[Reverse Shoulder Arthroplasty - Current Concepts]

Due to first promising long term outcome data, reverse shoulder arthroplasty experienced an immense increase of usage during the past decade. Moreover, the initial Grammont concept has constantly been refined and adapted to current scientific findings. Therefore, clinical and radiological problems like scapular notching and postoperative instability were constantly addressed but do still remain an area of concern.This article summarises current concepts in reverse shoulder arthroplasty and gives an overview of actual indications like cuff tear arthropathy, severe osteoarthritis, proximal humerus fractures, tumours, fracture sequelae as well as revision surgery and their corresponding clinical and radiological results.

Analysis of three different reverse shoulder arthroplasty designs for cuff tear arthropathy - the combination of lateralization and distalization provides best mobility

BACKGROUND

The two major reverse shoulder arthroplasty (RSA) designs are the Grammont design and the lateralized design. Even if the lateralized design is biomechanically favored, the classic Grammont prosthesis continues to be used. Functional and subjective patient scores as well as implant survival described in the literature so far are comparable to the lateralized design. A pure comparison of how the RSA design influences outcome in patients has not yet been determined. The aim of this study was a comparison focused on patients with cuff tear arthropathy (CTA).

METHODS

We analyzed registry data from 696 CTA patients prospectively collected between 2012 and 2020 in two specialized orthopedic centers up to 2 years post-RSA with the same follow-up time points (6,12 24 months). Complete teres minor tears were excluded. Three groups were defined: group 1 (inlay, 155° humeral inclination, 36 + 2 mm eccentric glenosphere (n = 50)), group 2 (inlay, 135° humeral inclination, 36 + 4 mm lateralized glenosphere (n = 141)) and group 3 (onlay, 145° humeral inclination, + 3 mm lateralized base plate, 36 + 2 mm eccentric glenosphere (n = 35)) We compared group differences in clinical outcomes (e.g., active and passive range of motion (ROM), abduction strength, Constant-Murley score (CS)), radiographic evaluations of prosthetic position, scapular anatomy and complications using mixed models adjusted for age and sex.

RESULTS

The final analysis included 226 patients. The overall adjusted p-value of the CS for all time-points showed no significant difference (p = 0.466). Flexion of group 3 (mean, 155° (SD 13)) was higher than flexion of group 1 (mean, 142° (SD 18) and 2 (mean, 132° (SD 18) (p < 0.001). Values for abduction of group 3 (mean, 145° (SD 23)) were bigger than those of group 1 (mean, 130° (SD 22)) and group 2 (mean, 118° (SD 25)) (p < 0.001). Mean external rotation for group 3 (mean, 41° (SD 23)) and group 2 (mean, 38° (SD 17)) was larger than external rotation of group 1 (mean, 24° (SD 16)) (p < 0.001); a greater proportion of group 2 (78%) and 3 (69%) patients reached L3 level on internal rotation compared to group 1 (44%) (p = 0.003). Prosthesis position measurements were similar, but group 3 had significantly less scapular notching (14%) versus 24% (group 2) and 50% (group 1) (p = 0.001).

CONCLUSIONS

Outcome scores of different RSA designs for CTA revealed comparable results. However, CTA patients with a lateralized and distalized RSA configuration were associated with achieving better flexion and abduction with less scapular notching. A better rotation was associated with either of the lateralized RSA designs in comparison with the classic Grammont prosthesis.

LEVEL OF EVIDENCE

Therapeutic study, Level III.

Evaluation of the efficiency of an ultrasound-supported infiltration technique in patients with tennis elbow applying the ITEC medical device: a multicenter study

Background

The treatment of lateral epicondylitis remains unsatisfactory in certain cases. The aim of this study is to investigate the efficiency of an ultrasound-guided infiltration combined with fenestration of the extensor tendon postulating a 50% reduction in pain on exertion within 6 months.

Methods

In a prospective, nonrandomized, multicenter study design, 68 patients with chronic lateral epicondylitis and symptoms lasted for at least 6 weeks were included. Each hospital has been assigned for Traumeel (A), autologous whole blood (B), or dextrose (C) in advance. Preinterventional, 6 weeks, 12 weeks, 6 and 12 months after infiltration, patient-related outcome parameter, and dorsal wrist extension strength were documented. Preinterventional (obligate) and after 6 months (optional) radiological evaluation (magnetic resonance imaging) was performed.

Results

The Visual Analog Scale showed a significant reduction after 6 months in all groups (A. 4.8-2.5, B. 6.2-2.3, C. 5.8-2.4). Similar results could be observed with Subjective elbow value, Disabilities of Arm, Shoulder, and Hand Score, Mayo Elbow Performance Score, and Patient Rated Tennis Elbow Evaluation. The loss of strength could be completely compensated after about 6 months. Magnetic resonance imaging did not fully reflect clinical convalescence. Re-infiltrations were sometimes necessary for final reduction of symptoms (A = 11, B = 8, C = 4). Switching to surgical intervention was most frequently observed in group C (A = 2, B = 1, C = 5). In 14.5% of the cases, no improvement of the symptoms could be achieved with this method.

Conclusion

The primary hypothesis of a significant long-term pain reduction of at least 50% could be achieved regardless of the medication chosen.

All-Suture Anchor vs. Knotless Suture Anchor for the Treatment of Anterior Shoulder Instability-A Prospective Cohort Study

All-suture or soft-anchors (SA) represent a new generation of suture anchor technology with a completely suture-based system. This study's objective was to assess Juggerknot® SA, for arthroscopic Bankart repair in recurrent shoulder instability (RSI), and to compare it to a commonly performed knotless anchor (KA) technique (Pushlock®). In a prospective cohort study, 30 consecutive patients scheduled for reconstruction of the capsulolabral complex without substantial glenoid bone loss were included and operated on using the SA technique. A historical control group was operated on using the KA technique for the same indication. Clinical examinations were performed preoperatively and 12 and 24 months postoperatively. RSI and WOSI at 24 months were the co-primary endpoints, evaluated with logistic and linear regression. A total of 5 out of 30 (16.7%) patients suffered from RSI in the SA group, one out of 31 (3.2%) in the KA group (adjusted odds ratio = 10.12, 95% CI: 0.89-115.35), and 13.3% in the SA group and 3.2% in the KAgroup had a revision. The median WOSI in the SA group was lower than in the KA group (81% vs. 95%) (adjusted regression coefficient = 10.12, 95% CI: 0.89-115.35). Arthroscopic capsulolabral repair for RSI using either the SA or KA technique led to satisfying clinical outcomes. However, there is a tendency for higher RSI and lower WOSI following the SA technique.

Functional and Radiologic Outcomes of Degenerative Versus Traumatic Full-Thickness Rotator Cuff Tears Involving the Supraspinatus Tendon

BACKGROUND

Arthroscopic rotator cuff repair (ARCR) is among the most commonly performed orthopaedic procedures. Several factors-including age, sex, and tear severity-have been identified as predictors for outcome after repair. The influence of the tear etiology on functional and structural outcome remains controversial.

PURPOSE

To investigate the influence of tear etiology (degenerative vs traumatic) on functional and structural outcomes in patients with supraspinatus tendon tears.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients undergoing ARCR from 19 centers were prospectively enrolled between June 2020 and November 2021. Full-thickness, nonmassive tears involving the supraspinatus tendon were included. Tears were classified as degenerative (chronic shoulder pain, no history of trauma) or traumatic (acute, traumatic onset, no previous shoulder pain). Range of motion, strength, the Subjective Shoulder Value, the Oxford Shoulder Score (OSS), and the Constant-Murley Score (CMS) were assessed before (baseline) and 6 and 12 months after ARCR. The Subjective Shoulder Value and the OSS were also determined at the 24-month follow-up. Repair integrity after 12 months was documented, as well as additional surgeries up to the 24-month follow-up. Tear groups were compared using mixed models adjusted for potential confounding effects.

RESULTS

From a cohort of 973 consecutive patients, 421 patients (degenerative tear, n = 230; traumatic tear, n = 191) met the inclusion criteria. The traumatic tear group had lower mean baseline OSS and CMS scores but significantly greater score changes 12 months after ARCR (OSS, 18 [SD, 8]; CMS, 34 [SD,18] vs degenerative: OSS, 15 [SD, 8]; CMS, 22 [SD, 15]) (P < .001) and significantly higher 12-month overall scores (OSS, 44 [SD, 5]; CMS, 79 [SD, 9] vs degenerative: OSS, 42 [SD, 7]; CMS, 76 [SD, 12]) (P≤ .006). At the 24-month follow-up, neither the OSS (degenerative, 44 [SD, 6]; traumatic, 45 [SD, 6]; P = .346) nor the rates of repair failure (degenerative, 14 [6.1%]; traumatic 12 [6.3%]; P = .934) and additional surgeries (7 [3%]; 7 [3.7%]; P = .723) differed between groups.

CONCLUSION

Patients with degenerative and traumatic full-thickness supraspinatus tendon tears who had ARCR show satisfactory short-term functional results. Although patients with traumatic tears have lower baseline functional scores, they rehabilitate over time and show comparable clinical results 1 year after ARCR. Similarly, degenerative and traumatic rotator cuff tears show comparable structural outcomes, which suggests that degenerated tendons retain healing potential.

One-Step Release Technique for Tendon Extraction During Biceps Tenodesis

All biceps tenodesis techniques involving extra-articular tendon preparation consist of 2 distinct steps for tenotomy and tendon grasping. These 2 maneuvers are performed by different instruments. A single-step tendon release technique is described for both arthroscopic and open shoulder surgery. This technique finds application in arthroscopic proximal suprapectoral tenodesis, open treatment of proximal humerus fractures, and suprapectoral mini-open tenodesis. Herein, we describe an arthroscopic biceps tenodesis technique that combines the actions of cutting and gripping the tendon in a single step.

Missed Osteochondral Shear Injury of the Humeral Head Following Anterior Shoulder Dislocation - A Case Report

CASE

Two months after anterior shoulder dislocation and spontaneous reduction, a 41-year-old man presented movement-related shoulder pain and a functional deficit. An initially missed osteochondral shearing injury of the humeral head with a Bankart lesion was diagnosed. Due to an extensive posteroinferior defect, an open reduction and internal fixation (ORIF) using bioabsorbable chondral darts was performed. At the 1-year follow-up, magnetic resonance images showed a completely healed osteochondral fragment and the patient presented an unrestricted shoulder function.

CONCLUSION

Even in missed osteochondral shear injuries, ORIF with bioabsorbable implants can be associated with an excellent functional outcome and sufficient integrity of the fragment. The absorbable implants are biocompatible, therefore the risk of revision surgery due to implant irritations is minimized.

Editorial Commentary: Button Fixation for Glenoid Bone Grafting Results in Less Graft Resorption Compared to Screws

Iliac crest bone grafting is conducted in cases of anteroinferior shoulder instability with substantial bone loss of the glenoid rim to reconstruct the glenoid concavity and its stabilizing function. The technique is more than 100 years old, and it evolved to include graft fixation with metal screws. The disadvantages of metal screw fixation include risk of screw migration, loosening, and breakage, as well as irritation and injury to the surrounding osseous and soft tissue structures (e.g., humeral cartilage and subscapularis muscle). With the implementation of arthroscopic techniques, new graft fixation techniques were introduced, including absorbable or biologic screws, buttons, interconnected suture anchors, and bone cerclage techniques. Recent research shows button fixation is a successful alternative to screw fixation. In addition, buttons show less graft resorption and related pain.

Non-operative management of humeral periprosthetic fracture after stemless shoulder arthroplasty

PURPOSE

Periprosthetic fractures around a stemless implant often involve lesser and greater tuberosities with a well-fixed implant in the metaphysis. This exposes the surgeon to unique questions and challenges as no surgical option (open reduction and internal fixation or revision to a stem) appears satisfactory to address them. Purpose of this study was to evaluate the clinical outcomes after non-operative management of periprosthetic fractures after stemless shoulder arthroplasty.

METHODS

A retrospective multicenter study was conducted to identify all patients who had sustained non-operative management of a periprosthetic fracture after a stemless shoulder. Exclusion criteria were as follows: (1) intraoperative fractures and (2) implant loosening. Primary outcomes included mean Constant score and mean active range of motion. Secondary outcomes were VAS, radiological analysis, and complications.

RESULTS

Nine patients were included. One was excluded due to the loss of follow-up at three months. Mean age was 79 years. At the last follow-up, no significant difference was observed between the Constant score, VAS, or the range of motion before fracture and at the last follow-up. Fracture healing did not result in any change in angulation in the frontal plane in seven cases and was responsible for a varus malunion in two cases of anatomic arthroplasty. No change in lateralization or distalization was reported. No cases of implant loosening after fracture have been observed.

CONCLUSIONS

Conservative management seems to be appropriate in cases of minimally displaced fractures without implant loosening.

Neuromuscular Electrical Stimulation-Enhanced Physical Therapist Intervention for Functional Posterior Shoulder Instability (Type B1): A Multicenter Randomized Controlled Trial

OBJECTIVE

Functional posterior shoulder instability (FPSI) (type B1) is a severe type of instability, mainly in teenagers and young adults, that leads to loss of function, pain, and stigmatization among peers. An experimental nonsurgical treatment protocol based on neuromuscular electrical stimulation (NMES) showed very promising early results in the treatment of FPSI. The hypothesis of this study was that NMES-enhanced physical therapy leads to better outcomes than physical therapy alone as the current gold standard of treatment in patients with FPSI.

METHODS

In this multicenter randomized controlled trial, patients with FPSI were randomly allocated in a 1:1 ratio to either 6 weeks of physical therapy or 6 weeks of physical therapy with simultaneous motion-triggered NMES. Baseline scores as well as outcome scores at 6 weeks, 3 months, 6 months, and 12 months after the intervention were obtained. The predefined primary outcome of this trial was the Western Ontario Shoulder Instability Index (WOSI) at the 3-month time point.

RESULTS

Forty-nine patients were randomized and eligible for the trial. The group that received physical therapy with simultaneous motion-triggered NMES showed a significantly better main outcome measurement in terms of the 3-month WOSI score (64% [SD = 16%] vs 51% [SD = 24%]). Two-thirds of the patients from the physical therapist group crossed over to the group that received physical therapy with simultaneous motion-triggered NMES due to dissatisfaction after the 3-month follow-up and showed a significant increase in their WOSI score from 49% [SD = 8%] to 67% [SD = 24%]. The frequency of instability episodes showed a significant improvement in the group that received physical therapy with simultaneous motion-triggered NMES at the 3-month follow-up and beyond, while in the physical therapist group, no significant difference was observed.

CONCLUSION

The current study shows that NMES-enhanced physical therapy led to statistically significant and clinically relevant improvement in outcomes in the treatment of FPSI compared to conventional physical therapy alone-from which even patients with prior unsatisfactory results after conventional physical therapy can benefit.

IMPACT

Based on the results of this study, NMES-enhanced physical therapy is an effective new treatment option for FPSI, a severe type of shoulder instability. NMES-enhanced physical therapy should be preferred over conventional physical therapy for the treatment of patients with FPSI.

Current Trends in Orthopaedics and Trauma in Germany

During the Guest Nation Symposium (cobranded with the Deutsche Gesellschaft für Orthopädie und Unfallchirurgie, Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie, and Deutsche Gesellschaft für Unfallchirurgie) at the 2023 American Academy of Orthopaedic Surgeons Congress in Las Vegas, the goal was to compile nationally important content from German orthopaedics and trauma surgery. This resulted in a mix of content on the latest developments in trauma care, knee arthroplasty, spinopelvic importance for hip arthroplasty, stemless shoulder endoprostheses, joint preservation for ankle osteoarthritis, trauma education, and research. Of course, this is only a small selection of the important issues that are being driven forward in Germany.

Lateralization and distalization shoulder angles do not predict outcomes in reverse shoulder arthroplasty for cuff tear arthropathy

BACKGROUND

In reverse shoulder arthroplasty (RSA), there are a plethora of measurements regarding implant lateralization and distalization to optimize the center of rotation. Two specific measurements known as the "lateralization shoulder angle" (LSA) and "distalization shoulder angle" (DSA) have been the recent focus of studies to assess their association with RSA and postoperative function. The aim of this study was to evaluate the prognostic clinical value of the LSA and DSA in a large cohort of patients with cuff tear arthropathy (CTA) who were treated with different RSA systems.

METHODS

Two local shoulder arthroplasty registries were reviewed for all RSA patients documented to have undergone a radiologic assessment and complete 2-year follow-up examination. The main inclusion criterion was primary RSA in patients with CTA. Patients with either a complete teres minor tear, os acromiale, or acromial stress fracture reported between the time of surgery and the 24-month follow-up were excluded. Five RSA implant systems with 4 neck-shaft angles (NSAs) were assessed. The Constant score, Subjective Shoulder Value, and range of motion at 2 years were correlated with both the LSA and DSA assessed on 6-month anteroposterior radiographs. Linear and parabolic univariable regressions were calculated for both shoulder angles, for each prosthesis system, and for the entire patient cohort.

RESULTS

Between May 2006 and November 2019, there were a total of 630 CTA patients who had undergone primary RSA. Of this large cohort of patients, 270 were treated with the Promos Reverse prosthesis system (NSA, 155°); 44, Aequalis Reversed II (NSA, 155°); 62, Lima SMR Reverse (NSA, 150°); 25, Aequalis Ascend Flex (NSA, 145°); and 229, Univers Revers (NSA, 135°). The mean LSA was 78° (standard deviation [SD], 10°; range, 6°-107°), and the mean DSA was 51° (SD, 10°; range, 7°-91°). The average Constant score at 24 months' follow-up was 68.1 points (SD, 13 points; range, 13-96 points). Neither the linear nor parabolic regression calculations for the LSA or DSA revealed significant associations with any of the clinical outcomes.

CONCLUSION

Different patients may achieve different clinical outcomes despite having identical LSA and DSA values. There is no association between angular radiographic measurements and 2-year functional outcomes after RSA.

The V angle compliments radiographic assessment of acute acromioclavicular joint dislocations by differentiating between Rockwood types III versus V and by considering dynamic horizontal translation in coronal radiographs

PURPOSE

Acromioclavicular joint (ACJ) dislocations are usually graded radiographically according to Rockwood, but differentiation between Rockwood types III and V may be ambiguous. The potentially clinically relevant horizontal instability is barely addressed in coronal radiographs. It was hypothesized that a new radiologic parameter (V angle) would complement ACJ diagnostics on anteroposterior radiographs by differentiating between cases of Rockwood III and V while also considering the aspect of dynamic horizontal translation (DHT).

METHODS

Ninety-five patients with acute ACJ dislocations (Rockwood types III and V) were included retrospectively between 2017 and 2020. On anteroposterior views (weightbearing: n = 62, non-weight-bearing: n = 33), the coracoclavicular (CC) distance and the newly introduced V angle for assessing scapular orientation were measured bilaterally. This angle is referenced between the spinal column and a line crossing the superior scapular angle and the crossing point between the supraspinatus fossa and the medial base of the coracoid process, reported as the side-comparative difference (non-injured side *minus* injured side). DHT on Alexander views was divided into stable, partially unstable or completely unstable.

RESULTS

The V angle on the injured side alone (mean 50.0°; 95% confidence interval (CI), 48.6°-51.3°) showed no correlation with the side-comparative CC distance [%] (r = - 0.040; n.s.). Thus, the V angle on the non-injured side was considered, displaying a normal distribution (n.s.) with a mean of 58.0° (95% CI, 56.6°-59.4°). The side-comparative V angle showed a correlation with the side-comparative CC distance (r = 0.83; p < 0.001) and was able to differentiate between Rockwood types III (4.7°; 95% CI, 3.9°-5.5°; n = 39) and V (10.3°; 95% CI, 9.7°-11.0°; n = 56) (p < 0.001). A cut-off value of 7° had a 94.6% sensitivity and an 82.1% specificity (area under curve, AUC: 0.954; 95% CI, 0.915-0.994). The side-comparative V angle was greater for cases with complete DHT (8.7°; 95% CI, 7.9°-9.5°; n = 78) than for cases with partial DHT (4.8°; 95% CI, 3.3°-6.3°; n = 16) (p < 0.001). A cut-off value of 5° showed a sensitivity of 84.6% and a specificity of 66.7% (AUC 0.824; 95% CI, 0.725-0.924).

CONCLUSION

The scapular-based V angle on anteroposterior radiographs distinguishes between Rockwood types III and V as well as cases with partial or complete DHT.

STUDY DESIGN

Diagnostic study.

LEVEL OF EVIDENCE

Level II.

Development and internal validation of a model predicting patient-reported shoulder function after arthroscopic rotator cuff repair in a Swiss setting

BACKGROUND

Prediction models for outcomes after orthopedic surgery provide patients with evidence-based postoperative outcome expectations. Our objectives were (1) to identify prognostic factors associated with the postoperative shoulder function outcome (the Oxford Shoulder Score (OSS)) and (2) to develop and validate a prediction model for postoperative OSS.

METHODS

Patients undergoing arthroscopic rotator cuff repair (ARCR) were prospectively documented at a Swiss orthopedic tertiary care center. The first primary ARCR in adult patients with a partial or complete rotator cuff tear were included between October 2013 and June 2021. Thirty-two potential prognostic factors were used for prediction model development. Two sets of factors identified using the knowledge from three experienced surgeons (Set 1) and Bayesian projection predictive variable selection (Set 2) were compared in terms of model performance using R squared and root-mean-squared error (RMSE) across 45 multiple imputed data sets using chained equations and complete case data.

RESULTS

Multiple imputation using data from 1510 patients was performed. Set 2 retained the following factors: American Society of Anesthesiologists (ASA) classification, baseline level of depression and anxiety, baseline OSS, operation duration, tear severity, and biceps status and treatment. Apparent model performance was R-squared = 0.174 and RMSE = 7.514, dropping to R-squared = 0.156, and RMSE = 7.603 after correction for optimism.

CONCLUSION

A prediction model for patients undergoing ARCR was developed using solely baseline and operative data in order to provide patients and surgeons with individualized expectations for postoperative shoulder function outcomes. Yet, model performance should be improved before being used in clinical routine.

Management of Acute High-Grade Acromioclavicular Joint Dislocations: Comparable Clinical and Radiological Outcomes After Bidirectional Arthroscopic-Assisted Stabilization With the Single Low-Profile Suture Button Technique Versus Double-Suture Button Technique

PURPOSE

To compare the 2-year clinical and radiological outcomes of an arthroscopic-assisted bidirectional stabilization procedure using a single low-profile (LPSB) or double-suture button (DSB) technique with additional percutaneous acromioclavicular (AC) cerclage fixation for patients with acute high-grade AC joint dislocation.

METHODS

This retrospective cohort study compared male patients aged between 18 and 56 years with acute high-grade AC joint dislocation fixed with either a LPSB or DSB technique. Patients were examined at least 24 months after surgery. Subjective Shoulder Value (SSV), Taft (TF), and Acromioclavicular Joint Instability (ACJI) scores were evaluated. Coracoclavicular difference, ossification, AC joint osteoarthritis, and dynamic posterior translation (DPT) were assessed on bilateral anteroposterior stress radiographs and modified Alexander views. The revision rate due to implant conflict and duration of surgery were reported. Group outcome differences were analyzed using standardized hypothesis tests.

RESULTS

28 patients aged 39.2 (LPSB) and 36.4 years (DSB) (P = .319; CI: -2.77-8.34) were eligible per cohort. The follow-up was 30.5 (LPSB) and 37.4 months (DSB) (P = .02; CI: -12.73-1.08). LPSB patients rated a significantly higher SSV (93.2% vs 81.9% [DSB]; P = .004). TF and ACJI scores were similar between the groups. Coracoclavicular difference markedly decreased from 12 mm to 3 mm for both cohorts (P < .001). Ossification was identified in over 85% in both cohorts (P = .160; CI -0.77-0.13) and osteoarthritis in 21.4% (LPSB) and 39.3% (DSB) (P = .150). Persistent DPT was found in around 30% for both cohorts (P = .561; CI -0.26-0.48). The revision rates were 0% (LPSB) and 7% (DSB) (P = .491). LPSB surgery was shorter (59.7 vs 71.5 mins [DSB]) (P = .011).

CONCLUSIONS

The results of the LPSB and DSB techniques with additional percutaneous AC cerclage fixation showed comparable outcomes with excellent clinical and satisfactory radiological results. The assessment of the subjective patient satisfaction was in favor of the LPSB technique and no postoperative revision event was observed following this procedure.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Concordance of shoulder strength assessments using a spring balance and isometric dynamometer in patients before and after arthroscopic rotator cuff repair

Background

Shoulder strength is an essential assessment to monitor the outcome of treatment interventions. Isometric strength assessment in the Constant Score (CS) was initially measured with a cable tensiometer or spring balance (SB). Some authors have questioned the validity of this strength assessment and the resulting CS. The purpose of this study was to investigate the concordance of strength measurements using an unsecured SB vs. isometric dynamometer and outline the impact of these methods on the CS.

Methods

In the context of routine clinical examination as well as participation in a Swiss national cohort study, shoulder strength was measured to calculate baseline (before surgery) and 6-month postoperative CS in adult rotator cuff tear patients who had undergone primary arthroscopic rotator cuff repair. Measurements of each of the operated and contralateral shoulders were made per patient routinely using an unsecured SB and study-specific using an isometric dynamometer in patients with the shoulder at 90° abduction in the scapular plane. Absolute and change values of strength and CS data were presented in scatter plots and assessed using concordance correlation coefficients (CCCs) and Bland-Altman plots.

Results

Between June 2020 and October 2021, baseline strength measurements from the operated shoulder of 78 patients ranged from 0.0 to 13.6 kg with a CCC of 0.64 (P < .001) and a mean difference of 0.81 kg between the SB and dynamometer methods. There were 89 measurements of the contralateral healthy shoulder that ranged from 3.6 to 15.6 kg; CCC and mean strength difference were 0.76 (P < .001) and 0.70 kg, respectively. At 6 months postsurgery, strength measurements of the operated shoulder ranged from 1.4 to 12.0 kg with a CCC of 0.66 (P < .001) and mean strength difference of 0.9 kg (n = 68). Respective 6-month measurements of the contralateral side (n = 52) ranged from 2.0 to 15.9 kg with a CCC of 0.73 (P < .001) and mean strength difference of 0.03 kg.

Conclusion

Absolute and change values in shoulder strength assessments using an unsecured SB and isometric dynamometer are fairly concordant with mean differences of less than 1 kg between methods. With the variability of strength differences among patients, interpretation of these values for individual patients may be challenging. Nonetheless, unsecured SB and dynamometer methods share only slight and clinically unimportant differences that can provide similar group mean values for use in research along with the calculation of the CS.

Position of scapula and clavicle in acute acromioclavicular joint dislocations: depressed scapula or elevated distal clavicle?

Background

Increased coracoclavicular distance due to acute acromioclavicular joint (ACJ) instability is often described as a pseudoelevation of the clavicle due to inferior hanging of the scapula, while the distal clavicle remains in its position. The aim of this study was to analyze whether the elevation of the distal clavicle, depression of the scapula, or both are associated with vertical instability and to evaluate the impact of weighted stress radiographs on the clavicle and scapular position in acute ACJ instabilities.

Methods

The cohort consisted of 505 patients (f = 52, m = 453; mean age 46 years) which presented to our emergency department or outpatient clinic and treated in our institution from 2006 to 2019 displaying an acute ACJ injury. The panorama views that displayed at least two vertebraes with their spinous processes were retrospectively evaluated. Two raters assessed the panorama views twice regarding the clavicular and coracoidal angle of both sides in relation to the cervicothoracal spine and the difference in height of both clavicles and coracoids.

Results

In our cohort, five types of displacement were distinguished: type A, only clavicle is elevated (N = 46); B, only scapula depressed (N = 36); C, the clavicle elevated and the scapula depressed (N = 67); D, both depressed (N = 133); and E, both elevated (N = 223). 123 patients had non-weighted radiographs and 353 patients stress views with 10 kg of axial load, whereas 29 patients had both radiological modalities. Among these 29 patients, a significant increase in coracoclavicular distance difference, clavicle, and scapula height (P < .05, respectively) was observed, when non-weighted radiographs were compared with weighted. A total of 13 shifts could be observed during the Rockwood type comparison of non-weighted radiographs with the weighted: six from Rockwood type II to III, two from type III to V, and five from type V to type III.

Conclusion

Acute injury to the ACJ does not exclusively lead to a depression of the scapula or an elevated distal clavicle but rather leads to various vertical displacement combinations, however mostly to the elevation of both structures possibly due to muscle spasm and pain. Comparing both radiological modalities of the same patients, the routine use of weighted views should be questioned, since often a shift of Rockwood stage can be observed might lead to on the one hand inadequate conservative treatment for underestimated injuries however on the other hand unnecessary surgery for overestimated dislocations.

Clavicular Tunnel Widening After Acromioclavicular Stabilization Shows Implant-Dependent Correlation With Postoperative Loss of Reduction

PURPOSE

To radiographically describe, quantify, and compare clavicular tunnel widening (cTW) of 2 different types of stabilization devices and investigate a possible correlation between cTW and loss of reduction.

METHODS

In a retrospective analysis of single-center registry data, we compared patients who were treated for an acute AC dislocation (Rockwood types III to V) with either the AC Dog Bone (DB) or low-profile AC (LP) repair systems. On 6-week and 6-month postoperative radiographs, we measured clavicle height and tunnel diameter. We calculated the button/clavicle filling (B/C) ratio to quantify how much of the clavicular tunnel height is covered by the low-profile inlet. The association between B/C ratio and the extent of cTW was defined, and we also compared cTW between treatment groups. Reduction of the AC joint was graded as either stable, partially dislocated or dislocated depending on the AC ratio. A 2-sample t-test was used for comparing cTW progression between the 2 groups. For continuous variables between more than 2 groups, the Kruskal-Wallis test was used.

RESULTS

Of 65 eligible patients, there were 37 and 28 included in the DB and LP groups, respectively. Overall, cTW was conically shaped with transclavicular widening noted in the DB group and cTW developing strictly inferior to the button in the LP group. For both implants, mean maximal cTW was 7.1 mm and located at the inferior cortex; the B/C ratio was not associated with increased inferior cTW (r = -0.23, P = .248). Only LP patients with complete loss of reduction had significantly increased cTW (P = .049).

CONCLUSIONS

Conical-shaped cTW is a common implant-independent phenomenon after AC stabilization using suture-button devices. It occurs only at the suture-bone interface and is less excessive for the LP implant. There is an association between increased cTW and loss of reduction specific to the LP implant only.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Primary Stability and Bone Contact Loading Evaluation of Suture and Screw based Coracoid Graft Fixation for Anterior Glenoid Bone Loss

BACKGROUND

Reconstruction techniques for anterior glenoid bone loss have seen a trend from screws to suture-based fixations. However, comparative biomechanical data, including primary fixation and glenoid-graft contact pressure mapping, are limited.

HYPOTHESIS

Suture-based bone block cerclage (BBC) and suspensory suture button (SB) techniques provide similar primary fixation and cyclic stability to double-screw fixation but with higher contact loading at the bony interface.

STUDY DESIGN

Controlled laboratory study.

METHODS

In total, 60 cadaveric scapulae were prepared to simulate anterior glenoid bone loss with coracoid autograft reconstruction. Graft fixation was performed with 3 different techniques: (1) an interconnected all-suture BBC, (2) 2 SB suspensions, and (3) 2 screws. Initial compression was analyzed during primary fixation. Cyclic peak loading with 50 N and 100 N over 250 cycles at 1 Hz was performed with a constant valley load of 25 N. Optical recording and pressure foils allowed for spatial bone block tracking and contact pressure mapping at the glenoid-graft interface. Load-to-failure testing was performed at a rate of 1.5 mm/s with ultimate load and stiffness measured.

RESULTS

Initial graft compression was higher with screw fixation (141 ± 5 N) compared with suture-based fixations (P < .001), with BBC fixation providing significantly higher compression than SB fixation (116 ± 7 N vs. 91 ± 5 N; P < .001). Spatial bone block migration and ultimate failure load were similar between the BBC and screw groups. The SB group showed significantly increased bone block translation (3.1 ± 1.0 mm; P≤ .014) and rotation (2.5°± 1.4°; P≤ .025) and significantly lower ultimate failure load (180 ± 53 N) compared with the BBC (P = .046) and screw (P = .002) groups. Both suture-based fixations provided significantly increased graft-glenoid contact loading with higher pressure amplitudes (P≤ .032) and contact pressure after cyclic loading (+13%; SB: P = .007; BBC: P = .004) compared with screw fixation.

CONCLUSION

Both SB and interconnected cerclage fixation improved dynamic contact loading compared with screw fixation in a biomechanical glenoid bone loss model. Cerclage fixation was biomechanically comparable with screw fixation but with a greater variability. SB fixation showed significantly lower primary fixation strength and greater bone block rotation and migration.

CLINICAL RELEVANCE

Suture-based bone block fixations improved graft-glenoid contact loading, but the overall clinical consequence on healing remains unclear.

Prospective Multicenter Randomized Controlled Trial of Surgical Versus Nonsurgical Treatment for Acute Rockwood Type 3 Acromioclavicular Injury

Background

Evidence for the superiority of surgical versus nonsurgical treatment of Rockwood type 3 acromioclavicular joint (ACJ) dislocation is still lacking.

Hypothesis

It was hypothesized that surgical treatment will outperform nonsurgical treatment.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

A prospective randomized trial involving 4 study centers was performed from January 1, 2011, to March 31, 2016. A total of 85 patients with acute Rockwood type 3 ACJ dislocations were allocated randomly to receive either nonsurgical or surgical treatment. A total of 70 patients were treated as allocated, and 8 patients made an early crossover from nonsurgical to surgical treatment, leaving 47 patients treated surgically and 31 patients nonsurgically. All patients were followed up longitudinally, including clinical evaluation using the Constant score and standardized radiographic evaluation, with final follow-up after 2 years.

Results

At no follow-up time point was there a significant difference in Constant score between the surgically and nonsurgically treated patients. Radiographic analysis showed not only an inferior coracoclavicular distance at all follow-up points for surgical treatment but also a higher incidence of posttraumatic osteoarthritis and heterotopic ossifications, without any negative clinical correlation. With regard to complications, 1 patient (3%) in the nonsurgical group underwent secondary surgical ACJ stabilization. The revision rate after surgical treatment was 17% (P < .001). Neither primary horizontal instability nor younger age were associated with inferior clinical outcomes after nonsurgical treatment.

Conclusion

Surgical treatment of ACJ Rockwood type 3 injuries did not lead to superior functional outcomes. Neither younger age nor horizontal instability were associated with inferior outcomes after nonsurgical treatment. Surgical treatment led to a slower recovery and to higher complication and revision rates.

Registration

ISRCTN registry (study ID: ISRCTN92265154).

[Treatment strategies for traumatic anterior shoulder dislocation]

Anterior glenohumeral instability is the most frequent type of shoulder instability. This is often associated with labral and osseous lesions leading to recurrent instability. A detailed medical history, a physical examination and targeted diagnostic imaging are necessary to assess possible pathological soft tissue alterations as well as bony lesions of the humeral head and the glenoid bone. Early surgical treatment has been shown to reduce the risk of recurrence, especially in young active athletes, and can avoid secondary damage. Shoulder dislocations in older patients also require a detailed assessment and selection of treatment as persisting pain and limitation of movement can occur due to rotator cuff lesions and nerve injuries. The purpose of this article is to provide an overview of the currently available evidence and results regarding diagnostic considerations and conservative vs. surgical treatment and time to return to sport after treatment of a primary anterior shoulder dislocation.

[Minimally Invasive Techniques for the Treatment of Acute and Chronic Acromioclavicular Joint Instabilities]

Acromioclavicular joint instabilities are one of the most common injuries of the shoulder girdle. Diagnostic measures include the vertical and horizontal components of instability. The main goals of treatment include pain reduction, joint stabilization, and return to physical activity. For operative treatment, there are numerous techniques available. Recently, minimally-invasive techniques were developed and showed equal results as with open approach. These procedures facilitate simultaneous treatment of concomitant shoulder lesions and reduce soft tissue trauma as well as the risk of infection. This article presents an overview of such minimally-invasive techniques for both acute and chronic instabilities. Both techniques address the aspect of horizontal instability, which was found to compromise clinical results. For an acute injury, we describe the use of a low-profile button system combined with an additional acromioclavicular cerclage. In the chronic setting with a bidirectional (vertical and horizontal) instability, a free tendon graft combined with a single TightRope augmentation is recommended.

Biceps Smash Technique: Biceps Tendon Autograft Augmentation for Arthroscopic Rotator Cuff Reconstruction

The proportion of postoperative retears after arthroscopic rotator cuff reconstruction remains constant despite advancement of suture techniques and improved anchor implants. The commonly degenerative nature of rotator cuff tears can carry the risk of compromised tissue. Several techniques have been developed to biologically enhance rotator cuff repair, and a considerable number of autologous, allogeneic, and xenogenous augmentation methods have been described. This article introduces the biceps smash technique, an arthroscopic augmentation procedure for posterosuperior rotator cuff reconstruction using an autograft patch of the long head of the biceps tendon.

In-vivo analysis of the Circles Measurement supports its use in evaluating acromioclavicular joint dislocations

BACKGROUND

Classification and treatment of acromioclavicular joint (ACJ) dislocations according to the Rockwood classification is controversial. The "Circles Measurement" on Alexander views was proposed to enable a clear assessment of displacement in ACJ dislocations. However, the method and its ABC classification were introduced on a sawbone model based on exemplary Rockwood scenarios without soft tissue. This is the first in-vivo study to investigate the "Circles Measurement". We aimed at comparing this new measuring method to the Rockwood classification and the previously described semi-quantitative degree of dynamic horizontal translation (DHT).

METHODS

100 consecutive patients (87 male, 13 female) with acute ACJ dislocations between 2017 and 2020 were included retrospectively. Mean age was 41 years (range, 18-71). ACJ dislocations on Panorama stress views were classified according to Rockwood (Type II=8; IIIA=9; IIIB=24; IV=7; V=52). On Alexander views, where the affected arm is rested on the contralateral shoulder, the "circles measurement" and the semi-quantitative degree of DHT (none: n=6; partial: n=15; complete: n=79) were assessed. Convergent and discriminant validity of the "Circles Measurement" (including its ABC classification according to displacement) with the coracoclavicular (CC) distance and Rockwood types as well as the semi-quantitative degree of DHT were tested.

RESULTS

The "Circles Measurement" showed a strong correlation with the CC distance according to Rockwood (r = 0.66; p < 0.001) and differentiated between Rockwood types according to the ABC classification, including types IIIA and IIIB. The "Circles Measurement" correlated with the semi-quantitative method for assessing DHT (r = 0.61; p < 0.001). Measurement values were smaller for cases without DHT than for cases with partial DHT (p = 0.008). Cases with a complete DHT had respectively larger measurement values (p < 0.001).

CONCLUSION

In this first in-vivo study, the "Circles Measurement" allowed a differentiation between Rockwood types according to the ABC classification in acute ACJ dislocations with a single measurement and correlated with the semi-quantitative degree of DHT. Based on these validations of the "Circles Measurement", its use for evaluating ACJ dislocations is recommended.

Stress shielding following stemless anatomic total shoulder arthroplasty

Background

Finite element analysis has suggested that stemless implants may theoretically decrease stress shielding. The purpose of this study was to assess the radiographic proximal humeral bone adaptations seen following stemless anatomic total shoulder arthroplasty.

Methods

A retrospective review of 152 prospectively followed stemless total shoulder arthroplasty utilizing a single implant design was performed. Anteroposterior and lateral radiographs were reviewed at standard time points. Stress shielding was graded as mild, moderate, and severe. The effect of stress shielding on clinical and functional outcomes was assessed. Also, the influence of subscapularis management on the occurrence of stress shielding was determined.

Results

At 2 years postoperatively, stress shielding was noted in 61 (41%) shoulders. A total of 11 (7%) shoulders demonstrated severe stress shielding with 6 occurring along the medial calcar. There was one instance of greater tuberosity resorption. At the final follow-up, no humeral implants were radiographically loose or migrated. There was no statistically significant difference in clinical and functional outcomes between shoulders with and without stress shielding. Patients undergoing a lesser tuberosity osteotomy had lower rates of stress shielding, which was statistically significant (p = 0.021).

Discussion

Stress shielding does occur at higher rates than anticipated following stemless total shoulder arthroplasty, but was not associated with implant migration or failure at 2 years follow-up.

Level of evidence

IV, Case series.

Subpectoral biceps tenodesis with BicepsButton fixation in the young population: which technique works best?

BACKGROUND

Injuries of the long head of the biceps (LHB) tendon are a prevalent source of anterior shoulder pain and are commonly treated with tenodesis. Not only a stable fixation of the LHB but also anatomic restoration of the length-tension relationship plays a central role in providing satisfactory functional and cosmetic outcomes, especially in young patients. We report the clinical outcomes of 2 different subpectoral tenodesis techniques using unicortical button fixation.

METHODS

Patients aged ≤ 50 years who were treated between April 2015 and January 2020 with 1 of the 2 following subpectoral tenodesis techniques were retrospectively selected and enrolled to undergo a follow-up examination at least 2 years after surgery: subpectoral in situ tenodesis followed by resection of the intra-articular portion leaving a residual tendon stump in the bicipital groove (group I) vs. tenotomy followed by resection of the stump and subpectoral tenodesis (group II). Patients who underwent concomitant rotator cuff repair, subsequent shoulder surgery, or contralateral biceps surgery were excluded. Clinical outcomes were evaluated using the LHB score and the Constant-Murley Score (CMS), as well as measurements of isometric elbow flexion and forearm supination strength. Sonographic evaluation included assessment of the integrity of the LHB and tenodesis, examination for signs of inflammation within the sulcus or around the tendon, and measurements of the distalization of the myotendinous junction of the LHB compared with the nonoperative side.

RESULTS

A total of 34 patients comprising group I (24 men; mean age at time of surgery, 40.3 years; mean follow-up period, 57.2 months) and 24 patients comprising group II (19 men; mean age at time of surgery, 39.8 years; mean follow-up period, 51.9 months) were evaluated. The total CMS, as well as the scores for each CMS subcategory, did not reveal significant differences between the groups. The overall LHB score was on average 10 points higher in group I (mean, 94 points) than in group II (mean, 84 points) (P = .016). Regarding the LHB score subcategories, group I showed significantly better results for patient-dependent cosmesis (mean, 15 points in group I vs. 12 points in group II; P = .005) and examiner-dependent cosmesis (mean, 14 points in group I vs. 10 points in group II; P = .001). This finding was substantiated by a significantly higher distalization of the myotendinous junction in group II (mean, 3.0 cm in group I vs. 3.8 cm in group II; P = .030).

CONCLUSION

This study shows that subpectoral in situ tenodesis of the LHB followed by arthroscopic resection of the intra-articular portion provides higher LHB scores and better cosmetic outcomes compared with proximal intra-articular tenotomy followed by subpectoral tenodesis.

Surgical treatment of a symptomatic os acromiale by arthroscopy-assisted double-button fixation: a case report

CASE

We present the case of a symptomatic os acromiale in a 51-year-old female patient. Arthroscopy-assisted treatment was performed using a double-button fixation system and additional suture cerclage. The patient presented with complete radiographic bone union, pain relief, improved range of motion and did not require hardware removal at the 12-month follow-up.

CONCLUSION

The achievement of persistent consolidation between the two fragmented bone surfaces, without further need for hardware removal and improved clinical outcome, suggests that our minimally invasive technique is appropriate for this specific indication. To our knowledge, this technique has not been described in the literature yet.

Midterm results of stemless impaction shoulder arthroplasty for primary osteoarthritis: a prospective, multicenter study

Background

Stemless shoulder arthroplasty using 4 open-fin press-fit anchors has been showing promising short-term clinical and radiographic results for patients' primary osteoarthritis. This prospective, multicenter study presents 5-year postoperative clinical and radiological outcomes of a stemless shoulder arthroplasty for primary osteoarthritis.

Methods

Between November 2012 and December 2015, 100 patients were treated for primary osteoarthritis with the Sidus stem-free shoulder system at 7 European centers. Clinical assessment included the Constant-Murley Score, American Shoulder and Elbow Standardized Shoulder Assessment Form score, Subjective Shoulder Value, and range of motion. True anteroposterior, axial and lateral radiographs were reviewed for osteolysis, glenoid and humerus loosening, heterotopic ossification, radiolucent lines, component migration and humeral bone resorption. In addition to a Kaplan-Meier survival analysis, a comparative analysis between total shoulder arthroplasty and hemiarthroplasty was performed.

Results

Seventy-one patients (36 females) with a mean age of 63.8 years (range: 47-79 years) were available for the 5-year clinical and radiographic follow-up (range: 52-79 months). There was a significant increase (P < .0001) in all outcome scores compared to baseline values. Patients with total shoulder arthroplasty (n = 48) achieved significantly better functional outcome than patients with shoulder hemiarthroplasty (n = 23) with regard to the absolute and relative Constant-Murley Score, American Shoulder and Elbow Standardized Shoulder Assessment Form score, and Subjective Shoulder Value as well as greater abduction strength and range of motion in forward elevation and external rotation (P ≤ .004). There were no cases of osteolysis or humeral loosening. There were some cases of heterotopic ossification (1.4%), radiolucency around the humerus (1.4%) or glenoid (25%), glenoid migration (2.1%), inferior osteophytes (1.4%) or humerus bone resorption (9.9%). The 5-year survival was 94%.

Conclusion

Patients treated with the Sidus stem-free shoulder system for primary osteoarthritis continue to achieve good clinical and radiographic results without any signs of aseptic humeral implant loosening at 5 years postsurgery.

Arthroscopic Anterior Glenoid Bone Grafting for Shoulder Instability Using an Interconnected Suture Anchor Technique

Anterior bone grafting is an established and frequently used treatment option for recurrent anterior shoulder instability in combination with significant glenoid bone loss. Several open and arthroscopic fixation techniques have been presented to this field in recent years. Some of these techniques are associated with different peri- and postoperative problems or complications. Therefore, the technical gold standard for anterior bone grafting has not been determined, resulting in an ongoing evolvement of bone-grafting techniques. Arthroscopic, metal-free fixation procedures were introduced to the field bone grafting to overcome previous problems of screw fixation. These metal-free techniques frequently include surgically challenging transglenoidal drilling and are placing anterior soft tissues and neurovascular structures at risk. We therefore present an arthroscopic anterior, PEEK (polyether ether ketone)-anchor based, interconnecting bone-grafting technique bypassing previous challenges to restore the anterior glenoid bone stock with adequate positioning and fixation of the bone graft.

[Anatomical fracture endoprosthesis-who and how?]

The aim of this review article is to present the indications for an anatomical fracture prosthesis, mostly as a shoulder hemiprosthesis (SHEP) and its value in comparison to other procedures. The healing of the tuberosities in the anatomical position and an intact rotator cuff are particularly important for the successful implantation of a SHEP after proximal humeral fractures. For older patients (> 70 years), the use of reverse shoulder arthroplasty achieves more reliable results and is associated with a lower revision rate. The indications for implantation of a SHEP in non-reconstructible proximal humeral fractures, usually with a head split, should be carefully considered and can be used in cases with well-preserved large tuberosities and in younger patients. Complications of SHEP, such as secondary rotator cuff insufficiency, tuberosity dislocation or resorption and secondary glenoid wear, can be treated using a conversion or a change to reverse shoulder arthroplasty.

[Treatment of subscapularis tendon lesions]

The further development of minimally invasive techniques in recent years, enables adequate intraoperative visualization, mobilization and stable reconstruction even of larger subscapularis tears resulting in good to excellent clinical and structural results. Chronic tears of the subscapularis tendon with high grade muscle atrophy and advanced fatty infiltration can be treated with a muscle tendon transfer (e.g. pectoralis major or latissimus dorsi transfer). If pseudoparalysis and/or signs of anterosuperior decentration of the humeral head or defect arthropathy are present, in most cases a reverse shoulder arthroplasty represents the only surgical option.

Bilateral glenohumeral internal rotation deficit (GIRD) in elite gymnasts

INTRODUCTION

The "Glenohumeral Internal Rotation Deficit (GIRD)" is known as the difference in internal rotation range of motion (IRRM) between the dominant and non-dominant shoulder of overhead athletes as a result of asymmetric loading. As in contrast loading pattern in gymnastics are quite symmetric and structural changes often occur bilaterally, the question arises if GIRD might develop bilaterally in gymnasts as one source of common bilateral shoulder pathologies and to search for underlying structural adaptations.

MATERIALS AND METHODS

A group of 35 elite gymnasts (8-24 years) were recruited from a local Olympic Training Centre and compared to a paired cohort of 28 non-overhead athletes. Clinical examinations, digital range of motion (ROM)-measurement, ultrasonographic humeral torsion measurement, and standardized MRI scans of both shoulders were obtained and examined for structural pathologies, cross-sectional areas (CSA) of the rotator cuff muscles and capsular thickness.

RESULTS

ROM-measurements showed significant decrease in IRRM in the gymnasts groups by age, with IRRM of 48.6° (SD: 8.4°, CI 95%: 43.0-54.3°) at age group 1 (8-10 years) and IRRM of 10° (SD: 11.4°; CI 95%: 0-22.0°) at age group 4 (18-26 years), that was statistically significant for the entire cohort (p = 0.017) compared to the controls. CSA were not significantly different between the cohorts, while there was a slightly increased humeral retrotorsion in the gymnasts as well as a statistically significant posterior capsular thickening.

CONCLUSION

A new bilateral form of GIRD was identified in higher age groups of youth and senior elite gymnasts enrolled in this study. Despite to former definition of GIRD there was no compensatory increase in external rotation range of motion (ERRM) but an association with posterior capsular thickening, while there was no periscapular muscle hypertrophy. Humeral retrotorsion was also slightly increased in the gymnasts group.

[Anatomy and diagnostics of subscapularis tendon lesions]

Among lesions of the rotator cuff, subscapularis tendon tears are one of the less common injuries and mostly occur in combination with additional lesions of the posterosuperior rotator cuff and the long biceps tendon. If a subscapularis tendon rupture is suspected in the initial clinical testing, the primary diagnostics should include modern cross-sectional magnetic resonance imaging to assess the tendon lesion and to detect concomitant pathologies. Nevertheless, subscapularis tendon lesions are often initially overlooked and first correctly diagnosed during shoulder arthroscopy.

Reverse Shoulder Arthroplasty for Proximal Humerus Head-Split Fractures-A Retrospective Cohort Study

Head-split fractures are proximal humerus fractures (PHF) that result from fracture lines traversing the articular surface. While head-split fractures are rare, surgical treatment of these complex injuries can be extremely challenging and is associated with high rates of complications. Treatment using primary reverse shoulder arthroplasty (RSA) has been associated with moderate complication rates and reproducible clinical results. The aim of this study was to evaluate clinical and radiographic outcomes, and complication rates of RSA for head-split PHF. Twenty-six patients were evaluated based on Constant Score (CS) and range of motion of both shoulders and Subjective Shoulder Value (SSV). Radiographic analysis evaluated tuberosity healing, prosthetic loosening and scapular notching. Patients achieved good clinical results with a CS of 73.7 points and SSV of 82% after a mean follow-up of 50 months. The relative CS comparing operated versus the unaffected shoulder was 92%. Greater tuberosity healing was achieved in 61%. Patients who suffered a high-energy trauma reached a significantly greater functional outcome. Patients who suffered multifragmentation to the humeral head performed the worst. There were no cases of loosening; scapular notching was visible in two cases. The complication rate was 8%. RSA is an adequate treatment option with for head-split PHF in elderly patients.

Metal-Free Fixation for Free Bone-Block Reconstruction of Chronic Anteroinferior Shoulder Instability

Background:

Anterior shoulder instability is common and may cause a considerable effect on quality of life. For cases with glenoid bone loss, there is still a controversial discussion regarding the optimal treatment. Most of the recent methods are using metal implants to attach the needed graft to the glenoid with reported disadvantages such as metal impingement, damage to the humeral head, cartilage destruction, and premature arthritis.

Indications:

(1) Erosion-type defects with significant bone loss (>15%-20%); (2) chronic fragment-type defects if the size of the fragment is not large enough for an anatomical reconstruction; and (3) non-reconstructible, multifragmented acute fragment type of lesions.

Technique Description:

After placing the patient in a lateral decubitus position and fixing the arm in a traction devise, 3 arthroscopic entries are established: a posterior portal, an anterosuperior portal, and an anteroinferior portal. A harvested tricortical iliac crest bone graft is provided with 2 drilling holes which match the drilling holes through the glenoid. The tapes are then placed from the posterior to the anterior side of the glenoid, and then the graft is passed from the anterior to the posterior side, thus compressing the cancellous side of the bone block onto the glenoid defect. A following interconnection of the sutures creates a continuous loop. The end of the tapes was loaded into a pretied racking hitch knot system, which creates sliding knots between the 2 pair of tapes, whereon the knots can be reduced to the glenoid in a symmetrical fashion. Finally, the reconstruction of the anterosuperior labrum can be done, to cover the bone block with enough soft tissue.

Results:

First short-term results show radiographic consolidation after 3 months and an increased median glenoid estimated surface area at 12 months. The functional scores showed good outcomes, and there were no serious complications reported.

Discussion/Conclusion:

The presented arthroscopic reconstruction of the glenoid using a tricortical bone graft and high-strength fiber tapes provides a metal-free technique which results in a high primary stability of the construct and should therefore be considered when treating anterior shoulder instability with significant bone loss.

Subacromial Bursa: A Neglected Tissue Is Gaining More and More Attention in Clinical and Experimental Research

The subacromial bursa has long been demolded as friction-reducing tissue, which is often linked to shoulder pain and, therefore, partially removed during shoulder surgery. Currently, the discovery of the stem cell potential of resident bursa-derived cells shed a new light on the subacromial bursa. In the meanwhile, this neglected tissue is gaining more attention as to how it can augment the regenerative properties of adjacent tissues such as rotator cuff tendons. Specifically, the tight fibrovascular network, a high growth factor content, and the large progenitor potential of bursa-derived cells could complement the deficits that a nearby rotator cuff injury might experience due to the fact of its low endogenous regeneration potential. This review deals with the question of whether bursal inflammation is only a pain generator or could also be an initiator of healing. Furthermore, several experimental models highlight potential therapeutic targets to overcome bursal inflammation and, thus, pain. More evidence is needed to fully elucidate a direct interplay between subacromial bursa and rotator cuff tendons. Increasing attention to tendon repair will help to guide future research and answer open questions such that novel treatment strategies could harvest the subacromial bursa's potential to support healing of nearby rotator cuff injuries.

Lateralized vs. classic Grammont-style reverse shoulder arthroplasty for cuff deficiency Hamada stage 1-3: does the design make a difference?

BACKGROUND

Reverse shoulder arthroplasty (RSA) with a lateralized design is thought to improve outcomes. Our aim was to compare RSA with the classic Grammont prosthesis against a prosthesis with 135° inclination and a lateralized glenosphere for cuff-deficient shoulders.

METHODS

Patients with irreparable massive posterosuperior rotator cuff tear Hamada grade 1-3 underwent RSA and were documented prospectively up to 24 months postsurgery. Comparative RSA groups were "lateralized" (L), with 135° humeral inclination and 36+4-mm lateralized glenosphere (n = 44), and "Grammont" (G), with 155° humeral inclination and 36+2-mm eccentric glenosphere (n = 23). Range of motion including the Apley scratch test, abduction strength, Constant-Murley score (CS), and Shoulder Pain and Disability Index (SPADI) were assessed. Anteroposterior and axial radiographs were evaluated at 24 months, and additional measurements of scapular neck and glenoid anatomy, baseplate and glenosphere position, center of rotation, humeral offset, and lateralization and distalization shoulder angles were made. Linear regression and mixed models adjusted for sex differences and preoperative values were applied.

RESULTS

Overall CS and SPADI outcomes were not significantly different between groups (P ≥ .654). For group L, external rotation remained stable up to the 2-year follow-up and was higher than for group G (P = .012 ); a greater proportion of group L patients could reach the lumbar vertebra 3 (L3) (70% vs. 48% in group G) (P = .26). Group G had a higher inferior glenosphere overhang (P = .020) and center of rotation (COR) medialization (P < .001), whereas group L had higher humeral offset (P < .001) and lateralization shoulder angle (P < .001) with a trend toward higher baseplate positioning (P = .045). The rate of scapular notching was 2.9 times higher for group G than group L (P = .001).

CONCLUSION

RSA with 135° humeral inclination and a lateralized glenosphere shows similar outcome scores as the classic Grammont design but enables better preservation of external rotation and reduces the rate of scapular notching compared with the classic Grammont design in Hamada 1-3 patients with irreparable posterosuperior tears.

Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Shoulder: An Orthoregeneration Network (ON) Foundation Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the shoulder including the rotator cuff tendons, glenohumeral articular cartilage, glenoid labrum, the joint capsule, and bone. Promising and established treatment modalities include hyaluronic acid (HA); platelet-rich plasma (PRP) and platelet rich concentrates (PRC); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs alternatively termed medicinal signaling cells and frequently, misleadingly labelled "mesenchymal stem cells"); MSC harvested from adipose, umbilical, or placental sources; factors including vascular endothelial growth factors (VEGF), basic fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), transforming growth factor-beta (TGFβ), bone morphogenic protein (BMP), and matrix metalloproteinases (MMPs); prolotherapy; pulsed electromagnetic field therapy; microfracture and other marrow-stimulation techniques; biologic resurfacing using acellular dermal allografts, allograft Achilles tendons, allograft lateral menisci, fascia lata autografts, and porcine xenografts; osteochondral autograft or allograft); and autologous chondrocyte implantation (ACI). Studies involving hyaluronic acid, platelet rich plasma, and medicinal signaling cells of various origin tissues have shown mixed results to-date as isolated treatments and as surgical adjuncts. Despite varied results thus far, there is great potential for improved efficacy with refinement of current techniques and translation of burgeoning preclinical work. LEVEL OF EVIDENCE: Level V, expert opinion.

Prediction of Shoulder Stiffness After Arthroscopic Rotator Cuff Repair

BACKGROUND

Postoperative shoulder stiffness (POSS) is a prevalent adverse event after arthroscopic rotator cuff repair (ARCR) that is associated with major limitations in everyday activities and prolonged rehabilitation.

PURPOSE/HYPOTHESIS

The purpose was to develop a predictive model for determining the risk of POSS within 6 months after primary ARCR. We hypothesized that sufficient discrimination ability of such a model could be achieved using a local institutional database.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Consecutive primary ARCRs documented in a local clinical registry between 2013 and 2017 were included, and patients who experienced POSS before the final clinical 6-month follow-up were identified. A total of 29 prognostic factor candidates were considered, including patient-related factors (n = 7), disease-related factors (n = 9), rotator cuff integrity factors (n = 6), and operative details (n = 7). We used imputed data for the primary analysis, and a sensitivity analysis was conducted using complete case data. Logistic regression was applied to develop a model based on clinical relevance and statistical criteria. To avoid overfitting in the multivariable model, highly correlated predictors were not included together in any model. A final prognostic model with a maximum of 8 prognostic factors was considered. The model's predictive accuracy was assessed by the area under the receiver operating characteristic curve (AUC). Internal validation was performed using bootstrapping.

RESULTS

Of 1330 ARCR cases (N = 1330 patients), 112 (8.4%) patients had POSS. Our final model had a moderate predictive ability with an AUC of 0.67. The predicted risks of POSS ranged from 2.3% to 38.9% and were significantly higher in women; patients with partial tears, low baseline passive shoulder abduction, and lack of tendon degeneration; and when no acromioplasty was performed.

CONCLUSION

A prognostic model for POSS was developed for patients with ARCR, offering a personalized risk evaluation to support the future decision process for surgery and rehabilitation.

Minced Cartilage Procedure for One-Stage Arthroscopic Repair of Chondral Defects at the Glenohumeral Joint

Chondral defects of the glenohumeral joint are common but still remain a diagnostic and management challenge. Whereas arthroplasty is a reasonable treatment option in the elderly and low-demand population, joint preservation should be aimed for the remaining patients. For larger defects the current gold standard of treatment is autologous chondrocyte implantation. However, disadvantages such as high cost, the restriction in availability of specialized laboratories, and the 2-stage surgical design need to be accounted for if choosing this option. Showing first good clinical results for the knee joint, minced cartilage implantation is moreover a cost-effective procedure bringing autologous cartilage chips harvested from the defect walls and bringing them into the area of damage in a single-step open or arthroscopic approach. We describe an arthroscopic strategy of this technique to treat chondral defects at the glenohumeral joint.

Evaluation and Management of Glenohumeral Instability With Associated Bone Loss: An Expert Consensus Statement Using the Modified Delphi Technique

PURPOSE

To establish an international expert consensus, using the modified Delphi technique, on the evaluation and management of glenohumeral instability with associated bone loss.

METHODS

A working group of 6 individuals generated a list of statements related to history and physical examination, imaging and specialized diagnostic tests, bone loss quantification and classification, treatment outcomes and complications, and rehabilitation for the management of glenohumeral instability associated with bone loss to form the basis of an initial survey for rating by a group of experts. The expert group (composed of 22 high-volume glenohumeral instability experts) was surveyed on 3 occasions to establish a consensus on the statements. Items with over 70% agreement and less than 10% disagreement achieved consensus.

RESULTS

After a total of 3 rounds, 31 statements achieved consensus. Eighty-six percent of the experts agreed that a history of multiple dislocations and failed soft-tissue surgery should raise suspicion about the possibility of an associated bone deficit. Ninety-five percent of the experts agreed that 3-dimensional (3D) computed tomography (CT) is the most accurate diagnostic method to evaluate and quantify bone loss. Eighty-six percent of the experts agreed that any of the available methods to measure glenoid bone deficiency is adequate; however, 91% of the experts thought that an en face view of the glenoid using 3D CT provides the most accurate method. Ninety-five percent of the experts agreed that Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Ninety percent of the experts agreed that in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed and any of the available options is valid. There was no consensus among experts on how Hill-Sachs injuries should be managed or on how postoperative rehabilitation should be carried out.

CONCLUSIONS

The essential statements on which the experts reached consensus included the following: A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit. Three-dimensional CT is the most accurate diagnostic method to evaluate and quantify bone loss. Although any of the available methods to measure glenoid bone deficiency is adequate, an en face view of the glenoid using 3D CT provides the most accurate method. Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Finally, in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed.

LEVEL OF EVIDENCE

Level V, consensus statement.

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study

INTRODUCTION

In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient's perspective.

METHODS AND ANALYSIS

A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated.

ETHICS AND DISSEMINATION

This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study.

TRIAL REGISTRATION NUMBER

NCT04321005.

PROTOCOL VERSION

Version 2 (13 December 2019).

The ligamentous injury pattern in acute acromioclavicular dislocations and its impact on clinical and radiographic parameters

BACKGROUND

Acromioclavicular (AC) joint dislocations are classified according to the Rockwood (RW) classification, which is based on radiographic findings. Several authors have suggested magnetic resonance imaging (MRI) for visualization of the capsuloligamentous structures stabilizing the AC joint. The aim of this study was to describe the ligamentous injury pattern in acute AC joint dislocations by MRI and investigate associations with clinical and radiographic parameters.

METHODS

This prospective study included 45 consecutive patients (5 women and 40 men; mean age, 33.6 years [range, 19-65 years]) with an acute AC joint separation (RW type I in 5, RW type II in 8, RW type III in 18, and RW type V in 14). All patients underwent physical examination of both shoulders, and clinical scores (Subjective Shoulder Value, Constant score, Taft score, and Acromioclavicular Joint Instability Score) were used to evaluate the AC joint clinically as well as radiographically. Post-traumatic radiography included bilateral anteroposterior stress views and bilateral Alexander views to evaluate vertical instability and dynamic posterior translation. MRI was performed for assessment of the AC and coracoclavicular (CC) ligaments and the delto-trapezoidal fascia.

RESULTS

Radiographic and MRI classifications were concordant in 23 of 45 patients (51%), whereas 22 injuries (49%) were misjudged; of these, 6 (13%) were reclassified to a more severe type and 16 (36%), to a less severe type. The integrity of the CC ligaments was found to have a clinical impact on vertical as well as horizontal translation determined by radiographs and on clinical parameters. Among patients with an MRI-confirmed complete disruption of the CC ligaments, 68% showed a radiographic CC difference > 30% and 75% showed complete dynamic posterior translation. Inferior clinical parameters were noted in these patients as compared with patients with intact CC ligaments or partial disruption of the CC ligaments (Constant score of 67 points vs. 49 points [P < .05] and Acromioclavicular Joint Instability Score of 51 points vs. 23 points [P < .05]). The inter-rater and intra-rater reliability for assessment of the ligamentous injury pattern by MRI was fair to substantial (r = 0.37-0.66).

CONCLUSION

The integrity of the CC and AC ligaments found on MRI has an impact on clinical and radiographic parameters.

Immobilization in External Rotation and Abduction Versus Arthroscopic Stabilization After First-Time Anterior Shoulder Dislocation: A Multicenter Randomized Controlled Trial

BACKGROUND

Treatment of first-time shoulder dislocation (FSD) is a topic of debate. After high rates of recurrent instability after nonoperative management were reported in the literature, primary repair of FSD significantly increased. At the same time, new concepts were proposed that had promising results for immobilization in external rotation (ER) and abduction (ABD).

PURPOSE

The aim of this study was to evaluate the recurrence rates (primary outcome) and clinical outcomes (secondary outcome parameters) of immobilization in ER+ABD versus arthroscopic primary stabilization after FSD.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In a multicenter randomized controlled trial, patients with FSD were randomized to either treatment with immobilization in 60° of ER plus 30° of ABD (group 1) or surgical treatment with arthroscopic Bankart repair (group 2). Clinical evaluation was performed 1, 3, and 6 weeks as well as 6, 12, and 24 months postoperatively or after reduction, including range of motion, instability testing, subjective shoulder value, Constant-Murley score, Rowe score, and Western Ontario Shoulder Instability Index. Recurrent instability events were prospectively recorded.

RESULTS

Between 2011 and 2017, a total of 112 patients were included in this study. Of these, 60 patients were allocated to group 1 and 52 to group 2. At the 24-month follow-up, 91 patients (81.3%) were available for clinical examination. The recurrence rate was 19.1% in group 1 and 2.3% in group 2 (P = .016). No significant differences were found between groups regarding clinical shoulder scores (P > .05). Due to noncompliance with the immobilization treatment protocol, 4 patients (6.7%) were excluded.

CONCLUSION

Immobilization in ER+ABD versus primary arthroscopic shoulder stabilization for the treatment of FSD showed no differences in clinical shoulder scores. However, recurrent instability was significantly higher after nonoperative treatment.

Arthroscopic iliac crest bone grafting in recurrent anterior shoulder instability: minimum 5-year clinical and radiologic follow-up

PURPOSE

To investigate the clinical and radiologic mid- to long-term results of arthroscopic iliac crest bone-grafting for anatomic glenoid reconstruction in patients with recurrent anterior shoulder instability.

METHODS

Seventeen patients were evaluated after a minimum follow-up of 5 years. Clinical [range of motion, subscapularis tests, apprehension sign, Subjective Shoulder Value (SSV), Constant Score (CS), Rowe Score (RS), Walch Duplay Score (WD), Western Ontario Shoulder Instability Index (WOSI)], and radiologic [X-ray (true a.p., Bernageau and axillary views) and computed tomography (CT)] outcome parameters were assessed.

RESULTS

Fourteen patients [mean age 31.1 (range 18-50) years] were available after a follow-up period of 78.7 (range 60-110) months. The SSV averaged 87 (range 65-100) %, CS 94 (range 83-100) points, RS 89 (range 30-100) points, WD 87 (range 25-100) points, and WOSI 70 (range 47-87) %. The apprehension sign was positive in two patients (14%). One patient required an arthroscopic capsular plication due to a persisting feeling of instability, while the second patient experienced recurrent dislocations after a trauma, but refused revision surgery. CT imaging showed a significant increase of the glenoid index from preoperative 0.8 ± 0.04 (range 0.7-0.8) to 1.0 ± 0.11 (range 0.8-1.2) at the final follow-up (p < 0.01).

CONCLUSION

Arthroscopic reconstruction of anteroinferior glenoid defects using an autologous iliac crest bone-grafting technique yields satisfying clinical and radiologic results after a mid- to long-term follow-up period. Postoperative re-dislocation was experienced in one (7.1%) of the patients due to a trauma and an anatomic reconstruction of the pear-shaped glenoid configuration was observed.

LEVEL OF EVIDENCE

IV.

The Schulthess local Shoulder Arthroplasty Registry (SAR): cohort profile

PURPOSE

Clinical registries are essential for evaluation of surgical outcomes. The Schulthess Shoulder Arthroplasty Registry (SAR) was established in 2006 to evaluate safety, function, quality-of-life and patient satisfaction in patients undergoing shoulder arthroplasty.

PARTICIPANTS

Adult patients undergoing anatomic or reverse shoulder joint replacement at the Schulthess Klinik, a high-volume, leading orthopaedic surgery centre in Zürich, Switzerland.

FINDINGS TO DATE

Between March 2006 and December 2019, the registry covered 98% of eligible operations. Overall, 2332 patients were enrolled with a total of 2796 operations and 11 147 person-years of follow-up. Mean age at baseline was 71 (range: 20-95), 65% were women. Most common indication was rotator cuff tears with osteoarthritis (42%) and the mean preoperative Constant Score was 31 (±15). The most frequent arthroplasty type was reverse, increasing from 61% in 2006-2010 to 86% in 2015-2019. Functional recovery peaked at 12-month postoperatively and did not show a clinically relevant deterioration during the first ten follow-up years. Since its establishment, the registry was used to address multiple pertinent clinical and methodological questions. Primary focus was on comparing different implant configurations (eg, glenosphere diameter) and surgical techniques (eg, latissimus dorsi transfer) to maximise functional recovery. Additionally, the cohort contributed to the determination of the clinical relevance and validity of radiological monitoring of cortical bone resorption and scapular notching. Finally, SAR data helped to demonstrate that returning to sports was among key patient expectations after reverse shoulder arthroplasty.

FUTURE PLANS

As first patients are approaching the 15 years follow-up landmark, the registry will continue providing essential data on long-term functional outcomes, implant stability, revision rates and aetiologies as well as patient satisfaction and quality-of-life. In addition to research and quality-control, the cohort data will be brought back to the patients by bolstering real-time clinical decision support.

Arthroscopic Knotless-Anchor Rotator Cuff Repair

The most common type of rotator cuff lesion is a tear of the supraspinatus tendon, with arthroscopic rotator cuff repair representing an established treatment option^1-3. Several double-row techniques have been described to achieve complete coverage of the rotator cuff footprint. Among these is the bridging, double-row, transosseous-equivalent rotator cuff repair, which has become one of the most popular techniques for its maximized contact area and initial fixation strength^4-9. However, medial cuff failure is a common complication following this procedure^9-14. To reduce medial strangulation and overall surgical time, all-knotless anchor repair has been introduced as an alternative technique¹⁵. The arthroscopic knotless, bridging, double-row, transosseous-equivalent technique is performed with the patient in the beach-chair position via lateral operative and viewing portals. A medial row of suture anchors is placed in the usual fashion. The tendon is then perforated twice per anchor with use of a suture-passer device, after which the suture limbs are bridged over the tendon and fixed in a lateral row of anchors. Excellent functional outcomes as well as satisfaction in >90% of patients have been reported with the supraspinatus knotted double-row, bridging, transosseous-equivalent repair^{4,9,11,13,16-19}. No significant differences have been reported for clinical results and tendon integrity on magnetic resonance imaging when comparing knot-tying and knotless double-row transosseous-equivalent rotator cuff repair; however, the rate of medial cuff failure was lower among knotless procedures^{1,12,16,17,20-25}. The major steps of the procedure, which are demonstrated in this video article, include (1) diagnostic arthroscopy; (2) supraspinatus tear visualization and debridement; (3) decortication of the footprint on the greater tuberosity; (4) placement of the medial row of anchors loaded with nonabsorbable suture tape; (5) separate suture passage of each limb, perforating the tendon with use of a suture passer; (6) fixation of the tape in the lateral row of anchors, creating a bridging configuration; and (7) anterolateral acromioplasty with use of an arthroscopic burr. Complications are rare following this procedure. As postoperative rehabilitation is essential for tendon healing, the operative arm should be placed in an abduction brace for 6 weeks, with only passive mobilization.