Publications

PURPOSE: To investigate location- and sex-specific glenoid labrum morphology of healthy young adults in vivo, and the labrum's effects on depth and radius of curvature (ROC) of the glenohumeral joint.

METHODS: Healthy young adults with no history of shoulder surgery, injury, or instability underwent computed tomography and magnetic resonance imaging scans. Bone, cartilage, and labrum tissues were segmented from the scans and used to create 3-dimensional models for each participant. Measurements were made on the coregistered 3-dimensional models. The labral thickness, height, and depth were expressed according to a clockface on the glenoid (3, 6, 9, and 12 o'clock locations). Glenoid depth and ROC were also measured. Comparisons were made between sexes and among clockface locations.

RESULTS: Sixty shoulders of 30 individuals (15 males/15 females, average age: 25 ± 7 years, body mass Index: 25.4 kg/m2) were included. Repeated segmentation of a subset of the data showed the average absolute differences in labrum depth ranged from 0.3 to 0.4 mm, the labrum thickness differences ranged from 0.3 to 0.8 mm, and the labrum height differences ranged from 0.4 to 0.8 mm between the original and resegmented scans. For the complete dataset, no location-specific differences in labrum morphology were found between males and females. The 12 o'clock location was at least 5.0 mm deeper, 4.3 mm thicker, and 8.4 mm taller than any other clockface location (all P < .001). The labrum increased the average depth of the glenoid between 2.4 and 5.6 mm in the anterior/posterior and superior/inferior locations, respectively (P < .001), contributing an average of 60.1% of the overall glenoid depth, and decreasing the average ROC by 22.6 mm in the anterior/posterior locations and by 8.8 mm in the superior/inferior locations.

CONCLUSIONS: The labrum in young healthy adults was found to be larger than previously reported in cadaver studies. The labrum at 12 o'clock is deeper, thicker, and taller than at other locations; however, no location-specific differences were found between men and women. The labrum contributed significantly to the depth and created a more congruent joint by minimizing differences between humerus and glenoid ROC.

CLINICAL RELEVANCE: Improved understanding of the morphology of the glenoid labrum in young adults may be used to guide surgical repair and design of anatomical shoulder replacements.

BACKGROUND: The impact of arthroscopic Bankart repair (ABR) alone vs. ABR with remplissage (ABR + R) on athlete return-to-play rates and number of games played after surgery is poorly understood. The objective of this study was to utilize online sports databases to compare number of games played and return-to-play rates between athletes who underwent ABR vs. ABR + R for "on-track" Hill-Sachs lesions (HSLs). We hypothesized that there would be no difference in relative games played nor return-to-play rates post-operatively between patients undergoing ABR vs. ABR + R.

METHODS: Patients aged 14-40 years with "on-track" HSLs who underwent either ABR or ABR + R between 2007 and 2022 for anterior shoulder instability were retrospectively reviewed. Exclusion criteria included revision surgery, <1-year follow-up, "off-track" HSLs, >20% glenoid bone loss, nonathletes, and missing data in online sports databases. Athletes were queried in online sports databases and games played were recorded the season before and 3 seasons after surgery, if available. The primary outcome was relative change in games played in the seasons after surgery compared to the season before surgery ( R e l a t i v e G a m e s P l a y e d = # G a m e s i n S e a s o n A f t e r S u r g e r y # G a m e s i n S e a s o n B e f o r e S u r g e r y ). Secondary outcomes included recurrent anterior shoulder instability, defined as recurrent dislocation and/or subluxation, and return-to-play.

RESULTS: Eighty-one patients (ABR: 60 | ABR + R: 21) were included in the analysis, with average age of 18 ± 2 years and average follow-up of 6.5 ± 3.7 years (range, 1.0-14.4 years). "Near-track" HSLs (distance-to-dislocation <10 mm) were present in 20% of the ABR group vs. 76% of the ABR + R group (P < .01). Return-to-play rates were similar between groups (ABR: 75% vs. ABR + R: 81%, P = .58). In the first season after surgery, the ABR group had significantly higher relative games played compared to the ABR + R group (ABR: 1.5 ± 1.5; n = 38 | ABR + R: 0.8 ± 0.5; n = 13, P = .02). This difference did not persist in the second and third seasons after surgery (P > .05). In an adjusted Generalized Estimating Equation model, surgical technique was not significantly associated with relative games played after surgery. Rates of recurrent anterior shoulder instability were not statistically different between groups (ABR: 28% (17/60) vs. ABR + R: 10% (2/21), P = .13).

CONCLUSION: Among athletes with "on-track" HSLs, ABR + R resulted in similar long-term game participation and return-to-play rates and compared to isolated ABR alone. Although patients undergoing ABR + R demonstrated fewer relative games played in the first post-operative season, this difference did not persist in subsequent seasons. Remplissage augmentation may therefore have a temporary impact on early post-operative performance without compromising overall return-to-play outcomes.

BACKGROUND: Calcific tendinitis of the shoulder is a common, painful rotator cuff disorder with both nonoperative and operative treatment options. The optimal nonoperative modality remains unclear, and it is not well understood how previous nonoperative treatments influence eventual surgical outcomes.

PURPOSE/HYPOTHESIS: The purpose of this study was to compare success rates, defined as avoidance of surgery, among 3 nonoperative treatments for calcific tendinitis: physical therapy (PT), corticosteroid injection (CSI), and ultrasound-guided barbotage (USB). For patients who underwent surgery, outcomes were compared according to previous nonoperative management. It was hypothesized that success rates and postoperative outcomes would not differ significantly between modalities.

STUDY DESIGN: Cohort study; Level of evidence, 3.

METHODS: A retrospective review of patients diagnosed with calcific tendinitis from 2009 to 2023 was performed. Exclusion criteria were lack of radiographic confirmation, <6 months follow-up, or incomplete electronic medical record data. Patients were categorized by attempted nonoperative treatment (none, PT, CSI, USB, multiple) and by final management (nonoperative vs operative). Patient-reported outcomes included the visual analog scale (VAS), Subjective Shoulder Value (SSV), and range of motion (ROM), collected at initial and final presentation. Radiographic findings were extracted from radiology reports. Statistical testing used parametric or nonparametric methods as well as a multivariable Cox proportional hazards model to predict nonoperative failure. Significance was set at P < .05.

RESULTS: A total of 257 patients (mean age 55 ± 11 years) were analyzed with a mean follow-up of 18 ± 16 months with an overall nonoperative success rate of 63%. Success rates did not differ significantly among PT (59%), CSI (75%), and USB (72%), but patients with multiple tendon involvement or calcifications >3 cm were more likely to fail nonoperative management. Patients completing successful nonoperative management improved in VAS, SSV, and ROM, with no between-group differences. All patients who attempted multiple modalities (18/18; 100%) required surgery (P < .01). Among 121 patients undergoing surgery, final VAS, SSV, and ROM outcomes did not differ based on previous nonoperative management.

CONCLUSION: PT, CSI, and USB demonstrate similar rates of avoiding surgery for calcific tendinitis. For patients ultimately requiring surgery, outcomes are not influenced by previous nonoperative management. Surgical intervention may be indicated after failure of a single nonoperative modality.

The purpose of this study was to evaluate how surgical technique and prosthesis design affect muscle activation after reverse shoulder arthroplasty (RSA) during hand-to-head (H2H) and hand-to-back (H2B) movements. Surface electromyography data from 8 muscles were collected while 28 RSA patients performed H2H and H2B. Muscle activation onset (AO) and total muscle activation (TMA) were calculated. Multiple regression was used to identify surgical technique and prosthesis design factors that predicted muscle AO and TMA. Correlation was used to identify associations between muscle activation and patient reported outcomes (CMS and DASH). During H2H, neck shaft angle predicted anterior deltoid, pectoralis, and latissismus muscle AO and lateral humeral offset (LHO) predicted latissimus AO. Glenosphere eccentricity, glenosphere tilt, glenosphere size, and LHO predicted TMA for anterior deltoid, middle deltoid, teres minor, and pectoralis muscles, respectively. During H2B, glenosphere lateralization predicted trapezius, anterior deltoid, and teres minor muscle AO, and glenosphere eccentricity and humeral retroversion change predicted trapezius TMA. During H2H, later middle deltoid AO was associated with better CMS, and later pectoralis major AO was associated with worse DASH scores. Additionally, higher teres minor TMA was associated with worse internal rotation score. During H2B, later latissimus AO was associated with better DASH scores. Improved understanding of how implant design and surgical technique affect muscle activation and clinical outcomes after RSA may help surgeons and therapists to optimize shoulder function after RSA.

BACKGROUND: To evaluate how patient-reported outcomes (PROs) trend over time following arthroscopic Bankart repair (ABR) for anterior shoulder instability with on-track Hill-Sachs lesions (HSLs).

METHODS: A retrospective review was performed of patients undergoing ABR with or without remplissage between 2007 and 2023. Exclusion criteria included age <14 years, glenoid bone loss >20%, off-track HSLs, and prior shoulder surgery. PROs and clinical outcomes, including Western Ontario Shoulder Index (WOSI), pain visual analog scale (pVAS), Subjective Shoulder Value (SSV), and recurrent instability, were collected at final follow-up. Spearman rank correlation assessed relationships between PROs and time from surgery. Rates of achieving Patient Acceptable Symptom State for WOSI and pVAS were compared across follow-up intervals (<5 years, 5-9 years, ≥10 years) and between patients with and without recurrent instability. Significance was set at P < .05.

RESULTS: A total of 121 patients (age: 23 ± 8 years, 27% females) were included at mean follow-up of 7.1 years (range: 1.6-17.2). Longer follow-up duration was associated with worsening WOSI (r = 0.239; P = .008), pVAS (r = 0.180; P = .049), and SSV (r = -0.186; P = .041) scores. Patients undergoing isolated ABR demonstrated significant deterioration in PROs over time (WOSI: r = 0.331, P = .002; pVAS: r = 0.261, P = .015; SSV: r = -0.216, P = .045), whereas those undergoing remplissage showed no change in PROs over time (all P > .05). Patients with recurrent instability had lower rates of achieving WOSI Patient Acceptable Symptom State at <5 years (56% vs. 88%; P = .029), 5-9 years (22% vs. 87%; P < .001), and ≥10 years (20% vs. 86%; P < .001) compared to patients without recurrent instability. On linear regression analysis, longer follow-up length remained an independent predictor of worse WOSI scores after controlling for recurrent instability.

CONCLUSION: PROs may decline over time following ABR for anterior shoulder instability for patients who experience recurrent anterior shoulder instability and undergo isolated ABR compared to ABR with remplissage. These findings may be relevant for pre-operative counseling regarding long-term subjective outcomes.

BACKGROUND: Previous literature has demonstrated that an increased number of preoperative anterior shoulder instability episodes is associated with recurrent anterior shoulder instability after arthroscopic Bankart repair (ABR). However, a threshold for the number of preoperative instability episodes that increases the risk of recurrent anterior shoulder instability is not well established.

PURPOSE: To establish a threshold value for the number of preoperative instability episodes that predicts recurrent anterior shoulder instability after ABR and to compare glenoid bone loss, the Hill-Sachs interval, and the distance to dislocation between patients who have surpassed the threshold and those who have not.

STUDY DESIGN: Retrospective cohort study; Level of evidence, 3.

METHODS: This retrospective review included consecutive patients with "on-track" Hill-Sachs lesions who underwent primary ABR for anterior shoulder instability at a single institution between 2007 and 2019. Patients with an unknown number of preoperative instability episodes, >20% glenoid bone loss, <2 years' follow-up, or age >40 or <14 years were excluded. Logistic regression assessed associations between preoperative anterior shoulder instability episodes and recurrent anterior shoulder instability after ABR, defined as a recurrent subluxation or dislocation. Receiver operating characteristic analysis determined the optimal threshold of preoperative anterior shoulder instability episodes to predict recurrent anterior shoulder instability. Significance was set as P < .050.

RESULTS: A total of 151 patients (mean age, 20 ± 5 years; mean follow-up, 6.0 ± 3.1 years) were included, of whom 28 (19%) experienced recurrent anterior shoulder instability. Multiple thresholds showed increased odds of recurrent anterior shoulder instability: ≥2 preoperative anterior shoulder instability events (odds ratio [OR], 9.70 [95% CI, 2.63-35.70]; P = .001), ≥3 events (OR, 3.47 [95% CI, 1.37-8.80]; P = .009), and ≥4 events (OR, 3.08 [95% CI, 1.17-8.08]; P = .023). Receiver operating characteristic analysis revealed that ≥2 preoperative anterior shoulder instability events was the strongest predictor of recurrent anterior shoulder instability (area under the curve = 0.72).

CONCLUSION: A threshold of ≥2 preoperative anterior shoulder instability episodes best predicted recurrent anterior shoulder instability after ABR. Stratification beyond 1 versus ≥2 preoperative anterior shoulder instability episodes did not increase predictive ability. This finding may help surgeons to counsel patients and consider earlier surgical stabilization in those who have sustained anterior shoulder instability episodes.

BACKGROUND: Recurrent anterior shoulder instability rates are high after isolated arthroscopic Bankart repair (ABR), especially among patients with off-track Hill-Sachs lesions (HSLs) and significant glenoid bone loss. However, there are limited data on long-term recurrent anterior shoulder instability rates and patient-reported outcomes (PROs) following isolated ABR among patients with on-track HSLs and <20% glenoid bone loss.

PURPOSE: To evaluate long-term clinical outcomes and PROs after isolated ABR for on-track HSLs with <20% glenoid bone loss, a population where isolated ABR remains indicated.

STUDY DESIGN: Case-control study; Level of evidence, 3.

METHODS: A retrospective review was conducted on patients undergoing isolated ABR for anterior shoulder instability between 2007 and 2018. Exclusion criteria included age <14 or >40 years, glenoid bone loss >20%, off-track HSL, concomitant remplissage, and revision procedures. All patients were contacted to obtain minimum 7-year clinical outcomes, including recurrent anterior shoulder instability and revision stabilization surgery, as well as PRO measures including Western Ontario Shoulder Index (WOSI), pain visual analog scale (pVAS), and Subjective Shoulder Value scores. Variables were compared between recurrent anterior shoulder instability and revision stabilization surgery groups. Significance was set to P < .05.

RESULTS: Long-term outcomes were obtained from 55 patients (mean age, 22 years; 32% of all eligible patients) at a mean follow-up of 10.4 years. Seventeen (31%) patients sustained ≥1 recurrent anterior shoulder instability event, and 8 (15%) patients underwent revision stabilization surgery. Younger age (P = .002) and collision athletics (P = .02) were associated with sustaining recurrent anterior shoulder instability, whereas distance to dislocation was not associated with recurrent anterior shoulder instability (P = .59). However, near-track HSLs (P = .02) and increased glenoid bone loss (P = .007) were associated with undergoing revision stabilization surgery. For every 1% increase in glenoid bone loss, there were 19% higher odds of undergoing revision stabilization surgery (P = .02). With regard to PROs, 67% of patients achieved the Patient Acceptable Symptom State (PASS) for WOSI and 55% of patients achieved the PASS for pVAS. Patients with recurrent anterior shoulder instability were less likely than those without recurrent instability to achieve the PASS for both WOSI (24% vs 87%; P < .001) and pVAS (29% vs 66%; P = .01).

CONCLUSION: Rates of recurrent anterior shoulder instability were high following isolated ABR for on-track HSLs with <20% glenoid bone loss and were associated with inferior PROs at mean 10-year follow-up. Younger age and collision athletics were associated with sustaining recurrent anterior shoulder instability, while increased glenoid bone loss was an independent predictor of undergoing revision stabilization surgery. There remains a clinical need for improved stratification of on-track HSLs to identify patients who may benefit from additional procedures to improve recurrent anterior shoulder instability rates and subjective outcomes at long-term follow-up.

BACKGROUND: Nonoperative management of atraumatic rotator cuff tears often includes corticosteroid injection (CSI). Concerns persist regarding CSI effect on tendon quality and rotator cuff repair (RCR) outcomes, though how timing of a single CSI influences RCR outcomes is unclear. This study evaluated whether CSI timing within 1 year before RCR affects repair failure, patient-reported outcomes (PROs), range of motion (ROM), and strength, compared to patients undergoing RCR without CSI. We hypothesized that CSI within 3 months of RCR would lead to higher failure rates and worse outcomes.

METHODS: This retrospective study examined consecutive adult patients undergoing primary RCR from 2015 to 2022 at 1 institution. Inclusion criteria were nonoperative management of an atraumatic rotator cuff tear ≥6 weeks and minimum 1-year follow-up. Exclusion criteria included prior shoulder surgery and traumatic injury. Patients with preoperative CSI were grouped by CSI timing before RCR: <3 months, 3-6 months, and 6 months-1 year. Primary outcome was repair failure (reoperation or magnetic resonance imaging-confirmed retear). Magnetic resonance imaging was performed only in patients with symptoms suggesting recurrent cuff pathology. Secondary outcomes included PROs (Subjective Shoulder Value, Patient-Reported Outcomes Measurement Information System scores, American Shoulder and Elbow Surgeons score, visual analog scale [VAS]), strength, and ROM.

RESULTS: Overall, 198 patients were included; 89 patients without preoperative CSI (controls), 44 with CSI within 3 preoperative months, 34 with CSI 3-6 months prior, and 31 with CSI 6-12 months prior. Mean ages were 59 (controls), 59 (CSI <3 months), 63 (CSI 3-6 months), and 57 years (CSI 6-12 months) (P = .13). Demographics, follow-up length, RCR technique, and tendons involved were comparable across groups (all P > .05). Overall repair failure was 24%, with 19% failure in patients who received CSI. Group failure rates were 30% (controls), 20% (<3 months), 18% (3-6 months), and 19% (6 months-1 year) (P = .34). Postoperative improvements were similar between all groups for visual analog scale (3 vs. 4 points, P > .05), Subjective Shoulder Value (21% vs. 29%, P > .05), and American Shoulder and Elbow Surgeons scores (15 vs. 12 points, P > .05). Postoperative external rotation decreased by 4° among all CSI patients (P = .02) but increased by 3° in controls. Postoperative PROs, ROM, and strength were similar between groups.

CONCLUSION: This study demonstrated comparable outcomes for patients receiving CSI within 1 year of RCR and control patients. Timing of 1 preoperative CSI within 1 year of RCR did not significantly affect failure, PROs, ROM, or strength, suggesting that 1 CSI before RCR does not strongly influence outcomes.

BACKGROUND: Recent literature has shown that inferior Hill-Sachs extension for on-track shoulders is predictive of recurrent instability after arthroscopic Bankart repair alone. Specifically, there is a high risk for recurrent instability when the lesion extends below the humeral equator on sagittal magnetic resonance imaging. This worrisome inferior extension has been termed "critical humeral bone loss (CHBL)." Remplissage has yet to be explored as a potential useful augmentation in patients with CHBL.

HYPOTHESIS: The addition of remplissage would decrease recurrence rates for Hill-Sachs lesions with inferior extension or CHBL compared with arthroscopic Bankart repair alone in patients with on-track Hill-Sachs lesions.

STUDY DESIGN: Case series; Level of evidence, 4Methods:Retrospective analysis was performed on the records of patients who underwent primary arthroscopic Bankart repair with or without the addition of remplissage from 2007 to 2021. Off-track shoulders, revision stabilization, glenoid bone loss (GBL) >20%, and those with follow-up <2 years or incomplete medical data were excluded. The primary outcome was recurrent instability, defined as either postoperative dislocation or subluxation. The Hill-Sachs position was measured relative to the humeral axis on sagittal magnetic resonance imaging as previously described. Univariate and multivariate logistic regression analyses were implemented to determine the protective effect of remplissage.

RESULTS: A total of 219 patients were included for analysis with a mean age of 21.1 years (range, 12.9-40.5 years) and mean follow-up of 7.0 years (range, 2-14.4 years); 44 patients (20%) underwent remplissage in addition to arthroscopic Bankart. In multivariate analysis, remplissage significantly reduced the risk of recurrent instability (OR, 0.06; P = .002) and CHBL was a significant predictor of recurrent instability (OR, 3.0; P = .029) while adjusting for age, multiple preoperative dislocations, contact athlete status, and percent GBL. When stratified by CHBL, remplissage remained protective (OR, 0.013; P = .007) against recurrent instability.

CONCLUSION: The addition of a remplissage for CHBL in patients with subcritical GBL and on-track Hill-Sachs lesions reduces the risk of recurrent instability in patients undergoing arthroscopic Bankart repair.