James P. Bradley

Background: Posterior shoulder instability has recently been linked to a higher and flatter acromion. However, the effect of acromial morphology on surgical outcomes has not been evaluated. Purpose: To evaluate differences in acromial morphology between patients undergoing primary and revision arthroscopic stabilization for posterior shoulder instability. Study Design: Case-control study; Level of evidence, 3. Methods: A series of patients who underwent either primary or revision arthroscopic stabilization for posterior shoulder instability between 2001 and 2022 were identified. Revision patients were matched to nonrevision patients based on age, sex, and sport. Comparisons of patient characteristics and acromial and glenoid morphology were done between groups using previously described magnetic resonance imaging parameters, including posterior acromial tilt (PAT), anterior acromial coverage (AAC), posterior acromial coverage (PAC), and posterior acromial height (PAH). Glenoid bone loss and glenoid version were also evaluated. Continuous variables were compared between groups using a 2-tailed Student t test. Results: A total of 37 patients who underwent revision posterior shoulder stabilization during the study period were identified and matched to 37 patients who underwent primary posterior shoulder stabilization. The mean ages of the primary and revision patients at the time of initial surgery were 21.5 ± 4.8 years (range, 13-35 years) and 19.6 ± 6.1 years (range, 12-45 years), respectively ( P = .95). Men comprised 54% of each group. The mean PAT in the primary and revision groups was 51.6° and 53.7° ( P = .32), while the mean PAH was 10 mm and 13.5 mm ( P = .04), respectively. The mean AAC in the primary and revision groups was 4.44° and 7.10° ( P = .20), while the mean PAC was 72.1° and 63.3°± 8.11° ( P = .08), respectively. No difference was found in the glenoid version (6.22° in the primary group vs 8.08° in the revision group; P = .06). The mean glenoid bone loss was 0.57% (range, 0%-8.9%) in the primary group and 1.4% (range, 0%-5.8%) in the revision group ( P = .02). Conclusion: A higher acromion was associated with requiring revision of previous arthroscopic posterior capsulolabral repair. PAT and coverage were not significantly different between patients undergoing primary versus revision repair. There was no significant difference in glenoid version between groups. Although the amount was small, glenoid bone loss was statistically higher in the revision group.

Background: The modified Jobe and docking techniques are the most utilized ulnar collateral ligament (UCL) reconstruction techniques, with previous research demonstrating successful and equivalent outcomes at midterm follow-up. However, these techniques have not been compared with UCL repair with suture augmentation (SA), nor has longer-term follow-up been reported. Purpose: To directly compare clinical outcomes at midterm follow-up of these 3 surgical techniques: the modified Jobe, docking, and repair with SA. Study Design: Cohort study; Level of evidence, 3. Methods: Twenty-four surgical procedures for UCL repair with SA were performed by a single surgeon, each with a minimum 2-year follow-up. Patients were matched by age, gender, and handedness to patients from previously published modified Jobe and docking cohorts. The following were compared among groups: Conway Scale, Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score, years played, gender, handedness, sport, position, graft type (for reconstructive techniques), future upper extremity injury, need for additional surgery, rates of ulnar nerve symptoms, and return-to-play time. Results: Patients were similar with respect to age ( P = .54), gender ( P = .66), handedness ( P = .29), sport ( P = .23), years played ( P = .72), level of competition ( P = .08), type of pathology ( P = .23), future shoulder surgery ( P = .71), and future elbow surgery ( P = .61). The mean ± SD follow-up was 6.2 ± 3.9, 7.3 ± 4.6, and 5.2 ± 1.1 years in the modified Jobe, docking, and repair + SA groups, respectively ( P = .66). The reconstruction groups had a greater proportion of pitchers than the repair + SA group ( P = .02). Tear locations in the SA cohort were proximal in 18 (75%) and distal in 6 (25%). In the SA cohort, 13 (54%) were partial tears, 10 (42%) were complete tears, and 1 (4%) was attenuated. The repair + SA cohort had a significantly greater proportion of proximal tears than the docking cohort ( P = .03). No difference was identified among techniques in results on the Kerlan-Jobe Orthopaedic Clinic score ( P = .70) or Conway Scale ( P = .06). The UCL repair + SA cohort returned to sports 4 months earlier than the reconstruction cohorts ( P = .0001). Conclusion: No differences in outcomes scores or return-to-play rates were found when the modified Jobe and docking UCL reconstruction techniques were compared with the UCL repair + SA technique at >5-year mean follow-up; however, the SA group returned to sport 4 months earlier on average. Given the similar outcomes among groups, all 3 techniques are viable treatment options for UCL injuries.

Background: Operative repair of partial proximal hamstring avulsions has been shown to improve pain and function at short- and midterm follow-up. Long-term outcomes have not yet been reported. Furthermore, it is unknown whether greater tendon involvement (ie, tendon number) in partial tears affects clinical outcomes. Hypothesis: Hamstring function and patient satisfaction would remain stable over time at minimum 5-year and mean 10-year follow-up, with no differences in outcomes when comparing isolated and combined tendon involvement. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent surgical repair of partial proximal hamstring avulsions refractory to nonoperative measures were included. Patient-reported outcome measures were completed and included the Lower Extremity Functional Score (LEFS), Marx Activity Rating Scale, custom LEFS, custom Marx, and total proximal hamstring score. Patient satisfaction, return to play, current sport participation, subjective strength, and postoperative complications were also recorded. Long-term outcomes were compared with midterm outcomes. Outcomes of isolated (semimembranosus or conjoint tendon) versus combined (semimembranosus and conjoint tendon) tendon injuries were also compared. Results: A total of 53 patients (57 hamstrings) met the inclusion criteria at a mean follow-up of 10.1 years (range, 5.1-16.2 years). The mean Marx score was 8.0 (range, 0-16), the custom Marx score was 95% (range, 15%-100%), the LEFS and custom LEFS were 90% (range, 22%-100%) and 83% (range, 19%-100%), respectively, and total proximal hamstring score was 89% (range, 19%-100%). In total, 91% of patients were satisfied with surgery and 95% of patients returned to sport at a mean of 11 months after surgery. Current participation in sport was endorsed by 86% of patients. Hamstring strength >75% compared with the contralateral leg was reported in 88% of patients, with 58% of patients reporting equal strength (100%). No differences were found in comparing long-term (mean 10.7 years) to midterm (mean 6.2 years) follow-up with the exception of decreases in the Marx score from 12.0 to 8.5 and custom Marx score from 100% to 95%. One case (1.7%) required revision due to acute reinjury at 4 months postoperatively, with other complications including sitting pain, occasional posterior thigh cramping, and posterior thigh or foot paresthesia. Conclusion: Surgical repair of partial proximal hamstring avulsions refractory to nonoperative measures led to successful outcomes and high rates of return to activities with low complications at mean 10.1-year follow-up, with no differences in outcomes comparing isolated versus combined tendon involvement.

Background: Previous surveys of the practice patterns for anterior cruciate ligament (ACL) reconstruction in collegiate and professional team physicians have shown bone–patellar tendon–bone (BPTB) autograft being the most common graft, with variable return-to-sports timing. Purpose: To evaluate the current practice patterns and return-to-sports timing of National Football League (NFL) head team physicians for ACL reconstruction. Study Design: Cross-sectional study. Method: All 32 NFL head team orthopaedic surgeons were surveyed and asked their primary ACL graft preference, revision ACL graft preference, use of lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALL), use of suture brace augmentation, return-to-sport timing, and whether functional testing was utilized in determining readiness of return to play. The years of experience of the physician were also evaluated. Results: All 32 head team physicians responded, with 31 (97%) using ipsilateral BPTB autograft in the primary setting and 1 using ipsilateral quadriceps autograft. In the revision setting, 24 (75%) physicians preferred a contralateral BPTB autograft, while 5 (16%) used an ipsilateral quadriceps autograft, 1 (3%) used a contralateral quadriceps autograft, and 2 (6%) used a BPTB allograft. One respondent (3%) used suture brace augmentation “most of the time” in the primary setting and always in the revision setting. No respondents utilized an ALL or LET in the primary setting and 2 (6%) respondents always performed an LET in revisions. Five others (16%) have performed at least 1 ALL or LET in an NFL athlete. Mean return to sports was at 9 months postoperatively, with no physicians allowing players to return before 7 months. All but 1 respondent used functional testing in return-to-sports decision-making. Conclusion: All but 1 of the 32 NFL head team physicians used BPTB autograft in primary ACL reconstruction. The majority preferred contralateral BPTB autograft in revisions, with a few considering extra-articular procedures or suture bracing in addition. On average, head team physicians allowed players to return at 9 months postoperatively, with none allowing return before 7 months. Nearly all utilized functional testing to aid in return-to-play decision-making. These homogenous findings in this high-risk and public athletic cohort aid in patient education and clinical decision-making for best treatment of ACL injuries, particularly in contact athletes.

Objectives: To determine if acromial morphology is associated with posterior or anterior shoulder instability as measured on MRI. Methods: MRI measurements of posterior acromial coverage (PAC), posterior acromial height (PAH), posterior acromial tilt (PAT), and anterior acromial coverage (AAC) were completed for three separate matched groups who underwent surgical intervention: posterior instability, anterior instability, and a comparison group of patients with who underwent arthroscopic surgery for snapping scapula. Inclusion criteria were patients with recurrent instability younger than 40 years of age without multidirectional instability, glenoid bone loss greater than 13.5% or glenoid retroversion greater than 10%. Results: Thirty-seven patients were included in each group. PAC was significantly less in the posterior instability group when compared to anterior and the comparison groups (68.3° vs. 88.7° vs. 81.7°, p<.001). PAH was significantly greater in the posterior group than compared to the anterior instability patients (11.0 mm vs -0.1 mm, p<.001) as well as the comparison patients (0.7 mm, p<.001). There was no difference between the posterior and anterior groups in terms of PAT or AAC (p=0.45, p=0.05). PAT was significantly smaller in the posterior instability group than the comparison group (55.2 degrees vs 62.2 degrees, p=0.026). The anterior and comparison groups were not significantly different in PAH or PAT (p=8.74, p=0.067) but were significantly different with AAC (p=0.26). Conclusions: The posterior acromion is significantly higher and flatter in patients with posterior shoulder instability who require arthroscopic capsulolabral repair when measured on pre-operative MRI. This information may help clinicians to both diagnose and predict the need for operative intervention for patients with posterior labral tears.

Background: Several studies have reported excellent results after surgical repair of proximal hamstring avulsions. However, the effect on these patients of receiving workers’ compensation has not yet been explored. Hypothesis: Workers’ compensation patients undergoing proximal hamstring repair of complete tears will have similar outcomes when compared with a matched control group of non–workers’ compensation patients. Study Design: Cohort study; Level of evidence, 3. Methods: Workers’ compensation patients who underwent complete proximal hamstring avulsion open repair between 2010 and 2019 were identified (WC group). A control group was matched by age (±3 years), sex, and body mass index (BMI; ±3). Demographics and patient-reported outcome measures were compared, including standard and custom Marx activity rating scale (MARS), standard and custom lower extremity functional scale (LEFS), and visual analog scale (VAS) for pain. Rate and time to return to work were recorded. Results: The WC group was composed of 20 patients (8 men, 12 women) with a mean age of 52.3 years and BMI of 32.4. The 20 matched controls (8 men, 12 women) who underwent repair had a mean age of 50.6 years and a mean BMI of 31.2. There was no difference between the groups regarding age ( P = .924), sex ( P > .999), or BMI ( P = .330). The WC group reported similar mean MARS (3.3 vs 5.4; P = .174), custom MARS (87.5 vs 97.0; P = .215), and VAS pain (3.3 vs 3.8; P = .698) scores compared with controls. However, the WC group had significantly lower standard LEFS (69.1 vs 94.1; P < .001) and custom LEFS (62.3 vs 87.9; P < .001) scores, returned to work at a lower rate (70.0% vs 94.1%; P = .039), and required more time to return to work after repair (4.3 vs 3.5 months; P = .029) compared with controls. Conclusion: Workers’ compensation patients who underwent open proximal hamstring repair for complete avulsions experienced inferior patient-reported outcomes, required more time to return to work, and returned to work at a lower rate than a matched control group.

Purpose: To evaluate and compare midterm outcomes and return to play (RTP) of throwers and nonthrowers who underwent type VIII SLAP repair. Methods: With 4‐year minimum follow‐up, stability, pain, range of motion (ROM), Kerlan‐Jobe Orthopaedic Clinic (KJOC), and American Shoulder and Elbow Surgeons (ASES) scores; surgical satisfaction; and RTP were compared between throwing and nonthrowing athletes who underwent repair of type VIII SLAP lesions between 2003 and 2014. Results: 46 patients (27 throwers and 19 nonthrowers) were included. The athletes were aged 24.2 ± 9.2 years at the time of surgery. The mean follow‐up period was 6.6 ± 2.0 years. A significant improvement in stability, pain, ROM, KJOC, and ASES scores was seen after surgery in both throwers and nonthrowers ( P < .05). When postoperative outcomes were compared, throwers had more pain ( P = .047), decreased ROM ( P = .03), lower KJOC scores (52.2 ± 24.0 in throwers vs 87.5 ± 18.8 in nonthrowers, P < .0001), and lower ASES scores (43.5 ± 7.1 in throwers vs 48.3 ± 3.0 nonthrowers, P = .02). There was no difference in stability ( P = .06), surgical satisfaction (96.3% in throwers vs 100% in nonthrowers, P > .99), or overall RTP (70.4% in throwers vs 94.7% in nonthrowers, P = .06). However, throwers were less likely to RTP at their preoperative level (37.0% in throwers vs 73.7% in nonthrowers, P = .02). Conclusions: Surgical repair of type VIII SLAP tears led to significant improvements in stability, pain, ROM, and outcome scores at midterm follow‐up. Compared with nonthrowers, throwers had significantly more pain, less ROM, and worse function. Throwers were also less likely to RTP at their preoperative level. These findings suggest that type VIII SLAP tears should be repaired in all athletes because outcomes do improve, although throwers require specific counseling and expectation management regarding their ability to RTP at their preinjury level. Level of Evidence: Level III, therapeutic case‐control study.