Joseph N. Liu

Outcomes of the Remplissage Procedure and Its Effects on Return to Sports: Average Five-Year Follow Up

Background: Short-term outcomes for patients with large, engaging Hill-Sachs lesions who underwent remplissage have demonstrated good results. However, limited data are available for longer term outcomes. Purpose: To evaluate the long-term outcomes of remplissage and determine the long-term rate of return to specific sports postoperatively. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of patients treated with the remplissage procedure from 2007 to 2013. All underwent preoperative magnetic resonance imaging demonstrating large Hill-Sachs lesions by the Rowe criteria and glenoid bone loss <20%. All Hill-Sachs lesions were “off track” by an arthroscopic examination and preoperative imaging. At final follow-up, patients underwent a range of motion evaluation and were administered a detailed outcome survey, which included Western Ontario Shoulder Instability Index (WOSI) and American Shoulder and Elbow Surgeons (ASES) scores as well as questions regarding sports, employment, physical activities, and dislocation events. Results: A total of 50 patients (51 shoulders) were included in the study. The average patient age at surgery was 29.8 years (range, 15.0-72.4 years), and the average follow-up time was 60.7 months (range, 25.5-97.6 months); 20.0% of patients underwent previous surgery on their shoulder. The average postoperative WOSI score was 79.5%, and the average ASES score was 89.3. Six shoulders had dislocation events (11.8%) postoperatively: 3 were traumatic, and 3 were atraumatic. Increased preoperative dislocations led to a greater risk of a postoperative dislocation (P < .001). There was also a trend toward higher postoperative dislocation rates in patients who underwent revision (P = .062). The average loss of external rotation was 5.26° (P = .13). The rate of return to ≥1 sports was 95.5% of patients at an average of 7.0 months postoperatively; 81.0% returned to their previous intensity and level of sport. Of patients who played a throwing sport, 65.5% (n = 19) stated that they had problems throwing, and 58.6% (n = 17) felt that they could not normally wind up throwing a ball. Direct rates of return to overhead sports were volleyball, 100%; basketball, 69%; baseball, 50%; and football, 50%. Conclusion: The redislocation rate after remplissage was 11.8% at an average of 5 years, with 95.5% of patients returning to full sports at an average of 7 months. For throwing sports, 65.5% of patients complained of decreased range of motion during throwing. The results should be considered preoperatively in candidates for remplissage who are engaged in throwing sports.

Outcomes in revision Tommy John surgery in Major League Baseball pitchers

BACKGROUND With the recent rise in the number of Tommy John surgeries, a proportionate rise in revisions is expected. However, much is unknown regarding the current revision rate of Tommy John surgery, return to play, and change in performance in Major League Baseball (MLB) pitchers. METHODS Publicly available databases were used to obtain a list of all MLB pitchers who underwent primary and revision Tommy John surgery. Pitching performance preoperatively and postoperatively for pitchers who returned to 1 or more MLB games after revision surgery was compared with controls matched for age and position. RESULTS Since 1999, 235 MLB pitchers have undergone Tommy John surgeries; 31 pitchers (13.2%) underwent revision surgery, and 37% underwent revision within 3 years of the index procedure. Twenty-six revisions had more than 2 years of follow-up; 17 pitchers (65.4%) returned to pitch at least 1 major league game, whereas only 11 (42.3%) returned to pitch 10 or more games. Of those who returned to MLB competition, the average length of recovery was 20.76 months. Compared with controls matched for age and position, MLB pitchers undergoing revision surgery had a statistically shorter career after revision surgery (4.9 vs 2.6 seasons, P = .002), pitched fewer innings, and had fewer total pitches per season. CONCLUSIONS The rate of revision Tommy John surgery is substantially higher than previously reported. For MLB pitchers, return to play after revision surgery is much lower than after primary reconstruction. The overall durability of MLB pitchers after revision ulnar collateral ligament reconstruction decreases significantly compared with controls matched for age and matched controls.

Higher critical shoulder angle increases the risk of retear after rotator cuff repair.

BACKGROUND No evaluation has been done on the relationship of the critical shoulder angle (CSA) with retear after rotator cuff repair. Our purpose was to evaluate whether a higher CSA is associated with retear after rotator cuff repair. METHODS This was a retrospective review of 76 patients who had undergone rotator cuff repair with postoperative ultrasound examination. Ultrasound findings were graded no retear (NT), partial-thickness (PT) retear, or full-thickness (FT) retear. Preoperative radiographs were used to measure CSA, glenoid inclination, lateral acromion angle, and acromion index. RESULTS Average age was 61.9 years (45.3-74.9 years). On ultrasound examination, 57 shoulders (74.0%) had NT, 11 (14.2%) had PT retears, and 8 (10.3%) had FT retears. There was no significant difference in retear rate by age, gender, or tension of repair. Average CSA was significantly lower for the NT group at 34.3° ± 2.9° than for the FT group at 38.6° ± 3.5° (P < .01). If CSA was >38°, the odds ratio of having an FT retear was 14.8 (P < .01). In addition, higher CSA inversely correlated with postoperative American Shoulder and Elbow Surgeons scores (P < .03). Average glenoid inclination was significantly lower in the NT group at 12.3° ± 2.7° compared with 17.3° ± 2.6° in the FT group (P < .01). If glenoid inclination was >14, the odds ratio of having a FT retear was 15.0 (P < .01). CONCLUSION At short-term follow-up, higher CSA significantly increased the risk of an FT retear after rotator cuff repair. Also, increasing CSA correlated with worse postoperative American Shoulder and Elbow Surgeons scores. This radiographic marker may help manage expectations for rotator cuff tear patients.

Anatomic Determinants of Sacral Dysmorphism and Implications for Safe Iliosacral Screw Placement

BACKGROUND Upper sacral segment dysplasia increases the risk of cortical perforation during iliosacral screw insertion. Dysmorphic sacra have narrow and angled upper osseous corridors. However, there is no validated definition of this anatomic variation. We hypothesized that pelves could be quantitatively grouped by anatomic measurements. METHODS One hundred and four computed tomography (CT) scans and virtual outlet views of uninjured pelves were analyzed for the presence of the five qualitative characteristics of upper sacral segment dysplasia. CT scans were reformatted to measure the cross-sectional area, angulation, and length of the osseous corridor. Principal components analysis was used to identify multivariable explanations of anatomic variability, and discriminant analysis was used to assess how well such combinations can classify dysmorphic pelves. RESULTS The prevalences of the five radiographic qualitative characteristics of upper sacral segment dysplasia, as determined by two reviewers, ranged from 28% to 53% in the cohort. The rates of agreement between the two reviewers ranged from 70% to 81%, and kappa coefficients ranged from 0.26 to 0.59. Cluster analysis revealed three pelvic phenotypes based on the maximal length of the osseous corridor in the upper two sacral segments. Forty-one percent of the pelves fell into the dysmorphic cluster. The five radiographic qualitative characteristics of dysmorphism were significantly more frequent (p < 0.007) in this cluster. A combination of upper sacral coronal and axial angulation effectively explained the variance in the data, and an inverse linear relationship between these angles and a long upper sacral segment corridor was identified. A sacral dysmorphism score was derived with the equation: (first sacral coronal angle) + 2(first sacral axial angle). An increase in the sacral dysmorphism score correlated with a lower likelihood of a safe transsacral first sacral corridor. No subjects with a sacral dysmorphism score >70 had a safe transsacral first sacral corridor. CONCLUSIONS Sacral dysmorphism was found in 41% of the pelves. The major determinants of sacral dysmorphism are upper sacral segment coronal and axial angulation. The sacral dysmorphism score quantifies dysmorphism and can be used in preoperative planning of iliosacral screw placement.

Sports after shoulder arthroplasty: a comparative analysis of hemiarthroplasty and reverse total shoulder replacement

BACKGROUND Traditionally, fewer postoperative sport restrictions are imposed on hemiarthroplasty (HHA) patients on than reverse total shoulder arthroplasty (RTSA) patients. However, functional outcomes have been shown to be superior in RTSA. No direct comparison of RTSA vs HHA has been done on rates of return to sports in patients with glenohumeral arthritis and rotator cuff dysfunction, proximal humeral fractures, or rheumatoid arthritis. METHODS This is a retrospective review of consecutive RTSA and HHA patients collected from our institutions shoulder arthroplasty registry. All patients playing sports preoperatively with minimum 1-year follow-up were included. Final follow-up included an additional patient-reported questionnaire with questions regarding physical fitness and sport activities. RESULTS The study included 102 RTSA and 71 HHA patients. Average age at surgery was 72.3 years for RTSA compared with 65.6 years for HHA (P < .001). Patients undergoing RTSA had improved visual analog scale scores compared with HHA (-5.6 vs -4.2, P = .007), returned to sports after RTSA at a significantly higher rate (85.9% vs 66.7%, P = .02), and were more likely to be satisfied with their ability to play sports (P = .013). HHA patients were also more likely to have postoperative complaints than RTSA patients (63% vs 29%, P < .0001). No sports-related complications occurred. Female sex, age <70 years, surgery on the dominant extremity, and a preoperative diagnosis of arthritis with rotator cuff dysfunction predicted a higher likelihood of return to sports for patients undergoing RTSA compared with HHA. CONCLUSIONS Despite traditional sport restrictions placed on RTSA, patients undergoing RTSA can return to sports at rates higher than those undergoing HHA, with fewer postoperative complaints.

Hemiarthroplasty Versus Total Shoulder Arthroplasty for Shoulder Osteoarthritis: A Matched Comparison of Return to Sports

Background: Return to activity is a commonly used indication for shoulder hemiarthroplasty (HA) compared with total shoulder arthroplasty (TSA). Despite clinical studies demonstrating better functional outcomes after TSA, the literature has failed to show a difference in return to sports. Purpose: To compare rates of return to sports in a matched cohort of TSA and HA patients with a preoperative diagnosis of glenohumeral osteoarthritis (OA). Study Design: Cohort study; Level of evidence, 3. Methods: A prospectively collected registry was queried retrospectively for consecutive patients who underwent HA. Inclusion criteria were preoperative diagnosis of OA and more than 2 years of follow-up. After meeting the inclusion criteria, all HA patients were statistically matched to a TSA patient. All patients had end-stage OA with significant glenohumeral joint space narrowing. Results: At final follow-up, 40 HA patients and 40 TSA patients were available. The average (±SD) age at surgery was 65.7 ± 10.5 years and 66.2 ± 9.6 years for the HA and TSA groups, respectively (P = .06). Average follow-up was 62.0 months and 61.1 months for the HA and TSA groups, respectively (P = .52). Average American Shoulder and Elbow Surgeons scores improved from 36.3 to 70.2 for HA patients and from 34.0 to 78.5 for TSA patients (P < .001 for both); final scores were not significantly different between groups (P = .21). Average visual analog scale pain scores improved from 6.3 to 2.2 for HA patients and from 6.1 to 0.6 for TSA patients (P < .001 for both). HA patients had significantly worse final visual analog scale scores compared with the TSA group (P = .002). Significantly more TSA patients were satisfied with their surgery compared with HA patients (100% vs 70%) (P = .01). Of both groups, 65.5% of HA patients (19 of 29) returned to at least 1 sport postoperatively compared with 97.3% of TSA patients (36 of 37) (P < .001). Average timing for return to full sports was 5.5 ± 4.2 months and 5.4 ± 3.1 months for the HA and TSA groups, respectively (P = .92). Significantly more TSA patients returned to higher upper extremity use sports (P = .01). Conclusion: In patients with OA, rate of return to sports was significantly better after TSA compared with HA. HA patients had significantly more pain, worse surgical satisfaction, and decreased ability to return to high upper extremity use sports. For patients with OA who wish to return to sporting activities, these results help manage expectations.

High Satisfaction and Return to Sports After Total Shoulder Arthroplasty in Patients Aged 55 Years and Younger

Background: Young, active candidates for total shoulder arthroplasty (TSA) are a unique group of patients. Not only do they demand longevity and improved function, but they also desire a return to physical activities. Purpose: To determine the rate of return to sports in patients aged ≤55 years undergoing TSA. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of consecutive patients who underwent anatomic TSA at a single institution. Exclusion criteria included age at the time of surgery >55 years and <2 years of follow-up. All patients had end-stage osteoarthritis with significant glenohumeral joint space narrowing. The final follow-up consisted of a patient-reported sports questionnaire, American Shoulder and Elbow Surgeons (ASES) score, and visual analog scale (VAS) score. Results: From 70 eligible patients, 59 patients (61 shoulders) were included with an average follow-up of 61.0 months (range, 25-103 months) and average age at the time of surgery of 48.9 years (range, 25-55 years). The average VAS score improved from 5.6 to 0.9 (P < .001), and the average ASES score improved from 39.3 to 88.4 (P < .001). Forty-nine procedures (80.3%) were performed for a primary diagnosis of osteoarthritis. Four shoulders returned to the operating room; none were for glenoid loosening. There was a 93.2% satisfaction rate, and 67.7% of patients (n = 40) stated that they underwent their surgery to return to sports. Moreover, patients in 96.4% of shoulders (55/57) restarted at least 1 sport at an average of 6.7 months. Direct rates of return were as follows: fitness sports (97.2%), golf (93.3%), singles tennis (87.5%), swimming (77.7%), basketball (75.0%), and flag football (66.7%). Patients in 47 shoulders (82.4%) returned to a similar or higher level of sports; 90.3% returned to high-demand sports, and 83.8% returned to high upper extremity sports. There was no significant difference in rates of return to sports by body mass index, sex, age, preoperative diagnosis, revision status, and dominant extremity. Conclusion: In patients aged ≤55 years undergoing TSA, there was a 96.4% rate of return to ≥1 previous sports at an average of 6.7 months. Furthermore, at an average follow-up of 61.0 months, no patients needed revision of their glenoid component, despite an 83.8% rate of return to high upper extremity sports. While caution should still be advised in young, active patients undergoing TSA, these results demonstrate a high satisfaction rate and improved ability to return to most sports after surgery.

Effect of bone loss in anterior shoulder instability

Anterior shoulder instability with bone loss can be a difficult problem to treat. It usually involves a component of either glenoid deficiency or a Hill-Sachs lesion. Recent data shows that soft tissue procedures alone are typically not adequate to provide stability to the shoulder. As such, numerous surgical procedures have been described to directly address these bony deficits. For glenoid defects, coracoid transfer and iliac crest bone block procedures are popular and effective. For humeral head defects, both remplissage and osteochondral allografts have decreased the rates of recurrent instability. Our review provides an overview of current literature addressing these treatment options and others for addressing bone loss complicating anterior glenohumeral instability.

Patellar Instability Management: A Survey of the International Patellofemoral Study Group:

Background: Although patellofemoral instability is among the most prevalent knee disorders, the management of patients with this condition is complex and remains variable, given the lack of long-term, high-level clinical outcome studies to compare various operative and nonoperative modalities. Purpose: To discover a consensus within treatment controversies in patellofemoral instability among experienced knee surgeons with a specific interest in the patellofemoral joint. Study Design: Expert opinion; Level of evidence, 5. Methods: A 3-step modified Delphi technique was used to establish a consensus. A 34-question, case-based online survey regarding patellofemoral instability was distributed to all active members of the International Patellofemoral Study Group. Consensus statements were generated if at least 66% of the respondents agreed and then redistributed to the same panel. Modifications to the consensus statements were made based on the iterative feedback process until no discordance was encountered in the third stage. Results: Eight consensus statements were achieved. Nonoperative management is the current standard of care for a first-time dislocation in the absence of an osteochondral fragment or loose body requiring excision (100% agreement). In patients with a first-time dislocation with an operative osteochondral fracture requiring excision or repair, patellar instability should be addressed concurrently (89% agreement). Recurrent instability should be treated surgically, with most surgeons favoring medial reconstruction (77%-86% agreement). While there is general agreement that bony procedures should be performed to correct underlying bony deformities, there is no consensus regarding the most appropriate type of procedure performed. Lateral release should not be performed in isolation for the treatment of patellar instability (89% agreement). Conclusion: Despite the consensus generated in this study, our current understanding remains limited by a lack of high-level evidence as well as the numerous complex variables influencing treatment decision making. High-quality, multicenter randomized controlled trials, particularly those directly comparing specific surgical treatment methods while controlling for underlying risk factors, are needed to address these areas of uncertainty.

Clinical Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability Among Patients With Trochlear Dysplasia

Background: Medial patellofemoral ligament (MPFL) reconstruction has become one of the most common and widely used procedures to regain stability among patients with recurrent lateral patellar dislocation. While recent studies demonstrated low recurrence rates, improved patient-reported outcome measures, and a high rate of return to sports, limited literature explored its effectiveness as an isolated intervention in the context of trochlear dysplasia. Purpose: To determine the efficacy of isolated MPFL reconstruction in treating patellar instability in the setting of trochlear dysplasia. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of consecutive patients who underwent uni- or bilateral medial patellofemoral ligament reconstruction for patellofemoral instability with a minimum 2-year follow-up. No osteotomies were included. Pre- and postoperative assessment included ligamentous laxity, patellar crepitus, tilt, translation, apprehension, and radiographic features, including tibial tubercle-trochlear groove (TT-TG) distance, Dejour classification, and Caton-Deschamps index. Results: A total of 121 MPFL reconstructions were included. Mean age at surgery was 23.8 years, and 4.4 dislocation events occurred before surgery. Mean follow-up was 44 months; 76% of patients were female. Mean preoperative TT-TG ratio was 13.5, and mean Caton-Deschamps ratio was 1.2; 92% of patients had Dejour B, C, or D trochlear dysplasia. Kujala score improved from 55.0 preoperatively to 90.0 (P < .001). Almost all patients (94.5%) were able to return to sports at 1 year, with 74% returning to the same or higher level of play. Only 3 patients reported a postoperative dislocation or subluxation event. Discussion: For patients without significantly elevated TT-TG distances or significant patella alta, isolated MPFL reconstruction provides a safe and effective treatment for patellofemoral instability, despite the presence of trochlear dysplasia. Most patients are able to return to sports by 1 year postoperatively at the same or higher level of play.