Humeral Head Reconstruction With Osteochondral Allograft: Bone Plug Optimization for Hill-Sachs Lesions Using CT-Based Computer Modeling Analysis

Background

Engaging Hill-Sachs lesions (HSLs) pose a significant risk for failure of surgical repair of recurrent anterior shoulder instability. Reconstruction with fresh osteochondral allograft (OCA) has been proposed as a treatment for large HSLs.

Purpose

To determine the optimal characteristics of talus OCA bone plugs in a computer-simulated HSL model.

Study Design

Descriptive laboratory study; Level of evidence, 6.

Methods

Included were 132 patients with recurrent anterior instability with visible HSLs; patients who had multidirectional instability or previous shoulder surgery were excluded. Three-dimensional computed tomography models were constructed, and a custom computer optimization algorithm was generated to maximize bone plug surface area at the most superior apex (superiorization) and minimize its position relative to the most medial margin of the HSL defect (medialization). The optimal number, diameter, medialization, and superiorization of the bone plug(s) were reported. Percentages of restored glenoid track width and conversion from off- to on-track HSLs after bone plug optimization were calculated.

Results

A total of 86 patients were included in the final analysis. Off-track lesions made up 19.7% of HSLs and, of these, the mean bone plug size was 9.9 ± 1.4 mm, with 2.2 mm ± 1.7 mm of medialization and 3.3 mm ± 2.9 mm of superiorization. The optimization identified 21% of HSLs requiring 1 bone plug, 65% requiring 2 plugs, and 14% requiring 3 plugs, with a mean overall coverage of 60%. The mean width of the restored HSLs was 68%, and all off-track HSLs (n = 17) were restored to on-track. A Jenks natural-breaks analysis calculated 3 ideal bone plug diameters of 8 mm (small), 10.4 mm (medium), and 12 mm (large) in order to convert this group of HSLs to on-track.

Conclusion

Using a custom computer algorithm, we have demonstrated the optimal talus OCA bone plug diameters for reconstructing HSLs to successfully restore the HSL track and, on average, 60% of the HSL surface area and 68% of the HSL width.

Clinical Relevance

Reconstructing HSLs with talus OCA is a promising treatment option with excellent fit and restoration of HSLs. This study will help guide surgeons to optimize OCA bone plugs from the humeral head, femoral head, and talus for varying sizes of HSLs.

How to Fashion the Bone Block for Reconstruction of the Glenoid in Anterior and Posterior Instability

BACKGROUND

Glenoid restoration techniques to address glenohumeral instability-induced anterior and posterior glenoid bone loss (AGBL and PGBL) often require reconstruction, but best-fit bone block (BFBB) modeling has not been developed.

PURPOSE

To provide glenoid bony reconstruction models for anterior and posterior instability of the shoulder using a bone loss instability cohort with high-fidelity 3-dimensional (3D) imaging.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

We reviewed consecutive patients indicated for operative stabilization who had posterior glenohumeral instability and suspected GBL who underwent 2-dimensional (2D) computed tomography (CT). Patients were matched by sex, laterality, and age to patients who underwent operative stabilization of anterior glenohumeral instability. Mimics software was used to convert all 2D CT scans into 3D models of the scapula. A BFBB model was designed to digitally reconstruct GBL and was used to predict the amount, anatomic configuration, and fixation configuration of bony reconstruction required in AGBL and PGBL.

RESULTS

The study included 30 patients with posterior instability and 30 patients with anterior instability; the participants' mean ± SD age was 28.8 ± 8.15 years (range, 16.0-51.0 years). Mean surface area of AGBL was 24.9% ± 7.7% (range, 14.7%-39.1%). Mean BFBB dimensions to reconstruct the anterior glenoid were determined to be a superior-inferior length of 23.9 ± 4.2 mm, anterior-posterior width of 6.4 ± 2.4 mm, and height of 1 cm. Mean angle of AGBL bone block interface relative to glenoid to reconstruct the native concavity was 79.4°± 5.9°. For PGBL, the mean surface area was 9.2% ± 5.6% (range, 3.0%-26.3%). Mean BFBB dimensions to reconstruct the posterior glenoid were a superior-inferior length of 21.9 ± 3.4 mm, width of 4.5 ± 2.3 mm, and height of 1 cm. The mean angle of PGBL bone block interface relative to the glenoid to reconstruct the native concavity was 38.6°± 14.3°. Orientation relative to the vertical glenoid axis was 77.2°± 13.8° in anterior reconstructions versus 105.9°± 10.9° in posterior reconstructions.

CONCLUSION

Patients with anterior instability required a more rectangular BFBB with a bone block-glenoid interface angle of 79°, whereas patients with posterior instability required a more trapezoidal, obtusely oriented BFBB with a bone block-glenoid interface angle of 39°. BFBBs for either AGBL or PGBL can be effectively designed, and their size and/or shape can be predicted based on approximate percentage of GBL.

Glenoid Bone Loss Directly Affects Hill-Sachs Morphology: An Advanced 3-Dimensional Analysis

BACKGROUND

While the glenoid track concept presents a useful prediction for recurrent glenohumeral instability, little is known about the humeral head bony architecture as it relates to glenoid erosion in the setting of bipolar bone loss.

PURPOSE

To (1) qualitatively and quantitatively analyze the interplay between glenoid bone loss (GBL) and Hill-Sachs lesions (HSLs) in a cohort of patients with anterior instability using 3-dimensional imaging software and (2) assess the relationships between GBL and HSL characteristics.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients were identified who had anterior shoulder instability with a minimum 5% GBL and evidence of HSL confirmed on computed tomography. Unilateral 3-dimensional models of the ipsilateral proximal humeral head and en face sagittal oblique view of the glenoid were reconstructed using MIMICS software (Materialise NV). GBL surface area, width, defect length, and glenoid track width were quantified. The volume, surface area, width, and depth of identified HSLs were quantified with their location (medial, superior, and inferior extent) on the humeral head. Severity of GBL was defined as percentage glenoid bone surface area loss and categorized as low grade (5%-10%), moderate grade (>10% to 20%), high grade (>20% to 30%), and extensive (>30%). Analysis of variance was then computed to determine significance (P < .05) between severity of GBL and associated HSL parameters.

RESULTS

In total, 100 patients met inclusion criteria (mean age, 27.9 years; range, 18-43 years), which included 58 right shoulders and 42 left shoulders (84 male, 16 female). Among groups, there were 32 patients with low-grade GBL (mean GBL = 6.1%), 38 with moderate grade (mean GBL = 16.2%), 17 with high grade (mean GBL = 23.7%), and 13 with extensive (mean GBL = 34.0%), with an overall mean GBL of 18.1% (range, 5%-39%). Patients with 5%-10% GBL had significantly narrower HSLs (average and maximum width; P < .03) and deeper HSLs (average depth; P = .002) as compared with all other GBL groups, while greater GBL was associated with wider and shallower HSLs. GBL width, percentage width loss, defect length, and glenoid track width all significantly differed across the 4 GBL groups (P < .05).

CONCLUSION

HSLs had significantly different morphological characteristics depending on the severity of GBL, indicating that GBL was directly related to the characteristics of HSLs. Patients presenting with smaller glenoid defects had significantly narrower and deeper HSLs with less humeral head surface area loss, while greater GBL was associated with wider and shallower HSLs.

Anterior and Posterior Glenoid Bone Loss In Patients Receiving Surgery for Glenohumeral Instability Is Not the Same: A Comparative 3-Dimensional Imaging Analysis

Background

Methods

Results

Conclusion

Anchor Arthropathy of the Shoulder Joint After Instability Repair: Outcomes Improve With Revision Surgery

PURPOSE

To report clinical and patient-reported outcome measures (PROMs) in patients undergoing revision surgery after diagnosis of anchor-induced arthropathy.

METHODS

Patients who underwent revision arthroscopic shoulder surgery and were diagnosed with post-instability glenohumeral arthropathy performed from January 2006 to May 2018 were included in the current study. Patients were excluded if they underwent prior open shoulder procedures, if glenoid bone loss was present, or if prerevision imaging and records were incomplete or not available. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, exam findings before revision surgery, and surgical intervention. PROMs were prospectively collected before surgery and at minimum 2-year follow-up.

RESULTS

Fourteen patients were included with a mean (± standard deviation) age at presentation of 35.2 ± 12.1 years (range 16 to 59). The follow-up rate was 86%, with a mean follow-up of 3.8 years (range 1.1 to 10.6). Mean time to development of arthropathy symptoms was 48.2 months (range <1 month to 13.8 years), all presenting with pain and decreased range of motion on exam. At time of revision surgery, all patients underwent either open or arthroscopic removal of previous implants, including anchors and suture material. Six patients underwent additional revision stabilization procedures, 1 underwent total shoulder arthroplasty, and 7 underwent arthroscopic intraarticular debridement, capsular release, and chondroplasty with or without microfracture. Pain significantly improved in 79% of patients (P = .05). Significant improvements in all PROMs were observed, including 12-item Short Form (43.8 to 54.8, P < .01); Disabilities of the Arm, Shoulder, and Hand, shortened version (31.8 to 8.4, P < .01); Single Assessment Numeric Evaluation (47.0 to 84.5, P < .05); and American Shoulder and Elbow Surgeons (61.6 to 92.1, P < .01). Average external rotation significantly improved, from 31° ± 22° to 52° ± 24° (P = .02).

CONCLUSION

Rapid intervention after diagnosis, through either revision arthroscopic or open debridement and stabilization, can lead to significant improvement in range of motion, pain, and overall patient function and satisfaction.

LEVEL OF EVIDENCE

IV, retrospective case series.

Advanced 3-Dimensional Characterization of Hill-Sachs Lesions in 100 Anterior Shoulder Instability Patients

PURPOSE

We sought to qualitatively and quantitatively describe characteristics of Hill-Sachs lesions (HSL) in a cohort of anterior shoulder instability patients using advanced 3-dimensional (3-D) modeling software and assess the impact of various HSL parameters on the HSL volume, location, and orientation in patients with anterior shoulder instability.

METHODS

A total of 100 recurrent anterior instability patients with evidence of HSL with a mean age of 27.2 years (range = 18 to 43 years) were evaluated. Three-dimensional models of unilateral proximal humeri were reconstructed from CT scans, and the volume, surface area (SA), width, and depth of identified HSLs were quantified along with their location (medial, superior, and inferior extent). Multiple angular orientation measures of HSLs were recorded, including Hill-Sachs rim (HSLr) angle in order to classify the level and location of potential humeral head engagement. Mann-Whitney U test assessed the relationship between measured parameters.

RESULTS

By volume, larger HSL had greater humeral head surface area (HH SA) loss (P = .001), HSL width (P = .001), were more medial (P = .015), and more inferior (P = .001). Additionally, more medial lesions had greater HSLr angles (P = 0.001). The mean depth, width, and volume of HSLs were 3.3 mm (range = 1.2-7.1 mm), 16.0 mm (range = 6.2-30.4 mm) and 449.2 mm³ (range = 62.0-1365.6 mm³), respectively. The medial border of the HSL extended to 17.2 ± 4.4 (range = 9.3-28.3 mm) off the most medial edge of the HH cartilage margin (medialization). The mean HSLr was 29.3 ± 10.5°.

CONCLUSION

There was a statistically significant association between HSL medialization and HSL volume, position, and orientation. More medialized HSL have larger volume, greater width, more SA loss and higher lesion angles and are more inferior in the humeral head. As it has been established that more medialized lesions have poorer clinical outcomes, this study highlights that HS lesions have varying angles and medialization, which may portend eventual treatment and outcomes.

LEVEL OF EVIDENCE

IV, case series.

Limited Predictive Value of the Instability Severity Index Score: Evaluation of 217 Consecutive Cases of Recurrent Anterior Shoulder Instability

PURPOSE

To review the existing variables and their ability to predict recurrence of shoulder instability as it relates to the Instability Severity Index Score (ISIS), as well as evaluate any other pertinent imaging and patient history variables that may impact risk of recurrent anterior instability after arthroscopic Bankart repair.

METHODS

All consecutive patients with recurrent anterior shoulder instability and who had arthroscopic instability repair were identified. Exclusion criteria were prior surgery on the shoulder, posterior or multidirectional instability, instability caused by seizure disorder, or a rotator cuff tear. All ISIS variables were recorded (age <20 years, sport type and level, hyperlaxity, Hill-Sachs on anteroposterior external rotation radiograph, loss of glenoid contour on anteroposterior radiograph), as well as additional variables: (1) number of instability events; (2) total time of instability; (3) glenoid bone loss (GBL) percent; and (4) Hill-Sachs measures (H/L/W/D/Volume). Postoperative outcomes were assessed based on the Western Ontario Shoulder Instability Index (WOSI), Single Assessment Numeric Evaluation (SANE) scores, and American Shoulder and Elbow Surgeons (ASES) scores, and recurrent anterior instability. Regression analysis was used to determine preoperative variables that predicted outcomes and failures.

RESULTS

There were 217 consecutive patients (209 male patients [96.5%], 8 female patients [3.5%]) who met the inclusion criteria and were all treated with a primary arthroscopic shoulder stabilization during a 3.5-year period (2007-2011), with a mean follow-up time of 42 months (range, 26-58). The mean age at first instability event was 23.9 years (range, 16-48 years) and the mean cumulative ISIS score for the overall group was 3.6 (range, 1-6). Outcomes were improved from mean preoperative (WOSI = 1,050/2,100; ASES = 61.0; SANE = 52.5) to postoperative (WOSI = 305/2,100; ASES = 93.5; SANE = 95.5). A total of 11.5% (25/217) of patients had evidence of recurrent instability (subluxation or dislocation). Additionally, all 25 patients who failed postoperatively also had consistently inferior ASES, SANE, and WOSI outcome scores when compared with successfully treated patients. Factors associated with failure were GBL greater than 14.5% (P < .001), total time of instability symptoms greater than 3 months (P = .03), Hill-Sachs volume greater than 1.3 cm³ (P = .02), contact sports participation (P = .05), and age 20 years or younger (P < .01). There was no correlation in outcomes with Hill-Sachs on presence of glenoid contour loss on radiograph (P = .07), participation sports, or ISIS (mean = 3.4 success vs 3.9 failure, P > .05).

CONCLUSIONS

At a mean follow-up of 42 months was an 11.5% failure rate after arthroscopic Bankart stabilization surgery. This study shows no correlation between treatment outcome and the ISIS measure, given a mean score of 3.4 for the overall cohort with little difference identified in those who failed. However, several important parameters previously unidentified were detected including, GBL greater than 14.5%, Hill-Sachs volume greater than 1.3 cm³, and duration of instability symptoms (>3 months). The ISIS may need to be redesigned to incorporate variables that more accurately portray the actual risk of failure after arthroscopic stabilization, including quantification of both glenoid and humeral head bone loss.

LEVEL OF EVIDENCE

III (Retrospective Case Series).

Risk Factors for Recurrence After Arthroscopic Instability Repair-The Importance of Glenoid Bone Loss >15%, Patient Age, and Duration of Symptoms: A Matched Cohort Analysis

BACKGROUND

Glenoid bone loss (GBL) has been implicated as a risk factor for failure of arthroscopic anterior glenohumeral instability repair. Although certain amounts of GBL are associated with higher recurrence rates, there are limited studies on successes versus failures in these cohorts.

PURPOSE

To compare the outcomes of arthroscopic Bankart repair in patients with and without GBL to determine a threshold percentage of GBL that predicts success.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

All consecutive patients who underwent arthroscopic Bankart repair for anterior shoulder instability between 2004 and 2013 were prospectively enrolled. Patients with ≤25% GBL were included. Patients with no GBL were grouped and compared with those having 5% to 25% GBL. Outcomes included Single Assessment Numerical Evaluation, Western Ontario Shoulder Index, and American Shoulder and Elbow Surgeons scores, with evidence of recurrent instability. Patients with and without GBL were statistically compared with respect to outcomes and recurrence rates.

RESULTS

Of 434 eligible patients, the cases of 405 (45 female, 360 male; mean age, 27.5 years [range, 18-47 years]) were followed for a mean 61 months (range, 48-96 months). There were 189 (46.6%) with no GBL and 216 (53.3%) with GBL; the mean GBL of the latter cohort was 15% (range, 5%-25%). The mean duration of instability symptoms was 7.9 months (range, 1-21 months) and was significantly longer in the GBL group (P < .05). The mean recurrence rate was 14.8%, which was significantly greater in patients presenting with GBL versus those with none (48/216 [22.2%] vs 12/189 [6.3%]; P < .01). Within the GBL group, GBL ≥15%, duration of symptoms >5 months, and younger age (<20 years) were independent risk factors for failure (P < .01). Patients with any GBL had >4-times greater odds of recurrence after arthroscopic stabilization (odds ratio, 4.21; 95% CI, 2.16-8.21). Moreover, patients presenting for arthroscopic Bankart repair with GBL ≥15% had nearly 3-times greater odds of recurrent instability.

CONCLUSION

GBL ≥15% in an active patient population portends to increased odds of recurrent instability events and inferior clinical outcomes after arthroscopic Bankart repair. Furthermore, nonmodifiable risk factors, such as age (<20 years) and duration of symptoms before presentation (>5 months), significantly affect risk of recurrence and should be key factors when counseling patients on risk of failure and determining the ideal procedure for the individual patient.

Terminal Sterilization of Anterior Cruciate Ligament (ACL) Allografts: A Systematic Review of Outcomes

INTRODUCTION

Anterior cruciate ligament (ACL) injuries are common and reconstruction can be completed with either autograft or allograft tissue. However, there is concern about an increased failure rate with allograft tissue. The purpose of this study was to systematically review the available evidence to determine the effect of irradiation and level of dose on the failure rates of allograft in ACL reconstruction.

METHODS

A literature search was performed using PubMed, Scopus, and Web of Science from January 2000 to September 2013. Inclusion criteria consisted of the following: (1) primary, unilateral, single-bundle allograft ACL procedure, (2) studies with data documenting graft type and terminal sterilization technique, (3) subjective assessments of outcome, and (4) objective assessments of outcome. Studies without reported subjective and objective outcomes and those pertaining to revision ACL reconstruction were excluded. Failures were defined and compared between irradiated and non-irradiated grafts, as well as between grafts irradiated with 1.2 - 1.8 Mrad and those with 2.0 - 2.5 Mrad.

RESULTS

Of the 242 articles identified via initial search, 17 studies met the final inclusion criteria. A total of 1,090 patients were evaluated in this study, all having undergone unilateral primary ACL reconstruction with allograft tissue with 155 failures. The failure rate between non-irradiated (98/687, 14.7%) and irradiated (57/408, 14.0%) was not statistically significant (p = 0.86). Grafts in the high-dose irradiation group (27/135, 20.0%) had a statistically significant higher (p < 0.001) rate of failure than those in the low-dose irradiation group (30/273, 10.6%).

CONCLUSION

The irradiation of an allograft increases the risk of failure after an ACL reconstruction but the use of lower doses of radiation decreases that risk.

Terminal Sterilization of Anterior Cruciate Ligament (ACL) Allografts: A Systematic Review of Outcomes

Introduction. Anterior cruciate ligament (ACL) injuries are common and reconstruction can be completed with either autograft or allograft tissue. However, there is concern about an increased failure rate with allograft tissue. The purpose of this study was to systematically review the available evidence to determine the effect of irradiation and level of dose on the failure rates of allograft in ACL reconstruction. Methods. A literature search was performed using PubMed, Scopus, and Web of Science from January 2000 to September 2013. Inclusion criteria consisted of the following: (1) primary, unilateral, single-bundle allograft ACL procedure, (2) studies with data documenting graft type and terminal sterilization technique, (3) subjective assessments of outcome, and (4) objective assessments of outcome. Studies without reported subjective and objective outcomes and those pertaining to revision ACL reconstruction were excluded. Failures were defined and compared between irradiated and non-irradiated grafts, as well as between grafts irradiated with 1.2 - 1.8 Mrad and those with 2.0 - 2.5 Mrad. Results. Of the 242 articles identified via initial search, 17 studies met the final inclusion criteria. A total of 1,090 patients were evaluated in this study, all having undergone unilateral primary ACL reconstruction with allograft tissue with 155 failures. The failure rate between non-irradiated (98/687, 14.7%) and irradiated (57/408, 14.0%) was not statistically significant (p = 0.86). Grafts in the high-dose irradiation group (27/135, 20.0%) had a statistically significant higher (p < 0.001) rate of failure than those in the low-dose irradiation group (30/273, 10.6%). Conclusion. The irradiation of an allograft increases the risk of failure after an ACL reconstruction but the use of lower doses of radiation decreases that risk.

Glenoid Track Instability Management Score: Radiographic Modification of the Instability Severity Index Score

PURPOSE

The purpose of this study is (1) to test the proposed treatment algorithm, the Glenoid Track Instability Management Score (GTIMS), which incorporates the glenoid track concept into the instability severity index score (ISIS), and (2) to compare treatment decision-making using either GTIMS versus ISIS in 2 cohorts of patients with operatively treated anterior instability.

METHODS

A multicenter, retrospective review of two consecutive groups consisting of 72 and 189 patients treated according to ISIS and GTIMS, respectively, was conducted. Inclusion criteria for all patients were ≥2 confirmed traumatic anterior shoulder instability events and a physical examination demonstrating a positive anterior apprehension and relocation test. The GTIMS was graded for all 189 patients in the cohort, which uses 3-dimensional computed tomography as the sole radiographic parameter to assess on-track (0 points) versus off-track (4 points) Hill-Sachs lesions. This method differs from ISIS, which uses multiple plain radiographs for the 4-point imaging portion of the score. Outcomes scores were compared within the GTIMS and ISIS groups, as well as between them for overall comparisons based on the Western Ontario Shoulder Instability Index (WOSI), the Single Assessment Numerical Evaluation (SANE) score, and the mean rates of recurrent instability.

RESULTS

A total of 261 consecutive patients from 2009 to 2014 who presented with recurrent anterior shoulder instability were treated according to either ISIS (n = 72/261, 27.6%) or GTIMS (n = 189/261, 72.4%). At a mean follow-up time of 33.2 months (range 24-49 months), the overall cohort mean ISIS of 2.9 ± 2.2 (range 0-9) was significantly higher than the mean GTIMS of 1.9 ± 1.9 (range = 0-9, P < .001). Of the 72 ISIS treated patients, 50 (69.4%) had an ISIS score of ≥ 4 and underwent a Latarjet, and the 22 patients (30.6%) with an ISIS score of < 4 underwent an arthroscopic Bankart repair. Based on GTIMS in the 189-patient cohort, using the same cutoff of 4 to indicate the need for a Latarjet, 162 patients were treated with arthroscopic Bankart repair (85.7%) and 27 with Latarjet (14.3%). The overall outcomes improved for patients treated with a Latarjet in both groups (GTIMS WOSI from 1099 [47.7% normal] to 395 [81.3% normal]; GTIMS SANE from 48 to 81; ISIS WOSI from 1050 [50% normal] to 345 [83.4% normal]; ISIS SANE from 50 to 84; P < .01). Similar positive outcomes were seen in patients treated with arthroscopic Bankart repair (GTIMS WOSI from 1062 [49.2% normal] to 402 [80.6% normal]; GTIMS SANE from 49 to 82; ISIS WOSI from 1080 [51.8% normal] to 490 [76.7% normal]; ISIS SANE from 48 to 77; P < .01). Of note, the patients with arthroscopically indicated ISIS had significantly worse outcomes scores than those treated arthroscopically according to GTIMS (P < .01). Of the 189 patients graded with GTIMS, there would have been 33 more Latarjet procedures recommended based on ISIS score. Thus the distribution of procedures based on ISIS versus GTIMS was significantly different (χ² = 45.950; P < .001), indicating a higher rate of recommending Latarjets when using ISIS versus GTIMS.

CONCLUSIONS

When ISIS scoring and plain radiograph parameters only are used, this predicted a 2-fold increase in recommending a Latarjet versus GTIMS scoring criteria, which uses advanced imaging and the on- and off-track principle to more conservatively delineate anterior instability treatment with promising postoperative patient outcomes. Overall, there were minimal differences in outcomes between GTIMS and ISIS Latarjet patients; however, better outcomes were seen in patients indicated for arthroscopic Bankart repair according to GTIMS and on-off track computed tomography scanning indications.

LEVEL OF EVIDENCE

II, Prospective Cohort Study.

Outcomes of Primary Biceps Subpectoral Tenodesis in an Active Population: A Prospective Evaluation of 101 Patients

PURPOSE

To evaluate the surgical outcomes of a primary subpectoral biceps tenodesis for long head of the biceps tendon (LHBT) pathology in a large cohort of prospectively, serially collected, patients in a young active population that has known high physical demands and requirements of their shoulder to perform their vocation.

METHODS

A retrospective review of prospectively collected data from an active military personnel with a diagnosis of a Type II SLAP tear or biceps tenosynovitis was performed. Outcomes were evaluated at a minimum follow-up time of 18 months based on preoperative and postoperative assessments of the Single Assessment Numeric Evaluation, Western Ontario Rotator Cuff index, biceps position, and return to active duty. Inclusion criteria were (1) SLAP tears on magnetic resonance arthrogram (classified into SLAP group), and (2) no SLAP tear but examination findings of biceps tendonitis (placed in the LHBT tendonitis group). Patients were excluded for full-thickness rotator cuff tears, high-grade partial thickness tears requiring repair, acromioclavicular joint pathology, and labral pathology outside of the SLAP lesion. Patients from both groups subsequently were treated with open, subpectoral tenodesis.

RESULTS

Over a 6-year period at a mean follow-up of 2.75 years (range 1.5-5.7 years), 125 active-duty military personnel with mean age of 42.6 years (range 26.3-56.5) were enrolled. A total of 101 of 125 patients (81%) completed study requirements at a mean of 2.75 years (range 1.5-5.7 years). In total, 40 patients were diagnosed with type II SLAP tears (39.6%) and 61 with biceps tendonitis without SLAP tear (60.4%). Following open, subpectoral tenodesis, there was a significant improvement in patient outcomes (Western Ontario Rotator Cuff = 54% preoperative vs 89% postoperative, Single Assessment Numeric Evaluation = 58 preoperative vs 89.5 postoperative, P < .01). In total, 82% of patients returned to full activity at a mean of 4.1 months. The biceps muscle measured relative to the antecubital fossa of operative (mean 3.20 cm) versus nonoperative (3.11 cm) was not clinically different (P = .57). There was an 8% complication rate, including 3 requiring revision, 2 superficial infections, and 3 transient neurapraxias.

CONCLUSIONS

Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the LHBT provides significant improvement in shoulder outcomes with a reliable return to activity level with low risk for complications.

LEVEL OF EVIDENCE

Level IV (Case series).

Distal Clavicular Augmentation with Acromioclavicular and Coracoclavicular Ligament Reconstruction in the Setting of Iatrogenic Induced Acromioclavicular Instability

Although chronic pain and dysfunction of the acromioclavicular (AC) joint can reliably be treated with distal clavicle excision, disruption of the local stabilizing ligamentous structures may result in iatrogenic instability of the joint. Iatrogenic AC joint instability is a rare condition caused by over resection of the distal clavicle with unintended injury to the stabilizing ligaments in the treatment of AC joint pain. Addressing postresection instability can prove to be difficult because most reconstruction techniques are intended for patients with traumatic AC joint instability with the goal of creating an anatomically stable joint. However, in the setting of iatrogenic instability, the decreased bone stock of the distal clavicle results in instability of the AC joint, especially in the horizontal plane, and may cause these techniques to fail. Thus, operative management must aim to correct both the osseous and ligamentous deficits responsible for the genesis of this instability. In this Technical Note, we describe bony augmentation of the distal clavicle with an iliac crest bone autograft for chronic iatrogenic acromioclavicular joint instability with concomitant reconstruction of the AC and coracoclavicular ligaments.

Characterization of Posterior Glenoid Bone Loss Morphology in Patients With Posterior Shoulder Instability

PURPOSE

To systemically describe posterior bone defects in the setting of posterior shoulder instability based on several parameters, including surface area, slope and version, defect height from the base of the glenoid, and extent of bone loss at equal intervals along the long axis of the fossa.

METHODS

A total of 40 young, active individuals with recurrent posterior shoulder instability and a bony injury confirmed on either computed tomography (n = 18; mean age, 26.3 ± 4.0 years) or magnetic resonance imaging (n = 22; mean age, 20.0 ± 4.9 years) were identified. The posterior glenoid bone defect was characterized using the following measures: (1) percentage of bone loss, (2) glenoid vault version, (3) slope of the posterior defect relative to the glenoid surface, (4) superior-inferior length of the defect, and (5) anterior-posterior width of the defect at 5 intervals along the glenoid fossa.

RESULTS

The mean age of the 40 patients was 22.9 ± 5.5 years (range, 14.9-35.5 years). The mean surface area of glenoid bone loss was 9.7% ± 4.7%. Glenoid version measured at 5 equal intervals along the inferior two-thirds of the glenoid was 12.8° ± 4.9°, 11.9° ± 5.0°, 10.1° ± 6.3°, 10.5° ± 6.5°, and 8.7° ± 7.2° from superior to inferior. The mean slope of the posterior defect relative to the glenoid fossa was 26.8° ± 11.5°. The mean superior-inferior height of the bony defect was 21.9 ± 0.4 mm. The anterior-posterior sloped width of the defect at 5 equal intervals along the glenoid fossa was 0.9 ± 1.5 mm, 2.8 ± 2.4 mm, 4.0 ± 1.7 mm, 4.0 ± 2.1 mm, and 2.9 ± 2.6 mm from superior to inferior. Low-grade (<10%) bone loss was diagnosed in most shoulders (23 of 40 evaluated), whereas 15 had moderate bone loss (10% to <20%) and 2 had high-grade bone loss (≥20%).

CONCLUSIONS

Posterior glenoid bone loss is characterized by a loss of posterior bony concavity, increased slope from anterior to posterior, and increased posterior version. The most anterior-posterior sloped width was quantified at the third and fourth intervals of 5 equal intervals from superior to inferior. This study highlights that patients with posterior instability have bone loss that is sloped relative to the glenoid fossa and suggests that management must be appropriately tailored given the distinctiveness of posterior bone loss.

LEVEL OF EVIDENCE

Level IV, case series.

Primary Acromioclavicular-Coracoclavicular Reconstruction Using 2 Allografts, TightRope, and Stabilization to the Acromion

Acromioclavicular (AC) joint injuries are a common cause of shoulder pain, particularly among young athletes participating in contact sports. Injuries to the AC joint most commonly occur from direct impact at the acromion and are classified as types I to VI. Although most AC joint injuries can be treated nonoperatively, types IV to VI are best treated with surgery, with type III being controversial and most surgeons recommending an initial trial of nonoperative treatment. Although numerous surgical techniques have been described, no gold standard technique has been established. Biomechanical testing suggests that anatomic reconstruction of both the AC and coracoclavicular ligaments results in a superior surgical construct. The objective of this Technical Note is to describe our preferred technique for the primary treatment of AC joint instability in the acute and chronic setting. Using 2 free tendon grafts in combination with a cortical button suspensory device combines the advantages of a nonrigid biologic and anatomic AC and coracoclavicular ligament reconstruction while benefiting from the strength of a cortical suspensory device in resisting displacement of the AC joint.

Impact of Sagittal Rotation on Axial Glenoid Width Measurement in the Setting of Glenoid Bone Loss

Standard 2-dimensional (2-D) computed tomography (CT) scans of the shoulder are often aligned to the plane of the body as opposed to the plane of the scapula, which may challenge the ability to accurately measure glenoid width and glenoid bone loss (GBL). The purpose of this study is to determine the effect of sagittal rotation of the glenoid on axial anterior-posterior (AP) glenoid width measurements in the setting of anterior GBL. Forty-three CT scans from consecutive patients with anterior GBL (minimum 10%) were reformatted utilizing open-source DICOM software (OsiriX MD). Patients were grouped according to extent of GBL: I, 10% to 14.9% (N = 12); II, 15% to 19.9% (N = 16); and III, >20% (N = 15). The uncorrected (UNCORR) and corrected (CORR) images were assessed in the axial plane at 5 standardized cuts and measured for AP glenoid width. For groups I and III, UNCORR scans underestimated axial AP width (and thus overestimated anterior GBL) in cuts 1 and 2, while in cuts 3 to 5, the axial AP width was overestimated (GBL was underestimated). In Group II, axial AP width was underestimated (GBL was overestimated), while in cuts 2 to 5, the axial AP width was overestimated (GBL was underestimated). Overall, AP glenoid width was consistently underestimated in cut 1, the most caudal cut; while AP glenoid width was consistently overestimated in cuts 3 to 5, the more cephalad cuts. Uncorrected 2-D CT scans inaccurately estimated glenoid width and the degree of anterior GBL. This data suggests that corrected 2D CT scans or a 3-dimensional (3-D) reconstruction can help in accurately defining the anterior GBL in patients with shoulder instability.

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.

Traditional Versus Congruent Arc Latarjet Technique: Effect on Surface Area for Union and Bone Width Surrounding Screws

PURPOSE

To compare the surface area available for bony contact and the width of bone on each side of the Latarjet fixation screws in the traditional Latarjet technique versus the congruent arc modification of the Latarjet technique.

METHODS

Computed tomographic scans of 24 shoulders in patients with glenohumeral instability who underwent multiplanar reconstruction measurements with multiple dimensions of the coracoid. The surface area of the coracoid available for bony contact with the anterior glenoid and width of bone on each side of a 3.5-mm screw was compared for the traditional Latarjet technique versus the congruent arc modification.

RESULTS

The surface area available for bony contact to the anterior glenoid was 5.65 ± 1.08 cm² using the traditional Latarjet technique compared with 3.64 ± 0.93 cm² using the congruent arc modification of the Latarjet technique (P < .001). The mean width of bone on each side of a 3.5-mm screw was 7.1 ± 1.0 mm using the traditional Latarjet technique compared with 4.1 ± 1.0 mm using the congruent arc modification (P < .001).

CONCLUSIONS

The traditional Latarjet technique has greater bony contact with the glenoid and greater bone width on each side of the screws compared with the congruent arc modification of the Latarjet technique. This potentially allows for a larger surface for healing in the traditional Latarjet technique. Moreover, because of smaller width of the bone around the screw, the congruent arc modification is potentially less tolerant of screw-positioning error compared with the traditional Latarjet technique.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Prospective Evaluation of Surgical Treatment of Humeral Avulsions of the Glenohumeral Ligament

BACKGROUND

Humeral avulsion of the glenohumeral ligament (HAGL) is an infrequent but significant contributor to shoulder dysfunction, instability, and functional loss.

PURPOSE

To prospectively identify patients with HAGL lesions and then conduct retrospective evaluation of the clinical history, examination findings, and surgical outcomes of these patients.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Over a 6-year period (2006-2011), patients with shoulder dysfunction and a HAGL lesion that was confirmed via magnetic resonance arthrogram (MRA) were prospectively evaluated with a minimum 2-year follow-up. Patient demographics, presentation, examination, and surgical findings were documented. Outcomes of return to activity as well as Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) scores were recorded at final follow-up. Anterior HAGL (aHAGL) lesions were repaired with a partial subscapularis tenotomy approach, while reverse (rHAGL) lesions were repaired arthroscopically.

RESULTS

Of 28 patients, 27 (96%) completed the study requirements at a mean of 36.2 months (range, 24-68 months). The sample contained 12 females (44%) and 15 males (56%), who had a mean age of 24.9 years (range, 18-34 years). The chief complaint reported was pain in 23 patients (85%), while only 4 (15%) patients complained primarily of recurrent instability symptoms. Fourteen patients (52%) had aHAGL lesions, 10 patients (37%) had rHAGL lesions, and 3 patients (11%) had combined aHAGL and rHAGL lesions. Ten patients (37%) had concomitant HAGL lesions and labral tears, whereas 17 patients (63%) had isolated HAGL lesion without labral tear. The 17 patients (63%) with aHAGL lesions or combined lesions underwent a partial subscapularis tenotomy approach, while the remaining 10 patients (37%) with rHAGL lesions underwent arthroscopic surgical repair. After surgery, WOSI outcomes improved from 54% to 88% and SANE outcomes improved from 50% to 91% ( P < .01 for both), with no reports in recurrence of instability symptoms at final follow-up.

CONCLUSION

This study demonstrated that patients with symptomatic HAGL lesions predominantly report shoulder pain and dysfunction, with few chief complaints of recurrent instability complaints. After surgery, patients showed predictable return to full activity, improvement in objective and patient-reported outcomes, and satisfaction with treatment outcome.

Classification and Analysis of Attritional Glenoid Bone Loss in Recurrent Anterior Shoulder Instability

BACKGROUND

Recognition and proper treatment of glenoid bone loss (GBL) are important for successful management of anterior shoulder instability. Although GBL has been described as the amount of bony loss from the front of the glenoid, there is also a fragment of bone that is usually displaced and often undergoes attrition. Thus, due to attritional bone loss (ABL) of the fragment, insufficient bone is left to fully reconstruct the glenoid.

PURPOSE

To (1) evaluate ABL of the glenoid fragment in recurrent anterior shoulder instability and (2) correlate ABL with clinical history, fragment size, and radiographic findings.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

GBL was evaluated on 3-dimensional computed tomography (3D CT) en-face view and was measured as percentage loss. The bone fragment size was measured, and attrition of the fragment was determined by evaluation of the amount remaining relative to the initial defect; patients were stratified into minimal (<34%), moderate (34% to <67%), and severe (≥67%) attritional loss groups. Clinical history and demographics were correlated to ABL, and GBL and ABL were compared.

RESULTS

The overall median percentage GBL was 15.3% (interquartile range [IQR], 9.9%-20.0%), with a mean (±SD) percentage GBL of 16.5% ± 9.0%. Study participants had a corresponding median percentage ABL of 75.8% (IQR, 53.8%-95.7%) and a mean percentage ABL of 72.0% ± 24.4%. A total of 61.2% of patients (n = 85) exhibited severe ABL, while 30.2% had moderate ABL and 8.6% had minimal ABL. The total time of instability was significantly associated with percentage of attritional bone loss ( P < .05). In addition, the time of instability was greatest in patients in the third tertile of ABL (≥87.5%; P = .08). A significant difference was found in total time of instability among patients in the highest tertile of ABL (38.6 months) versus both the middle (26.7 months) and lowest (32.8 months) tertiles ( P < .05).

CONCLUSION

The study results indicate that in the majority of patients with recurrent anterior instability, GBL presents with extensive attrition of the bone fragment independent of initial glenoid bone loss; therefore, surgeons should be cognizant that the remaining bone fragment is unable to reconstitute glenoid bone stock. In addition, the results showed more attritional bone loss in patients with a longer duration of instability symptoms, indicating a role for incorporating symptom duration in determining proper management.

Surgical Release of the Pectoralis Minor Tendon for Scapular Dyskinesia and Shoulder Pain

BACKGROUND

Pectoralis minor (PM) tightness has been linked to pain and dysfunction of the shoulder joint secondary to anterior tilt and internal rotation of the scapula, thus causing secondary impingement of the subacromial space.

PURPOSE

To describe outcomes pertaining to nonoperative and operative treatment via surgical release of the PM tendon for pathologic PM tightness in an active population.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Over a 3-year period, a total of 46 patients were enrolled (mean age, 25.5 years; range, 18-33 years). Inclusion criteria consisted of symptomatic shoulder pain, limited range of overhead motion, inability to participate in overhead lifting activities, and examination findings consistent with scapular dysfunction secondary to a tight PM with tenderness to palpation of the PM tendon. All patients underwent a lengthy physical therapy and stretching program (mean, 11.4 months; range, 3-23 months), which was followed by serial examinations for resolution of symptoms and scapular tilt. Of the 46 patients, 6 (13%) were unable to adequately stretch the PM and underwent isolated mini-open PM release. Outcomes were assessed with scapula protraction measurements and pain scales as well as American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) scores.

RESULTS

Forty of the 46 patients (87%) resolved the tight PM and scapular-mediated symptoms with a dedicated therapy program (pre- and posttreatment mean outcome scores: 58 and 91 [ASES], 50 and 90 [SANE], 4.9 and 0.8 [VAS]; P < .01 for all), but 6 patients were considered nonresponders (mean score, 48 [ASES], 40 [SANE], 5.9 [VAS]) and elected to have surgical PM release, with improved scores in all domains (mean score, 89 [ASES], 90.4 [SANE], 0.9 [VAS]; P < .01) at final follow-up of 26 months (range, 25-30 months). Additionally, protraction of the scapula improved from 1.2 to 0.3 cm in a mean midline measurement from the chest wall preoperatively to postoperatively ( P < .01), similar to results in nonoperative responders. No surgical complications were reported, and all patients returned to full activities.

CONCLUSION

In most patients, PM tightness can be successfully treated with a nonoperative focused PM stretching program. However, in refractory and pathologically tight PM cases, this series demonstrates predictable return to function with notable improvement in shoulder symptoms after surgical release of the PM. Additional research is necessary to evaluate the long-term efficacy of isolated PM treatment.

Encapsulated Fat Necrosis Lesion Caused by Morel-Lavallée Lesion in a Professional Ice Hockey Player

Morel-Lavallée (ML) lesions occur when subcutaneous tissue is stripped from fascia and replaced with hematoma or necrotic fat. Encapsulated fat necrosis lesions, which are rare, can occur with disruption of the blood supply in the subcutaneous area, which occurs with ML lesions. In this article, we report the case of a professional ice hockey player with an ML lesion that caused a symptomatic encapsulated fat necrosis lesion to develop. The encapsulated lesion required surgical removal.

Radiographic Analysis of the Hill-Sachs Lesion in Anteroinferior Shoulder Instability After First-Time Dislocations

PURPOSE

To identify the relation between the Hill-Sachs (H-S) angle and arm position at the time of the initial dislocation, and to see if this correlates with the glenoid track.

METHODS

A total of 102 patients (89 male patients, 87.2%), with a mean age of 32 years (range, 17 to 38 years), were divided into 2 groups, abduction (ABD) and adduction (ADD), dependent on the position of the arm at the time of the instability event. All patients were evaluated with bilateral computed tomography scans (3-dimensional) to define the H-S position on the glenoid track and to measure the H-S angle. One-way analysis of variance was used to compare the H-S angle between the 2 groups.

RESULTS

Dislocation occurred in ABD in 45 patients (44.1%) and in ADD in 57 (55.9%). The H-S angle was 32.4° ± 4.7° in the ABD group versus 16.1° ± 2.9° in the ADD group. All patients' injuries were "on-track" glenoid injuries in both groups.

CONCLUSIONS

This study identified a difference in the H-S angle relative to arm position at the time of initial dislocation. Patients whose injury occurred in the ABD position showed a higher H-S angle, leading to an increased risk of engagement, because the long axis of the H-S lesion is parallel to the glenoid in a position of function. Thus arm position at the time of the initial instability event may be a risk factor for engagement and higher risk of recurrence. LEVEL OF

EVIDENCE

Level IV, prognostic case series.

The effect of sagittal rotation of the glenoid on axial glenoid width and glenoid version in computed tomography scan imaging

BACKGROUND

Computed tomography (CT) scans of the shoulder are often not well aligned to the axis of the scapula and glenoid. The purpose of this paper was to determine the effect of sagittal rotation of the glenoid on axial measurements of anterior-posterior (AP) glenoid width and glenoid version attained by standard CT scan. In addition, we sought to define the angle of rotation required to correct the CT scan to optimal positioning.

METHODS

A total of 30 CT scans of the shoulder were reformatted using OsiriX software multiplanar reconstruction. The uncorrected (UNCORR) and corrected (CORR) CT scans were compared for measurements of both (1) axial AP glenoid width and (2) glenoid version at 5 standardized axial cuts.

RESULTS

The mean difference in glenoid version was 2.6% (2° ± 0.1°; P = .0222) and the mean difference in AP glenoid width was 5.2% (1.2 ± 0.42 mm; P = .0026) in comparing the CORR and UNCORR scans. The mean angle of correction required to align the sagittal plane was 20.1° of rotation (range, 9°-39°; standard error of mean, 1.2°).

CONCLUSION

These findings demonstrate that UNCORR CT scans of the glenohumeral joint do not correct for the sagittal rotation of the glenoid, and this affects the characteristics of the axial images. Failure to align the sagittal image to the 12-o'clock to 6-o'clock axis results in measurement error in both glenoid version and AP glenoid width. Use of UNCORR CT images may have notable implications for decision-making and surgical treatment.

Biceps tenodesis for long head of the biceps after auto-rupture or failed surgical tenotomy: results in an active population

BACKGROUND

Long head of the biceps (LHB) deformity after surgical tenotomy or auto-rupture may result from attrition or injury. The purpose of this study was to describe the surgical outcomes of biceps tenodesis after failed surgical tenotomy or auto-rupture of the LHB tendon in a population of active patients.

METHODS

During a 5-year period, 11 patients with a mean age of 43.3 years (range, 33-56 years) presented with symptoms of biceps cramping with activity (100%), deformity (100%), or pain (36%) at a mean of 8 months (range, 0.5-22 months) from a tenotomy (6 of 11) or an auto-rupture (5 of 11). All patients underwent a mini-open subpectoral biceps tenodesis with interference screw fixation. Patients were independently evaluated by patient-reported outcome measures (Single Assessment Numeric Evaluation [SANE] and Western Ontario Rotator Cuff Index [WORC]) and a biceps position examination.

RESULTS

Of the 11 patients, 10 (91%) completed the study requirements at a mean of 2.6 years (range, 1.6-4.2 years). A total of 9 of the 10 patients (90%) returned to full activity. The mean preoperative SANE score was 61.1 (standard deviation [SD], 8.8), and the mean preoperative WORC score was 53.2 (SD, 9.2), which improved postoperatively to a SANE score of 84.2 (SD, 7.1) and a WORC score of 86 (SD, 8.2). There were no differences in LHB muscle position relative to the antecubital fossa (3.17 cm preoperatively to 3.25 cm postoperatively; P = .35). Deformity was resolved in all patients; 9 of 10 patients reported full resolution of cramping, and pain was resolved in 8 of 10.

CONCLUSIONS

LHB tenodesis after auto-rupture or surgical tenotomy improved symptoms and allowed predictable return to activity and patient satisfaction. Additional work is necessary to determine the optimal treatment of primary biceps lesions.

Shoulder instability in the military

Shoulder instability is common in military populations, and this demographic represents individuals at high risk for recurrence. Surgical management is often indicated, especially in high-demand young individuals, and provides a predictable return to military duties. Accurate recognition of glenoid bone loss and other associated anatomic lesions is of importance for appropriate selection between arthroscopic capsulolabral repair and bony reconstruction procedures. A thorough understanding of underlying pathology, diagnostic testing, and available treatment options provides for optimal care of the unstable shoulder.

Isolated iliotibial band rupture after corticosteroid injection as a cause of subjective instability and knee pain in a military special warfare trainee

Iliotibial band friction syndrome (ITBFS) of the knee is a common overuse injury in athletes, especially in runners. The syndrome occurs when the ITB, a lateral thickening of the fascia lata of the thigh moves repetitively over the lateral femoral condyle. A variety of nonoperative measures are used for ITBFS treatment, including stretching, core strengthening, and therapeutic injection. Isolated distal ITB rupture is a rare entity and has never yet to be reported in the orthopedic literature. We present a case of isolated ITB rupture as a cause of varus instability and knee pain in a Naval Special Warfare candidate diagnosed with ITBFS and previously treated with several local corticosteroid injections before ITB rupture. Because of continued knee pain and a sense of instability, along with an inability to return to his military special warfare duties, the ITB was surgically repaired. This case highlights the presentation and management of isolated distal ITB rupture and discusses some of the potential risk factors for rupture, including prior local corticosteroid injection.

The efficacy of biceps tenodesis in the treatment of failed superior labral anterior posterior repairs

BACKGROUND

The incidence and arthroscopic treatment of superior labral anterior posterior (SLAP) tears have increased over the past decade. Recent evidence has identified factors associated with poor outcomes, including age, overhead activity, and concomitant rotator cuff tears. Biceps tenodesis has also been suggested as an alternative treatment to repair. Moreover, there are no studies demonstrating effective treatment strategies for failed type II SLAP repairs.

PURPOSE

To prospectively evaluate the surgical outcomes of biceps tenodesis for patients who undergo elected revision surgery after an arthroscopically repaired type II SLAP tear.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

After institutional review board approval, 46 patients who met failure criteria for an arthroscopically repaired type II SLAP tear elected to undergo open subpectoral tenodesis by 2 fellowship-trained surgeons from 2006 to 2010 at a tertiary care military treatment facility. Objective outcomes were preoperative and postoperative assessments with the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability Index (WOSI) scores and an independent physical examination. Statistical analysis was performed via analysis of variance.

RESULTS

Of the 46 patients, 42 completed the study (91% follow-up rate). The mean age of the patients was 39.2 years, 85% were male, and the mean follow-up period was 3.5 years (range, 2.0-6.0 years). The rate of return to active duty and sports was 81%. There was a clinically and statistically significant improvement across all outcome assessments after revision surgery (preoperative mean scores: ASES = 68, SANE = 64, WOSI = 65; postoperative mean scores: ASES = 89, SANE = 84, WOSI = 81) (P < .0001) and shoulder range of motion (preoperative mean values: forward flexion = 135°, abduction = 125°; postoperative mean values: forward flexion = 155°, abduction = 155°) (P < .0001). There was 1 case of transient musculocutaneous nerve neurapraxia.

CONCLUSION

Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up. The majority of patients obtained good to excellent outcomes using validated measures with a significant improvement in range of motion.