Normalization of the Constant score

The strength of the normal shoulder may differ by gender and deteriorate with age. Thus, the Constant score may also decrease in absolute value while still reflecting a normal score. To account for age- and gender-related differences, normal results for this scale must be determined across a population of patients without shoulder disease. Patients presenting for evaluation of nonshoulder conditions participated. A subjective questionnaire was completed. Range of motion and strength were measured. This analysis includes the data of 441 patients. The mean Constant score for men was significantly greater than that for women in each age group ( P < .05). Significant age-related differences were noted in each group ( P < .05). Normative values for the Constant score based on age and gender were determined. The adjusted score represents the gender- and age-matched function of the shoulder and is useful in the evaluation of shoulder outcomes.

Establishing clinically significant outcome after arthroscopic rotator cuff repair

BACKGROUND

Outcomes reporting in rotator cuff repair (RCR) literature has been variable. The minimal clinical important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) bridge the gap between statistical significance and clinical relevance.

METHODS

The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and Constant-Murley (Constant) scores were collected preoperatively and 1 year postoperatively for patients undergoing RCR between 2014 and 2017. An anchor-based approach was used to calculate the MCID, SCB change, and PASS for the ASES questionnaire.

RESULTS

The study included 288 patients who underwent RCR. The MCID, SCB, and PASS were, respectively, 11.1, 17.5, and 86.7 for ASES, 4.6, 5.5, and 23.3 for the Constant score, and 16.9, 29.8, and 82.5 for the SANE score. Factors associated with reduced odds of achieving MCID were current smoking for ASES (odds ratio, 0.056) and single-row repair for the Constant score (odds ratio, 0.310). Workers' compensation patients had reduced odds of achieving ASES SCB (odds ratio, 0.267) and were associated with reduced odds of achieving PASS by ASES (odds ratio, 0.244), SANE (OR, 0.452), and Constant (odds ratio, 0.313). Lower preoperative scores were associated with achieving MCID and SCB and higher preoperative Constant scores associated with PASS (P < .001).

CONCLUSION

This study establishes MCID, SCB, and PASS for ASES, Constant, and SANE scores in patients undergoing RCR. Factors associated with failing to achieve clinically significant values included current smoking, single-row repairs, high body mass index, and workers' compensation status.

Long-term outcomes after Bankart shoulder stabilization

PURPOSE

The purposes of this study were (1) to analyze long-term outcomes in patients who have undergone open or arthroscopic Bankart repair and (2) to evaluate study methodologic quality through validated tools.

METHODS

We performed a systematic review of Level I to IV Evidence using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Clinical outcome studies after open or arthroscopic Bankart repair with a minimum of 5 years' follow-up were analyzed. Clinical and radiographic outcomes were extracted and reported. Study methodologic quality was evaluated with Modified Coleman Methodology Scores and Quality Appraisal Tool scores.

RESULTS

We analyzed 26 studies (1,781 patients). All but 2 studies were Level III or IV Evidence with low Modified Coleman Methodology Scores and Quality Appraisal Tool scores. Patients analyzed were young (mean age, 28 years) male patients (81%) with unilateral dominant shoulder (61%), post-traumatic recurrent (mean of 11 dislocations before surgery) anterior shoulder instability without significant glenoid bone loss. The mean length of clinical follow-up was 11 years. There was no significant difference in recurrence of instability with arthroscopic (11%) versus open (8%) techniques (P = .06). There was no significant difference in instability recurrence with arthroscopic suture anchor versus open Bankart repair (8.5% v 8%, P = .82). There was a significant difference in rate of return to sport between open (89%) and arthroscopic (74%) techniques (P < .01), whereas no significant difference was observed between arthroscopic suture anchor (87%) and open repair (89%) (P = .43). There was no significant difference in the rate of postoperative osteoarthritis between arthroscopic suture anchor and open Bankart repair (26% and 33%, respectively; P = .059). There was no significant difference in Rowe or Constant scores between groups (P > .05).

CONCLUSIONS

Surgical treatment of anterior shoulder instability using arthroscopic suture anchor and open Bankart techniques yields similar long-term clinical outcomes, with no significant difference in the rate of recurrent instability, clinical outcome scores, or rate of return to sport. No significant difference was shown in the incidence of postoperative osteoarthritis with open versus arthroscopic suture anchor repair. Study methodologic quality was poor, with most studies having Level III or IV Evidence.

LEVEL OF EVIDENCE

Level IV, systematic review of studies with Level I through IV Evidence.

Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior Outcomes Compared With Other Therapies in the Treatment of Knee Osteoarthritis? A Systematic Review of Overlapping Meta-analyses

PURPOSE

The aims of this study were (1) to perform a systematic review of meta-analyses evaluating platelet-rich plasma (PRP) injection in the treatment of knee joint cartilage degenerative pathology, (2) to provide a framework for analysis and interpretation of the best available evidence to provide recommendations for use (or lack thereof) of PRP in the setting of knee osteoarthritis (OA), and (3) to identify literature gaps where continued investigation would be suggested.

METHODS

Literature searches were performed for meta-analyses examining use of PRP versus corticosteroids, hyaluronic acid, oral nonsteroidal anti-inflammatory drugs, or placebo. Clinical data were extracted, and meta-analysis quality was assessed. The Jadad algorithm was applied to determine meta-analyses that provided the highest level of evidence.

RESULTS

Three meta-analyses met the eligibility criteria and ranged in quality from Level II to Level IV evidence. All studies compared outcomes of treatment with intra-articular platelet-rich plasma (IA-PRP) versus control (intra-articular hyaluronic acid or intra-articular placebo). Use of PRP led to significant improvements in patient outcomes at 6 months after injection, and these improvements were seen starting at 2 months and were maintained for up to 12 months. It is unclear if the use of multiple PRP injections, the double-spinning technique, or activating agents leads to better outcomes. Patients with less radiographic evidence of arthritis benefit more from PRP treatment. The use of multiple PRP injections may increase the risk of self-limited local adverse reactions. After application of the Jadad algorithm, 3 concordant high-quality meta-analyses were selected and all showed that IA-PRP provided clinically relevant improvements in pain and function compared with the control treatment.

CONCLUSIONS

IA-PRP is a viable treatment for knee OA and has the potential to lead to symptomatic relief for up to 12 months. There appears to be an increased risk of local adverse reactions after multiple PRP injections. IA-PRP offers better symptomatic relief to patients with early knee degenerative changes, and its use should be considered in patients with knee OA.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II through IV studies.

Functional Performance Testing After Anterior Cruciate Ligament Reconstruction: A Systematic Review

Background:

When to allow an athlete to return to unrestricted sporting activity after anterior cruciate ligament (ACL) reconstruction remains controversial.

Purpose:

To report the results of functional performance testing reported in the literature for individuals at differing time points following ACL reconstruction and to examine differences between graft types.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review of Medline, Scopus, and Cochrane Central Register of Controlled Trials was performed using PRISMA guidelines. Inclusion criteria were English-language studies that examined any functional rehabilitation test from 6 months to 2 years following ACL reconstruction. All patient-, limb-, and knee-specific demographics were extracted from included investigations. All functional rehabilitation tests were analyzed and compared when applicable.

Results:

The search term returned a total of 890 potential studies, with 88 meeting inclusion and exclusion criteria. A total of 4927 patients were included, of which 66% were male. The mean patient age was 26.5 ± 3.4 years. The predominant graft choices for reconstruction were bone–patellar tendon–bone (BPTB) autograft (59.8%) and hamstring autograft (37.9%). The most commonly reported functional tests were the hop tests. The results of these functional tests, as reported in the Limb Symmetry Index (LSI), improved with increasing time, with nearly all results greater than 90% at 1 year following primary ACL reconstruction. At 6 months postoperatively, a number of isokinetic strength measurements failed to reach 80% LSI, most commonly isokinetic knee extension testing in both BPTB and hamstring autograft groups. The knee flexion strength deficit was significantly less in the BPTB autograft group as compared with those having hamstring autograft at 1 year postoperatively, while no significant differences were found in isokinetic extension strength between the 2 groups.

Conclusion:

Hop testing was the most commonly reported functional test following ACL reconstruction. Increases in performance on functional tests were predictably seen as time increased following surgery. Those with hamstring autografts may experience increased strength deficits with knee flexion versus those having BPTB autograft. These data provide information that may assist providers in determining timing of return to unrestricted sporting activity.

Complications associated with subpectoral biceps tenodesis: low rates of incidence following surgery

BACKGROUND

Tenodesis of the long head of the biceps tendon is a common procedure used to alleviate pain caused by instability or inflammation of the tendon. The purpose of this study is to report on the incidence and types of complications following an open subpectoral biceps tenodesis (OBT) procedure.

HYPOTHESIS

Our hypothesis was that the rate of adverse events after OBT was low.

METHODS

From January 2005 to December 2007, all patients that underwent an OBT with bioabsorbable interference screw fixation performed by 1 of the 2 senior authors for biceps tendonitis were reviewed, excluding tenotomy, revision cases, or fixation methods other than interference screw fixation.

RESULTS

Over a 3-year period, 7 of 353 patients had complications with OBT with an incidence of 2.0%. The mean age of patients with complications was 44.67 years, with 57.1% males and 42.9% females. There were 2 patients (0.57%) with persistent bicipital pain. Two patients (0.57%) had failure of fixation resulting in a Popeye deformity. One patient (0.28%) presented with a deep postoperative wound infections that necessitated irrigation and debridement with intravenous antibiotics. Another patient (0.28%) developed a musculotaneous neuropathy. Another patient (0.28%) developed reflex sympathetic dystrophy necessitating pain management and stellate ganglion block.

CONCLUSION

The incidence of complications after subpectoral biceps tenodesis with interference screw fixation in a population of 353 patients over the course of 3 years was 2.0%.

Does the literature confirm superior clinical results in radiographically healed rotator cuffs after rotator cuff repair?

PURPOSE

Because recurrent or persistent defects in the rotator cuff after repair are common, we sought to clarify the correlation between structural integrity of the rotator cuff and clinical outcomes through a systematic review of relevant studies.

METHODS

Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials were searched for all literature published from January 1966 to December 2008 that used the key words shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, integrity, healed, magnetic resonance imaging (MRI), computed tomography arthrography (CTA), and ultrasound. The inclusion criteria were studies (Levels I to IV) that reported outcomes after arthroscopic rotator cuff repair in healed and nonhealed repairs based on ultrasound, CTA, and/or MRI. Exclusionary criteria were studies that included open repair or subscapularis repair and studies that did not define outcomes based on healed versus nonhealed but rather used another variable (i.e., repair technique). Data were abstracted from the studies including patient demographics, tear characteristics, surgical procedure, rehabilitation, strength, range of motion, clinical scoring systems, and imaging studies.

RESULTS

Thirteen studies were included in the final analysis: 5 used ultrasound, 4 used MRI, 2 used CTA, and 2 used combined CTA/MRI for diagnosis of a recurrent tear. Statistical improvement in patients who had an intact cuff at follow-up was seen in Constant scores in 6 of 9 studies; in University of California, Los Angeles scores in 1 of 2 studies; in American Shoulder and Elbow Surgeons scores in 0 of 3 studies; and in Simple Shoulder Test scores in 0 of 2 studies. Increased range of motion in forward elevation was seen in 2 of 5 studies and increased strength in forward elevation in 5 of 8 studies.

CONCLUSIONS

The results suggest that some important differences in clinical outcomes likely exist between patients with healed and nonhealed rotator cuff repairs. Further study is needed to conclusively define this difference and identify other important prognostic factors related to clinical outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review.

Prospective evaluation of allograft meniscus transplantation: a minimum 2-year follow-up

BACKGROUND

Clinical and biomechanical studies have demonstrated the increase in contact pressure and progressive deterioration of the tibiofemoral compartments that occur after partial or complete meniscectomy. Meniscus transplantation has been indicated for the symptomatic postmeniscectomy patient to alleviate symptoms and potentially prevent the progression of articular degeneration.

PURPOSE

To report the early-term results after allograft meniscus transplantations from a single institution performed by a single surgeon.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Forty-four meniscus transplants in 39 patients were evaluated at minimum 2-year follow-up using the Lysholm, Tegner, International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Noyes symptom rating and sports activity, and SF-12 scoring systems; visual analog pain scales; patient satisfaction; and physical examination. Four transplants failed early, leaving 40 transplants in 36 patients for review. Patients were grouped into medial and lateral transplant groups as well as those with isolated and combined procedures. Twenty-one menisci were transplanted in isolation (52.5%), and 19 were combined with other procedures (47.5%) to address concomitant articular cartilage injury.

RESULTS

Patients demonstrated statistically significant improvements in standardized outcomes surveys and visual analog pain and satisfaction scales. In 7 patients, treatment had failed at final follow-up. Overall, 77.5% of patients reported they were completely or mostly satisfied with the procedure, and 90% of patients were classified as normal or nearly normal using the International Knee Documentation Committee knee examination score at final follow-up. There were no significant differences in the medial and lateral subgroups, although the lateral subgroup did demonstrate a trend toward greater improvement. No significant differences were noted in the isolated and combined subgroups.

CONCLUSION

Meniscus transplantation alone or in combination with other reconstructive procedures results in reliable improvements in knee pain and function at minimum 2-year follow-up. Longer term studies are necessary to determine if transplantation can prevent the articular degeneration associated with meniscectomy.

Interobserver and intraobserver reliability of the Goutallier classification using magnetic resonance imaging: proposal of a simplified classification system to increase reliability

BACKGROUND

The Goutallier classification of fatty infiltration of the rotator cuff was developed for use in axial computed tomography arthrography. Now the Goutallier classification is being used with magnetic resonance imaging (MRI). Not only is there debate on the validity of the use of this system in MRI, but current literature is unclear as to the clinical use of the Goutallier classification.

HYPOTHESIS

There will be significant inter- and intraobserver variability of the Goutallier classification grading system for patients with chronic rotator cuff tears.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

An online database consisting of 35 single MRI images from 35 patients with chronic rotator cuff tears was designed and sent to members of the American Shoulder and Elbow Society. Surgeons were asked to identify the stage of rotator cuff fatty infiltration using the Goutallier classification system. Thirty surgeons responded and completed the survey in its entirety. At a minimum of 2 months later, 28 of the 30 initial respondents completed evaluations of the same online database. The responding surgeons were divided dichotomously according to their demographics and the interobserver reliability of the groups compared. A kappa analysis was performed to determine inter- and intraobserver reliability using 95% confidence intervals (95% CIs). A simplified 3-tiered classification was proposed combining Goutallier grades 0 and 1 as well as grades 2 and 3.

RESULTS

Statistical analysis of all respondent data demonstrated moderate intraobserver variability with a κ value of 0.56 (95% CI, 0.53-0.60). In addition, moderate interobserver variability was shown with a κ value of 0.43 (range, 0.16-0.74). With the simplified classification, intraobserver reliability was 0.70 (95% CI, 0.66-0.74) and interobserver reliability was 0.61 (range, 0.21-0.87). Correlation analysis showed no correlation with the presence or absence of fellowship training or board certification with either the Goutallier classification or the proposed modification (P > .05). Sports versus shoulder/elbow fellows had statistically better intraobserver variability (κ = 0.63 vs 0.50) with the Goutallier classification. Years in practice was negatively correlated with the level of agreement for both classifications (-r value, P < .05). The number of rotator cuff repairs performed per year negatively correlated with the level of agreement in the proposed modification only (r = -0.44, P = .022). Percent of practice dedicated to the shoulder did not correlate significantly with either classification (P > .05).

CONCLUSION

There is significant inter- and intraobserver variability observed among experienced shoulder surgeons using the Goutallier classification for assessing fatty infiltration of the rotator cuff muscles after chronic rotator cuff tears. Respondents were more likely to agree with themselves than with other respondents. A simplification of the MRI classification system is proposed that takes into consideration the variability determined by this study.

How Much Do Psychological Factors Affect Lack of Return to Play After Anterior Cruciate Ligament Reconstruction? A Systematic Review

Background:

Variables affecting return to sport after anterior cruciate ligament reconstruction (ACLR) are multifactorial. The nonphysical factors germane to successful return to play (RTP) are being increasingly recognized.

Purpose:

To (1) evaluate the available evidence base for psychological factors relating to RTP after ACLR, (2) identify psychological factors affecting RTP after ACLR, and (3) understand currently available metrics used to assess psychological RTP readiness.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A review of the MEDLINE database was performed for studies reporting RTP after ACLR. Studies reporting on the psychological determinants of RTP were included. Demographic, methodological, and psychometric properties of the included studies were extracted. Weighted analysis was performed after patients were pooled across included studies.

Results:

Of 999 studies identified in the initial search, 28 (2.8%) studies, comprising 2918 patients, were included; 19 studies (n = 2175 patients) reported RTP rates. The mean time for RTP was 17.2 months. There was a 63.4% rate of RTP, and 36.6% of patients returning to sport were not able to perform at their prior level of play. Of the 795 patients who did not achieve RTP, 514 (64.7%) cited a psychological reason for not returning. Fear of reinjury was the most common reason (n = 394; 76.7%); other psychological factors included lack of confidence in the treated knee (n = 76; 14.8%), depression (n = 29; 5.6%), and lack of interest/motivation (n = 13; 2.5%). The Tampa Scale for Kinesiophobia, the Hospital Anxiety and Depression Scale, the ACL–Return to Sport after Injury scale, and the Knee Self-Efficacy Scale were reported measures for assessing the influence of psychology on RTP.

Conclusion:

Psychological factors play an important role in RTP after ACLR. Among studies evaluating the impact of psychology on RTP, there was a delay in returning as well as lower RTP rates compared with the previously reported normative literature. Fear of reinjury was the most commonly reported impediment to RTP. The psychosocial measures identified in this review may have a role in RTP protocols for assessing mental resiliency; however, their roles need to be further investigated and validated in patients who have undergone ACLR.

The role of platelet-rich plasma in arthroscopic rotator cuff repair: a systematic review with quantitative synthesis

PURPOSE

Despite the theoretic basis and interest in using platelet-rich plasma (PRP) to improve the potential for rotator cuff healing, there remains ongoing controversy regarding its clinical efficacy. The objective of this systematic review was to identify and summarize the available evidence to compare the efficacy of arthroscopic rotator cuff repair in patients with full-thickness rotator cuff tears who were concomitantly treated with PRP.

METHODS

We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, and PubMed for eligible studies. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed using a random effects model to arrive at summary estimates of treatment effect with associated 95% confidence intervals.

RESULTS

Five studies (2 randomized and 3 nonrandomized with comparative control groups) met the inclusion criteria, with a total of 261 patients. Methodologic quality was uniformly sound as assessed by the Detsky scale and Newcastle-Ottawa Scale. Quantitative synthesis of all 5 studies showed that there was no statistically significant difference in the overall rate of rotator cuff retear between patients treated with PRP and those treated without PRP (risk ratio, 0.77; 95% confidence interval, 0.48 to 1.23). There were also no differences in the pooled Constant score; Simple Shoulder Test score; American Shoulder and Elbow Surgeons score; University of California, Los Angeles shoulder score; or Single Assessment Numeric Evaluation score.

CONCLUSIONS

PRP does not have an effect on overall retear rates or shoulder-specific outcomes after arthroscopic rotator cuff repair. Additional well-designed randomized trials are needed to corroborate these findings.

LEVEL OF EVIDENCE

Level III, systematic review of Level I, II, and III studies.

Return to sport after ACL reconstruction

Objective guidelines permitting safe return to sport following anterior cruciate ligament (ACL) reconstruction are infrequently used. The purpose of this study was to determine the published return to sport guidelines following ACL reconstruction in Level I randomized controlled trials. A systematic review was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Level I randomized controlled trials were included if they reported a minimum 2-year follow-up after ACL reconstruction and return to sport criteria. Outcomes analyzed were the timing of initiation of return to sport, follow-up duration, and use of quantitative/qualitative criteria to determine return to sport. Forty-nine studies were included (N=4178; 68% male; mean patient age, 27.5±3.2 years; mean follow-up, 3.0±1.9 years; mean time from injury to reconstruction, 379±321 days). Ninety-six percent of reconstructions used autograft and 87% were single-bundle reconstructions. Lysholm score, single-leg hop, isokinetic strength, and KT-1000 or KT-2000 arthrometer (MEDmetric, San Diego, California) testing were performed in 67%, 31%, 31%, and 82% of studies, respectively. Only 5 studies reported whether patients were able to successfully return to sport. Ninety percent and 65% of studies failed to use objective criteria or any criteria, respectively, to permit return to sport. Description of permission/allowance to return to sport was highly variable and poor. Twenty-four percent of studies failed to report when patients were allowed return to sport without restrictions. Overall, 39%, 45%, and 51% of studies permitted running at 3 months, return to cutting/pivoting sports at 6 months, and return to sport without restrictions at 6 months, respectively. Further research into validated return to sport guidelines is necessary to fill the existing void in contemporary literature and to guide clinical practice.

All-arthroscopic versus mini-open rotator cuff repair: a retrospective review with minimum 2-year follow-up

PURPOSE

To compare the clinical outcomes of patients undergoing all-arthroscopic versus mini-open rotator cuff repair. In addition, ultrasound was used to assess the integrity of the repair.

METHODS

A total of 38 patients who had undergone all-arthroscopic repair and 33 patients who had undergone mini-open repair with minimum 2-year follow-up were evaluated. All patients completed the American Shoulder and Elbow Surgeons' Scoring Survey (ASES), the Simple Shoulder Test, the L'Insalata Scoring Survey, and visual analog scales for pain. Physical examination, including strength testing and ultrasound evaluation to determine the integrity of the rotator cuff, was performed.

RESULTS

No statistical difference in ASES scores was noted between patients who had all-arthroscopic repair versus mini-open repair, and 24% of all-arthroscopic repairs and 27% of mini-open repairs showed recurrent defects on ultrasound at follow-up. This difference was not statistically significant. Patients with an original tear larger than 3 cm were 7 times more likely to have a recurrent defect at follow-up. Patients with persistent defects had statistically significant deficits in strength on forward elevation and external rotation when compared with those with a normal shoulder. However, no difference was observed with regard to pain or outcome scores between patients with intact repairs and those with persistent defects.

CONCLUSIONS

No difference in clinical outcomes was found between patients with rotator cuffs repaired arthroscopically and those repaired with use of a mini-open technique.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Is Local Viscosupplementation Injection Clinically Superior to Other Therapies in the Treatment of Osteoarthritis of the Knee: A Systematic Review of Overlapping Meta-analyses

PURPOSE

To conduct a systematic review of overlapping meta-analyses comparing treatment of knee osteoarthritis (OA) with intra-articular viscosupplementation (intra-articular hyaluronic acid [IA-HA]) versus oral nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular corticosteroids (IA-corticosteroids), intra-articular platelet-rich plasma (IA-PRP), or intra-articular placebo (IA-placebo) to determine which meta-analyses provide the best current evidence and identify potential causes of discordance.

METHODS

Literature searches were performed for meta-analyses examining use of IA-HA versus NSAIDs, IA-corticosteroids, IA-PRP, or IA-placebo. Clinical data were extracted, and meta-analysis quality was assessed. The Jadad algorithm was applied to determine which meta-analyses provided the highest level of evidence.

RESULTS

Fourteen meta-analyses met the eligibility criteria and ranged in quality from Level I to IV evidence. In studies reporting patient numbers, there were a total of 20,049 patients: 13,698 receiving IA-HA, 355 receiving NSAIDs, 294 receiving IA-corticosteroids, and 5,702 receiving IA-placebo. Ten studies examined the effects of IA-HA versus IA-placebo; of these, 5 found that IA-HA improved pain and 4 found that IA-HA improved function. No clinically relevant differences in the efficacy of IA-HA versus NSAIDs regarding pain and function were found. Regarding IA-HA versus IA-PRP, IA-HA improved knee function at 2 and 6 months after injection but the effects were less robust than those of IA-PRP. Regarding IA-HA versus IA-corticosteroids, the positive effects of IA-HA were greater at 5 to 13 weeks and persisted for up to 26 weeks. After application of the Jadad algorithm, 2 concordant high-quality meta-analyses were selected and both showed that IA-HA provided clinically relevant improvements in pain and function compared with IA-placebo.

CONCLUSIONS

This systematic review of overlapping meta-analyses comparing IA-HA with other nonoperative treatment modalities for knee OA shows that the current highest level of evidence suggests that IA-HA is a viable option for knee OA. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. IA-HA has a good safety profile, and its use should be considered in patients with early knee OA.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Fastball Pitch Velocity Helps Predict Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers

BACKGROUND

Ulnar collateral ligament injury and its subsequent surgical reconstruction are some of the most common issues among Major League Baseball (MLB) players.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine factors predictive of ulnar collateral ligament reconstruction (UCLR) among MLB pitchers. The hypothesis was that pitchers who underwent UCLR would have higher preinjury peak fastball pitch velocity.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data on pitch velocity, number, and type (fastball, curveball, etc) for every pitcher and game within MLB from April 2, 2007 to April 14, 2015 were gathered from the publically available PitchFx database. Pitcher demographic information was also recorded. Data from after 2012 were excluded to avoid lead-time bias. Using publically available information, the names and approximate dates of surgery for every MLB pitcher who ever underwent UCLR, including those before 2007 and after 2012, were collected. Each pitcher-game was then classified as "control," "preinjury," or "postoperative." Control and preinjury pitchers were then compared to determine risk factors for UCLR.

RESULTS

Overall, 1327 pitchers were included, of whom 309 (26.8%) had undergone UCLR. Of these, 145 had preinjury velocity data. Peak pitch velocity was significantly higher among preinjury pitchers than control pitchers (mean [95% CI], 93.3 mph [92.8-93.8] vs 92.1 mph [91.9-92.3]; P < .001), as was mean pitch velocity (87.8 mph [87.3-88.3] vs 86.9 mph [86.7-87.1]; P = .001). Both demonstrated a dose-response relationship. Although height did not differ (P = .934), weight was significantly higher for preinjury pitchers than controls (P = .005). Pitch counts per year were significantly lower for preinjury pitchers compared with control pitchers, although preinjury pitchers threw more breaking pitches (P = .003). On multivariate regression, peak pitch velocity was the primary independent predictor of whether a pitcher underwent UCLR (P < .001), with mean velocity (P = .013), body mass index (P = .010), and age (P = .006) being secondary predictors. However, a model constructed with these variables only explained 7% of the variance in UCLR rates. Pitch counts were not significant predictors.

CONCLUSION

Higher pitch velocity is the most predictive factor of UCLR in MLB pitchers, with higher weight and younger age being secondary predictors, although these factors only explained 7% of the variance in UCLR rates.

Multimedia article. The arthroscopic management of partial-thickness rotator cuff tears: a systematic review of the literature

PURPOSE

There is currently limited information available in the orthopaedic surgery literature regarding the appropriate management of symptomatic partial-thickness rotator cuff tears.

METHODS

A systematic search was performed in PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials of all published literature pertaining to the arthroscopic management of partial-thickness rotator cuff tears. Inclusion criteria were all studies that reported clinical outcomes after arthroscopic treatment of both articular-sided and bursal-sided lesions using a validated outcome scoring system and a minimum of 12 months of follow-up. Data abstracted from the selected studies included tear type and location (articular v bursal sided), treatment approach, postoperative rehabilitation protocol, outcome scores, patient satisfaction, and postoperative imaging results.

RESULTS

Sixteen studies met the inclusion criteria and were included for the final analysis. Seven of the studies treated partial-thickness rotator cuff tears with debridement with or without an associated subacromial decompression, 3 performed a takedown and repair, 5 used a transtendon repair technique, and 1 used a transosseous repair method. Among the 16 studies reviewed, excellent postoperative outcomes were reported in 28.7% to 93% of patients treated. In all 12 studies with available preoperative baseline data, treatment resulted in significant improvement in shoulder symptoms and function. For high-grade lesions, the data support arthroscopic takedown and repair, transtendon repairs, and transosseous repairs, with all 3 techniques providing a high percentage of excellent results. Debridement of partial-thickness tears of less than 50% of the tendon's thickness with or without a concomitant acromioplasty also results in good to excellent surgical outcomes; however, a 6.5% to 34.6% incidence of progression to full-thickness tears is present.

CONCLUSIONS

This systematic review of 16 clinical studies showed that significant variation is present in the results obtained after the arthroscopic management of partial-thickness rotator cuff tears. What can be supported by the available data is that tears that involve less than 50% of the tendon can be treated with good results by debridement of the tendon with or without a formal acromioplasty, although subsequent tear progression may occur. When the tear is greater than 50%, surgical intervention focusing on repair has been successful. There is no evidence to suggest a differential in outcome for tear completion and repair versus transtendon repair of these lesions because both methods have been shown to result in favorable outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Distal Tibia Allograft Glenoid Reconstruction in Recurrent Anterior Shoulder Instability: Clinical and Radiographic Outcomes

PURPOSE

To assess the clinical and radiographic outcomes of patients with recurrent anterior shoulder instability treated with fresh distal tibia allograft (DTA) glenoid reconstruction.

METHODS

Consecutive patients with a minimum 15% anterior glenoid bone loss associated with recurrent anterior instability who underwent stabilization with DTA glenoid reconstruction were retrospectively reviewed. Patients were evaluated with the American Shoulder and Elbow Society score, Western Ontario shoulder instability index, and single numerical assessment evaluation score at a minimum 2 years after surgery. All patients also underwent postoperative imaging evaluation with computed tomography where graft incorporation and allograft angle were measured. Statistical analysis was performed with paired t-tests, with P < .05 considered significant.

RESULTS

A total of 27 patients (100% male) with an average age of 31 ± 5 years and an average follow-up of 45 months (range, 30-66) were included. There were significant improvements in preoperative to postoperative American Shoulder and Elbow Society score (63-91, P < .01), Western Ontario shoulder instability index (46% to 11% of normal, P < .01), and single numerical assessment evaluation score (50-90.5, P < .01) outcomes. Analysis of computed tomography data at an average 1.4 years postoperatively (available for 25 patients) showed an allograft healing rate of 89% (range, 80% to 100%), average allograft angle of 14.9° (range, 6.6° to 29.3°), and average allograft lysis of 3% (range, 0% to 25%). Grafts with lesser allograft angles (<15°) were better opposed to the anterior glenoid, showing superior healing and graft incorporation. There were no cases of recurrent instability.

CONCLUSIONS

At an average follow-up of 45 months, fresh DTA reconstruction for recurrent anterior shoulder instability results in a clinically stable joint with excellent clinical outcomes and minimal graft resorption. Optimal allograft placement resulted in superior bony incorporation with the native glenoid.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

An evidenced-based examination of the epidemiology and outcomes of traumatic rotator cuff tears

PURPOSE

The purpose of this study was to systematically review the literature to better define the epidemiology, mechanism of injury, tear characteristics, outcomes, and healing of traumatic rotator cuff tears. A secondary goal was to determine if sufficient evidence exists to recommend early surgical repair in traumatic rotator cuff tears.

METHODS

An independent systematic review was conducted of evidence Levels I to IV. A literature search of PubMed, Medline, Embase, and Cochrane Collaboration of Systematic Reviews was conducted, with 3 reviewers assessing studies for inclusion, methodology of individual study, and extracted data.

RESULTS

Nine studies met the inclusion and exclusion criteria. Average patient age was 54.7 (34 to 61) years, and reported mean time to surgical intervention, 66 days (3 to 48 weeks) from the time of injury. The most common mechanism of injury was fall onto an outstretched arm. Supraspinatus was involved in 84% of tears, and infraspinatus was torn in 39% of shoulders. Subscapularis tears were present in 78% of injuries. Tear size was <3 cm in 22%, 3 to 5 cm in 36%, and >5 cm in 42%. Average active forward elevation improved from 81° to 150° postoperatively. The weighted mean postoperative UCLA score was 30, and the Constant score was 77.

CONCLUSIONS

Traumatic rotator cuff tears are more likely to occur in relatively young (age 54.7), largely male patients who suffer a fall or trauma to an abducted, externally rotated arm. These tears are typically large and involve the subscapularis, and repair results in acceptable results. However, insufficient data prevent a firm recommendation for early surgical repair.

LEVEL OF EVIDENCE

Level IV, systematic review Levels III and IV studies.

Does the Use of Platelet-Rich Plasma at the Time of Surgery Improve Clinical Outcomes in Arthroscopic Rotator Cuff Repair When Compared With Control Cohorts? A Systematic Review of Meta-analyses

PURPOSE

The aims of the study were as follows: (1) to perform a systematic review of meta-analyses evaluating platelet-rich plasma (PRP) use at the time of arthroscopic rotator cuff repair surgery and to determine its effect on retear rates and clinical outcomes; (2) to provide a framework for the analysis and interpretation of the best currently available evidence; and (3) to identify gaps within the literature where suggestions for continued investigational efforts would be valid.

METHODS

Literature searches were performed to identify meta-analyses examining arthroscopic rotator cuff repairs augmented with PRP versus control (no PRP). Clinical data were extracted and meta-analysis quality was assessed using the Quality of Reporting of Meta-analyses and Oxman-Guyatt scales.

RESULTS

Seven meta-analyses met inclusion and exclusion criteria. All were considered as being of similar quality with Quality of Reporting of Meta-analyses scores >15 and Oxman scores of 7. A total of 3,193 overlapping patients treated were included with mean follow-up from 12 to 31 months. When compared with control patients, use of PRP at the time of rotator cuff repair did not result in significantly lower overall retear rates or improved clinical outcome scores. The following postoperative functional scores comparing PRP versus control were reported: Constant (no significant difference demonstrated with PRP use in 5 of 6 reporting meta-analyses), University of California - Los Angeles (no difference, 6 of 6), American Shoulder and Elbow Society (no difference, 4 of 4), and Simple Shoulder Test (no difference, 3 of 5). Subgroup analysis performed by 3 meta-analyses showed evidence of improved outcomes with solid PRP matrix versus liquid, small- and/or medium-sized versus large and/or massive tears, PRP application at the tendon-bone interface versus over tendon, and in the setting of double-row versus single-row rotator cuff.

CONCLUSIONS

The current highest level of evidence suggests that PRP use at the time of arthroscopic rotator cuff repair does not universally improve retear rates or affect clinical outcome scores. However, the effects of PRP use on retear rates trend toward beneficial outcomes if evaluated in the context of the following specific variables: use of a solid PRP matrix; application of PRP at the tendon-bone interface; in double-row repairs; and with small- and/or medium-sized rotator cuff tears.

LEVEL OF EVIDENCE

Level III, systematic review of Level II and III studies.

The Relationship Between Pitching Mechanics and Injury: A Review of Current Concepts

Context:

The overhand pitch is one of the fastest known human motions and places enormous forces and torques on the upper extremity. Shoulder and elbow pain and injury are common in high-level pitchers. A large body of research has been conducted to understand the pitching motion.

Evidence Acquisition:

A comprehensive review of the literature was performed to gain a full understanding of all currently available biomechanical and clinical evidence surrounding pitching motion analysis. These motion analysis studies use video motion analysis, electromyography, electromagnetic sensors, and markered motion analysis. This review includes studies performed between 1983 and 2016.

Study Design:

Clinical review.

Level of Evidence:

Level 5.

Results:

The pitching motion is a kinetic chain, in which the force generated by the large muscles of the lower extremity and trunk during the wind-up and stride phases are transferred to the ball through the shoulder and elbow during the cocking and acceleration phases. Numerous kinematic factors have been identified that increase shoulder and elbow torques, which are linked to increased risk for injury.

Conclusion:

Altered knee flexion at ball release, early trunk rotation, loss of shoulder rotational range of motion, increased elbow flexion at ball release, high pitch velocity, and increased pitcher fatigue may increase shoulder and elbow torques and risk for injury.

Does Double-Bundle Anterior Cruciate Ligament Reconstruction Improve Postoperative Knee Stability Compared With Single-Bundle Techniques? A Systematic Review of Overlapping Meta-analyses

PURPOSE

Multiple meta-analyses of randomized controlled trials, the highest available level of evidence, have been conducted to determine whether double-bundle (DB) or single-bundle (SB) anterior cruciate ligament reconstruction (ACL-R) provides superior clinical outcomes and knee stability; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SB and DB ACL-R to discern the cause of the discordance and to determine which of these meta-analyses provides the current best available evidence.

METHODS

We evaluated available scientific support for SB as compared with DB ACL-R by systematically reviewing the literature for published meta-analyses. Data on patient clinical outcomes and knee stability (as measured by KT arthrometry and pivot-shift testing) were extracted. Meta-analysis quality was judged using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence.

RESULTS

Nine meta-analyses were included, of which 3 included Level I Evidence and 6 included both Level I and Level II Evidence. Most studies found significant differences favoring DB reconstruction on pivot-shift testing, KT arthrometry measurement of anterior tibial translation, and International Knee Documentation Committee objective grading. Most studies detected no significant differences between the 2 techniques in subjective outcome scores (Tegner, Lysholm, and International Knee Documentation Committee subjective), graft failure, or complications. Oxman-Guyatt and Quality of Reporting of Meta-analyses scores varied, with 2 studies exhibiting major flaws (Oxman-Guyatt score <3). After application of the Jadad decision algorithm, 3 concordant high-quality meta-analyses were selected, with each concluding that DB ACL-R provided significantly better knee stability (by KT arthrometry and pivot-shift testing) than SB ACL-R but no advantages in clinical outcomes or risk of graft failure.

CONCLUSIONS

The current best available evidence suggests that DB ACL-R provides better postoperative knee stability than SB ACL-R, whereas clinical outcomes and risk of graft failure are similar between techniques.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Anterior cruciate ligament reconstruction: can anatomic femoral placement be achieved with a transtibial technique?

BACKGROUND

Recent reports have suggested that a traditional transtibial technique cannot practically accomplish an anatomic anterior cruciate ligament (ACL) reconstruction.

HYPOTHESIS

The degree to which a transtibial technique can anatomically position both tibial and femoral tunnels is highly dependent on tibial tunnel starting position.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Eight fresh-frozen adult knee specimens were fixed at 90° of flexion and then dissected to expose the femoral and tibial ACL footprints. After the central third patellar tendon length was measured for each specimen, computer-assisted navigation was used to identify 2 idealized tibial tunnel starting points, optimizing alignment with the native ligament in the coronal plane but distal enough on the tibia to provide manageable bone-tendon-bone autograft-tibial tunnel mismatch (point A = 10-mm mismatch; point B = 0-mm mismatch). Tibial tunnels were then reamed to the center of the tibial insertion using point A in half of the knees and point B in the other half. Guide pin positioning on the femoral side was then assessed before and after tibial tunnel reaming, after beveling the posterolateral tibial tunnel rim, and after performing a standard notchplasty. After the femoral tunnel was reamed, the digitized contours of the native insertions were compared with those of both tibial and femoral tunnels to calculate percentage overlap.

RESULTS

Starting points A and B occurred 15.9 ± 4.5 mm and 33.0 ± 3.3 mm distal to the joint line, respectively, and 9.8 ± 2.4 mm and 8.3 ± 4.0 mm from the medial edge of the tibial tubercle, respectively. The anterior and posterior aspects of both tibial tunnels' intra-articular exits were within a few millimeters of the native insertion's respective boundaries. After the tibial tunnel was reamed from the more proximal point A, a transtibial guide pin was positioned within 2.1 ± 1.6 mm of the femoral insertion's center (vs 9.3 ± 1.9 mm for point B; P = .02). After beveling a mean 2.6 mm from the back of the point A tibial tunnels, positioning improved to within 0.3 ± 0.7 mm from the center of the femoral insertion (vs 4.2 ± 1.1 mm for the point B tibial tunnels; P = .008). Compared with the more distal starting point, use of point A provided significantly greater insertional overlap (tibial: 97.9% ± 1.4% vs 71.1% ± 15.1%, P = .03; femoral: 87.9% ± 9.2% overlap vs 59.6% ± 8.5%, P = .008). No significant posterior femoral or tibial plateau breakthrough occurred in any specimen.

CONCLUSION

Tibial and femoral tunnels can be positioned in a highly anatomic manner using a transtibial technique but require careful choice of a proximal tibial starting position and a resulting tibial tunnel that is at the limits of practical. Traditional tibial tunnel starting points will likely result in less anatomic femoral tunnels.

CLINICAL RELEVANCE

A transtibial single-bundle technique can accomplish a highly anatomic reconstruction but does require meticulous positioning of the tibial tunnel with little margin for error and some degree of graft-tunnel mismatch.

Current Concepts in the Operative Management of Acromioclavicular Dislocations: A Systematic Review and Meta-analysis of Operative Techniques

BACKGROUND

Acromioclavicular (AC) instability is a frequent injury affecting young and athletic populations. Symptomatic, high-grade dislocations may be managed by a myriad of operative techniques that utilize different grafts to achieve reduction. Comparative data are lacking on the ability of these techniques to achieve excellent patient outcomes and stable AC reduction and to minimize complications.

PURPOSE

To systematically review the outcomes and complications of different techniques of AC joint reconstruction.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The MEDLINE, Scopus, Embase, and Cochrane Library databases were accessed to perform a systematic review of the scientific literature from 2000 to 2018 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following keywords: "acromioclavicular" and "reconstruction." Included articles were evaluated for loss of reduction, complication rate, revision rate, and change in coracoclavicular distance. Articles were stratified by graft and surgical material used: suture only, Endobutton with suture, TightRope, GraftRope, synthetic artificial ligament, tendon graft, and Weaver-Dunn coracoacromial ligament transfer. These outcomes were pooled using a random-effects model and stratified by surgical technique and arthroscopic versus open reconstruction.

RESULTS

Fifty-eight articles were included in the analysis, with 63 homogeneous populations composed of 1704 patients. The mean age was 37.1 years (range, 15-80 years) with a mean follow-up of 34.3 months (range, 1.5-186 months). The overall failure rate was 20.8% (95% CI, 16.9%-25.2%). The overall pooled complication rate was 14.2% (95% CI, 10.5%-18.8%). The most common complications were infection (6.3% [95% CI, 4.7%-8.2%]), fracture to the coracoid or distal clavicle (5.7% [95% CI, 4.3%-7.6%]), and hardware/button failure (4.2% [95% CI, 3.1%-5.8%]). There were no differences between arthroscopic and open techniques in regard to loss of reduction (P = .858), overall complication rate (P = .774), and revision rate (P = .390). Open surgery had a greater rate of clavicular/coracoid fractures than arthroscopic surgery (P = .048). Heterogeneity, best assessed from the pooled loss of reduction, was measured as I² = 64.0%.

CONCLUSION

Open and arthroscopic AC joint reconstruction techniques have no differences in loss of reduction, the complication rate, and the revision rate based on the available literature. Complications are significant, and profiles vary between surgical techniques, which should be evaluated in the decision making of selecting the technique.

Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty

BACKGROUND

Single Assessment Numeric Evaluation (SANE) offers a simple method of evaluating patients' sense of functional improvement after shoulder arthroplasty.

METHODS

Patients receiving total shoulder arthroplasties were retrospectively queried between 2014 and 2017. Patients completed questionnaires involving SANE, American Shoulder and Elbow Surgeons (ASES) score, and Constant scores at the 1-year interval. Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were calculated using the anchor-based methodology.

RESULTS

A total of 207 patients with an average age of 66.7 ± 10.3 years and a body mass index of 31.5 ± 7.3 were available for analysis. The SANE score was the only score to have acceptable area under curve (AUC) (70.5%) for achieving MCID with a cutoff of 28.8. In terms of SCB, ASES (88%) and SANE (70.5%) had acceptable AUC with cutoffs of 20.7 and 50.2, respectively. All 3 scores had excellent AUC (>80%) for PASS with cutoffs of 81.9, 75.5, and 24.5 for ASES, SANE, and Constant scores, respectively. Normalized SANE scores were weakly correlated with ASES and Subjective Constant after normalizing for scale (R2 < 0.4). Achieving MCID by SANE was correlated with achieving MCID by Constant (P < .001). Achieving SCB and PASS by SANE was correlated with achieving SCB and PASS by ASES and Constant (ASES: P = .007, P < .001; Constant: P < .001, P < .001).

CONCLUSION

The present study establishes clinically significant outcomes for SANE. Achievement of clinically significant outcomes in SANE was correlated with achieving meaningful outcomes with legacy measures of ASES and Constant scores. SANE may be used as a simple and efficient measure of patient outcome after total shoulder arthroplasty.

Retrospective analysis of arthroscopic management of glenohumeral degenerative disease

PURPOSE

The purpose of this study was to examine the results of arthroscopic debridement for isolated degenerative joint disease of the shoulder.

METHODS

We retrospectively identified 81 patients who had arthroscopic debridement to treat glenohumeral arthritis. Of these patients, 71 (88%) were available for follow-up. The preoperative Simple Shoulder Test score, American Shoulder and Elbow Surgeons score, Short Form 12 score, visual analog scale score for pain, and range of motion were recorded. These were compared against postoperative scores by use of the statistical paired t test. In addition, patients completed postoperative University of California, Los Angeles; Constant; and Single Assessment Numeric Evaluation scores. Forty-six preoperative radiographs were blindly evaluated and classified. Finally, the need for subsequent shoulder arthroplasty was recorded.

RESULTS

The mean follow-up for the 55 patients who did not progress to arthroplasty was 27 months. The mean preoperative and postoperative American Shoulder and Elbow Surgeons, Simple Shoulder Test, and pain visual analog scale scores all significantly improved (P < .05). Furthermore, range of motion significantly improved (P < .05) in flexion, abduction, and external rotation. Additional postoperative scores were as follows: University of California, Los Angeles, 28.3; Single Assessment Numeric Evaluation, 71.1; Constant score for affected shoulder, 72.0; and Constant score for unaffected shoulder, 78.5. Of the patients, 16 (22%) underwent arthroplasty at a mean of 10.1 months after debridement. Radiographic review showed that 13 shoulders with a mean joint space of 1.5 mm and grade 2.4 arthrosis went on to have shoulder arthroplasty. In contrast, 33 shoulders with a mean joint space of 2.6 mm and grade 1.9 arthrosis did not go on to have shoulder arthroplasty.

CONCLUSIONS

Patients with residual joint space and an absence of large osteophytes can avoid arthroplasty and have increased function with decreased pain after arthroscopic debridement for degenerative joint disease. Significant risk factors for failure include the presence of grade 4 bipolar disease, joint space of less than 2 mm, and large osteophytes.

LEVEL OF EVIDENCE

Level IV, case series.