Barlow, Jonathan D.

Background: Wrestling is a physically demanding sport with young athletes prone to traumatic shoulder instability and a paucity of data evaluating the results of shoulder instability surgery (SIS). Purpose: To assess reoperation rates, patient-reported outcomes, and return to wrestling (RTW) after SIS in a cohort of competitive wrestlers. Study Design: Case series; Level of evidence, 3. Methods: All competitive wrestlers with a history of shoulder instability and subsequent surgery at a single institution between 1996 and 2020 were identified. All directions of shoulder instability (anterior shoulder instability [ASI], posterior shoulder instability [PSI], and traumatic multidirectional shoulder instability [TMDI]) were analyzed. Exclusions included revision SIS and <2 years of follow-up. Athletes were contacted for determination of complications, RTW, and Western Ontario Shoulder Instability Index scores. Results: Ultimately, 104 wrestlers were included with a mean age at initial instability of 16.9 years (range, 12.0-22.7 years), mean age at surgery of 18.9 years (range, 14.0-29.0 years), and a mean follow-up of 5.2 years (range, 2.0-22.0 years). A total of 58 (55.8%) wrestlers were evaluated after a single shoulder instability event, while 46 (44.2%) sustained multiple events before evaluation. ASI was the most common direction (n = 79; 76.0%), followed by PSI (n = 14; 13.5%) and TMDI (n = 11; 10.6%). Surgical treatment was most commonly an arthroscopic soft tissue stabilization (n = 88; 84.6%), with open soft tissue repair (n = 13; 12.5%) and open bony augmentation (n = 3; 2.9%) performed less frequently. RTW occurred in 57.3% of wrestlers at a mean of 9.8 months. Recurrent instability was the most common complication, occurring in 18 (17.3%) wrestlers. Revision SIS was performed in 15 (14.4%) wrestlers. Across the entire cohort, survivorship rates free from recurrent instability and revision surgery were 90.4% and 92.5% at 2 years, 71.9% and 70.7% at 5 years, and 71.9% and 66.5% at 10 years, respectively. Preoperative recurrent instability was an independent risk factor for postoperative recurrent instability (hazard ratio, 3.8; 95% CI, 1.33-11.03; P = .012). Conclusion: Competitive wrestlers with multiple dislocations before initial clinical evaluation were 3.8 times more likely to experience postoperative recurrent instability. Patients should be counseled that despite SIS, only 57.3% returned to wrestling after surgery.

Background: Irreparable rotator cuff tears represent approximately 12% of all presenting cuff tears, and multiple surgical techniques have been described for treatment, including allograft/bridge augmentation, debridement, partial repair, subacromial balloon, tendon transfer, and superior capsule reconstruction (SCR). SCR has demonstrated durable improvement in range of motion (ROM) and outcome scores at 2 and 5 years. Indications: Surgical indications for SCR include an irreparable tear of the supraspinatus and/or infraspinatus with a preserved or reparable subscapularis and preserved glenohumeral joint cartilage. Technique Description: Diagnostic arthroscopy is performed to identify and characterize the rotator cuff tear. Thorough debridement of the greater tuberosity is performed. Two all-suture FiberTak anchors are placed in the superior aspect of the glenoid. Two 2.6-mm FiberTak suture anchors are placed in the humeral head at the chondral margin. After measuring, the dermal allograft is cut to size with 15-mm overhang left on the far lateral edge. A 12-mm passport cannula is inserted laterally and the sutures from the glenoid and humeral head anchors are brought out through the cannula maintaining their position and orientation. The sutures are passed through the graft outside the cannula. The graft is introduced into the shoulder via the passport cannula with a back grasper. A cannula-in-cannula technique is used to tie the glenoid anchors first and then the medial row anchors. Two lateral row swivel lock anchors are used to complete a standard double row repair. Margin convergence is performed between the dermal allograft and remaining rotator cuff anterior and posterior. Postoperatively, patients are kept in a sling for 6 weeks, with no shoulder ROM. From weeks 6 to 12, patients discontinue sling and begin passive progression to active ROM. Strengthening is initiated at 12 weeks, and return-to-sport or work is at approximately 6 months. Results: Irreparable rotator cuff tears treated with arthroscopic rotator cuff repair and SCR show durable improvement in patient-reported outcomes at 2 and 5 years. Re-tear rates did not differ between athletes and non-athletes. Discussion/Conclusion: Arthroscopic rotator cuff repair with SCR is a durable and reliable surgical option for patients presenting with preserved glenohumeral joint and irreparable supraspinatus and/or infraspinatus tear. 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: Medial-sided elbow injuries are becoming increasingly common among throwing athletes due to overuse and increased specialization at early ages. High valgus stress and repetitive elbow flexion/extension during throwing not only affects the ligaments and dynamic support of the elbow, but commonly affects the ulnar nerve. Indications: Management of cubital tunnel syndrome is initially rest, therapy, and functional training; however, if conservative measures do not appropriately address the ulnar neuropathy, surgical decompression with subcutaneous transposition is a reliable treatment option. Technique Description: An incision is created over the medial epicondyle. The medial antebrachial cutaneous nerve is identified and protected. The ulnar nerve is identified and tagged with a vessel loop to allow for appropriate handling of the nerve. Decompression of the ulnar nerve begins proximally by spreading the tissues superficial to the ulnar nerve and splitting the fascia overlying it. Then, dissection deep to the nerve is performed. A small strip of the medial intermuscular septum will be used as a sling to hold the nerve securely in the transposed position. This is released proximally and the distal attachment to the medial epicondyle is left in place. Decompression is then continued distally by releasing the superficial fascia over the flexor carpi ulnaris (FCU) and a portion of the deep FCU muscle belly and fascia. The nerve is decompressed circumferentially, while preserving penetrating branches to the FCU as able. Ultimately, the ulnar nerve is decompressed 10 cm proximal and 10 cm distal to the medial epicondyle. The intermuscular septum is then pulled over the nerve, checked for appropriate length, and sutured in place both posterior and anterior to the ulnar nerve. Results: Symptom improvement after decompression and transposition is high (>90%); however, performance outcomes in overhead and throwing athletes is variable, and return to previous or higher level of play ranges from 60% to 90%. Discussion/Conclusion: Ulnar nerve decompression and transposition can reliably address underlying symptoms, but results are mixed for return to sport outcomes in overhead and throwing athletes. 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.

Case: This report describes the case of an athletic 12-year-old boy who presented with a 64° left proximal humeral varus angulation deformity and physeal bar secondary to multiple operations for a proximal humeral metaphyseal cystic lesion and pathologic fracture. Using a combined lateral closing and medial opening-wedge osteotomy, a 68° valgus correction was achieved with excellent clinical and functional outcomes at 16-month follow-up. Forward flexion increased from 120 to 170° preoperatively to postoperatively while abduction improved from 110° preoperatively to 170° postoperatively. Conclusion: A combined lateral closing and medial opening-wedge osteotomy of the proximal humerus can successfully treat cases of extreme proximal humerus varus in the growing shoulder where unilateral or dome osteotomies are not suitable.

Purpose To compare the cost‐effectiveness of an initial trial of nonoperative treatment to that of early arthroscopic debridement for stable osteochondritis dissecans (OCD) lesions of the capitellum. Methods A Markov Chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1,000 simulated patients undergoing nonoperative management versus early arthroscopic debridement for stable OCD lesions of the capitellum. Health utility values, treatment success rates, and transition probabilities were derived from the published literature. Costs were determined on the basis of the typical patient undergoing each treatment strategy at our institution. Outcome measures included costs, quality‐adjusted life‐years (QALYs), and the incremental cost‐effectiveness ratio (ICER). Results Mean total costs resulting from nonoperative management and early arthroscopic debridement were $5,330 and $21,672, respectively. On average, early arthroscopic debridement produced an additional 0.64 QALYS, resulting in an ICER of $25,245/QALY, which falls well below the widely accepted $50,000 willingness‐to‐pay (WTP) threshold. Overall, early arthroscopic debridement was determined to be the preferred cost‐effective strategy in 69% of patients included in the microsimulation model. Conclusions Results of the Monte Carlo microsimulation and probabilistic sensitivity analysis demonstrated early arthroscopic debridement to be a cost‐effective treatment strategy for the majority of stable OCD lesions of the capitellum. Although early arthroscopic debridement was associated with higher total costs, the increase in QALYS that resulted from early surgery was enough to justify the cost difference based on an ICER substantially below the $50,000 WTP threshold. Level of Evidence Level III, economic computer simulation model.

AimsThe scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula.MethodsWe reviewed 61 patients (37 male, 24 female; mean age 42 years (SD 19)) who had undergone resection of the scapula. The most common resection was type 2 (n = 34) according to the Tikhoff-Linberg classification, or type S1A (n = 35) on the Enneking classification.ResultsThe ten-year disease-specific survival was 76%. High tumour grade (hazard ratio (HR) 4.27; p = 0.016) and a total resection of the scapula (HR 3.84; p = 0.015) were associated with worse survival. The ten-year metastasis-free and local recurrence-free survivals were 82% and 86%, respectively. Total scapular resection (HR 6.29; p = 0.004) was associated with metastatic disease and positive margins were associated with local recurrence (HR 12.86; p = 0.001). At final follow-up, the mean shoulder forward elevation and external rotation were 79° (SD 62°) and 27° (SD 25°), respectively. The most recent functional outcomes evaluated included the mean Musculoskeletal Tumor Society Score (76% (SD 17%)), the American Shoulder and Elbow Score (73% (SD 20%)), and the Simple Shoulder Test (7 (SD 3)). Preservation of the glenoid (p = 0.001) and scapular spine (p < 0.001) improved clinical outcomes; interestingly, preservation of the scapular spine without the glenoid improved outcomes (p < 0.001) compared to preservation of the glenoid alone (p = 0.05).ConclusionResection of the scapula is a major undertaking with an oncological outcome related to tumour grade, and a functional outcome associated with the status of the scapular spine and glenoid. Positive resection margins are associated with local recurrence.Cite this article: Bone Joint J 2023;105-B(12):1314–1320.

Background: There is a paucity of research on the management of partial-thickness tears of the distal bicep tendon, and even less is known about the long-term outcomes of this condition. Purpose: To identify patients with partial-thickness distal bicep tendon tears and determine (1) patient characteristics and treatment strategies, (2) long-term outcomes, and (3) any identifiable risk factors for progression to surgery or complete tear. Study Design: Case-control study; Level of evidence, 3. Methods: A fellowship-trained musculoskeletal radiologist identified patients diagnosed with a partial-thickness distal bicep tendon tear on magnetic resonance imaging between 1996 and 2016. Medical records were reviewed to confirm the diagnosis and record study details. Multivariate logistic regression models were created using baseline characteristics, injury details, and physical examination findings to predict operative intervention. Results: In total, 111 patients met inclusion criteria (54 treated operatively, 57 treated nonoperatively), with 53% of tears in the nondominant arm and a mean follow-up time after surgery of 9.7 ± 6.5 years. Only 5% of patients progressed to full-thickness tears during the study period, at a mean of 35 months after the initial diagnosis. Patients who were nonoperatively treated were less likely to miss time from work (12% vs 61%; P < .001) and missed fewer days (30 vs 97 days; P < .016) than those treated surgically. Multivariate regression analyses demonstrated increased risk of progression to surgery with older age at initial consult (unit odds ratio [OR], 1.1), tenderness to palpation (OR, 7.5), and supination weakness (OR, 24.8). Supination weakness at initial consult was a statistically significant predictor for surgical intervention (OR, 24.8; P = .001). Conclusion: Clinical outcomes were favorable for patients regardless of treatment strategy. Approximately 50% of patients were treated surgically; patients with supination weakness were 24 times more likely to undergo surgery than those without. Progression to full-thickness tear was a relatively uncommon reason for surgical intervention, with only 5% of patients progressing to full-thickness tears during the study period and the majority occurring within 3 months of initial diagnosis.

Purpose To compare the clinical outcomes of operative and nonoperative management, identify risk factors for recurrent instability, and identify risk factors for progression to surgery after failed nonoperative management for patients with first‐time anterior shoulder dislocation after the age of 50 years. Methods An established geographic medical record system was used to identify patients who experienced a first‐time anterior shoulder dislocation after the age of 50 years. Patient medical records were reviewed to identify treatment decisions and outcomes of interest, including rates of frozen shoulder and nerve palsy, progression to osteoarthritis, recurrent instability, and progression to surgery. Outcomes were evaluated using Chi‐square tests and survivorship curves were generated using Kaplan‐Meier methods. A Cox model was developed to evaluate for potential risk factors of recurrent instability and progression to surgery after an initial trail of at least 3 months of nonoperative treatment. Results 179 patients were included with a mean follow‐up of 11 years. 14% ( n = 26) underwent early surgery within 3 months and 86% ( n = 153) were initially treated nonoperatively. Mean age (59 years), was similar for both groups, but those that underwent early surgery had an increased rate of full‐thickness rotator cuff tears (82% vs 55%; P = .01), labral tears (24% vs 8.0%; P = .01), and humeral head fracture (23% vs 8.5%; P = .03). When comparing the early surgery group to the nonoperative group, there were similar rates of persistent moderate‐severe pain (19% vs 17%; P = .78) and frozen shoulder (8 vs 9%, respectively; P = .87) at final follow‐up. Although nerve palsy (19% vs 8%; P = .08) and progression to osteoarthritis (20% vs 14%; P = .40) were more common in surgical patients, they experienced lower rates of recurrent instability after surgical intervention (0% vs 15%; P = .03) compared to nonoperatively treated patients. Increasing number of instability events prior to presentation was the greatest risk factor for recurrent instability (HR 232; P < .01). Fourteen percent ( n = 21) failed initial nonoperative treatment and proceeded to surgical intervention at an average of 4.6 years after the initial instability event, and the greatest risk factors for progression to surgery were recurrent instability (HR 3.41; P < .01). Conclusions Although the majority of patients >50 years that experience ASI are treated nonoperatively, those that require surgery tend to have more significant injury pathology, a lower risk of recurrent instability after surgery, but a higher progression to osteoarthritis compared to patients that do not require surgical intervention. There was no difference in pain severity at final follow‐up, rates of frozen shoulder or nerve palsy between patients who underwent initial nonoperative treatment after instability and those who underwent surgery. A history of multiple instability episodes prior to presentation was the greatest predictor of recurrent instability and failure of nonoperative treatment and progression to surgery. Level of Evidence Level III, retrospective cohort study.

Purpose To evaluate the outcomes of arthroscopic superior capsular reconstruction (SCR) and arthroscopy‐assisted lower trapezius tendon transfer (LTT) for posterosuperior irreparable rotator cuff tears (IRCTs). Methods Over an almost 6‐year period (October 2015 to March 2021), all patients who underwent IRCT surgery with a minimum 12‐month follow‐up period were identified. For patients with a substantial active external rotation (ER) deficit or lag sign, LTT was preferentially selected. Patient‐reported outcome scores included the visual analog scale (VAS) pain score, strength score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Results We included 32 SCR patients and 72 LTT patients. Preoperatively, LTT patients had more advanced teres minor fatty infiltration (0.3 vs 1.1, P = .009), a higher global fatty infiltration index (1.5 vs 1.9, P = .035), and a higher presence of the ER lag sign (15.6% vs 48.6%, P < .001). At a mean follow‐up of 2.9 ± 1.3 years (range, 1.0‐6.3 years), no differences in patient‐reported outcome scores were observed. Postoperatively, SCR patients had a lower VAS score (0.3 vs 1.1, P = .017), higher forward elevation (FE) (156° vs 143°, P = .004), and higher FE strength (4.8 vs 4.5, P = .005) and showed greater improvements in the VAS score (6.8 vs 5.1, P = .009), FE (56° vs 31°, P = .004), and FE strength (1.0 vs 0.4, P < .001). LTT patients showed greater improvement in ER (17° vs 29°, P = .026). There was no statistically significant between‐cohort difference in complication rate (9.4% vs 12.5%, P = .645) or reoperation rate (3.1% vs 10%, P = .231). Conclusions With adequate selection criteria, both SCR and LTT provided improved clinical outcomes for posterosuperior IRCTs. Additionally, SCR led to better pain relief and restoration of FE whereas LTT provided more reliable improvement in ER. Level of Evidence Level III, treatment study with retrospective cohort comparison.