John M. Tokish

Clinical outcomes of suprascapular nerve decompression: a systematic review

BACKGROUNDnSuprascapular neuropathy is an uncommon clinical diagnosis. Although there have been a number of case series reporting on this pathologic process, to date there has been no systematic review of these studies. This study aimed to synthesize the literature on suprascapular neuropathy with regard to clinical outcomes. The secondary objective was to detail the diagnosis and treatment of suprascapular neuropathy and any associated complications.nnnMETHODSnA systematic review was performed to identify studies that reported the results or clinical outcomes of suprascapular nerve decompression. The searches were performed using MEDLINE through PubMed and Cochrane Database of Systematic Reviews.nnnRESULTSnTwenty-one studies comprising 275 patients and 276 shoulders met inclusion criteria. The mean age was 41.9 years, and mean follow-up was 32.5 months. The most common symptom was deep, posterior shoulder pain (97.8%), with a mean duration of symptoms before decompression of 19.0 months; 94% of patients underwent electrodiagnostic testing before decompression, and 85% of patients had results consistent with suprascapular neuropathy. The most common outcome reported was the visual analog scale score, followed by the Constant-Murley score. The mean postoperative Constant-Murley score obtained was 89% of ideal maximum. Ninety-two percent of athletes were able to return to sport. Only 2 (0.74%) complications were reported in the included studies.nnnCONCLUSIONSnSurgical decompression in the setting of suprascapular neuropathy leads to satisfactory outcomes as evidenced by the patient-reported outcomes and return to sport rate. Furthermore, the rate of complications appears to be low.

Outcomes for subscapularis management techniques in shoulder arthroplasty: a systematic review

BACKGROUNDnThis systematic review aims to synthesize published data for the most common subscapularis takedown and repair to compare outcomes in the setting of shoulder arthroplasty.nnnMETHODSnSearches of MEDLINE and Cochrane Library databases identified studies that reported clinical or radiologic outcomes for subscapularis management in the setting of shoulder arthroplasty. Comparisons included musculotendinous integrity, subscapularis testing and strength, shoulder range of motion, and functional outcome scores.nnnRESULTSnThe 14 included studies reported considerable variability in techniques, outcomes, and musculotendinous integrity. Lesser tuberosity osteotomy (LTO) demonstrated better healing rates (93.1%) than subscapularis peel (SP; 84.1%) and midsubstance tenotomy (ST; 75.7%), although not significantly different. A statistically significant increase in fatty infiltration was found after surgery across techniques, and range of motion and strength were similar. Mean rates of normal results for belly-press and lift-off tests were uniformly better for LTO (79.1% and 80.7%) over ST (66.7% and 65.6%), although multiple studies showed poor correlation between subscapularis functional testing and musculotendinous integrity. Mean total Constant and Western Ontario Osteoarthritis of the Shoulder Index outcome scores were slightly better for LTO (77.6, 84.2) than for SP (71.8 and 82.7). Mean American Shoulder and Elbow Surgeons scores favored the ST group (80.8) over the SP (79.1) and LTO (73) groups.nnnCONCLUSIONSnThe data suggest no significant differences exist for postoperative musculotendinous integrity or clinical outcomes among the subscapularis management techniques in shoulder arthroplasty. Subscapularis healing and integrity appear to favor the lesser tuberosity takedown method. Additional randomized controlled comparisons with long-term follow-up are needed to more effectively compare these surgical approaches.

Glenoid Bone Loss in Posterior Shoulder Instability: Prevalence and Outcomes in Arthroscopic Treatment.

Background: Glenoid bone loss is a well-accepted risk factor for failure after arthroscopic stabilization of anterior glenohumeral instability. Glenoid bone loss in posterior instability has been noted relative to its existence in posterior instability surgery. Its effect on outcomes after arthroscopic stabilization has not been specifically evaluated and reported. Purpose: The purpose was to evaluate the presence of posterior glenoid bone loss in a series of patients who had undergone arthroscopic isolated stabilization of the posterior labrum. Bone loss was then correlated to return-to-duty rates, complications, and validated patient-reported outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective review was conducted at a single military treatment facility over a 4-year period (2010-2013). Patients with primary posterior instability who underwent arthroscopic isolated posterior labral repair were included. Preoperative magnetic resonance imaging was used to calculate posterior glenoid bone loss using a standardized “perfect circle” technique. Demographics, return to duty, complications, and reoperations, as well as outcomes scores including the Single Assessment Numeric Evaluation and the Western Ontario Shoulder Instability Index (WOSI) scores, were obtained. Outcomes were analyzed across all patients based on percentage of posterior glenoid bone loss. Bone loss was then categorized as below or above the subcritical threshold of 13.5% to determine if bone loss effected outcomes similar to what has been shown in anterior instability. Results: There were 43 consecutive patients with primary, isolated posterior instability, and 32 (74.4%) completed WOSI scoring. Mean follow-up was 53.7 months (range, 25-82 months) The mean posterior glenoid bone loss was 7.3% (0%-21.5%). Ten of 32 patients (31%) had no appreciable bone loss. Bone loss exceeded 13.5% in 7 of 32 patients (22%), and 2 patients (6%) exceeded 20% bone loss. Return to full duty or activity was nearly 90% overall. However, those with >13.5%, subcritical glenoid bone loss, were statistically less likely to return to full duty (relative risk = 1.8), but outcomes scores, complications, and revision rates were otherwise not different in those with no or minimal bone loss versus those with more significant amounts. Conclusion: Posterior glenoid bone loss has not previously been evaluated independently relative to patients with shoulder instability repairs. Sixty-nine percent of our patients had measurable bone loss, and 22% had greater than 13.5%, or above subcritical bone loss. While these patients were statistically less likely to return to full duty, the reoperation rate, complications, and patient-reported outcomes between groups were not different.

Distal Clavicular Osteochondral Autograft Augmentation for Glenoid Bone Loss: A Comparison of Radius of Restoration Versus Latarjet Graft:

Background: Bone loss in shoulder instability is a well-recognized cause of failure after stabilization surgery. Many approaches have been described to address glenoid bone loss, including coracoid transfer. This transfer can be technically difficult and has been associated with high complication rates. An ideal alternative to coracoid transfer would be an autologous source of fresh osteochondral graft with enough surface area to replace significant glenoid bone loss. The distal clavicle potentially provides such a graft source that is readily available and low-cost. Purpose: To evaluate distal clavicular autograft reconstruction for instability-related glenoid bone loss, specifically comparing the width of the clavicular autograft with the width of an ipsilateral coracoid graft as prepared for a Latarjet procedure. Further, we sought to compare the articular cartilage thickness of the distal clavicle graft with that of the native glenoid. Study Design: Controlled laboratory study. Methods: Twenty-seven fresh-frozen cadaver specimens were dissected, and an open distal clavicle excision was performed. The coracoid process in each specimen was prepared as has been described for a classic Latarjet coracoid transfer. In each specimen, the distal clavicle graft was compared with the coracoid graft for size and potential of glenoid articular radius of restoration. The distal clavicle graft was also compared with the native glenoid for cartilage thickness. Results: In all specimens, the distal clavicle grafts provided a greater radius of glenoid restoration than the coracoid grafts (P < .0001). On average, the clavicular graft was able to reconstruct 44% of the glenoid diameter, compared with 33% for the coracoid graft (P < .0001). The articular cartilage of the glenoid was significantly thicker (1.4 mm thicker, P < .0001) than that of the distal clavicular autograft (average ± SD, 3.5 ± 0.6 mm vs 2.1 ± 0.8 mm, respectively). When specimens with osteoarthritis were excluded, this difference decreased to 0.97 mm when compared with the clavicular cartilage (P = .0026). Conclusion: The distal clavicle autograft can restore a significantly greater glenoid bone deficit than the Latarjet procedure and has the additional benefit of restoring articular cartilage to the glenoid. The articular cartilage thickness of the distal clavicle is within 1.4 mm of that of the native glenoid. Clinical Relevance: The distal clavicular autograft may be a suitable option for reconstruction of instability-related glenoid bone loss. This graft provides a structural osteochondral autograft with a broader radius of reconstruction than that of a coracoid graft, is locally available, has minimal donor site morbidity, is anatomic, and provides articular cartilage.

Using Stress Ultrasonography to Understand the Risk of UCL Injury Among Professional Baseball Pitchers Based on Ligament Morphology and Dynamic Abnormalities

Background: Ulnar collateral ligament (UCL) injury of the elbow is a common and debilitating problem seen frequently among elite baseball pitchers. Ultrasound is a useful diagnostic tool in evaluating UCL injuries. Hypothesis: Evaluation with stress ultrasound of the elbow to measure the morphology of the UCL and the ulnohumeral joint space gapping is indicative of higher risk of UCL injury among professional baseball pitchers. Study Design: Cohort study; Level of evidence, 2. Methods: Ultrasound imaging was used to assess the medial joint laxity of the elbow of 70 asymptomatic professional baseball pitchers during spring training. Medial joint laxity and UCL morphology were assessed with OsiriX imaging software under 2 conditions—gravity valgus load and 5.5 lb of valgus load per a handheld dynamometer—with the shoulder in the maximal cocking position and the elbow in 90° of flexion. Two trials of resting position, elbow gapping, and UCL thickness were collected, measured, and averaged for data analysis. Intra- and interrater reliabilities were established and maintained, with intraclass correlation coefficients in the acceptable range for all measures (0.84-0.99). One-way analysis of variance was used to compare dominant variables between those pitchers who sustained a subsequent UCL injury and those who did not. A receiver operating curve was used to identify pitchers who, based on elbow gapping measures (by cut score), were at high risk versus low risk for UCL injury. Results: Players who went on to injure the UCL (n = 7) displayed a significantly wider opening under 5.5 lb of applied stress (6.5 ± 1.2 vs 5.3 ± 1.2 mm, P = .01) when compared with pitchers without UCL injury history (n = 63); they also presented a trend toward wider dominant arm resting joint opening (4.9 ± 1.2 vs 4.0 ± 1.1 mm, P = .07). Professional pitchers with valgus stress ulnohumeral joint gapping ≥5.6 mm (area underneath the curve, 0.77; P = .02) of the dominant arm were at a 6-times greater risk of sustaining a UCL tear requiring reconstruction within a season. Conclusion: Our data suggest that ultrasound evaluation of UCL morphology may be indicative of pitchers who are at risk of sustaining UCL injury and that it may improve player assessment.

High Tibial Osteotomy Performed With All-PEEK Implants Demonstrates Similar Outcomes but Less Hardware Removal at Minimum 2-Year Follow-up Compared With Metal Plates

Background: High tibial osteotomy (HTO) is a valuable treatment option in the high-demand patient with chondral damage and an altered mechanical axis. Traditional opening wedge HTO performed with metal plates has several limitations, including hardware irritation, obscuration of detail on magnetic resonance imaging, and complexity of revision surgery. Recently, an all-polyetheretherketone (PEEK) HTO implant was introduced, but no studies to date have evaluated the performance of this implant with minimum 2-year outcomes compared with a traditional metal plate. Purpose: To compare patient outcomes and complications of HTO performed using a traditional metal plate with those performed using an all-PEEK implant. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent HTO by a single surgeon with a minimum 2-year follow-up over a 4-year period were identified. Medical records were reviewed for patient demographics, concomitant procedures, implant used, type and degree of correction, complications, reoperations, and failures. Recorded patient outcomes included EuroQol–5 dimensions (EQ-5D), resiliency, Single Assessment Numeric Evaluation (SANE), Tegner activity level scale, International Knee Documentation Committee (IKDC), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. HTO performed using a traditional metal plate served as the control group. Statistical analysis was performed using the Student t test for continuous variables and chi-square analysis for nonparametric data, with P < .05 considered significant. Results: A total of 41 patients (21 in the all-PEEK group, 20 in the control group) were identified with greater than 2-year follow-up. The mean patient age was 44 years, and there were no differences between the groups with regard to demographics, degree of correction, or concomitant procedures. In addition, no significant differences were found for any of the patient-reported outcomes. Complications (10% vs 15%, respectively; P = .59), failures (10% vs 5%, respectively; P = .58), and reoperations (10% vs 30%, respectively; P = .10) were similar for the all-PEEK and control groups. However, the all-PEEK group did not have any hardware removal, while 4 patients in the control group underwent hardware removal (P = .03). Conclusion: This study suggests that an all-PEEK implant may be safely used with comparable outcomes and complication rates to the traditional method but with less need for hardware removal.

Outcomes of Trabecular Metal–backed glenoid components in anatomic total shoulder arthroplasty

BACKGROUNDnAs glenoid failure is one of the primary causes of failure of anatomic total shoulder arthroplasty (TSA), Trabecular Metal-backed glenoid components have become popular. This study reports implant survival and clinical outcomes of patients who received a Trabecular Metal-backed glenoid component during primary anatomic TSA.nnnMETHODSnPatients who underwent TSA with a Trabecular Metal-backed glenoid component by a single surgeon were identified and reviewed for clinical, radiographic, and patient-reported outcome measures with a minimum of 2 years follow-up.nnnRESULTSnOf 47 patients identified, radiographic and clinical follow-up was available on 36 patients (77%). Average age was 66.36 years (range, 50-85 years), and the average follow-up 41 months (range, 24-66 months). Three patients showed signs of osteolysis, 4 had radiographic evidence of metal debris, and 1 patient had a catastrophic failure after a fall. Of the 47 TSAs, 5 (11%) were revised to a reverse TSA for subscapularis failure and pain. Visual analog scale for pain scores improved by an average of 4.4. At final follow-up, the average Single Assessment Numeric Evaluation score was 72.4; Penn satisfaction score, 7.5; Penn score, 70.35; and American Shoulder and Elbow Surgeons score, 69.23. Outcome scores were similar in the 7 patients with osteolysis or metal debris compared to those without.nnnCONCLUSIONnTrabecular Metal-backed glenoids had a 25% rate of radiographic metal debris and osteolysis at a minimum 2-year follow-up in this series with one catastrophic failure. This implant should be used with caution, and patients followed closely.

Arthroscopic Pectoralis Minor Release

The scapula has long been recognized as a key component in shoulder motion and a crucial part of the kinetic chain connecting the bodys core and upper extremity. The pectoralis minor (PM) has garnered increasing attention as we better understand scapular kinematics and its role in shoulder pain and dysfunction. This is particularly important in patients with scapular dyskinesis and especially in overhead throwing athletes. The most of these patients achieve their recovery goals through nonoperative management, stretching, and strengthening protocols; however, some patients do not respond to nonoperative modalities. Several studies have recently shown improvement in shoulder motion and outcome scores after open surgical release of the PM from its scapular attachment. Arthroscopic release of the PM can be accomplished in the lateral decubitus position with standard shoulder arthroscopic portals.

Use of a Knotless Suture Anchor to Perform Double-Pulley Capsulotenodesis of Infraspinatus

In this Technical Note, we describe an arthroscopic remplissage procedure to treat anterior instability. Specifically, we use a technique to perform double-pulley capsulotenodesis of the infraspinatus tendon using a Knotless SutureTak Suture Anchor (Arthrex, Naples, FL). This is a modification of a previously described double-pulley technique. The primary advantage of our technique compared with the previous double-pulley techniques described is that knot tying is not required.

Applying the Glenoid Track Concept in the Management of Patients with Anterior Shoulder Instability

Purpose of ReviewThe purpose of this paper is to evaluate the recent evolution in the treatment of anterior shoulder instability and the dynamic interaction between the glenoid and Hill-Sachs lesion.Recent FindingsThrough the glenoid track concept, glenoid- and humeral-sided bone loss are evolving away from being approached as separate entities. Recent cadaveric studies have validated the glenoid track concept. Moreover, a recent clinical study has demonstrated a much higher rate of failure after arthroscopic Bankart repair for shoulders that were off track.SummaryThe glenoid track concept is a useful tool in evaluating patients with anterior shoulder instability. Shoulders that are off track may require more than a simple arthroscopic Bankart, and the addition of a remplissage or bony transfer may be considered.