the scapular spine. It should be mobilized to maximize excursion by releasing adhesions. An Achilles tendon allograft is anchored into the anterior aspect of the greater tuberosity arthroscopically. The Achilles tendon is then secured to the LT tendon. Alternatives: In addition to tendon transfer, options include: Partial or complete attempted repair 13–17 . Augmentation or bridging with allografts 18–23 . Superior capsular reconstruction 24 . Subacromial balloon 25 . Rationale: There remains a paucity of literature comparing tendon transfers with alternatives. However, when considering a tendon transfer, certain principles are critical in order to achieve an optimal outcome: The recipient and transferred tendons must have similar musculotendinous excursion. The recipient and transferred tendons should have similar lines of pull. One tendon (the transferred) should be designed to replace 1 function (of the recipient). The function of the transferred tendon and muscle should be expendable without substantial donor site morbidity. The strength of the transferred muscle must be at least grade 4. When deciding between the LT and LD transfer, certain considerations should be taken into account. The LD transfer has a proven history of successfully treating massive irreparable posterosuperior rotator cuff tears in studies with long-term follow-up 1–6 . Alternatively, although the LT transfer has only recently gained popularity, it has the advantage of “in-phase” muscle function, since the trapezius naturally contracts during shoulder external rotation. Furthermore, its line of pull almost completely mimics the infraspinatus.

AbstractInjury to the posterolateral corner (PLC) of the knee can lead to both varus and rotational instability. Multiple PLC reconstruction techniques have been described, including one-tailed graft (fibula-based constructs) or two-tailed graft (combined fibula- and tibia-based constructs). The purpose of our study was to evaluate the clinical outcomes of anatomical two-tailed graft reconstruction of the PLC in the setting of multiligament knee injuries (MKLIs) with grade III varus instability. Patients were identified through a prospective MLKI database between 2004 and 2013. Patients who received fibular collateral ligament and PLC reconstructions using a two-tailed graft and had a minimum follow-up of 2 years were included. Patients were assessed for clinical laxity grade, range of motion, and functional outcomes using Lysholm and International Knee Documentation Committee (IKDC) scores. Twenty patients (16 male, 4 female) with a mean age of 30.7 (range: 16–52) and a mean follow-up of 52.2 months (range: 24–93 months) were included. Knee dislocation (KD) grades included: 4 KD-1, 10 KD 3-L, 5 KD-4, and 1 KD-5. No patients had isolated PLC injuries. Mean IKDC and Lysholm score were 73.1 ± 25.8 and 78 ± 26, respectively. Mean range of motion was –1.1 to 122.8. In full extension, two patients (10%) had grade 1 laxity to varus stress. In 30 degrees of knee flexion, five (25%) patients had grade 1 laxity, and two (10%) had grade 2 laxity. Anatomical two-tailed PLC reconstruction can reliably restore varus stability when performed on patients with MLKIs and type C posterolateral instability with hyperextension external rotation recurvatum deformity. Satisfactory functional outcome scores were achieved in the majority of patients. This study supports the use of an anatomical two-tailed PLC reconstruction in the multiligament injured knee. The level of evidence is IV, case series.