Posterior Shoulder Instability Part I - Diagnosis, Non-Operative Management, and Labral Repair for Posterior Shoulder Instability - An International Expert Delphi Consensus Statement

PURPOSE

The purpose of this study was to establish consensus statements on the diagnosis, non-operative management, and labral repair for posterior shoulder instability.

METHODS

A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating based on their level of expertise in the field. Experts were assigned to one of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80-89% agreement, whereas strong consensus was defined as 90-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement.

RESULTS

Unanimous agreement was reached on the indications for non-operative management and labral repair which include whether patients had primary or recurrent instability, with symptoms/functional limitations, and whether there was other underlying pathology, or patient's preference to avoid or delay surgery. Additionally, there was unanimous agreement that recurrence rates can be diminished by attention to detail, appropriate indication and assessment of risk factors, recognition of abnormalities in glenohumeral morphology, careful capsulolabral debridement and reattachment, small anchors with inferior placement and multiple fixation points that create a bumper with the labrum, treatment of concomitant pathologies, and a well-defined rehabilitation protocol with strict postoperative immobilization.

CONCLUSION

The study group achieved strong or unanimous consensus on 63% of statements related to the diagnosis, nonoperative treatment, and labrum repair for posterior shoulder instability. The statements that achieved unanimous consensus were the relative indications for non-operative management, and the relative indications for labral repair, as well as the steps to minimize complications for labral repair. There was no consensus on whether an arthrogram is needed when performing advanced imaging, the role of corticosteroids/orthobiologics in non-operative management, whether a poster-inferior portal is required.

Posterior Shoulder Instability Part II - Glenoid Bone-Grafting, Glenoid Osteotomy, and Rehabilitation/Return to Play - An International Expert Delphi Consensus Statement

PURPOSE

The purpose of this study was to establish consensus statements on glenoid bone-grafting, glenoid osteotomy, rehabilitation, return to play, and follow-up for posterior shoulder instability.

METHODS

A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating based on their level of expertise in the field. Experts were assigned to one of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80-89% agreement, whereas strong consensus was defined as 90-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement.

RESULTS

All of the statements relating to rehabilitation, return to play, and follow-up achieved consensus. There was unanimous consensus that the following criteria should be considered: restoration of strength, range of motion, proprioception, and sport-specific skills, with a lack of symptoms. There is no minimum time point required to return to play. Collision athletes and military athletes may take longer to return because of their higher risk for recurrent instability, and more caution should be exercised in clearing them to return to play, with elite athletes potentially having different considerations in returning to play. The relative indications for revision surgery are symptomatic apprehension, multiple recurrent instability episodes, further intra-articular pathologies, hardware failure, and pain.

CONCLUSION

The study group achieved strong or unanimous consensus on 59% of statements. Unanimous consensus was reached regarding the criteria for return to play, collision/elite athletes having different considerations in return to play, indications for revision surgery, and imaging only required as routine for those with glenoid bone-grafting/osteotomies at subsequent follow-ups. There was no consensus on optimal fixation method for a glenoid bone-block, the relative indications for glenoid osteotomy, whether fluoroscopy is required or if the labrum should be concomitantly repaired.

LEVEL OF EVIDENCE

Level V Expert Opinion.

Clinical Outcomes in Prospective versus Retrospective Studies on Arthroscopic Bankart Repair: A Systematic Review

BACKGROUND

The majority of the current literature on arthroscopic Bankart repair is retrospective and discrepancies exist regarding clinical outcomes including recurrent instability and return to play amongst studies of different levels of evidence.

PURPOSE

The purpose of this study is to perform a systematic review of the literature to compare the outcomes of prospective and retrospective studies on arthroscopic Bankart repair.

METHODS

A search was performed using the PubMed/Medline database for all studies that reported clinical outcomes on Bankart repair for anterior shoulder instability. The search term "Bankart repair" with all results being analyzed via strict inclusion and exclusion criteria. Three independent investigators extracted data and scored each included study based on the 10 criteria of the Modified Coleman Methodology Score (CMS) out of 100. A chi-square test was performed to assess if recurrent instability, revision, return to play, and complications are independent of prospective and retrospective studies.

RESULTS

One hundred ninety-three studies were included in the analysis with 53 prospective studies and 140 retrospective in design. Encompassing a total of 13,979 patients and 14,019 surgical procedures for Bankart repair for shoulder instability. The rate of re-dislocation in the prospective studies was 8.0% vs. 5.9% in retrospective (p < 0.001). The rate of recurrent subluxation in the prospective studies was 3.4% vs. 2.4% in retrospective (p = 0.004). The rate of revision was higher in retrospective studies at 4.9% vs. 3.9% in prospective studies (p = 0.013) There was no significant difference in terms of overall rate to return to play in prospective and retrospective studies was 90% and 91%, respectively (p=0.548). The overall rate of complications in the prospective cohort was 0.27% and 0.78% in the retrospective studies (p = 0.002).

CONCLUSION

The overall rates of recurrent dislocations, subluxations are higher in prospective studies compared to retrospective studies. However, rates of revision were reportedly higher in retrospective studies. Complications after arthroscopic Bankart repair are rare in both prospective and retrospective studies, and there was no difference in rates of return to play.

Latarjet for Anterior Shoulder Instability Literature Shows Limited Reporting of Outcomes in Females: Females Show Similar Outcomes but Higher Rate of Emergency Room Visits and Possible Higher Rates of Complications

It has been reported that use of the Latarjet procedure for anterior shoulder instability from 2008-2019 increased 250%. With the rise in utilization, it is imperative to minimize complications. At present, the majority of the literature focuses on male patients, with scant evidence regarding female patients. Outcomes are similar comparing female to male patients, but female patients have higher emergency department postoperative visits than males, requiring specific attention during the post-operative period. In addition, literature reporting complications in females versus males after Latarjet are conflicting; some studies show similar rates of complications, while other studies show higher rates of adverse events in females. Prior consensus statements recommended a) careful dissection; b) identifying the musculocutaneous and axillary nerves; c) preventing overlateralization of the graft; d) tranexamic acid to reduce blood loss; e) accurate screw placement; and f) careful preparation of the glenoid neck and coracoid to reduce rates of non-union or delayed union.

Return to Duty in Military Servicemembers After High Tibial Osteotomy Not Associated With Preoperative Radiographic Parameters : A Retrospective Analysis

Background

Evidence on return to sports/work after high tibial osteotomy (HTO) is limited, especially in a young, high-demand population.

Purpose

To (1) identify whether preoperative knee pathology or intraoperative correction was associated with successful return to duty (RTD) and (2) assess whether postoperative complications and reoperation were associated with failure to RTD.

Study Design

Case series; Level of Evidence, 4.

Methods

We performed a retrospective cohort study of a consecutive series of patients in the Military Health System aged 18 to 55 years with medial compartment osteoarthritis who underwent HTO between 2003 and 2018. Concomitant meniscal and cartilage procedures were included, while cases with concomitant ligamentous procedures were excluded. The inclusion criteria were as follows: active-duty military status, minimum 2-year follow-up, preoperative knee radiographs, and pre- and postoperative long-leg alignment radiographs. Preoperative Kellgren-Lawrence grades and pre- and postoperative hip-knee-ankle angles were measured. The primary outcome was RTD. Failure was defined as knee-related medical separation from the military or conversion to total knee arthroplasty. The secondary outcome was reoperation.

Results

A total of 55 HTOs were performed in 50 patients who met the inclusion criteria, with a mean age of 39 years old (range, 22.8-55 years). The mean follow-up was 5 years (range, 2.1-10.7 years). Ten knees (18.2%) failed HTO (1 conversion to total knee arthroplasty, 9 medical separations), 15 additional knees (27.3%) had permanent activity restrictions, and 30 knees (54.5%) returned to duty without restrictions. Reoperation occurred in 36.4% of knees and was associated with medical separation (P = .039). Younger age was associated with medical separation (P = .003) and permanent restrictions (P = .006). Patients with a postoperative varus deformity of >5° were more likely to undergo medical separation (P = .023).

Conclusion

In a young, high-demand population, HTO succeeded in returning 54.5% of knees to full duty without restriction despite 36.4% of knees requiring reoperation. Residual varus deformity or reoperation was associated with lower RTD rates. No association was identified between RTD and preoperative osteoarthritis grading or deformity.

Minimal Important Clinical Difference Values Are Not Uniformly Valid in the Active Duty Military Population Recovering from Shoulder Surgery

BACKGROUND

There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population's fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of two different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operator curve (ROC) -based MCIDs and baseline-adjusted ROC MCIDs.

METHODS

All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROMs battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons score (ASES), Patient Reported Outcome Management Information System (PROMIS) Physical Function (PF), PROMIS Pain Interference (PI), and the Warfighter Readiness survey. Standard anchor-based and baseline-adjusted ROC MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval either completely negative or positive).

RESULTS

There were 117 patients (136 operations) identified, comprised of 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7.

CONCLUSION

When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC method was more effective at discerning changes across a battery of PROMs among the same cohort.

Glenohumeral morphological predictors of recurrent shoulder instability following arthroscopic Bankart repair

PURPOSE

The purpose of this study was to evaluate glenohumeral morphological features on a magnetic resonance arthrogram (MRA) to determine risk factors for recurrence of anterior shoulder instability following arthroscopic Bankart repair (ABR).

METHODS

A retrospective review of patients who underwent ABR between 2012 and 2017 was performed to identify patients who had recurrence of instability following stabilisation (Group 1). These were pair-matched in a 2:1 ratio for age, gender and sport with a control (Group 2) who underwent ABR without recurrence. Preoperative MRAs were evaluated for risk factors for recurrence, with glenoid bone loss and Hill-Sachs lesions also measured. Multilinear and multilogistic regression models were used to evaluate factors affecting recurrence.

RESULTS

Overall, 72 patients were included in this study, including 48 patients without recurrence and 24 patients with recurrent instability. There was a significant difference between the two groups in mean glenoid bone loss (Group 1: 7.3% vs. Group 2: 5.7%, p < 0.0001) and the rate of off-track Hill-Sachs lesions (Group 1: 20.8% vs. Group 2: 0%, p = 0.0003). Of the variables analysed in logistic regression, increased glenoid anteversion (p = 0.02), acromioclavicular (AC) degeneration (p = 0.03) and increased Hill-Sachs width were associated with increased risk of failure. Increased chondral version (p = 0.01) and humeral head diameter in the anteriorposterior view were found to be protective and associated with a greater likelihood of success.

CONCLUSION

Glenoid anteversion was a risk factor for recurrent instability, whereas increased chondral version and humeral head diameter were associated with higher rates of success following ABR. Glenoid bone loss, presence of an off-track Hill-Sachs lesion, increased Hill-Sachs width and AC degeneration were also associated with failure. These findings should be used by surgeons to stratify risk for recurrence following ABR.

LEVEL OF EVIDENCE

Level III.

Young Collision Athletes Have High Rate of Return to Play and Good Clinical Outcomes Following Open Latarjet Procedure

PURPOSE

To evaluate return to play (RTP), clinical outcomes, and recurrence rates in collision athletes 20 years of age and younger who underwent open Latarjet for anterior shoulder instability.

METHODS

A retrospective review of collision athletes 20 years of age and younger, who underwent an open Latarjet procedure by a single surgeon between the years of 2010-2020 was carried out. Inclusion criteria were 1) collision athlete, 2) underwent open Latarjet procedure, 3) 16-20 years old, and 4) minimum 24-month follow-up. Exclusion criteria were 1) other pathology of the ipsilateral shoulder and 2) noncollision athlete. Rate of RTP, time to RTP, rate of return to preinjury level, the Shoulder Instability Return to Sport after Injury score (SIRSI) score, Subjective Shoulder Value (SSV), visual analogue scale (VAS) scores, and recurrence events were recorded. Quantitative statistical analysis was carried out.

RESULTS

The study included 105 male collision athletes with a mean age of 18.6 ± 1.0 years (range: 17-20). The mean follow-up for patients was 36 ± 26.2 months. A total of 93 (88.6%) RTP at a mean time of 6.3 ± 2.2 months, with 73 (69.5%) returning to their preinjury level of participation. The mean SIRSI score was 69.2 ± 21.8, the mean VAS score was 2.3 ± 2.1, and the mean SSV score was 84.1 ± 16.8. Five patients (4.8%) redislocated their shoulder, with 4 of these requiring a further surgery (3.8%). Two patients (1.9%) reported incidents of subluxation.

CONCLUSIONS

The open Latarjet procedure in young collision athletes results in high rates of RTP, excellent functional outcomes and low recurrence rates at mid-term follow-up. Additionally, complication rates are low in this cohort.

LEVEL OF EVIDENCE

Level IV, case series.

Type V Superior-Labrum Anterior-Posterior (SLAP) Repair - A Systematic Review

BACKGROUND

The purpose of this study is to systematically review the evidence in the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following type V superior labrum anterior-posterior (SLAP) repair.

METHODS

Two independent reviewers performed a literature search based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Studies were included if they had clinical outcomes on the patients undergoing type V SLAP repair. Statistical analysis was performed using SPSS (IBM, Armonk, NY, USA). A P value of < 0.05 was considered to be statistically significant.

RESULTS

Our review found 13 studies, including 451 shoulders meeting our inclusion criteria. The majority of patients were male (89.3%), with an average age of 25.9 years (range 15-58) and a mean follow-up of 53.8 months. The Rowe score was the most utilized functional outcome score, with a weighted mean of 88.5. Additionally, the mean Constant score was 91.0, the mean ASES score was 88.3, the mean SSV score was 85.5%, and the mean VAS pain score was 1.2. The overall rate of return to play was 84.8%, with 80.2% returning to the same level of play. The overall reoperation rate was 6.1%, with a recurrent dislocation rate of 8.2%. In the studies comparing type V SLAP and isolated Bankart repair, there were statistically insignificant differences in VAS pain scores (MD; 0.15, 95% CI, -0.13 to 0.44, I2 = 0%, p = 0.29) and recurrence rates (RR; 1.38, 95% CI, 0.88 to 2.15, I2 = 0%, p = 0.16).

CONCLUSION

Arthroscopic repair of type V SLAP tears results in excellent functional outcomes, with high return to play rates in athletes. There are low rates of reoperations and recurrent dislocations. Additionally, in comparison to an isolated Bankart repair, SLAP repair does not increase recurrence rates or postoperative pain.

Editorial Commentary: At Present, ChatGPT Cannot Be Relied Upon to Answer Patient Questions and Requires Physician Expertise to Interpret Answers for Patients

ChatGPT is designed to provide accurate and reliable information to the best of its abilities based on the data input and knowledge available. Thus, ChatGPT is being studied as a patient information tool. This artificial intelligence (AI) tool has been shown to frequently provide technically correct information but with limitations. ChatGPT provides different answers to similar questions based on the prompts, and patients may not have expertise in prompting ChatGPT to elicit a best answer. (Prompting large language models has been shown to be a skill that can improve.) Of greater concern, ChatGPT fails to provide sources or references for its answers. At present, ChatGPT cannot be relied upon to address patient questions; in the future, ChatGPT will improve. Today, AI requires physician expertise to interpret AI answers for patients.

Evaluation High-Quality of Information from ChatGPT (Artificial Intelligence-Large Language Model) Artificial Intelligence on Shoulder Stabilization Surgery

PURPOSE

To analyze the quality and readability of information regarding shoulder stabilization surgery available using an online AI software (ChatGPT), using standardized scoring systems, as well as to report on the given answers by the AI.

METHODS

An open AI model (ChatGPT) was used to answer 23 commonly asked questions from patients on shoulder stabilization surgery. These answers were evaluated for medical accuracy, quality, and readability using The JAMA Benchmark criteria, DISCERN score, Flesch-Kincaid Reading Ease Score (FRES) & Grade Level (FKGL).

RESULTS

The JAMA Benchmark criteria score was 0, which is the lowest score, indicating no reliable resources cited. The DISCERN score was 60, which is considered a good score. The areas that open AI model did not achieve full marks were also related to the lack of available source material used to compile the answers, and finally some shortcomings with information not fully supported by the literature. The FRES was 26.2, and the FKGL was considered to be that of a college graduate.

CONCLUSIONS

There was generally high quality in the answers given on questions relating to shoulder stabilization surgery, but there was a high reading level required to comprehend the information presented. However, it is unclear where the answers came from with no source material cited. It is important to note that the ChatGPT software repeatedly references the need to discuss these questions with an orthopaedic surgeon and the importance of shared discussion making, as well as compliance with surgeon treatment recommendations.

CLINICAL RELEVANCE

As shoulder instability is an injury that predominantly affects younger individuals who may use the Internet for information, this study shows what information patients may be getting online.

Surgical Treatment of Focal Chondral Lesions of the Knee in the Military Population: Current and Future Therapies

INTRODUCTION

Chondral and osteochondral defects of the knee are common injuries in the military population that have a significant impact on readiness. Definitive treatment of these injuries is challenging since cartilage has a limited capacity for self-repair and regeneration. Management is particularly challenging in military patients who maintain a higher level of activity similar to athletes. Existing surgical techniques have variable results and often long recovery times, sparking the development of several new innovative technologies to return service members back to duty more quickly and effectively after cartilage injury. The purpose of this article is to review the current and future surgical treatments for chondral and osteochondral knee lesions and their relevance in managing these injuries in the military.

METHODS

In this review article, we describe the current treatments for chondral and osteochondral defects of the knee, reporting on outcomes in military populations. We explore emerging treatment modalities for cartilage defects, reporting innovations, stage of research, and current data. Published results of each treatment option in military populations are reviewed throughout the article.

RESULTS

This review includes 12 treatments for chondral lesions. Of these therapies, four are considered synthetic and the remaining are considered regenerative solutions. Regenerative therapies tend to perform better in younger, healthier populations with robust healing capacity. Success of treatment depends on lesions and patient characteristics. Nearly all modalities currently available in the USA were successful in improving patients from presurgical function in the short (<6 months) term, but the long-term efficacy is still challenged. Upcoming technologies show promising results in clinical and animal studies that may provide alternative options desirable for the military population.

CONCLUSIONS

The current treatment options for cartilage lesions are not entirely satisfactory, usually with long recovery times and mixed results. An ideal therapy would be a single procedure that possesses the ability to enable a quick return to activity and duty, alleviate pain, provide long-term durability, and disrupt the progression of osteoarthritis. Evolving technologies for cartilage lesions are expanding beyond currently available techniques that may revolutionize the future of cartilage repair.

Bone Marrow Stimulation for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Bone marrow stimulation (BMS) has been proposed to augment healing at the time of arthroscopic rotator cuff repair (ARCR) by creating several bone marrow vents in the footprint of the rotator cuff, allowing mesenchymal stem cells, platelets, and growth factors to cover the area as a "crimson duvet."

PURPOSE

To perform a meta-analysis of randomized controlled trials (RCTs) to compare the outcomes after BMS and a control for those undergoing ARCR.

STUDY DESIGN

Meta-analysis; Level of evidence, 1.

METHODS

A literature search of 3 databases was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RCTs comparing BMS and a control for ARCR were included. Clinical outcomes were compared, and a P value <.05 was considered to be statistically significant.

RESULTS

A total of 7 RCTs with 576 patients were included. Overall, 18.8% of patients treated with BMS and 21.0% of patients treated with a control had a retear (I2 = 43%; P = .61). With BMS, the mean Constant score was 88.2, and with the control, the mean Constant score was 86.7 (P = .12). Additionally, there was no significant difference in the American Shoulder and Elbow Surgeons score (94.3 vs 93.2, respectively; P = .31) or visual analog scale score (0.9 vs 0.9, respectively; P = .89).

CONCLUSION

The level 1 evidence in the literature did not support BMS as a modality to improve retear rates or clinical outcomes after ARCR.

Similar outcomes between biceps tenodesis and SLAP repair for SLAP tears in younger patients - A meta-analysis

OBJECTIVES

The purpose of this study is to systematically review the comparative studies in the literature to ascertain if biceps tenodesis or superior-labrum anterior to posterior (SLAP) repair results in superior clinical outcomes in the treatment of type II SLAP tears in patients under 40.

METHODS

A systematic search of articles in Pubmed, EMBASE and The Cochrane Library databases was carried out according to the PRISMA guidelines. Cohort studies comparing biceps tenodesis to repair in type II SLAP tears in patients under 40 were included. Clinical outcomes were extracted including return to play, reoperations, ASES, and VAS for pain. All statistical analysis was performed using Review Manager. A p-value of <0.05 was considered to be statistically significant.

RESULTS

Five studies were included. Biceps tenodesis resulted in comparable rates of return to play compared to SLAP repair (78.5% vs 67.7%, p ​= ​0.33), and there was no significant difference in return to play in overhead athletes (83.6% vs 74%, p ​= ​0.82). There was no significant difference in ASES score (87.2 vs 86.2, p ​= ​0.27) or VAS score for pain (1.8 vs 2.1, p ​= ​0.48). There was no significant difference in re-operation rates (2.9% vs 10.8%, p ​= ​0.22).

CONCLUSION

This study found that biceps tenodesis has no significant difference in rates of return to play in athletes, as well as in functional outcome scores and rates of revision surgery in younger patients compared to SLAP repair.

LEVEL OF EVIDENCE

Level III, Systematic review of Level III studies.

No Difference in Recurrent Instability Between Knotted and Knotless Repair Techniques in Arthroscopic Treatment of Isolated Posterior Labral Tears: A Systematic Review

Purpose

To compare clinical failure, recurrent instability, patient-reported outcome measures (PROMs), and return to sport (RTS) between knotted and knotless fixation methods in arthroscopic posterior labral repair for isolated posterior shoulder instability (PSI).

Methods

Multiple databases were queried according to Preferred Reported Items for Systematic Reviews and Meta-Analyses guidelines for clinical studies with Level I to IV evidence, including knotted and knotless suture anchors for arthroscopic posterior labral repair. Combined anterior and posterior instability, multidirectional instability, SLAP injuries, unspecified repair techniques, majority open procedures, and revision surgery were excluded.

Results

Screening yielded 17 full-text articles reporting on 852 shoulders undergoing posterior labral repair. Recurrent instability ranged from 0% to 21%, and the rate of revision surgery ranged from 0% to 11% in knotted only, 0% in knotless only, and 2.0% to 8.1% in knotted and knotless studies. Six studies with both pre- and postoperative visual analog scale scores and 7 studies with both pre- and postoperative American Shoulder and Elbow Score scores all showed improvement in scores after intervention regardless of repair technique. Thirteen studies reported RTS or duty rates with a minimum of 79%.

Conclusions

Overall recurrent instability after posterior labral repair for isolated PSI was low with improvement in PROMs and favorable RTS rates regardless of fixation method. There was no clear difference in recurrent instability or revision surgery between knotted and knotless fixation methods for isolated posterior labral repair. However, the current literature is predominantly limited by Level III and IV evidence. The quality of literature and lack of standardization on the definition of clinical failure and recurrent instability among surgeons preclude any definitive conclusion regarding one clinically superior fixation method.

Level of Evidence

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

Majority of Studies Show Similar Rates of Return to Play After Arthroscopic Bankart Repair or Latarjet Procedure: A Systematic Review

PURPOSE

To systematically review the current evidence in the literature to compare return to play following arthroscopic Bankart repair versus open Latarjet procedure for the treatment of anterior shoulder instability.

METHODS

A literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comparative studies reporting return to play following arthroscopic Bankart repair versus open Latarjet procedure were included. Return to play was compared, with all statistical analysis performed using Review Manager, Version 5.3.

RESULTS

Nine studies with 1,242 patients (mean age: 15-30 years) were included. The rate of return to play was 61% to 94.1% among those undergoing arthroscopic Bankart repair and 72% to 96.8% in those undergoing an open Latarjet procedure. Two studies (Bessiere et al. and Zimmerman et al.) found a significant difference in favor of the Latarjet procedure (P < .05 for both, I2 = 37%). The rate of return to play at preinjury level was 9% to 83.8% among those undergoing arthroscopic Bankart repair and 19.4% to 80.6% in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 0%). The mean time of return to play was 5.4 to 7.3 months among those undergoing arthroscopic Bankart repair and 5.5 to 6.2 months in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 39%).

CONCLUSIONS

Overall, the majority of studies showed no significant difference in rates of return to play or timing following arthroscopic Bankart repair or open Latarjet procedure. Furthermore, no study has found a significant difference in rate of return to play at pre-injury level, or rate of return to play among collision athletes.

LEVEL OF EVIDENCE

Level III, systematic review of Level I-III studies.

Complications following arthroscopic Bankart repair: a systematic review

BACKGROUND

Complications are rare after arthroscopic Bankart repair, and as a result, there is a lack of guidance over rates of complications that can be used to consent patients. The purpose of this study is to systematically review the literature to assess the complications after arthroscopic Bankart repair, other than recurrent instability.

METHODS

A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Clinical studies reporting on the complications after arthroscopic Bankart repair were included.

RESULTS

A total of 194 studies were included in the analysis, with 13,979 patients and 14,019 shoulders undergoing arthroscopic Bankart repair. The overall complication rate was 0.67%, with frozen shoulder being the most common complication occurring in 0.32%. Persistent pain occurred in 0.17%. The rates of nerve, hardware, and wound complications were 0.07%, 0.05%, and 0.03%, respectively.

CONCLUSION

The arthroscopic Bankart repair has a very low rate of complications. Frozen shoulder and persistent pain are the most frequently encountered complications.

Acute Anterior Cruciate Ligament Reconstruction Performed Within 10 Days of Injury Does Not Increase Risk of Postoperative Arthrofibrosis: A Systematic Review and Meta-analysis

BACKGROUND

The optimal timing of anterior cruciate ligament (ACL) reconstruction (ACLR) remains a controversial topic. Previous reviews have demonstrated that there are no differences between early and delayed ACLR; however, these studies have been limited by heterogeneous definitions of acute ACL injury.

PURPOSE

To evaluate postoperative patient functional outcomes and risk for arthrofibrosis after acute arthroscopic ACLR performed ≤10 days after injury.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using multiple medical databases. Inclusion criteria were studies that evaluated postoperative range of motion outcomes for patients undergoing ACLR ≤10 days after initial ACL injury. For included comparative studies comparing patient groups undergoing ACLR ≤10 days and patients undergoing "delayed" ACLR after ≥3 weeks of initial injury, quantitative analysis was performed to assess for differences in postoperative arthrofibrosis, reoperation rates, and patient-reported outcomes between groups. DerSimonian-Laird binary random-effects models were constructed to quantitatively describe the association between the ACLR time period and patient outcomes by generating effect estimates in the form of odds ratios with 95% CIs. Qualitative analysis was performed to describe variably reported patient outcomes and the risk of arthrofibrosis after ACLR for noncomparative studies.

RESULTS

Screening yielded 6 full-text articles with 448 patients who underwent ACLR (296 ACLR <10 days, 152 ACLR >3 weeks), with a pooled mean age of 28.1 years. For studies amenable to quantitative analysis, there were no significant differences between ACLR performed ≤10 days and ACLR performed at the 3-week point or after in terms of postoperative stiffness (3 studies; odds ratio, 1.27; P = .508), Tegner scores (2 studies; mean difference, -0.056; P = .155), or reoperation for stiffness (3 studies; odds ratio, 0.869; P = .462). The overall incidence of postoperative arthrofibrosis after 12 months of follow-up was 11 of 296 (3.7%) for ACLRs performed ≤10 days versus 6 of 152 (3.9%) for those performed at the 3-week point or after.

CONCLUSION

ACLR performed ≤10 days after the inciting injury does not increase the risk of postoperative arthrofibrosis and demonstrates similar patient-reported outcomes compared with ACLR performed at the 3-week point or after.

Primary Latarjet procedure versus Latarjet in the setting of previously failed Bankart repair: a systematic review

OBJECTIVES

The purpose of this study is to systematically review the comparative studies in the literature to compare the outcomes of the Latarjet procedure in the setting of a previously failed Bankart repair versus those undergoing the Latarjet procedure as a primary surgery for anterior shoulder instability.

METHODS

A systematic search in Pubmed, EMBASE, and The Cochrane Library databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Cohort studies comparing outcomes in the Latarjet procedure as a primary surgery versus the Latarjet procedure in the setting of a previously failed Bankart repair were included.

RESULTS

Ten studies with 1913 patients were included. There was a significantly lower rate of recurrent instability in those with a Latarjet procedure as a primary surgery (4.8% vs 12.1%, p ​= ​0.007). There was also a significantly lower rate of complications with the Latarjet procedure as a primary surgery (6.2% vs 10.2%, p ​= ​0.03). Furthermore, there was a significant difference in the rate of revision surgery in favour of the Latarjet procedure as a primary surgery (4.8% vs 10.9%, p ​= ​0.02). However, there were similar rates of redislocations (2.8% vs 3.4%, p ​= ​0.82) and return to play (67.7% vs 78.5%, p ​= ​0.30) between the two cohorts.

CONCLUSION

This study found that the Latarjet procedure as a revision procedure for a previously failed Bankart repair resulted in higher rates of complications, recurrent instability, and revisions than the Latarjet procedure performed as a primary procedure.

LEVEL OF EVIDENCE

Level III, Systematic Review & Meta-Analysis of Level III studies.

Favorable short-term outcomes of micronized allogenic cartilage scaffold for glenoid cartilage defects associated with posterior glenohumeral instability

Purpose

To determine clinical outcomes associated with micronized allogenic cartilage scaffold use for treatment of posterior glenoid cartilage defects at 2 years.

Study Design

Case series.

Methods

A retrospective analysis of prospectively collected data was performed on a consecutive series of patients who underwent arthroscopic treatment of a symptomatic posterior glenoid cartilage defect with micronized allogenic cartilage scaffold between January 2019 and December 2020. The primary outcome was subjective shoulder value (SSV) at latest follow-up. Secondary outcomes included visual analog scale (VAS), recurrence of instability, and range of motion (ROM).

Results

Seven patients, including 4 in the setting of primary posterior instability and 3 in the setting of recurrent symptoms after arthroscopic posterior glenohumeral stabilization, were included in the analysis with a mean follow up of 2.6 years (range, 2-3.7 years). Statistically significant improvements were seen in SSV (median = 40, interquartile range [IQR] = 40-50 before surgery; vs median = 85, IQR = 67.5-87.5 after surgery; P = .018) and VAS (median = 4, IQR = 4-6.3 before surgery; vs median = 1, IQR = 0-1.5 after surgery; P = .010). No significant differences were seen in ROM. There were no cases of recurrent instability or reoperation.

Conclusions

The use of micronized allogenic cartilage scaffold for glenoid cartilage defects is associated with clinical improvement at 2-year follow-up. This is the case when performed in conjunction with index posterior labral repair when there is a concomitant glenoid cartilage defect or when performed in the setting of persistent pain and mechanical symptoms after prior posterior labral repair.

Level of Evidence

Level IV, therapeutic case series.

Review of Burkhart and DeBeer's (2000) article on traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repair: Where have we taken the concept of glenoid bone loss in 2023?

This classic discusses the original publication by Burkhart and DeBeer "Traumatic Glenohumeral Bone Defects and Their Relationship to Failure of Arthroscopic Bankart Repair" published in 2000 in Arthroscopy. At that time, the authors sought to understand the reasons behind the failure of arthroscopic soft tissue repair. Based on their findings, the authors introduced the concept of the inverted pear glenoid and engaging Hill-Sachs lesion which is now part of the orthopedic lexicon. The importance of bony pathologic changes in anterior glenohumeral instability has become so apparent, that it now forms the basis of clinical understanding and underpins treatment algorithms. Since this publication over 20 years ago, the idea of glenohumeral bone loss has been extensively explored and refined. There is no doubt of the importance of structural bone loss yet there is still uncertainty as to the best management of those with subcritical bone loss. The purpose of revisiting this classic article is to look at where we are in understanding recurrent instability and bony deficiency while appreciating how far we have come. This review begins with a detailed summary of the classic article along with a historic perspective. Next, we look at the current evidence as it pertains to the classic article and how modern technology and innovation has advanced our ability to assess and quantify glenohumeral bone loss. We finish with expert commentary on the topic from two current surgeons with a research interest in shoulder instability to offer an insight into how modern surgeons view and address this issue. One of the original authors also reflects on the topic. The findings of this classic study changed the way we think about shoulder instability and opened the doors to an exciting body of research that is still growing today. Future research offers an opportunity for high quality evidence to guide management in the group of patients with subcritical bone loss and we eagerly await the results.

Beach-Chair Versus Lateral Decubitus Positioning for Primary Arthroscopic Anterior Shoulder Stabilization: A Consecutive Series of 641 Shoulders

BACKGROUND

There are limited data comparing the beach-chair (BC) versus lateral decubitus (LD) position for arthroscopic anterior shoulder stabilization.

PURPOSE

To identify predictors of instability recurrence and revision after anterior shoulder stabilization and evaluate surgical position and glenoid bone loss as independent predictors of recurrence and revision at short- and midterm follow-ups.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A consecutive series of 641 arthroscopic anterior stabilization procedures were performed from 2005 to 2019. All shoulders were evaluated for glenohumeral bone loss on magnetic resonance imaging. The primary outcomes of interest were recurrence and revision. Multivariable logistic regression models were used to assess the relationships of outcomes with age, position, glenoid bone loss group, and track.

RESULTS

A total of 641 shoulders with a mean age of 22.3 years (SD, 4.45 years) underwent stabilization and were followed for a mean of 6 years. The overall 1-year recurrent instability rate was 3.3% (21/641) and the revision rate was 2.8% (18/641). At 1 year, recurrence was observed in 2.3% (11/487) and 6.5% (10/154) of BC and LD shoulders, respectively. The 5-year recurrence and revision rates were 15.7% (60/383) and 12.8% (49/383), respectively. At 5 years, recurrence was observed in 16.4% (48/293) and 13.3% (12/90) of BC and LD shoulders, respectively. Multivariable modeling demonstrated that surgical position was not associated with a risk of recurrence after 1 year (odds ratio [OR] for LD vs BC, 1.39; P = .56) and 5 years (OR for LD vs BC, 1.32; P = .43), although younger age at index surgery was associated with a higher risk of instability recurrence (OR, 1.73 per SD [4.1 years] decrease in age; P < .03). After 1 and 5 years, surgical position results were similar in a separate multivariable logistic regression model of revision surgery as the dependent variable, when adjusted for age, surgical position, bone loss group, and track. At 5 years, younger age was an independent risk factor for revision: OR 1.68 per SD (4.1 years) decrease in age (P < .05).

CONCLUSION

Among fellowship-trained orthopaedic surgeons, there was no difference in rates of recurrence and revision surgery after performing arthroscopic anterior stabilization in either the BC or the LD position at 1- and 5-year follow-ups. In multivariable analysis, younger age, but not surgical position, was an independent risk factor for recurrence.

Posterior Shoulder Instability but Not Anterior Shoulder Instability Is Related to Glenoid Version

Purpose

To assess and compare glenoid version in patients with anterior shoulder instability (ASI), posterior shoulder instability (PSI), and a control group.

Methods

The operative notes of all patients that had undergone arthroscopic shoulder instability repair between January 2017 and May 2022 were retrospectively reviewed. Magnetic resonance imaging scans were then analyzed, and glenoid version was measured by a single blinded observer. A P value <.05 was considered statistically significant.

Results

There were 100 patients included in the ASI group, 65 in PSI group, and 100 in the control group. The mean glenoid versions for the ASI group were -16°, -9.1°, and -9.2° for the vault version, simplified vault version, and chondrolabral version, respectively. The mean glenoid versions for the PSI group were -21°, -13.4°, and -16.6° for the vault version, simplified vault version, and chondrolabral version, respectively. The mean versions for the control group were -17.8°, -9.5°, and -9.8° for the vault version, simplified vault version and chondrolabral version, respectively. ANOVA testing and post hoc comparisons revealed the PSI group to be significantly more retroverted than both other groups P < .001. The ASI group's degree of glenoid version was not significantly different to that of the control P = .009.

Conclusion

Patients with PSI have a higher degree of retroversion in comparison to those with ASI and control. There is no significant difference in glenoid version among patients with ASI when compared with control.

Level of Evidence

Level III, retrospective comparative study.

Acromion morphology is associated with glenoid bone loss in posterior glenohumeral instability

BACKGROUND

The acromion morphology in a shoulder with posterior instability differs from that of a shoulder without glenohumeral instability. Specifically, the acromion with a flatter sagittal tilt, greater posterior acromial height, and less posterior coverage is associated with posterior instability. However, the association between acromion morphology and glenoid bone loss (GBL) in the setting of posterior glenohumeral instability has not previously been investigated. The purpose of this study was to determine whether acromial morphology influences the extent or pattern of posterior GBL in a cohort of patients with posterior glenohumeral instability.

METHODS

This multicenter retrospective study identified 89 shoulders with unidirectional posterior glenohumeral instability. Total area GBL was measured using the best-fit circle method on magnetic resonance imaging (MRI). Shoulders were divided into 3 groups: (1) no GBL (n = 30), (2) GBL 0%-13.5% (n = 45), or (3) GBL ≥13.5% (n = 14). Acromion measurements were performed on MRI and included acromial tilt, posterior acromial height, anterior acromial coverage, and posterior acromial coverage.

RESULTS

Patients without GBL had a steeper acromial tilt (58.5° ± 1.4°) compared with those with 0%-13.5% GBL (64.3° ± 1.5°) or GBL ≥13.5% (67.7° ± 1.8°) (P = .004). Patients without GBL also had greater posterior coverage (65.4° ± 1.7°) compared with those with GBL (60.3° ± 1.4°) (P = .015). Posterior acromion height was not significantly different among groups.

CONCLUSION

The results demonstrate that an acromion with a flatter sagittal tilt and less posterior coverage is associated with GBL in the setting of posterior glenohumeral instability. This is important to consider as posterior GBL has been identified as a risk factor for failure of posterior soft tissue-stabilizing procedures.

Revision Arthroscopic Bankart Repair Results in High Failure Rates and a Low Return to Duty Rate Without Recurrent Instability

PURPOSE

The purpose of this study was to determine, in a military population without critical bone loss, the rate of recurrent instability after revision arthroscopic stabilization for failed primary arthroscopic Bankart repair.

METHODS

Forty-one revision arthroscopic stabilizations were performed at a single military institution between 2005 to 2016 for recurrent anterior shoulder instability after primary arthroscopic Bankart repair. Minimum follow-up was 2 years, and shoulders with glenoid bone loss >20% were excluded. The primary outcome of interest was the incidence of failure, defined by recurrent instability.

RESULTS

Age at revision surgery averaged 22.9 ± 4.3 years, and 88% were either service academy cadets or active duty combat arms soldiers. Mean follow-up was 7.8 years. Twenty-three patients (56%) returned to duty without recurrent instability after revision arthroscopic stabilization. Eighteen patients (44%) experienced recurrent instability after return to duty. Glenoid bone loss averaged 6.2% (95% confidence interval [CI], 3.2%-9.2%) in the successful group and 5.7% (95% CI, 3.1%-8.3%) in the failure group (P = .808).

CONCLUSIONS

Revision arthroscopic stabilization of failed primary arthroscopic Bankart repair has a failure rate of 44% in a young military population. The similar amounts of bone loss between groups indicates that bone loss is not the primary determinant of failure in revision arthroscopic stabilization.

LEVEL OF EVIDENCE

IV, Case Series.

An Exploratory Factor Analysis of the National Institutes of Health Patient-Reported Outcomes Measurement Information System and the Single Assessment Numeric Evaluation in Knee Surgery Patients

INTRODUCTION

Patient-Reported Outcomes (PROs) have been suggested for use in measuring treatment effectiveness. To minimize patient burden, two approaches have been proposed: An orthopedic-specific Single Assessment Numeric Evaluation (SANE) or computer adaptive testing methods such as the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS). The goal of this work was to examine the constructs measured by the SANE and PROMIS system in a military orthopedic population undergoing knee surgery.

MATERIALS AND METHODS

In 732 patients and 2,166 complete observations, the SANE-Knee PRO and PROMIS surveys for Depression, Anxiety, Pain Interference, Sleep Disturbance, and Physical Function were obtained. A correlation matrix between the PROs was calculated, the number of latent factors to extract was determined via parallel plot, and the final principal axis exploratory factor analysis was performed.

RESULTS

The parallel plot analysis indicated that two latent factors existed. One latent factor corresponded to measures of psychological distress (PROMIS Sleep Disturbance, Depression, and Anxiety) and the second latent factor corresponded to physical capability (SANE, PROMIS Physical Function, Pain Interference, and Sleep Disturbance). Both PROMIS Physical Function (0.83) and Pain Interference (-0.80) more strongly weigh on the physical capability latent factor than SANE (0.69).

CONCLUSIONS

In a knee surgical population, the SANE, PROMIS Physical Function, and PROMIS Pain Interference measure the same human dimension of physical capability; however, PROMIS Physical Function and Pain Interference may measure this construct more effectively in isolation. The SANE may be a more viable option to gauge physical capability when computer adaptive testing is not possible.

Distal Clavicle Autograft Versus Traditional and Congruent Arc Latarjet Procedures: A Comparison of Surface Area and Glenoid Apposition With 3-Dimensional Computed Tomography and 3-Dimensional Magnetic Resonance Imaging

BACKGROUND

Limited studies have compared graft-glenoid apposition and glenoid augmentation area between the Latarjet procedure and distal clavicle graft in glenohumeral stabilization. Additionally, preoperative planning is typically performed using computed tomography (CT), and few studies have used 3-dimensional (3D) magnetic resonance imaging (MRI) reformations to assess graft dimensions.

PURPOSE

The purpose of this study was 2-fold: (1) to compare bony apposition, glenoid augmentation, and graft width among coracoid and distal clavicle bony augmentation techniques and (2) to determine the viability of 3D MRI to assess bone graft dimensions.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 24 patients with recurrent glenohumeral instability and bone loss were included in this study. 3D CT and 3D MRI reformations were utilized to measure pertinent dimensions for 5 orientations of coracoid and distal clavicle autografts: (1) standard Latarjet procedure (SLJ), (2) congruent arc Latarjet procedure (CLJ), (3) distal clavicle attached by its posterior surface (DCP), (4) distal clavicle attached by its inferior surface (DCI), and (5) distal clavicle attached by its resected end (DCR). Glenoid augmentation was defined as the graft surface area contributing to the glenoid. Bone-on-bone apposition was defined as the graft-glenoid contact area for bone healing potential, and graft width was pertinent for fixation technique. Glenoid bone loss ranged from 0% to 34%. Paired t tests were used to compare graft sizes between patients and compare 3D CT versus 3D MRI measurements.

RESULTS

The CLJ had the largest graft surface area (mean, 318.41 ± 74.44 mm²), while the SLJ displayed the most bone-on-bone apposition (mean, 318.41 ± 74.44 mm²). The DCI had the largest graft width (mean, 20.62 ± 3.93 mm). Paired t tests revealed no significant differences between the Latarjet techniques, whereas distal clavicle grafts varied significantly with orientation. All 3D CT and 3D MRI measurements were within 1 mm of each other, and only 2 demonstrated a statistically significant difference (coracoid width: 13.03 vs 13.98 mm, respectively [P = .010]; distal clavicle thickness: 9.69 vs 10.77 mm, respectively [P = .002]). 3D CT and 3D MRI measurements demonstrated a strong positive correlation (r > 0.6 and P < .001 for all dimensions).

CONCLUSION

Glenoid augmentation, bony apposition, and graft width varied with coracoid or distal clavicle graft type and orientation. Differences between 3D CT and 3D MRI were small and likely not clinically significant.

CLINICAL RELEVANCE

3D MRI is a viable method for preoperative planning and graft selection in glenoid bone loss.

Survival of anterior cruciate ligament reconstructions in active-duty military populations

PURPOSE

Anterior cruciate ligament tears and anterior cruciate ligament reconstruction (ACLR) are common in young athletes. The modifiable and non-modifiable factors contributing to ACLR failure and reoperation are incompletely understood. The purpose of this study was to determine ACLR failure rates in a physically high-demand population and identify the patient-specific risk factors, including prolonged time between diagnosis and surgical correction, that portend failure.

METHODS

A consecutive series of military service members with ACLR with and without concomitant procedures (meniscus [M] and/or cartilage [C]) done at military facilities between 2008 and 2011 was completed via the Military Health System Data Repository. This was a consecutive series of patients without a history of knee surgery for two years prior to the primary ACLR. Kaplan-Meier survival curves were estimated and evaluated with Wilcoxon test. Cox proportional hazard models calculated hazard ratios (HR) with 95% confidence intervals (95% CI) to identify demographic and surgical factors that influenced ACLR failure.

RESULTS

Of the 2735 primary ACLRs included in the study, 484/2,735 (18%) experienced ACLR failure within four years, including (261/2,735) (10%) undergoing revision ACLR and (224/2,735) (8%) due to medical separation. The factors that increased failure include Army Service (HR 2.19, 95% CI 1.67, 2.87), > 180 days from injury to ACLR (HR 1.550, 95% CI 1.157, 2.076), tobacco use (HR 1.429 95% CI 1.174, 1.738), and younger patient age (HR 1.024, 95% CI 1.004, 1.044).

CONCLUSION

The overall clinical failure rate of service members with ACLR is 17.7% with minimum four-year follow-up, where more patients are likely to fail due to revision surgery than medical separation. The cumulative probability of survival at 4 years was 78.5%. Smoking cessation and treating ACLR patients promptly are modifiable risk factors impacting either graft failure or medical separation.

LEVEL OF EVIDENCE

Level III.

Glenoid Bone Loss Pattern in Patients With Posterior Instability Versus Anterior Instability: A Matched Cohort Study

Background

The pattern of glenoid bone loss (GBL) in anterior glenohumeral instability is well described. It was recognized recently that posterior GBL after instability has a posteroinferior pattern.

Purpose/Hypothesis

The purpose of this study was to compare GBL patterns in a matched cohort of patients with anterior versus posterior glenohumeral instability. The hypothesis was that the GBL pattern in posterior instability would be more inferior than the GBL pattern in anterior instability.

Study Design

Cohort study; Level of evidence, 3.

Methods

In this multicenter retrospective study, 28 patients with posterior instability were matched with 28 patients with anterior instability by age, sex and number of instability events. GBL location was defined using a clockface model. Obliquity was defined as the angle between the long axis of the glenoid and a line tangent to the GBL. Superior and inferior GBL were measured as areas and defined relative to the equator. The primary outcome was the 2-dimensional characterization of posterior versus anterior GBL. The secondary outcome was a comparison of the posterior GBL patterns in traumatic and atraumatic instability mechanisms in an expanded cohort of 42 patients.

Results

The mean age of the matched cohorts (n = 56) was 25.2 ± 9.87 years. The median obliquity of GBL was 27.53° (interquartile range [IQR], 18.83°-47.38°) in the posterior cohort and 9.28° (IQR, 6.68°-15.75°) in the anterior cohort (P < .001). The mean superior-to-inferior bone loss ratio was 0.48 ± 0.51 in the posterior cohort and 0.80 ± 0.55 (P = .032) in the anterior cohort. In the expanded posterior instability cohort (n = 42), patients with traumatic injury mechanism (n = 22), had a similar GBL obliquity compared to patients with an atraumatic injury mechanism (n = 20) (mean, 27.73° [95% CI, 20.26°-35.20°] vs 32.20° [95% CI, 21.27°-43.14°], respectively) (P = .49).

Conclusion

Posterior GBL occurred more inferiorly and at an increased obliquity compared with anterior GBL. This pattern is consistent for traumatic and atraumatic posterior GBL. Bone loss along the equator may not be the most reliable predictor of posterior instability, and critical bone loss may be reached more rapidly than a model of loss along the equator may predict.

Treatment Following a First-Time Shoulder Dislocation: What Should I Do?

A first-time shoulder dislocation is a challenging topic that requires consideration of anatomic and patient-specific factors. Initial management is predicated on determining functional demands, activity level, and expectations of the patient, in addition to assessing the risk of recurrent instability. When considering surgical indications, it is imperative to understand the biomechanical implications of injury to the glenohumeral joint complex and how specific surgical procedures can restore stability. It is important to provide an overview of the current treatment algorithm for management of first-time shoulder dislocation, with a special focus on diagnosis and intervention in the young athlete.

Posterior Shoulder Instability in the Military and Athlete: An Evidence and Experience-Based Treatment Approach

Background:

Recognition of posterior glenohumeral instability has increased in young, athletic populations, leading to evolution in operative approaches to management. As with anterior instability surgery, successful treatment for these challenging injuries is dependent on understanding the key principles of pathology and restoration of the functional anatomy.

Indications:

Operative management of posterior glenohumeral instability is indicated for recurrent instability events or persistent pain refractory to physical therapy in the setting of posterior labral pathology with or without bone loss.

Technique:

In this video article, we present our approach to operative management of posterior glenohumeral instability in a young, athletic population, as developed through extensive experience in military and athlete populations and supported by research. Our approach to posterior glenohumeral instability is to restore the functional anatomy of the bone, labrum, and capsuloligamentous static restraints. We consider concomitant pathology and bone loss as components of these restraints that need to be restored to achieve a stable, painless shoulder. Using standard portals and tools, we prepare the glenoid and mobilize the labrum. When present, large osseous lesions can be restored using allograft distal tibia. We then repair and superiorize the inferior labrum, taking care to create a secure buttress against translation by positioning anchors at the edge of the chondral surface and everting the interior flap of tissue. If capsular pathology is present, this is also addressed. In the setting of significant posterior glenoid bone loss, we reconstruct the osseous support with a distal tibial allograft, which we perform arthroscopically and augment with labral repair. Using these techniques, surgeons can expect a low overall failure rate. In our young, highly active population, we observed 17.2% failure by 5 years, although this is dependent on multiple factors including age and bone loss.

Discussion:

Outcomes for posterior glenohumeral instability can be excellent with both nonoperative and operative treatments. When operative intervention is pursued, it is important to critically evaluate the anatomy, place portals considerately, and functionally restore the damaged structures.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic-Assisted Anterior Glenoid Reconstruction Using Nonrigid Fixation With Distal Tibia Osteochondral Allograft

Introduction:

Traumatic anterior glenohumeral instability events result in a capsulolabral (Bankart lesion) and/or osseous injury with subsequent attritional bone loss, particularly with recurrence. Up to 88% of patients with recurrent instability experience glenoid bone loss, which predisposes to future dislocations and subluxations, even with arthroscopic capsulolabral repair. The surgical management of glenoid bone loss includes a number of different techniques such as the Latarjet or coracoid transfer as well as other osseous and osteoarticular autografts and allografts. However, operative management of shoulder instability has increasingly shifted toward arthroscopic approaches with preservation of anatomy when possible.

Indications:

Arthroscopic-assisted allograft distal tibia bone block augmentation to the anterior glenoid is indicated for revision anterior glenohumeral instability procedures with anterior bone loss and in primary cases of anterior instability with critical bone loss.

Technique:

Our technique for nonrigid arthroscopic anterior glenoid reconstruction with allograft distal tibia and anterior labral repair is performed preferentially in the lateral position without necessitating patient repositioning. The preplanned tibial bone block is prepared on a back table prior to the arthroscopic procedure. After creation of portals and elevation of labral tissue, a guide and drill are used to introduce a retrograde reamer which is deployed to create a perpendicular edge for apposition of the allograft tibia. The bone block is then introduced through a rotator interval portal by pulling sutures retrograde through glenoid bone tunnels and is secured to the prepared surface medial to the liberated labrum. The articular surface of the graft and glenoid are aligned and suture-based fixation is used to compress the bone block against the native glenoid. The anterior labral tissue is then mobilized over the graft and repaired to the native glenoid when possible.

Description/Conclusion:

The benefits of allograft tibia augmentation for anterior instability with glenoid bone loss include an anatomic joint surface restoration including articular cartilage, lack of donor site morbidity, and a minimally invasive arthroscopic approach. When performed arthroscopically and with nonrigid fixation, this technique permits concurrent anterior labral repair and anatomic reconstruction, safe graft passage without necessity of a far medial portal, and expeditious return to function.

Characterization of Cartilage Injury and Associated Treatment at the Time of Primary Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) tears with concomitant cartilage injuries resulting in ACL reconstruction (ACLR) with cartilaginous procedures are common in the young, high-demand population. The purpose of this study was to report and characterize cartilage treatments performed at the time of index ACLR reconstruction and to determine if those treatments are associated with revision surgery (of any kind) in the 4-year follow-up. We performed a consecutive series of active duty service members in the Military Health System Data Repository with ACLR with and without concomitant cartilage procedures done at military facilities between October 2008 and September 2011. Patients were continuously enrolled with no history of knee surgeries for 2 years prior to primary ACLR. ACLR failure was defined as revision ACLR within 4 years following the primary ACLR. Of the 2,735 primary ACLRs included in the study, 5.3% (143/2,735) underwent isolated ACLR with a cartilage procedure. Of these patients, 23.07% (33/143) experienced ACLR failure within 4 years after ACLR with cartilage procedures, including 33.33% (11/33) undergoing revision ACLR. We found concomitant cartilage procedures at time of index ACLR to have the following rates of revision 35.59% (21/59) for microfracture, 14.63% (6/41) for chondroplasty, and 13.95% (6/43) for osteochondral grafts. The overall clinical failure rate of service members with ACLR plus concomitant cartilage procedure is 23.07% with minimum 4-year follow-up. Further research should be done to identify modifiable demographic and surgical factors associated with failure. This is a retrospective case-control study that reflects level of evidence III.

Prospective Evaluation of Posterior Glenoid Bone Loss After First-time and Recurrent Posterior Glenohumeral Instability Events

BACKGROUND

Although posterior glenohumeral instability is becoming an increasingly recognized cause of shoulder pain, the role of posterior glenoid bone loss on outcomes remains incompletely understood.

PURPOSES

To prospectively determine the amount of bone loss associated with posterior instability events and to determine predisposing factors based on preinstability imaging.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 1428 shoulders were evaluated prospectively for ≥4 years. At baseline, a subjective history of shoulder instability was ascertained for each patient, and bilateral noncontrast magnetic resonance imaging (MRI) scans of the shoulders were obtained regardless of any reported history of shoulder instability. The cohort was prospectively followed during the study period, and those who were diagnosed with posterior glenohumeral instability were identified. Postinjury MRI scans were obtained and compared with the screening MRI scans. Glenoid version, perfect-circle-based bone loss was measured for each patient's pre- and postinjury MRI scans using previously described methods.

RESULTS

Of the 1428 shoulders that were prospectively followed, 10 shoulders sustained a first-time posterior instability event and 3 shoulders sustained a recurrent posterior instability event. At baseline, 11 of 13 shoulders had some amount of glenoid dysplasia and/or bone loss. The change in glenoid bone loss was 5.4% along the axis of greatest loss (95% CI, 3.8%-7.0%; P = .009), 4.4% at the glenoid equator (95% CI, 2.7%-6.2%; P = .016), and 4.2% of total glenoid area (95% CI, 2.9%-5.3%; P = .002). Recurrent glenoid instability was associated with a greater amount of absolute bone loss along the axis of greatest loss compared with first-time instability (recurrent: 16.8% ± 1.1%; 95% CI, 14.6%-18.9%; first-time: 10.0% ± 1.5%; 95% CI, 7.0%-13.0%; P = .005). Baseline glenoid retroversion ≥10° was associated with a significantly greater percentage of bone loss along the axis of greatest loss (≥10° of retroversion: 13.5% ± 2.0%; 95% CI, 9.6%-17.4%; <10° of retroversion: 8.5% ± 0.8%; 95% CI, 7.0%-10.0%; P = .045).

CONCLUSIONS

Posterior glenohumeral instability events were associated with glenoid bone loss of 5%. The amount of glenoid bone loss after a recurrent posterior glenohumeral instability event was greater than that after first-time instability. Glenoid retroversion ≥10° was associated with a greater amount of posterior glenoid bone loss after a posterior instability event.

Acute Intervention With Selective Interleukin-1 Inhibitor Therapy May Reduce the Progression of Posttraumatic Osteoarthritis of the Knee: A Systematic Review of Current Evidence

PURPOSE

To evaluate the efficacy of selective interleukin (IL)-1 inhibitor therapy in the reduction of posttraumatic osteoarthritis (PTOA) progression following knee ligament or meniscal injury.

METHODS

A systematic review was conducted evaluating the disease-modifying efficacy of selective IL-1 inhibition in the setting of knee PTOA.

RESULTS

The literature search identified 364 articles and 11 studies were included (n = 10 preclinical, n = 1 clinical). Drug delivery in preclinical studies was administered using IL-1Ra-encoded helper-dependent adenovirus particles (n = 3), synovial cells transfected with an IL-1Ra-encoded retroviral vector (n = 3), or varying chemical compositions of nonviral microcapsule gene carriers (n = 4). Intervention with selective IL-1 inhibitor therapy within 2 weeks of injury provided the greatest protective benefits in reducing the progression of PTOA regardless of drug delivery methodology in preclinical models. The majority of studies reported significantly better cartilage integrity and reduction in lesion size in animals treated with gene therapy with the greatest effects seen in those treated within 5 to 7 days of injury.

CONCLUSIONS

Early intervention with selective IL-1 inhibitor therapy were effective in reducing proinflammatory IL-1β levels in the acute and subacute phases following traumatic knee injury in preclinical animal model studies, while significantly reducing cartilage damage, lesion size, and PTOA progression at short-term follow-up. However, it was found that the effect of these therapies diminished over time.

CLINICAL RELEVANCE

Acute, intra-articular injection of selective IL-1 inhibitors may reduce PTOA progression, supporting the need for additional basic and clinical investigation.

Analgesia in Athletes: A Review of Commonly Used Oral and Injectable Modalities

Pain is common among athletes at all levels and the treatment of pain can be a challenging and frustrating task. The team physician needs a fundamental knowledge of analgesic strategies as it relates to athletes. It is important to understand the mechanism of action, side effect profile/associated complications, incidence of and indications for use, as well as the controversies associated with the most common analgesic medications used in sports medicine. Several "in vogue" treatment modalities, including cannabidiol, are also becoming more commonly used and are worth discussion.

Unicompartmental Knee Arthroplasty: More Conversions, Fewer Complications Than Proximal Tibial Osteotomy in a Young Population

BACKGROUND

Patients with isolated medial compartment osteoarthritis requiring surgical intervention generally have two surgical options: unicompartmental knee arthroplasty (UKA) and proximal tibial osteotomy (PTO). Outcomes of reoperation rates and survivorship are important for counseling patients on treatment options.

METHODS

A retrospective, comparative cohort study was performed for a consecutive series of patients in the Military Health System who underwent either UKA or PTO between 2003 and 2018. All patients were between 18 and 55 years old and diagnosed with isolated medial compartmental arthritis. Cases with concurrent meniscal or cartilage procedures were included, while cases with concurrent ligament reconstruction were excluded. A minimum 2-year follow-up was required. The primary outcome was conversion to total knee arthroplasty, and the secondary outcome was reoperation for any reason.

RESULTS

A total of 383 procedures were performed for isolated medial compartment arthritis in 303 patients (UKA 270, PTO 113). A multivariate analysis showed that PTO was associated with decreased risk of conversion to TKA compared to UKA (P = .0364). However, the reoperation due to complications was significantly higher in the PTO group (21.2% vs 2.2%; P ≤ .01). The 5-year conversion rate was 13.7% for UKA and 3.5% for PTO (P = .0033) with an average time to conversion of 3.1 years for UKA and 2.9 years for PTO (P = .7805).

CONCLUSIONS

In young patients with isolated medial compartment arthritis, conversion rates to TKA are higher with UKA compared to PTO. However, overall reoperation rate is higher with PTO, secondary to complications and revision procedures. Overall survivorship is acceptable for both procedures.

Are We Able to Determine Differences in Outcomes Between Male and Female Servicemembers Undergoing Hip Arthroscopy? A Systematic Review

Background:

Female servicemembers sustain higher rates of lower extremity injuries as compared with their male counterparts. This can include intra-articular pathology in the hip. Female patients are considered to have worse outcomes after hip arthroscopy for femoroacetabular impingement and for hip labral repair.

Purpose:

To (1) compare published rates of hip arthroscopy between male and female military servicemembers and (2) determine if there are any sex-based differences in outcomes after hip arthroscopy in the military.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

We reviewed the literature published from January 1, 2000, through December 31, 2020, to identify studies in which hip arthroscopy was performed in military personnel. Clinical trials and cohort studies were included. The proportion of women within each cohort was identified, and results of any between-sex analyses were reported.

Results:

Identified were 11 studies that met established criteria. Studies included 2481 patients, 970 (39.1%) of whom were women. Surgery occurred between January 1998 and March 2018. Despite women accounting for approximately 15% of the active-duty military force, they represented 39.1% (range, 25.7%-57.6%) of patients undergoing hip arthroscopy. In most cases, there were no differences in self-reported outcomes (pain, disability, and physical function), return to duty, or medical disability status based on sex.

Conclusion:

Women account for approximately 15% of the military, but they made up 40% of patients undergoing hip arthroscopy. Outcomes were not different between the sexes; however, definitive conclusions were limited by the heterogeneity of outcomes, missing data, lack of sex-specific subgroup analyses, and zero studies with sex differences as the primary outcome. A proper understanding of sex-specific outcomes after hip arthroscopy will require a paradigm shift in the design and reporting of trials in the military health system.

A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population

BACKGROUND

Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages.

PURPOSE

To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis.

RESULTS

A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R² = 0.71-0.74; root mean square error = 9.3-10.0).

CONCLUSION

The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

Latarjet After Failed Arthroscopic Bankart Repair Results in Twice the Rate of Recurrent Instability Compared With Primary Latarjet

PURPOSE

To assess recurrent instability of the shoulder following open Latarjet performed as the primary stabilization procedure or as a salvage procedure.

METHODS

A retrospective, comparative cohort study was performed for a consecutive series of patients in the Military Health System who underwent open Latarjet from January 1, 2010, to December 31, 2018. All patients were diagnosed with recurrent anterior shoulder instability and had a minimum of 2 years of postoperative follow-up. Patients were categorized as either having a primary Latarjet (PL; no prior shoulder stabilization procedure) or salvage Latarjet (SL; ≥1 previous arthroscopic surgical stabilization procedures).

RESULTS

A total of 234 Latarjet procedures were performed in 234 patients. The overall recurrent instability rate was 15.8% (37/234), the overall reoperation rate was 16.7% (36/234), and the overall complication rate was 14.2% (33/234) over a mean 5.0 years of follow-up. There were 99 PL procedures and 135 SL procedures. The SL group had significantly more recurrent instability than the PL group (SL 28/135, 20.7%; PL 9/99, 9.1%; P = .0158). There was no difference in overall reoperation rates (SL 26/135, 19.3%; PL 13/99, 13.1%; P = .2140) or complication rates (SL 20/135, 14.8%; PL 13/99, 13.3%; P = .9101).

CONCLUSION

The rate of recurrent instability following the Latarjet procedure in an active, high-risk population is 15.8%. Primary Latarjet was found to have lower rates of recurrence compared with salvage Latarjet procedures (9.1% versus 20.7%).

LEVEL OF EVIDENCE

III.

Coracoid or Clavicle Fractures Associated With Coracoclavicular Ligament Reconstruction

BACKGROUND

Coracoclavicular (CC) ligament reconstruction is a commonly performed procedure for high-grade acromioclavicular (AC) joint separations. Although distal clavicle and coracoid process fractures represent potential complications, they have been described in only case reports and small case series.

PURPOSE

To identify the incidence and characteristics of clavicle and coracoid fractures after CC ligament reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The US Military Health System Data Repository was queried for patients with a Current Procedural Terminology code for CC ligament repair or reconstruction between October 2013 and March 2020. The electronic health records, including patient characteristics, radiographs, operative reports, and clinical notes, were evaluated for intraoperative or postoperative clavicle or coracoid fractures. Initial operative technique, fracture management, and subsequent clinical outcomes were reviewed for these patients.

RESULTS

A total of 896 primary CC ligament repairs or reconstructions were performed during the study period. There were 21 postoperative fractures and 1 intraoperative fracture in 20 patients. Of these fractures, 12 involved the coracoid and 10 involved the clavicle. The overall incidence of fracture was 3.81 fractures per 1000 person-years. In 5 patients who sustained a fracture, bone tunnels were not drilled in the fractured bone during the index procedure. A total of 17 fractures were ultimately treated operatively, whereas 5 fractures had nonoperative management. Of the 16 active-duty servicemembers who sustained intraoperative or postoperative fractures, 11 were unable to return to full military duty after their fracture care.

CONCLUSION

Fracture of the distal clavicle or coracoid process after CC ligament repair or reconstruction is a rare but serious complication that can occur independent of bone tunnels created during the index procedure. Fractures associated with CC ligament procedures occurred at a rate of 2.46 per 100 cases. Most patients were ultimately treated surgically with open reduction and internal fixation or revision CC ligament reconstruction. Although the majority of patients with intraoperative or postoperative fractures regained full range of motion, complications such as anterior shoulder pain, AC joint asymmetry, and activity-related weakness were common sequelae resulting in physical limitations and separation from military service.

Femoral Neck Over-Resection After Hip Arthroscopy Treated with Vascularized Fibula Autograft: A Case Report

CASE

We describe a case of femoroacetabular impingement syndrome treated with labral repair and arthroscopic femoral osteoplasty in a 30-year-old man. The case was complicated by resection of 50% of the femoral neck resulting in high risk of an impending femoral neck fracture. The patient was treated with a vascularized fibula autograft and internal fixation.

CONCLUSION

Complications of femoral neck over-resection can threaten the viability and structural integrity of the hip joint but may successfully be treated with vascularized fibula autograft.

Anchored Minimal Clinically Important Difference Metrics: Considerations for Bias and Regression to the Mean

Minimal clinically important differences (MCIDs) are used to understand clinical relevance. However, repeated observations produce biased analyses unless one accounts for baseline observation, known as regression to the mean (RTM). Using an International Knee Documentation Committee (IKDC) survey dataset, we can demonstrate the effect of RTM on MCID values by (1) MCID-estimate dependence on baseline observation and (2) MCID-estimate bias being higher when the posttest-pretest data correlation is lower. We created 10 IKDC datasets with 5000 patients and a specific correlation under both equal and unequal variances. For each 10-point increase in baseline IKDC, MCID decreased by 3.5, 2.7, 1.9, 1.2, and 0.7 points when posttest-pretest correlations were 0.10, 0.25, 0.50, 0.75, and 0.90, respectively, under equal variances. Not accounting for RTM resulted in a static 20-point MCID. Minimal clinically important difference estimates may be unreliable. Minimal clinically important difference calculations should include the correlation and variances between posttest and pretest data, and researchers should consider using a baseline covariate-adjusted receiver operating characteristic curve analysis to calculate MCID.

Incidence and Risk Factors of Acute Patellar Tendon Rupture, Repair Failure, and Return to Activity in the Active-Duty Military Population

BACKGROUND

Patellar tendon ruptures have a reported incidence of 0.68 per 100,000 person-years in the general population. The epidemiology of surgically treated patellar tendon ruptures in the US military has yet to be reported, which would provide opportunity for identification of risk factors for these otherwise healthy and active patients.

PURPOSE

To determine the incidence of patellar tendon rupture in the Military Health System (MHS) population and to analyze demographic patterns, surgical fixation methods, and rerupture rates.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

We utilized the MHS Data Repository (MDR) to identity active-duty military servicemembers surgically treated for patellar tendon rupture between 2010 and 2015. Records were reviewed for demographic information, injury characteristics, fixation technique, and occurrence of rerupture. Risk factors for rupture were calculated using Poisson regression based on population counts and demographic data obtained in the MDR. Risk factors for rerupture and return to duty were analyzed via univariate analysis and multivariate regression.

RESULTS

A total of 504 operatively treated primary patellar tendon repairs in 483 patients were identified, with an overall incidence of 6 per 100,000 person-years. Mean age was 33.6 years (range, 17-54 years) and 98% of patients were male. Fixation method was 81% bone tunnels and 7% suture anchors, and 12% were unknown. Black race had a higher relative rate ratio for rupture compared with the race categories White (9.21; P < .0001) and Other (3.27; P < .0001). The rupture rate was higher in 35- to 44-year-old patients compared with those aged 18 to 24 years (P < .0001), 25 to 34 years (P < .0001), and 45 to 64 years (P = .004). Return to full previous level of activity occurred in 75.8% of patients, 14.6% returned to activity with limitations, and 9.5% were medically separated. The rerupture rate was 3%. Fixation method, tobacco usage, body mass index, and race were not significant risk factors for rerupture.

CONCLUSION

The incidence of patellar tendon rupture in the US military population is substantially higher than has been reported in the civilian population. Among military personnel, men, Black servicemembers, and those aged 35 to 44 years were at highest risk for patellar tendon rupture. Three-quarters of patients were able to return to full activity without limitations. The rerupture rate was low and unaffected by fixation method.

Latent Factor Analysis of the PROMIS and Single Assessment Numeric Evaluation in Patients Undergoing Shoulder Surgery

INTRODUCTION

Patient-reported outcomes (PROs) are reporting tools that quantify patients' perceptions of their mental and physical health. Many PROs may inadvertently measure the same or overlapping theoretical constructs (e.g., pain, function, depression, etc.), which is both inefficient and a patient burden. The purpose of this study was to examine the functional relationship of the Single Assessment Numeric Evaluation (SANE) score and general constructs measured with the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) in young patients undergoing shoulder surgery.

MATERIAL AND METHODS

This study was an institutional review board approved retrospective case control of the Military Orthopaedics Tracking Injuries and Outcomes Network using 805 patients and 1,373 observations. All patients underwent shoulder surgery and had multiple observations ranging from 28 days pre-surgery to 428 days post-surgery. Correlation matrices and exploratory factor analysis were used to examine how each of the measured variables (PROMIS physical function, PROMIS pain interference, PROMIS sleep disturbance, PROMIS anxiety, PROMIS depression, and SANE surveys) contribute or "weigh" on latent factors, which are then mapped to a theoretical construct. This statistical method helps uncover structural relationships between measured variables.

RESULTS

The PROMIS and SANE surveys collectively weigh on two latent factors: psychological health (measured variables: PROMIS anxiety [0.95] and PROMIS depression [0.86]) and physical capabilities (measured variables: PROMIS physical function [0.81], PROMIS pain interference [-0.82], PROMIS sleep disturbance [-0.51], and SANE [0.68]). Although the physical capability construct is functionally related to psychological health (-0.45), there is no direct relation between SANE and measures of depression or anxiety.

CONCLUSIONS

This study supports the use of the SANE as a valid single question to assess physical function providing similar information to the PROMIS in regard to measuring physical capabilities. Its simplicity makes it easy to use and implement with minimal uplift or change in workflow.