Sanjeev Bhatia

Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss.

Recurrent instability of the glenohumeral joint is usually associated with a Bankart tear—a soft-tissue injury of the glenoid labrum attachment. However, patients with recurrent shoulder instability often present with osseous injury to the glenoid and humeral head as well. Understanding and appropriately addressing irregularities in the osseous architecture of the glenohumeral joint are critical to the overall success of surgical repair for the treatment of glenohumeral instability1. The integrity of the osseous architecture of the glenoid has recently been highlighted as one of the most important factors related to the success of surgical repair2,3. After the initial traumatic shoulder dislocation, an associated glenoid rim fracture or attritional bone injury may compromise the static restraints of the glenohumeral joint, making further instability more likely. With recurrent instability, there can be further attritional glenoid bone loss. Glenoid bone deficiency with recurrent shoulder instability is an increasingly recognized cause of failed shoulder stabilization surgery. It is critical to evaluate all patients with recurrent shoulder instability for the presence of osseous injuries to the glenoid. Specific findings in the history and the physical examination provide important clues to the presence of glenoid bone loss, and a careful preoperative evaluation to diagnose and quantify anterior glenoid deficiency is crucial for the success of surgical treatment. Appropriate preoperative imaging is essential for detection and quantification of osseous abnormalities in patients with recurrent shoulder instability. The apical oblique view described by Garth et al.4, the West Point view5, and the Didiee view6 are recognized as being the most sensitive radiographs for detecting osseous abnormalities of the glenoid. Magnetic resonance imaging and magnetic resonance arthrography may be used, but they are primarily employed to assess the surrounding soft tissues. If any osseous lesion is discovered on radiographs, …

Meniscal Root Tears: Significance, Diagnosis, and Treatment

Meniscal root tears, less common than meniscal body tears and frequently unrecognized, are a subset of meniscal injuries that often result in significant knee joint disorders. The meniscus root attachment aids meniscal function by securing the meniscus in place and allowing for optimal shock-absorbing function in the knee. With root tears, meniscal extrusion often occurs, and the transmission of circumferential hoop stresses is impaired. This alters knee biomechanics and kinematics and significantly increases tibiofemoral contact pressure. In recent years, meniscal root tears, which by definition include direct avulsions off the tibial plateau or radial tears adjacent to the root itself, have attracted attention because of concerns that significant meniscal extrusion dramatically inhibits normal meniscal function, leading to a condition biomechanically similar to a total meniscectomy. Recent literature has highlighted the importance of early diagnosis and treatment; fortunately, these processes have been vastly improved by advances in magnetic resonance imaging and arthroscopy. This article presents a review of the clinically relevant anatomic, biomechanical, and functional descriptions of the meniscus root attachments, as well as current strategies for accurate diagnosis and treatment of common injuries to these meniscus root attachments.

The outcomes and surgical techniques of the latarjet procedure.

PURPOSE To determine the optimal position and orientation of the coracoid bone graft for the Latarjet procedure for recurrent instability in patients with recurrent anterior instability and high degrees of glenoid bone loss. METHODS A systematic review of the literature including the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2012), and Medline (1980-2012) was conducted. The following search teams were used: glenoid bone graft, coracoid transfer, glenoid rim fracture, osseous glenoid defect, and Latarjet. Studies deemed appropriate for inclusion were then analyzed. Study data collected included level of evidence, patient demographic characteristics, preoperative variables, intraoperative findings, technique details, and postoperative recovery and complications where available. RESULTS The original search provided a total of 344 studies. A total of 334 studies were subsequently excluded because they were on an irrelevant topic, used an arthroscopic technique, or were not published in English or because they were review articles, leaving 10 studies eligible for inclusion. Given the different methods used in each of the studies included in the review, descriptive analysis was performed. The duration of follow-up ranged from 6 months to 14.3 years postoperatively. With the exception of 2 studies, all authors reported on recurrent shoulder instability after Latarjet reconstruction; the rate of recurrent anterior shoulder instability ranged from 0% to 8%. Overall patient satisfaction was listed in 4 studies, each of which reported good to excellent satisfaction rates of more than 90% at final follow-up. CONCLUSIONS As noted in this review, the current literature on Latarjet outcomes consists mostly of retrospective Level IV case series. Although promising outcomes with regard to a low rate of recurrent instability have been seen with these reports, it should be noted that subtle variations in surgical technique, among other factors, may drastically impact the likelihood of glenohumeral degenerative changes arising in these patients. LEVEL OF EVIDENCE Level IV, systematic review of Level IV studies.

Outcomes of Arthroscopic Rotator Cuff Repair in Patients Aged 70 Years or Older

PURPOSE To evaluate outcomes of arthroscopic rotator cuff repair in patients aged 70 years or older. METHODS We identified 44 consecutive patients aged 70 years or older undergoing primary all-arthroscopic repair of symptomatic full-thickness tears of the rotator cuff. A minimum 2-year follow-up was performed by an independent examiner including range of motion and dynamometer strength testing, and shoulder functional outcome scores including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and pain score on a visual analog scale were determined. Paired t tests were performed to compare preoperative and postoperative measures. Postoperative Constant-Murley scores were normalized with scores from age- and sex-matched healthy individuals. RESULTS Of the patients, 39 (88.6%) were available for follow-up evaluation, with a mean age of 75.3 ± 4.2 years (range, 70.1 to 89.8 years) and a mean follow-up of 36.1 ± 9.9 months (range, 24.3 to 59.4 months). The American Shoulder and Elbow Surgeons score improved from 45.8 ± 16.6 (mean ± SD) to 87.5 ± 14.4 at final follow-up (P < .0001). The Simple Shoulder Test score improved from 3.9 ± 2.3 to 9.8 ± 2.5 (P < .0001). The pain score on the visual analog scale improved from 4.6 ± 2.2 to 0.5 ± 0.9 (P < .0001), and forward elevation increased from 114.8° ± 42.0° to 146.2° ± 33.2° (P = .0012). Mean age- and sex-matched normalized Constant-Murley scores ranged from 88.3% to 97.2% of normal in men and 81.7% to 88.8% of normal in women. CONCLUSIONS Arthroscopic rotator cuff repair provides significant improvement in pain and function in carefully selected patients aged 70 years or older with symptomatic full-thickness rotator cuff tears and has a low complication rate. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Outcomes After Arthroscopic Revision Rotator Cuff Repair

Background Although a number of reports have documented outcomes after open revision rotator cuff repair, there are few studies reporting results after arthroscopic revision. Hypothesis Arthroscopic repair of failed rotator cuff results in significant improvement in shoulder functional outcome and pain relief. Study Design Case series; Level of evidence, 4. Methods Multiple variables including demographic data, the number of prior ipsilateral shoulder surgeries, and tear size were recorded from chart review. An independent examiner then measured shoulder strength, range of motion, and shoulder functional outcome scores including American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog pain scale. Paired t tests were performed to compare preoperative and postoperative measures. Additionally, contingency table analysis was performed to identify prognostic factors for failure of repair requiring further surgery and American Shoulder and Elbow Surgeons score less than 50. Results Fifty-four patients (88.5%) were available for follow-up evaluation with a mean age of 54.9 ± 10.1 years (range, 22.7-82.5 years) and a mean follow-up of 31.1 ± 11.9 months. American Shoulder and Elbow Surgeons scores improved from 43.8 ± 5.7 (mean ± 95% confidence interval) before revision to 68.1 ± 7.2 at final follow-up (P = .0039). The Simple Shoulder Test improved significantly from 3.56 ± 0.8 before surgery to 7.5 ± 1.1 at most recent follow-up (P < .0001). Visual analog pain scale scores improved from 5.17 ± 0.8 to 2.75 ± 0.8 (P = .03), and forward elevation increased from 121.0° ± 12.3° to 136° ± 11.8° postoperatively (P = .025). Greater than 1 prior shoulder surgery was associated with cases that required additional surgery (P = .031). Female gender (P = .007) and preoperative abduction less than 90° (P = .009) were associated with American Shoulder and Elbow Surgeons scores less than 50. Conclusion Arthroscopic revision rotator cuff repair may be a reasonable treatment option even after prior open repairs and provides both improved pain relief and shoulder function. Nonetheless, results are not completely optimal. Female patients and those who have undergone more than 1 ipsilateral shoulder surgery are at increased risk for poorer results.

Comparison of Glenohumeral Contact Pressures and Contact Areas After Glenoid Reconstruction With Latarjet or Distal Tibial Osteochondral Allografts

Background: Glenoid reconstruction with distal tibial allografts offers the theoretical advantage over Latarjet reconstruction of improved joint congruity and a cartilaginous articulation for the humeral head. Hypothesis/Purpose: To investigate changes in the magnitude and location of glenohumeral contact areas, contact pressures, and peak forces after (1) the creation of a 30% anterior glenoid defect and subsequent glenoid bone augmentation with (2) a flush Latarjet coracoid graft or (3) a distal tibial osteochondral allograft. It was hypothesized that the distal tibial bone graft would best normalize glenohumeral contact areas, contact pressures, and peak forces. Study Design: Controlled laboratory study. Methods: Eight cadaveric shoulder specimens were dissected free of all soft tissues and randomly tested in 3 static positions of humeral abduction with a 440-N compressive load: 30°, 60°, and 60° of abduction with 90° of external rotation (ABER). Glenohumeral contact area, contact pressure, and peak force were determined sequentially using a digital pressure mapping system for (1) the intact glenoid, (2) the glenoid with a 30% anterior bone defect, and (3) the glenoid after reconstruction with a distal tibial allograft or a Latarjet bone block. Results: Glenoid reconstruction with distal tibial allografts resulted in significantly higher glenohumeral contact areas than reconstruction with Latarjet bone blocks in 60° of abduction (4.87 vs 3.93 cm2, respectively; P < .05) and the ABER position (3.98 vs 2.81 cm2, respectively; P < .05). Distal tibial allograft reconstruction also demonstrated significantly lower peak forces than Latarjet reconstruction in the ABER position (2.39 vs 2.61 N, respectively; P < .05). Regarding the bone loss model, distal tibial allograft reconstruction exhibited significantly higher contact areas and significantly lower contact pressures and peak forces than the 30% defect model at all 3 abduction positions. Latarjet reconstruction also followed this same pattern, but differences in contact areas and peak forces between the defect model and Latarjet reconstruction in the ABER position were not statistically significant (P > .05). Conclusion: Reconstruction of anterior glenoid bone defects with a distal tibial allograft may allow for improved joint congruity and lower peak forces within the glenohumeral joint than Latarjet reconstruction at 60° of abduction and the ABER position. Although these mechanical properties may translate into clinical differences, further studies are needed to understand their effects. Clinical Relevance: Glenoid bone reconstruction with a distal tibial osteochondral allograft may result in significantly improved glenohumeral contact areas and significantly lower glenohumeral peak forces than reconstruction with a Latarjet bone block, which could play a role in improving postoperative outcomes after glenoid reconstruction.

Bony Incorporation of Soft Tissue Anterior Cruciate Ligament Grafts in an Animal Model: Autograft Versus Allograft With Low-Dose Gamma Irradiation

Background: The effect of low-dose gamma irradiation on healing of soft tissue allografts remains largely unknown. Hypothesis: The authors hypothesized that soft tissue allograft healing to bone would be delayed compared with that of autograft tissue and that low-dose (1.2 Mrad) gamma irradiation would not affect the healing response of allograft tissue after anterior cruciate ligament (ACL) reconstruction. Study Design: Controlled laboratory study. Methods: Forty-eight New Zealand White rabbits underwent bilateral ACL reconstructions with semitendinosus tendon graft. Sixteen rabbits were reconstructed with autografts and the remainder with allografts. The 32 allograft rabbits each received 1 irradiated allograft (1.2 Mrad), with the contralateral leg receiving a nonirradiated allograft. Animals were euthanized at 2 weeks or 8 weeks postoperatively. Tensile stiffness, maximum load, and displacement at maximum load were measured. Tibial and femoral segments were sectioned perpendicular to the tunnel axis allowing for histologic and histomorphometric analyses at the tendon-bone interface. Results: There were no significant differences between the maximum load or stiffness values among all groups at 8 weeks. At 2 weeks, autograft exhibited significantly (P < .01) lower maximum load than did the nonirradiated grafts. Regarding histology, at both 2- and 8-week time points, autograft tendon displayed more advanced degenerative and remodeling processes in comparison with irradiated allograft and nonirradiated allograft. Discussion: The maximum load and stiffness of a healing tendon allograft in ACL reconstruction appear to be unaltered by low-dose (1.2 Mrad) irradiation. At 8 weeks, there were no biomechanical differences in tendon-bone healing of allografts when compared with autograft controls. Histologic analyses suggested a faster remodeling response in autograft specimens in comparison with allografts at both time points. Clinical Relevance: The findings support the contention that low-dose gamma irradiation is safe for sterilization of ACL soft tissue allografts without compromise of graft properties at early time points.

Two-Year Outcomes After Arthroscopic Rotator Cuff Repair in Recreational Athletes Older Than 70 Years:

Background: Outcomes after arthroscopic rotator cuff repair in recreational athletes older than 70 years are not widely reported. Purpose: To evaluate clinical outcomes after arthroscopic repair of full-thickness rotator cuff tears in recreational athletes aged 70 years or older. Study Design: Case series; Level of evidence, 4. Methods: Institutional review board approval was obtained before initiation of this study. Data were collected prospectively and were retrospectively reviewed. From December 2005 to August 2012, patients who were at least 70 years of age, who described themselves as recreational athletes, and who underwent a primary or revision arthroscopic repair of full-thickness supraspinatus tears by a single surgeon were identified from a surgical registry. Demographic data, surgical data, and the following pre- and postoperative clinical outcomes scores were collected: American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Short Form–12 Physical Component Summary (SF-12 PCS), and Single Assessment Numeric Evaluation (SANE). Acromiohumeral distance and Goutallier classifications were recorded. Patient satisfaction (range, 1-10, 10 = best) and reasons for activity modification were collected at final follow-up. Results: Forty-nine shoulders (44 patients) were included. The mean age was 73 years (range, 70-82 years). There were 33 men and 11 women (5 bilateral). The mean preoperative acromiohumeral distance was 9.2 mm (range, 3.0-15.9 mm). All patients had Goutallier classifications of 0, 1, or 2. Mean follow-up was 3.6 years (range, 2.0-6.9 years) in 43 of 49 (88%) shoulders. No rotator cuff repairs were revised, however, 1 patient had surgical treatment for stiffness. All postoperative outcomes measures demonstrated significant improvements when compared with their preoperative baselines. The mean ASES score was 90.3 (range, 60-100), the mean SANE score was 85.1 (range, 29-100), the mean QuickDASH score was 11.3 (0-50), and the mean SF-12 PCS score was 51.6 (range, 38-58) with a median patient satisfaction of 10 (range, 1-10). Patients who modified their recreational activities due to postoperative weakness were significantly less satisfied (P = .018). In this study, 24 of 31 (77%) who responded were able to return to their sport at a similar level of intensity. Conclusion: Arthroscopic rotator cuff repair was highly effective at reducing pain, improving function, and returning patients to sport in recreational athletes 70 years of age and older.

The Importance of the Recognition and Treatment of Glenoid Bone Loss in an Athletic Population

Context: Osseous injury to the glenoid is increasingly being recognized as one of the most important aspects in the successful management of recurrent shoulder instability. Proper early recognition of glenoid bone injury in the setting of recurrent instability will lead to successful nonoperative and operative decision making, particularly in the athletic patient. Evidence Acquisition: We conducted a MEDLINE search on shoulder instability from 2000 to 2010. The emphasis was placed on patient-oriented Level 1 literature from 2000 to 2010. Results: After a traumatic anterior dislocation of the shoulder, the most common structural injury is an avulsion of the anteroinferior capsulolabrum, which is also known as a Bankart lesion. If this specific injury is accompanied by an associated fracture in the glenoid rim, the term bony Bankart lesion is more applicable. With diminished articular constraints, the glenohumeral joint is subject to recurrent instability, thereby potentiating the bony injury cycle. Additionally, patients with osseous defects usually complain of instability within the midranges of motion, or they recall a progression of instability. If glenoid bone loss is present, the humeral head often easily subluxates over the glenoid in the midranges of abduction (30°-90°) and lower levels of external rotation. Imaging workup should begin with plain radiographs, but advanced imaging should be obtained if there is any suspicion of bone loss. Treatment includes both nonoperative and operative interventions. Conclusions: Estimation of the amount of glenoid bone loss and the failure of nonoperative care is essential for guiding management, patient expectations, and surgical decision making.

Comparison of Glenohumeral Contact Pressures and Contact Areas After Posterior Glenoid Reconstruction With an Iliac Crest Bone Graft or Distal Tibial Osteochondral Allograft

Background: Posterior glenoid bone deficiency in the setting of posterior glenohumeral instability is typically addressed with bone block augmentation with iliac crest bone grafts (ICBGs). Reconstruction with fresh distal tibial allograft (DTA) is an alternative option, with the theoretical advantages of restoring the glenoid articular surface, improving joint congruity, and providing the biological restoration of articular cartilage loss. Hypothesis: Reconstruction with an ICBG and DTA would more effectively restore normal glenoid contact pressures, contact areas, and peak forces when compared with the deficient glenoid. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen human cadaveric shoulders were tested in 4 conditions: (1) intact glenoid, (2) 20% posterior-inferior defect of the glenoid surface area, (3) 20% defect reconstructed with a flush ICBG, and (4) 20% defect reconstructed with a fresh DTA. For each condition, a 0.1 mm–thick dynamic pressure-sensitive pad was placed between the humeral head and glenoid. A compressive load of 440 N was applied for each condition in the following clinically relevant arm positions: (1) 30° of humeral abduction, (2) 60° of humeral abduction, and (3) 90° of flexion–45° of internal rotation (FIR). Glenohumeral contact pressures (kg/cm2), contact areas (cm2), and joint peak forces (N) were compared. Results: Glenoid reconstruction with DTA resulted in significantly higher contact areas than the 20% defect model at 30°, 60°, and FIR at the time of surgery (P < .01 in all cases). The intact state exhibited significantly higher contact areas than the defect in all positions, significantly higher contact areas than the ICBG in all positions, and significantly higher contact areas than the DTA at 30° (P < .05 in all cases). The intact state experienced significantly lower contact pressures than the defect at 60° and FIR, while reconstruction with both a DTA and ICBG resulted in significantly lower contact pressures than the defect at 60° (P < .05 in all cases). There were no differences in contact pressures when comparing both the DTA and ICBG to the intact glenoid (P > .05 in all cases). There were no differences in peak forces between the groups, for any of the conditions, in any of the positions (P > .05 in all cases). Conclusion: Reconstruction of posterior glenoid bone defects with DTA conferred similar contact mechanics as reconstruction with ICBGs at the time of surgery. Clinical Relevance: This study supports posterior glenoid reconstruction with fresh DTA as a viable alternative solution, with the potential advantage of improving joint congruity via an anatomic reconstruction, resulting in a cartilaginous, congruent articulation with the humeral head. Further studies are required to determine potential clinical effects of the glenohumeral joint contact mechanics reported here.