Arthroscopy Research Articles

Comparison of the clinical efficacy and prognosis of the two techniques for treating partial articular-sided supraspinatus tendon tears under arthroscopy

BackgroundAt present, shoulder arthroscopy is usually used for treatment of rotator cuff injuries. There is still debate over the precise technique of using shoulder arthroscopy to treat partial articular-sided supraspinatus tendon injuries.ObjectiveTo compare the clinical efficacy of the arthroscopic transtendon repair method and the arthroscopic full-thickness repair method in the treatment of patients with Ellman III partial articular-sided supraspinatus tendon tears and to analyze the influencing factors of postoperative efficacy.Study designCohort study; level of evidence,4.MethodsA total of 84 partial-thickness rotator cuff tear (PTRCT) patients with Ellman III injuries who underwent surgical treatment in our hospital between January 2017 and January 2020 were selected and divided into the arthroscopic trans-tenon repair group (32 cases) and the arthroscopic full-thickness repair group (52 cases). Shoulder joint pain and functional status were assessed by the Constant score, ASES score and VAS score; shoulder mobility was assessed by measuring shoulder ROM. The clinical outcomes of the two groups of patients were compared, and the factors affecting the postoperative efficacy of the patients were investigated.ResultsAll patients were followed up for at least 2 years. The Constant score, ASES score, and VAS score of the two groups of patients were all improved compared with those before surgery, and the differences were statistically significant (P < 0.05). There were no significant differences in the Constant score, ASES score, or VAS score between the two groups (P > 0.05). The results of binary logistic regression analysis showed that the preoperative ASES score and whether biceps tenotomy was performed were independent risk factors for satisfactory postoperative efficacy (P < 0.05).ConclusionFor patients with Ellman III partial articular-sided supraspinatus tendon tears, the arthroscopic transtendon repair method and the arthroscopic full-thickness repair method can both significantly improve the shoulder pain and function of the patient, but there is no significant difference between the efficacy of the two surgical methods. The preoperative ASES score and whether biceps tenotomy was performed were independent risk factors for satisfactory postoperative efficacy in PTRCT patients with Ellman III injury.

Effect of noise on the performance of arthroscopic simulator

BackgroundNoise is omnipresent in the operating room. The average noise in the operating room generally ranges between 60 and 65 dB and can sometimes exceed 100 dB, despite the ARS (Agence Régionale de Santé) and WHO (World Health Organization) recommending levels of 35 dB(A). This study aimed to evaluate the effect of different kinds of background auditory stimuli on the performance of surgeons during an arthroscopic simulation task. MethodsForty-seven surgeons with varying experience in arthroscopic surgery undertook different exercises under four different conditions: quiet, classical music, hard rock, and sustained chatter. All background auditory stimuli were set at 65 dB(A). Each participant underwent double randomization for the four sound stimuli and the four exercises to be performed. A musical questionnaire was also completed by each participant. Data related to each exercise included operating time in seconds, distance from the camera or instruments in centimeters, and an overall score automatically calculated by the simulator based on safety, economy of movement, and speed (scale: 0–20 points). ResultsOperative time in an environment with classical music was significantly lower than in an environment with hard rock (95.9 s vs. 128.7 s, p = 0.0003). The overall rating in an environment with chatter was significantly lower than in a silent environment (11.7 vs. 15.7, p < 0.0001). The overall rating in an environment with hard rock was significantly lower than in an environment with classical music (14.3 vs. 17.5, p = 0.0008).Surgeons who preferred listening to music in the operating room performed differently than those who did not. The mean operative time for surgeons who preferred music was 99.52 s (SD = 47.20), compared to 117.16 s (SD = 61.06) for those who did not prefer music, though this difference was not statistically significant (p = 0.082). The mean overall score for surgeons who preferred music was significantly higher at 17.46 (SD = 2.29) compared to 15.57 (SD = 3.49) for those who did not prefer music (p = 0.001). ConclusionsOur study suggests that exposure to classical music and silence may confer greater benefits to the surgeon compared to the impact of hard rock and chatter. These conclusions are grounded in significant differences observed in operative time and overall evaluations, highlighting the potential advantages of an environment characterized by acoustic tranquility for surgical professionals. Preferences for music in the operating room also play a role, with those who prefer music demonstrating better performance scores.

Treatment of massive irreparable rotator cuff tears by different surgical technigues: comparative analysis of early outcomes

Background. Massive rotator cuff tears are up to 40% and can progress to the stage of irreparable ones. Nowadays, there are many treatment options available for irreparable rotator cuff injuries, from conservative treatment and arthroscopic reconstructions to reverse shoulder arthroplasty. Currently, the comparative effectiveness of various treatment methods remains uncertain, and therefore there is no clear algorithm for choosing treatment tactics of such orthopedic shoulder pathologies. The aim of the study is to compare short-term treatment outcomes of patients with irreparable rotator cuff tears using arthroscopic partial rotator cuff repair, latissimus dorsi tendon transfer, pectoralis major tendon transfer and reverse shoulder arthroplasty. Methods. The study enrolled 75 patients who underwent the following types of surgical interventions: partial arthroscopic repair, posterior and anterior arthroscopically assisted latissimus dorsi tendon transfer, pectoralis major tendon transfer and reverse shoulder arthroplasty. Treatment results were assessed using measurements of the range of active movements in the shoulder joint, the ASES and Constant-Murley Score (CMS) questionnaires, the Visual Analog Scale (VAS), assessment of radiographs and MRI. The assessments were performed preoperatively and at 6 and 12 months after surgery. Results. In all groups, there was a statistically significant improvement by all indicators (p0.05). Clinical and functional results at the short-term follow-up after partial rotator cuff repair and various options of latissimus dorsi tendon transfer are largely comparable, while at the same time superior to the results of reverse shoulder arthroplasty and pectoralis major tendon transfer. Conclusions. The use of partial rotator cuff repair and musculotendinous transfers at the short-term follow-up gives comparable and better results in comparison with the use of reverse shoulder arthroplasty, which allows to consider “joint-preserving” interventions as an option in patients with massive irreparable rotator cuff tears.

Robotic Assistance and Haptic Feedback in Arthroscopic Procedures: Design and Preliminary Evaluation of a Two-Arm System

Robot-assisted arthroscopic surgery has been receiving growing attention in the field of orthopedic surgery. Most of the existing robot-assisted surgical systems in orthopedics place more focus on open surgery than minimally invasive surgery (MIS). In traditional arthroscopic surgery, the surgeon needs to hold an arthroscope with one hand while performing the surgical operations with the other hand, which can restrict the dexterity of the surgical performance and increase the cognitive load. On the other hand, the surgeon heavily relies on the arthroscope view when conducting the surgery, whereas the arthroscope view is a largely localized view and lacks depth information. To assist the surgeon in both scenarios, in this work, we develop a two-arm robotic system. The left-arm robot is used as a robot-assisted arthroscope holder, and it can hold the arthroscope still at a designated pose and reject all other potential disturbances, while also allowing the operator to move it via a pedal switch whenever needed. The left-arm robot is implemented with an impedance controller and a gravity iterative learning (Git) scheme, where the former can provide compliant robot behavior, thus ensuring a safe human–robot interaction, while the latter can accurately learn for gravity compensation. The right-arm robot is used as a robot-assisted surgical tool, providing virtual fixture (VF) assistance and haptic feedback during the surgery. The right-arm robot is implemented with a point-based VF algorithm, which can generate VF directly from point clouds in any shape, render force feedback, and deliver it to the operator. Furthermore, the VF, the bone, and the surgical tool position are visualized in a 3D digital environment as additional visual feedback for the operator. A series of experiments are conducted to evaluate the effectiveness of the prototype. The results demonstrate that both arms can provide satisfactory assistance as designed.

Dexmedetomidine versus Dexamethasone as Adjuvant to Bupivacaine in Fascia Iliaca Block in Knee Arthroscopy for Postoperative Pain

Abstract Background Knee arthroscopy is one of the most frequently performed interventions in orthopedic surgery that is commonly performed on a day-case basis. It allows the diagnosis and management of a wide range of knee problems without making a large incision, thus decreasing soft tissue trauma. However, postoperative pain is a common upsetting symptom following arthroscopic knee surgery that if inadequately treated, leads to prolonged duration of the functional rehabilitation of the knee, recovery time and the length of hospital stay thus a significant increase in the medical care costs. Aim of the Work To compare the adjuvant effect of adding dexmedetomidine and/or dexamethasone to bupivacaine while using facsia iliaca block for knee arthroscopy and their efficacy in achieving postoperative analgesia. Patients and Methods The type of study was a prospective double – blinded randomized controlled Trial conducted in Ain Shams University hospitals, Cairo, Egypt at 6 months. Patients aged 20 to 60 years scheduled for elective knee arthroscopy under spinal anesthesia were included to receive FICB. Results In general, there was no significant difference between the three study groups regarding general patient characteristics as well as operative time. That ensured proper randomization conducted between our study groups. Additionally, that should nullify any bias that may have skewed the results in favor of one group rather than another one. There was statistically significant difference between groups according to heart rate from after 2hrs to after 24hrs this was also observed while measuring the systolic blood pressure and diastolic blood pressure but there was no significant difference between group B and C. Conclusion Our study shows that adding Dexmedetomidine and/or Dexamethasone (8mg) to Bupivacaine for FICB significantly prolonged the duration of block and decreased the requirement of rescue analgesics as compared to patients who received Bupivacaine alone. FICB is relatively easy and safe to perform. In our study we did not encounter any complication while doing the procedures and also by adding dexmedetomidine and/or dexamethasone (8mg).

Arthroscopic repair of Non Traumatic Small to Medium Sized Full Thickness Rotator Cuff Tears with and without Acromioplasty

Abstract Background The shoulder joint has the greatest range of motion of any other joint. Pain of the shoulder joint is very common and accounts for about 16% of musculoskeletal disorders taking the third place after spine and knee. Rotator cuff disorders including degeneration or tear are most common causes of chronic shoulder pain. Causes of rotator cuff tear (RCT) still unclear and occur as a result of many factors. As degenerative changes of the rotator cuff that occur in old age increase the risk of rotator cuff tear also overhead workers and athletes considered a risk factor. Objective To evaluate the role of acromioplasty in arthroscopic repair of small to medium sized full thickness tear of rotator cuff according to the complication rate, the active range of motion and the function scores of the shoulder to add surgeons in deciding whether acromioplasty must be done routinely during arthroscopic repair of rotator cuff or not. Patients and Methods During the period between February 2019 and May 2022, A Prospective, Randomized Controlled Clinical trial was conducted in Ain Shams University hospital in Cairo. This study was designed to involve 36 cases with symptomatic small to medium sized RC tear, the patients were separated into two groups of 18. Group A comprised those applied with arthroscopic rotator cuff repair, bursectomy and antero- inferior acromioplasty. In Group B, arthroscopic rotator cuff repair was applied with bursectomy only and no acromioplasty. Each patient in this study was carefully assessed clinically by taking a detailed medical history and adequate clinical examination. Results There was a significant difference between the pre-operative and post-operative ASES score, WORC score and ROM but according to postoperative evaluation regarding ASES score, WORC score and ROM there was no statistically significance between the group of acromioplasty and the group of non-acromioplasty. Regarding complications, 3 cases of study population (36) cases were complicated, one case in group A (frozen shoulder) and 2 cases in group B (frozen and revision). With respect of the literature, the results were comparable to that of the literature as regard the functional outcome and complication rate. Conclusion The result of this study showed that there may be no need for routine application of acromioplasty during arthroscopic rotator cuff repair as it has concerns being less cost effective. We acknowledge that the cost was not assessed in our study. However, they are intuitive. Also, more long term follow up studies are required to assess the incidence of retear in rotator cuff repair without-acromioplasty as controversy is still present in the literature.

A Comparative Study between Sub-sartorial Canal Block and Femoral Nerve Block for Postoperative Analgesia after Arthroscopic Knee Surgery

Abstract Background Knee arthroscopy is a common orthopedic procedure worldwide, despite its minimally invasive nature compared to the traditional knee surgery, post-arthroscopic pain may be severe, and the patients generally require a significant amount of opioid-based analgesics after such procedures. Femoral nerve block (FNB) is commonly used for analgesia inpatients undergoing knee or ankle surgery. Aim of the Work The aim of the study is to compare the analgesic efficacy and functional recovery of ACB and FNB in patients who have undergone knee arthroscopy. Patients and Methods In the period from April 2021 to October 2021 sixty patients who underwent Arthroscopic knee surgery were randomly allocated to one of two groups and comparative study was done. Group I (group FNB): patients received Femoral Nerve Block (FNB) after spinal anaesthesia, group II (group ACB): Patients received Sub-sartorial canal block (Adductor Canal Block) (ACB) after spinal anaesthesia. After the end of the surgery, the femoral nerve block or adductor canal block will be performed according to patient group allocation. Results During our study, it was found that ACB is equally effective with FNB in patient satisfaction for post operative analgesia (NRS at 4 hrs, 8 hrs, 12 hrs, 16 hrs, 20 hrs and 24 hrs was non-significant as P value was 0.3, 0.29, 0.1, 0.5, 0.35, 0.87 respectively) but ACB is more effective than FNB in post operative ambulation and rehabilitation after arthroscopic knee surgery (ACB ambulated after 180.7 ± 23.6 mins in ACB and 241.2 ± 29.12 mins in FNB with pvalue &amp;lt;0.001). Numerous studies compared adductor canal block with femoral nerve block in motor power and analgesia. Conclusion Our study concluded that Adductor Canal Block is more effective than Femoral Nerve Block in post operative ambulation and equally effective with Femoral nerve block in patient satisfaction for post operative analgesia after arthroscopic knee surgery.

45 Skin Preparation in Arthroscopic Surgery – Are There Environmental Savings to Be Made?

Abstract Background The environmental impact of surgery is concern that has been raised in recent years. Operating theatres have been found to create up to 230kg of waste per day. There is a need to reduce surgical waste whilst maintaining patient safety. This study assessed the waste and CO2 production associated with two accepted skin preparation techniques. Method Groups consisted of two consultant surgeons, both performing 5 arthroscopic procedures. Surgical skin preparation was performed with disposable ChloraPrep™ sticks or bottled Hydrex 0.5% solution with red dye. Annual waste and CO2 production was assessed via modelling. Results The disposable group generated a total of 876g of net waste compared to 1727g in the solution group. Waste per surgical case was 134.6g (SD 14.97) in the disposable group compared to 328.8g (SD 86.09) in the solution group. The disposable group produced significantly less waste than the solution group (P &amp;lt;0.0069). In 2022, a total of 514 arthroscopies were performed at our institution (134 shoulder, 380 knee). Modelling using the research group data provided estimated annual waste in both groups; 225.132kg in the ChloraPrep™ stick group compared to 443.839kg in the Hydrex 0.5% solution group, with Kg CO2 production of 241.79-701.57 Kg and 476.68-1383.13 Kg in each group respectively. Conclusions This study demonstrates that choice of skin preparation in arthroscopy can significantly reduce waste and CO2 production, without a significant increase in cost.

Impact of Intrathecal Dexmedetomidine versus Intrathecal Fentanyl as Adjuvants to Bupivacaine on Post Spinal Urinary Retention in Knee Joint Arthroscopic Surgeries

Abstract Background Patients undergoing orthopedic surgery are prone to developing postoperative urinary retention (POUR). They have an estimated relative risk of 8% to 55% higher than other surgical patients. This inability to void increases patient’s risk of urinary tract infections (UTIs) and bacteremia, and can lead to chronic voiding difficulties due to bladder architecture alterations. A great degree of variability exists among studies describing the prevalence and risk factors of postoperative urinary retention and its management strategies. Objective To compare the effects of Dexmedetomidine or Fentanyl added to intrathecal bupivacaine in knee arthroscopic procedures in terms of the occurrence of postoperative urinary retention. Patients and Methods This prospective randomized clinical study was conducted at tertiary care hospital at Ain Shams University hospitals from September 2021 till Mars 2022 and performed on a total of 70 patients who assigned for knee joints orthoscopic surgery. Results The current study results revealed that the incidence of postoperative urine retention in dexmedetomidine group was 5.7% while was 28.6% in Fentanyl group, the difference was statistically significant. however, the need to postoperative urinary catheterization was statistically non-significantly among the two groups. The current study results revealed that the Time to achieve maximum block was significantly shorter in dexmedetomidine group and the duration of motor block statistically was significantly longer in dexmedetomidine group. Conclusion On the basis of current evidence, when compared to fentanyl, our study revealed that intrathecal dexmedetomidine, as adjuvant to local anesthetics for intrathecal injection, can statistically significantly prolong the duration of sensory and motor block, as well as the pain free period, meanwhile significantly reducing the incidence of urinary retention. Intrathecal dexmedetomidine seems to be an attractive alternative as an adjuvant to spinal bupivacaine in surgical procedures, especially those requiring long time. It has excellent quality of postoperative analgesia with minimal side effects.

Dexmedetomidine vs. Propofol: Haemodynamic Changes in Conscious Sedation in Arthroscopic Shoulder Surgery in the Beach Chair Position: A Randomized Control Trial

Background: Interscalene brachial plexus block (ISB) combined with conscious sedation is a viable alternative to general anaesthesia for arthroscopic shoulder surgery in the beach chair position. The purpose of the trial was to compare the haemodynamic instability and safety of Dexmedetomidine vs Propofol for conscious sedation in arthroscopic shoulder surgery in the beach chair position. Method: A single-blinded prospective randomized trial was conducted in 56 patients randomly allocated into Dexmedetomidine and Propofol groups for conscious sedation following ISB placement. The primary outcome was to measure intraoperative haemodynamic variations (systolic blood pressure, mean arterial pressure, heart rate) in the two groups maintaining adequate conscious sedation during arthroscopic shoulder surgery in the beach chair position. Results: In the dexmedetomidine group a significantly higher percentage of systolic blood pressure (21.86 𝑣𝑠 10.81%, p = 0.001, 𝑑 = 1.05) and a higher percentage heart rate (18.52 vs 9.02%, p = 0.002, 𝑑 = .98) drop from baseline measurements was noted. A large (d ≥ 0.8) Cohen’s effect size suggested the high practical significance of the finding. Perioperative hypotensive (f=19, p&lt;0.001) and bradycardic (f=21, p=0.003) episodes were significantly more frequent in the dexmedetomidine group. The propofol group had a greater incidence of airway complications requiring intervention (f=6 vs f=0, p=.023). Conclusion: Dexmedetomidine leads to significant blood pressure and heart rate reductions from baseline values in the beach chair position providing controlled hypotension and has minimal airway complications in patients undergoing arthroscopic shoulder surgery in the beach chair position under ISB and conscious sedation compared to Propofol.

Poster 385: Incidence of Preoperative Depression in Knee and Shoulder Arthroscopy Using Patient Health Questionnaire-2 (PHQ-2)

Objectives: Preoperative depression has been associated with worse outcomes following orthopaedic surgery including lower patient-reported outcomes, increased pain and impairment, and a higher rate of complications. Patient Health Questionnaire-2 (PHQ-2) is a commonly administered screening tool for measuring depressive symptoms, however the relationship between PHQ-2 and preoperative characteristics of patients presenting for arthroscopic knee and shoulder surgery have not been established. The purpose of this study was to investigate the association between depression and preoperative demographics and patient recorded outcomes of patients presenting for arthroscopic knee and shoulder surgery. Methods: This retrospective chart review evaluated data from all patients who underwent elective primary arthroscopic shoulder and knee surgery at 1 health system. Current Procedural Terminology codes were used to identify patients undergoing anterior cruciate ligament reconstruction (ACLR) (29888), meniscectomy (29880/29881), meniscus repair (29882/29883), knee chondroplasty (29877), labral repair (29807), rotator cuff repair (29827), and capsulorrhaphy (29806). Patients were included if they had completed Patient-Reported Outcomes Measurement Information System - Pain Interference (PROMIS-PI) and a PHQ-2 score at least 3 months prior to their surgery. The PHQ-2 is a validated tool used to screen for depression with scores ranging from 0-6. Patients were categorized as either depressed (PHQ-2 ≥ 3) or non-depressed (PHQ-2 &lt; 3). Demographic characteristics and PROMIS scores were compared and a univariate and multivariate regression analysis was performed. Results: A total of 979 patients were included with 128 (13%) depressed patients and 851 nondepressed patients. There was no significant differences between the depressed and nondepressed group for age (49.18 ± 16.13 vs. 49.01 ± 15.71; P=0.926), sex (53.1% vs. 47.8% female; P = 0.263), median household income ($65,230 ± $24,684 vs. $66,810 ± $22,414; P=0.463), area deprivation index national percentile (62.48 ± 24.31 vs. 64.12 ± 24.58; P = 0.494), and depression diagnosis (4.7% vs. 3.1%; P = 0.333). Preoperative PROMIS-PI was significantly worse in the depressed cohort versus non-depressed (66.1 ± 5.9 vs. 63.6 ± 6.3; P &lt; 0.001). Preoperative PROMIS-Depression score (R2 = 0.34) was the highest correlated variable to preoperative PHQ2 score in the univariate analysis. In the multivariate regression analysis, higher preoperative PROMIS-PI scores were found to be a risk factor for a PHQ2 score &gt;3 (P &lt; 0.001). Patients undergoing knee chondroplasty were less likely to be in the depressed cohort (odds ratio: 0.092 (0.009-0.914); P = 0.042). No other surgeries were more or less likely to be depressed. There was no difference between groups for age, sex, smoking status, insurance type, Area Deprivation Index, Metabolic Health Index, comorbid depression, and anxiety diagnosis. Conclusions: Overall, a larger number of patients screened positive for depression amongst patients undergoing knee and shoulder arthroscopy than were formally diagnosed. Demographic and socioeconomic variables were similar indicating these patients may be hard to identify without a screening tool like PHQ-2. Preoperative pain scores were higher amongst the depressed patients, indicating higher pain scores may be associated with increased risk of depression. This study highlights the need for further research on preoperative mood screening before arthroscopic surgery.

Poster 244: Magnetic Resonance Imaging versus Diagnostic Arthroscopy to Identify Intraarticular Pathology Associated with Patellar Instability: A High Rate of Discordant Findings Altering Surgical Treatment

Objectives: While uncommon, acute traumatic patellar dislocations can lead to recurrent symptoms of patellar instability in 15% to 45% of patients. Patellar stability is an interplay of bony and soft tissue restraints as well as anatomic factors, however, a mainstay of treatment remains reconstruction of the medial patellofemoral ligament (MPFL). Instability events can lead to intra-articular derangements of the knee, both in the acute and chronic patellar instability setting. These findings may not always be appropriately identified on magnetic resonance imaging (MRI). The incidence of these “surprise” injuries have not been previously reported. The purpose of this study is to determine the rates of coexisting intra-articular pathology in patients with patellar instability requiring MPFL reconstruction and elucidate any discordance between preoperative MRI findings and diagnostic arthroscopy findings. Methods: All patients undergoing MPFL reconstruction at a single institution between 2010 and 2023 were identified and preoperative MRI reports, defined as the most recent MRI report to the date of surgery with no interval traumatic events, were queried. Records without full MRI reports as read by a radiologist or cases in which a diagnostic arthroscopy was not conducted were excluded. MRI findings were discordant from arthroscopic findings if a lesion identified on diagnostic arthroscopy was not present in the full MRI report. Procedures that were undertaken because of these missed pathologies on MRI were recorded. Results: A total of 640 patients were identified during the study period, and 507 complete records were ultimately included. Preoperative MRI identified patellar osteochondral lesions or cartilage fissures in 333 patients (66%), loose bodies in 119 patients (24%), lateral femoral condyle osteochondral lesions or fissures in 97 patients (19%) and meniscus tears in 47 patients (9%). Among these patients, 172 (34%) had a diagnosis at the time of arthroscopy which was not identified on the preoperative MRI. These arthroscopic findings resulted in 75 loose body removals, 74 patellar shaving chondroplasties, 16 partial meniscectomies, 3 microfractures, 3 osteochondral lesion open reduction internal fixation, and 2 meniscal repairs which would have been missed without diagnostic arthroscopy due to discordant MRI findings. Conclusions: Over one-third of patients at a single institution who underwent diagnostic arthroscopy in the setting of patellar instability surgery had pathology identified which required surgical intervention that was not reported on a preoperative MRI. A comparison of MRI and diagnostic arthroscopy has been extensively reported on for other knee pathologies including ACL tear and lateral meniscal tear; however, there has been no similar investigation of the reliability of MRI for identification of concomitant pathology in the setting of patellar instability to date. The findings of this study highlight the importance of diagnostic arthroscopy in the treatment of patellar instability, the frequency with which this altered treatment, and the high preponderance of discordant MRI findings.

Poster 160: Preoperative MRI Underestimates Shoulder Labral Injuries Compared with Diagnostic Arthroscopy

Objectives: To compare the overall agreement in the magnitude of shoulder labral injuries between preoperative MRI and assessment at the time of diagnostic arthroscopy. Methods: A retrospective chart review was performed of patients undergoing primary arthroscopic labral repair procedures between February 2018 and February 2023. Exclusion criteria included prior ipsilateral shoulder surgery, MRI study performed at outside health system, and incomplete documentation of labral tear location. Age, gender, and dates of injury, imaging, and surgery were recorded. Radiology and operative reports were reviewed to record the location and extent of the labral tear using conventional clock-face coordinates. Tear locations were further classified as either anterior (2-6 o’clock), posterior (6-10 o’clock), or superior (10-2 o’clock). MRI studies were performed by 1.5-Tesla scanner and all radiology reports were performed by fellowship-trained musculoskeletal radiologists at a single health system. Subgroup analysis of labral tear size on radiology interpretation was performed between MRI arthrogram (MRA) and conventional MRI studies. Results: A total of 138 subjects (mean age 25.8 years, 73% male) met criteria for inclusion in this study. Of the included subjects, 105 underwent MRI arthrogram and 33 underwent conventional MRI studies. The average time from initial injury to MRI was 153.4 days and the average time from MRI to surgical intervention was 66.8 days. The average total recorded labral tear size in clock-face coordinates was significantly greater on diagnostic arthroscopy compared with the radiologist MRI interpretation (4.4 vs 3.6, p&lt;0.01). The average labral tear size in the posterior region was also significantly greater on diagnostic arthroscopy (2.4 vs 1.6, p&lt;0.01). The average labral tear size in the anterior (2.5 vs 2.2, p=0.08) and superior (1.6 vs 1.5, p=0.29) regions was greater on diagnostic arthroscopy but did not reach statistical significance. The difference in total and posterior tear size remained significant in both the arthrogram and conventional MRI subgroups. Subjects undergoing MRI arthrogram had a significantly greater reported size of anterior labral tears in clock-face coordinates compared with conventional MRI (2.7 vs 2.0, p=0.03), but did not reach significance for the posterior (p=0.40), superior (p=0.31), and the overall global labrum (p=0.29). Conclusions: MRI significantly underestimate the overall size of labral tears in setting of shoulder instability, particularly in the posterior labrum. Surgeons should account for potential underestimation of true labral injury during preoperative planning for surgical management of shoulder instability.

Poster 153: Decreased Coracoid Index in Patients with Recurrent Instability after an Arthroscopic Bankart Procedure: A Retrospective Analysis with a Mean Follow-Up of 12.9 Years

Objectives: Traumatic anterior shoulder instability is a common sports medicine pathology, disproportionally affecting competitive, contact athletic and military populations. Currently, arthroscopic Bankart repair is the gold standard for managing patients with anterior instability and associated labral injury with subcritical bone loss. However, recurrent instability remains common after the index operation, with rates between 5% and 20% reported in the literature. Multiple prognostic calculators and scoring indices have been developed in attempts to proactively determine which cohorts may benefit from a bony (Latarjet or free bone graft) or soft tissue (Remplissage) augmentation procedure to further stabilize the joint and decrease the risk of recurrence. Importantly, there has been a growing appreciation for the effects of coracoid process morphology on shoulder pathology, including subcoracoid impingement and subscapularis tears. However, there is a paucity of literature exploring the effect of coracoid morphology on anterior shoulder instability. Therefore, the purpose of this study was to compare known osseous risk factors for recurrent instability, as well as the coracoid index, between patients with and without recurrent instability after an arthroscopic Bankart repair, and to compare long-term outcomes between the 2 cohorts. Methods: Following institutional review board approval, a retrospective cohort comparison of patients with anterior glenohumeral instability treated at a single academic military medical facility was performed. After identifying the initial cohort, patients were invited to complete Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) surveys. Inclusion criteria included symptomatic anterior shoulder instability, surgical treatment with arthroscopic Bankart repair, and survey completion. Preoperative MRIs were obtained, and glenoid bone loss, Hill-Sachs interval, and coracoid index were quantified. Patients with recurrent instability at last follow up were age-matched in a 1:2 ratio for comparison with those without recurrent instability. Subsequently, unpaired two-tailed t tests were used to compare anatomic morphologies and patient-reported outcome measures (PROMs) between the 2 cohorts. Finally, linear regression was used to evaluate the relationship between the anatomic measurements and PROMs. Results: At a mean of 12.9 years follow-up, 12 patients were confirmed to have recurrent shoulder instability by survey and chart review and were age-matched to 24 patients without recurrent instability (n = 36; mean age 26.0 ± 5.2 years). Patients with recurrent instability after arthroscopic Bankart repair had lower coracoid indices (by 3.28 ± 1.55 mm; p = .0412), greater glenoid bone loss (by 6.67 ± 1.62%; p = .0002), and larger Hill-Sachs Intervals (by 5.88 ± 2.30 mm; p = .0153) on preoperative MRI. The cohort with recurrent instability had lower SANE scores (by 38.0 ± 9.1; p = .0002), and higher WOSI scores (by 692 ± 174; p = .0003) at final follow-up. Coracoid index, glenoid bone loss and Hill-Sachs interval were not correlated with PROMs at latest follow-up (p &gt; 0.05). Conclusions: To our knowledge, this is the first study to assess coracoid morphology in a cohort of patients with symptomatic shoulder instability. The current study findings suggest that a more laterally-projecting coracoid may be protective against recurrent shoulder instability after an arthroscopic Bankart repair. In accordance with recent literature, the recurrent instability cohort had greater glenoid bone loss and larger Hill-Sachs lesions on their index pre-operative MRI and had worse subjective outcomes at latest follow-up. As the shoulder is a complex joint with static and dynamic stabilizers, it is important to understand the effects of anatomic variation on pathoanatomy, as well as patient symptomatology. These preliminary findings highlight the need for further large cohort studies investigating the role of coracoid morphology on shoulder stability. A clearer understanding of the anatomic risk factors for recurrent instability will improve surgical planning and decision making, as well as minimizing time missed from athletic activities or military service.

Paper 23: Functional Stability Testing and Athletic Shoulder Performance Testing Higher in Patients Able to Return to Sport Following Arthroscopic Shoulder Stabilization

Objectives: There is a paucity of literature on return to sport functional testing following arthroscopic labral repair for shoulder instability leading to uncertainty of when it is safe to return to sport. Currently, the most commonly used evaluation metrics are time after surgery and less commonly range of motion and strength of operative extremity. There is currently no validated return to sport testing protocol after arthroscopic labral repair. The aim of this study was to compare elements of a proposed return to sport battery for those undergoing arthroscopic Bankart repair between those able to return to play and those who were not able to by 6 months. Methods: All patients who participated in athletics who underwent arthroscopic labral repair for shoulder instability from June 2021 to December 2022 with a fellowship trained orthopedic surgeon were eligible to participate. Study protocol was to undergo functional testing at 4 months post operatively and every 2 months thereafter until cleared for athletics. Functional testing included Closed Kinetic Chain Upper Extremity Stability Test (CKCUES), Posterior Shoulder Endurance Test (PSET), Strength via handheld dynamometry at various range of motion positions. The Athletic Shoulder Test (ASH) has two components- peak force in I, T, Y position (PEAK), and rate of force development in I, T, Y position (RATE). Absolute value as well as limb symmetry index (LSI) were compared. For each test, passing was determined to be greater than 90% symmetry with contralateral extremity. Tests that had a greater than 20% difference in pass rates between the not return to play group (NRTP) and the return to play (RTP) groups were considered to be predictive. Results: Overall, 22 patients with at least 6 months of follow up, completed functional testing battery, and cleared to return to play were included. Mean age was 19.8 years (range 11-44 years), with 12 males and 10 females, and the mean follow up was 11 months (6-24 months). Seventeen returned to play (RTP) at mean 6.3 months (range 4.5-23.1), five did not to return (NRTP). Mean SANE score was higher in RTP vs NRTP, 61 (range 25-95) vs 86.7 (60-100), p=0.03). Those that returned to sport met a mean of 6.25 of the 12 criteria at 4 months compared to 4.20 of those that did not return to sport (p-value = .22). At 4 months, RTP group passed several tests at higher rates than NRTP group - CKCUES (78% vs 0%), PEAK (62.5% vs 20%), RATE (50% vs 0%), and Shoulder Flexion strength (88.9% vs 50%). Other strength measurements were not significantly different between groups. Conclusions: CKCUES and ASH (PEAK and RATE) performance testing criteria were significantly higher at 4 months in patients who are able to eventually be cleared to return to sport compared to those that are not able to. Traditional strength testing did not demonstrate differences between groups. Therefore, we recommend that CKCUES testing and ASH testing with force plates should be incorporated in functional testing as early as 4 months.

Good clinical outcomes and low recurrence rate in patients undergoing arthroscopic revision Latarjet for failed arthroscopic Bankart repair

BackgroundThe role of arthroscopic Latarjet stabilization after failed arthroscopic Bankart repair has yet to be definitively established and merits further investigation. ObjectiveTo assess clinical and radiological outcomes after arthroscopic Latarjet stabilization as a revision procedure for failed Bankart repair, as well as the return to athletic activity and complication rates. MethodsBetween 2009 and 2020, patients with a previous failed arthroscopic Bankart repair who were treated with an arthroscopic Latarjet were retrospectively evaluated. Clinical outcomes at a minimum of 24 months postoperatively included Rowe score, Western Ontario Shoulder Instability Index (WOSI), Constant-Murley Shoulder Outcome score (CS), and Single Assessment Numeric Evaluation (SANE). Dislocations, subluxations, complications, pre and postoperative level of activity and degree of osteoarthritis were also assessed. ResultsA total of 77 patients, mean age at revision surgery 31.2 ± 9.1 and with either one (n = 59), two (n = 13), or three (n = 4) arthroscopic previous stabilizations underwent revision surgery using arthroscopic Latarjet procedure were studied. Postoperatively, the mean ROWE and CS scores increased from 41.8 ± 16 to 90.7 ± 14.3 (p<0.001) and from 50.5 ± 13.8 to 90.5 ± 10.3 (p<0.001), respectively. WOSI decreased from 1247 ± 367.6 to 548.9 ± 363 at the final follow-up (p<0.001). After a mean follow-up of 39.6 ± 23.1 months, 64 shoulders (83.1%) were subjectively graded as good to excellent using SANE score. Grade 1, 2, and 3 osteoarthritis, according to Ogawa et al were found in 18 (23.4%), 6 (7.8%), and 3 (3.9%) shoulders, respectively. Six dislocations after revision surgery were reported (7.8%). In four failed cases an Eden-Hybinette procedure was conducted and in remaining two patients an arthroscopic extraarticular anterior capsular reinforcement was performed. Significantly decreased level of athletic activity was observed postoperatively (p= 0.01). ConclusionsArthroscopic Latarjet for revision of failed arthroscopic Bankart repair provides satisfactory patient-reported subjective outcomes with low rate of recurrences and complications. However, decreased level of athletic activity is expected.

Poster 108: Arthroscopic Posterior Labral Repair Patients Experience Less Instability Events and Full Dislocations Yet Are More Commonly Male Contact Athletes that Require Concomitant Procedures When Compared to Arthroscopic Anterior Labral Repair Patients

Objectives: Direct comparisons between the direction of shoulder instability as it pertains to clinical and demographic risk factors are lacking. The purpose of this study is to identify and compare demographic, clinical, and peri-operative variables in patients receiving arthroscopic treatment for anterior and posterior shoulder instability. Methods: A retrospective chart review was performed for consecutive patients who underwent primary arthroscopic labral repair surgery for anterior and posterior shoulder instability with a minimum 2-year follow-up. Surgeries were performed by six surgeons at a single institution between 2012-2020. Patients with prior shoulder instability surgeries of any kind were excluded. Demographics and operative variables included sex, body mass index (BMI), Contact/collision sports, tobacco use, ASA grade, number of dislocations (&lt;1, 1, 2, &gt;2), tear size (120, 240, and 360 degrees), age, time from first dislocation to surgery, number of anchors, and concomitant procedures. Study groups were compared using student’s t-tests and Mann-Whitney U test for continuous variables and Chi-Square or Fisher’s Exact tests for discrete variables with a significance of 0.05. Results: Five hundred and twenty-four (524) patients met inclusion criteria. Overall, there were 133 females (25.4%) and 291 males (74.6%) with a mean age of 27.1 years at the time of surgery (SD ± 9.9) and a BMI of 26.6 (SD ± 5.6). Posterior instability patients were less likely to have experienced a dislocation (15.1% without prior dislocation) than patients with anterior instability (3.4%). Additionally, posterior instability patients that did experience a dislocation (22.6%) were less likely to have greater than two dislocations when compared to anterior instability patients (53.6%). Posterior instability was more frequently associated with males (85%), higher BMI (mean = 28.25), and contact/collision sports (41%). Posterior instability patients were more likely than anterior instability patients to have concomitant procedures performed at the time of labral repair, including capsular plication, (31.6%) biceps tenodesis (14%), and distal clavicle excision (8.8%). Lastly, posterior instability patients typically required fewer anchors (3.4) than anterior instability patients (3.98) at the time of labral repair. Conclusions: Despite having fewer instability events or dislocations, patients that receive a posterior labral repair are more likely to have additional injuries in their shoulder requiring treatment when compared to patients that have received an arthroscopic anterior labral repair. Interestingly, posterior labral repair patients are more commonly male, and contact athletes, as well. With posterior shoulder instability being less common, we speculate that these findings could correlate with a more significant amount of energy/mechanism involved when a shoulder does dislocate posteriorly, thus leading to injuries to additional shoulder structures. It also correlates with the repetitive microtrauma mechanism that can happen with posterior labral tears. Whereas patients may be more likely to experience symptoms over a longer period of time without ever having a full instability event and additional shoulder structures become injured.

Adding Dexmedetomidine to Intra-articular Local Anesthetics Results in Prolonged Analgesia After Knee Arthroscopy: A Systematic Review and Meta-analysis

To assess the efficacy and safety of dexmedetomidine as an adjuvant to intra-articular (IA) injections of local anesthetics (LA) in adult patients undergoing knee arthroscopy. We searched MEDLINE, Embase, and Cochrane Library for randomized controlled trials (RCTs) comparing IA dexmedetomidine plus LA versus LA alone for knee arthroscopy in adults. We used the DerSimonian and Laird random-effects model for all outcomes and conducted a sensitivity analysis with the leave-one-out method, as well as a subgroup analysis for the type of LA. We used R version 4.1.2 for all statistical analyses. We included 16 RCTs encompassing 799 patients, of whom 49.8% received IA dexmedetomidine. In the pooled analysis, time to first analgesia rescue was prolonged in almost 4 hours with the use of dexmedetomidine (mean difference [MD] 229 minutes; P < .001). We found statistically significant differences favoring dexmedetomidine in pain scores at rest and movement throughout the first 2, 6, 12, and 24 hours postoperatively (P < .001). Although the MD ranged from -0.3 to -0.9 cm, corresponding to a 3% to 9% reduction in pain scores, this change is not clinically significant compared with the minimal clinically important difference (MCID). Additionally, the intervention group showed a statistically significant reduction in cumulative opioid consumption over 24 hours (MD -4.5 mg; P < .001). However, this reduction did not meet the threshold for the MCID. There was no difference between groups on the incidence of hypotension (P= .190), bradycardia (P= .430), and postoperative nausea and vomiting (P= .550). Adding dexmedetomidine to LA in IA injections for knee arthroscopy significantly extended analgesia duration. Additionally, it lowered pain scores and opioid use, although these effects did not reach the MCID. Furthermore, this addition did not increase the risk of adverse events. Level II, meta-analysis of Level I and II studies.

Pre-operative transverse tendon thickness in small and mid-sized rotator cuff tears does not affect clinical outcomes after arthroscopic repair

IntroductionPrevious studies on rotator cuff tears have examined both clinical and radiographic parameters which may influence post-operative clinical outcomes. While rotator cuff tears are frequently classified by size or depth, there is currently no literature available examining the thickness of the remnant tendon, and its impact on post-operative outcomes. We hypothesize that decreased pre-operative transverse tendon thickness will result in poorer post-operative clinical outcomes. MethodsWe prospectively recruited patients who underwent arthroscopic repair of small to medium full-thickness rotator cuff tears. These patients were followed up for a minimum of 2 years post-operatively. Basic biodata, as well as Visual Analog Scale (VAS) for pain, Constant-Murley Score (CMS), UCLA Shoulder Score (USS), and Oxford Shoulder Score (OSS) at 3 different time points (pre-operatively, 1 year post-operatively, and 2 years post-operatively) were collected. Transverse tendon thickness was measured by independent blinded radiologists on pre-operative ultrasonographic images. Wilcoxon signed-rank test was used to compare outcome scores and multivariable robust linear model was fitted to assess the effect of transverse tendon thickness on post-operative scores. ResultsA total of 63 patients were enrolled in this study, predominantly female (65%) and had a median age of 72 years. Pre-operatively, the median transverse cuff thickness was 5.0 ​mm and median tear size was 1.4 ​cm. The median VAS at preoperative was 7, which reduced to 0 ​at 2 year post-operative, indicating statistically significant improvement in pain levels (p ​< ​0.001). Statistically significant improvement in shoulder function measured by CMS, UCLA score and OSS were also seen over time (p ​< ​0.001). Robust regression analysis revealed that transverse cuff thickness had no statistically significant effect on VAS (p ​= ​0.99), CMS (p ​= ​0.84), UCLA score (p ​= ​0.22), and OSS scores (p ​= ​0.73) at 2 years postoperatively. DiscussionPre-operative transverse tendon thickness of small- to mid-sized supraspinatus tears does not influence clinical outcomes after arthroscopic repair. Differences in transverse tendon thickness may have an association with tendon healing but do not translate to an association with post-operative outcomes in terms of pain, function, and patient-reported outcome measures. Level of evidenceIV.

Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 10-Year Follow-up of a Prospective, Randomized Controlled Trial

Background: Short- and midterm evaluations of arthroscopic meniscal surgery have shown little or no effect in favor of surgery, although long-term effects, including radiographic changes, are unknown. Purpose: To compare the 10-year outcomes in middle-aged patients with meniscal symptoms between a group that received an exercise program alone and a group that received knee arthroscopy in addition to the exercise program with respect to the prevalence of radiographic and symptomatic osteoarthritis (OA), patient-reported outcomes, and clinical status. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Of 179 eligible patients aged 45 to 64 years, 150 were randomized to undergo either 3 months of exercise therapy (nonsurgery group) or knee arthroscopy in addition to the exercise therapy (surgery group). Surgery usually consisted of partial meniscectomy (n = 56) or diagnostic arthroscopy (n = 8). Radiographs were assessed according to the Kellgren-Lawrence score at the baseline and 5- and 10-year follow-ups. Patient-reported outcome measures were reported at the baseline and 1-, 3-, 5-, and 10-year follow-ups. Clinical status was assessed at a 10-year follow-up. The primary outcomes were radiographic OA and changes in the Knee injury and Osteoarthritis Outcome Score Pain subscale (KOOSPAIN) from the baseline to the 10-year follow-up. The primary analysis was performed using the intention-to-treat approach. Results: At the time of the 10-year follow-up, eight patients had died, leaving 142 eligible patients. Radiographic OA was assessed for 95 patients (67%), questionnaires were answered by 110 (77%), and the clinical status was evaluated for 95 (67%). Radiographic OA was present in 67% of the patients in each group (P≥ .999); symptomatic OA was present in 47% of the nonsurgery group and 57% of the surgery group (P = .301). There were no differences between groups regarding changes from baseline to 10 years in any of the KOOS subscales. Conclusion: Knee arthroscopic surgery, in most cases consisting of partial meniscectomy or diagnostic arthroscopy, in addition to exercise therapy in middle-aged patients with meniscal symptoms, did not increase the rates of radiographic or symptomatic OA and resulted in similar patient-reported outcomes at the 10-year follow-up compared with exercise therapy alone. Considering the short-term benefit and no long-term harm from knee arthroscopic surgery, the treatment may be recommended when first-line treatment—including exercise therapy for ≥3 months—does not relieve patient’s symptoms. Registration: Clinical Trials NCT01288768 (ClinicalTrials.gov identifier).