Orthopedics

Feature Article 

Biomechanical Study of a Subscapularis Repair Technique for Total Shoulder Arthroplasty

Evan Lederman, MD; John Idoine, DO; Jonathan Streit, MD; Yousef Shishani, MD; Reuben Gobezie, MD

Abstract

Secure subscapularis repair is an essential element of total shoulder arthroplasty. Some surgeons prefer subscapularis peel because of ease of use, but some evidence suggests that lesser tuberosity osteotomy provides better fixation. The authors developed a novel, through-implant repair technique and performed a biomechanical study of its strength with cadaveric specimens. The authors obtained 20 matched pairs of cadaveric shoulders and inserted an uncemented short-stemmed humeral prosthesis that facilitates through-implant repair in all specimens. For each cadaver, the subscapularis was repaired with lesser tuberosity osteotomy and standard suture technique on 1 side, and the contralateral subscapularis was repaired with a novel through-implant suture repair and subscapularis peel technique. Displacement of the subscapularis footprint, ultimate load to failure, and stiffness of each repair were measured and compared between fixation groups. Mean±SD displacement of the lesser tuberosity osteotomy group was 0.75±0.94 mm at 10 cycles and 2.24±2.76 mm at 500 cycles. Mean±SD load to failure was 612±185 N, and mean±SD ultimate stiffness was 119±32 N/mm. No significant differences were noted between the lesser tuberosity osteotomy group and the subscapularis peel group in mean±SD displacement at 10 cycles (1.09±1.30 mm, P=.31), mean±SD displacement at 500 cycles (2.85±2.43 mm, P=.26), mean±SD load to failure (683±274 N, P=.31), or mean±SD ultimate stiffness (117±37 N/mm, P=.88). In a biomechanical testing model, through-implant subscapularis repair provided secure fixation relative to currently accepted subscapularis repair techniques in total shoulder replacement. [Orthopedics. 2016; 39(5):e937–e943.]

Abstract

Secure subscapularis repair is an essential element of total shoulder arthroplasty. Some surgeons prefer subscapularis peel because of ease of use, but some evidence suggests that lesser tuberosity osteotomy provides better fixation. The authors developed a novel, through-implant repair technique and performed a biomechanical study of its strength with cadaveric specimens. The authors obtained 20 matched pairs of cadaveric shoulders and inserted an uncemented short-stemmed humeral prosthesis that facilitates through-implant repair in all specimens. For each cadaver, the subscapularis was repaired with lesser tuberosity osteotomy and standard suture technique on 1 side, and the contralateral subscapularis was repaired with a novel through-implant suture repair and subscapularis peel technique. Displacement of the subscapularis footprint, ultimate load to failure, and stiffness of each repair were measured and compared between fixation groups. Mean±SD displacement of the lesser tuberosity osteotomy group was 0.75±0.94 mm at 10 cycles and 2.24±2.76 mm at 500 cycles. Mean±SD load to failure was 612±185 N, and mean±SD ultimate stiffness was 119±32 N/mm. No significant differences were noted between the lesser tuberosity osteotomy group and the subscapularis peel group in mean±SD displacement at 10 cycles (1.09±1.30 mm, P=.31), mean±SD displacement at 500 cycles (2.85±2.43 mm, P=.26), mean±SD load to failure (683±274 N, P=.31), or mean±SD ultimate stiffness (117±37 N/mm, P=.88). In a biomechanical testing model, through-implant subscapularis repair provided secure fixation relative to currently accepted subscapularis repair techniques in total shoulder replacement. [Orthopedics. 2016; 39(5):e937–e943.]

Total shoulder arthroplasty (TSA) is an effective treatment for glenohumeral joint arthritis in the setting of an intact rotator cuff. Current techniques for TSA using the deltopectoral approach necessitate detachment of the subscapularis tendon from the humerus for placement of the prosthesis. This may be accomplished by tenotomizing the subscapularis tendon, peeling the tendon insertion away from the lesser tuberosity, or performing an osteotomy of the lesser tuberosity, with refixation of the tendon insertion after the procedure. Most surgeons restrict shoulder motion in the postoperative period to allow healing of the subscapularis repair. Despite this period of rest, several clinical studies showed that partial or complete failure of the repair is common and likely negatively affects the final outcome.1,2

Several biomechanical studies have been performed in an attempt to determine the strongest method of subscapularis fixation after TSA. Despite a lack of consensus in the literature,1,3–10 lesser tuberosity osteotomy is considered to provide the most secure construct over the long term because it relies on osseous healing and does not compromise the tendon insertion site and footprint. However, subscapularis tenotomy and subscapularis peel procedures take less surgical time and avoid the possibility of tuberosity nonunion.2 Regardless of technique, many surgeons perform subscapularis repair by passing heavy nonabsorbable suture around the humeral prosthesis.

The authors developed a novel TSA design and repair technique for the subscapularis that uses the prosthesis as an anchoring device. The authors performed a cadaveric study of the strength of the repair, and this report describes the technique and the results of a biomechanical study of an uncemented humeral prosthesis that allows subscapularis repair with multiple sutures that are passed through the device.

Materials and Methods

Approach and Humeral Preparation

Total shoulder arthroplasty with a suture-incorporating prosthesis is performed with the patient in the beach chair position. A standard deltopectoral approach to the shoulder is used to provide exposure of the subscapularis and rotator interval. The surgeon may perform subscapularis tenotomy, subscapularis peel, or lesser tuberosity osteotomy to gain access to the glenohumeral joint. The authors' preferred technique is to perform a subscapularis peel that involves removal of the entire tendon from its footprint on the lesser tuberosity.

Once the subscapularis is released, the glenohumeral joint can be disarticulated to deliver the proximal humerus into the surgical field. Any osteophytes that distort the native anatomy are removed with a rongeur. Preparation of the humerus begins with an anatomic neck cut. A sound is used to identify the humeral canal, followed by reaming and broaching until a snug fit without toggle is achieved. The size of the final broach corresponds to the size of the final humeral implant.

Through-implant Subscapularis Suture Repair

After broaching, the final humeral prosthesis is ready to be inserted. On the back table, the prosthesis is loaded with 6 nonabsorbable sutures, for a total of 12 suture strands to be tied (Figure 1). The first 2 sutures are passed through the lateral fin of the implant; the superior suture is blue, and the inferior suture is tiger striped. The remaining 4 sutures are passed through specially designed suture holes along the medial edge of the implant. It is important to alternate the suture color to facilitate knot tying later in the case. Before implantation, 2 holes are drilled in the bicipital groove to receive the 2 sutures that were initially passed through the lateral fin on the prosthesis (Figure 2). The authors use the prosthesis itself as a guide for the location of these holes and pass the sutures with a suture passer. The implant is then impacted into the humeral canal, with care taken to maintain tension on the medial suture strands so that they retain their order (Figure 3). With the implant seated, the 8 medial suture strands are passed through the subscapularis tendon in a uniform fashion (Figure 4). The authors' preferred method is to pass the suture with an Arthrex FastPass Scorpion suture passer (Arthrex, Inc, Naples, Florida), but free needles also can be used.


The prosthesis is loaded with 6 nonabsorbable sutures, for a total of 12 suture strands to be tied.

Figure 1:

The prosthesis is loaded with 6 nonabsorbable sutures, for a total of 12 suture strands to be tied.


Before implantation, 2 holes are drilled in the bicipital groove to receive the 2 sutures that were initially passed through the lateral fin on the prosthesis.

Figure 2:

Before implantation, 2 holes are drilled in the bicipital groove to receive the 2 sutures that were initially passed through the lateral fin on the prosthesis.


The implant is impacted into the humeral canal, with care taken to maintain tension on the medial suture strands so that they retain their order.

Figure 3:

The implant is impacted into the humeral canal, with care taken to maintain tension on the medial suture strands so that they retain their order.


With the implant seated, the 8 medial suture strands are passed through the subscapularis tendon in a uniform fashion.

Figure 4:

With the implant seated, the 8 medial suture strands are passed through the subscapularis tendon in a uniform fashion.

Suture Configuration

The knot tying sequence follows a specific pattern, as shown in Figure 5. No sutures are tied to themselves, and each strand is tied to a different strand in the configuration. Therefore, the suture-implant complex does not become taut until the final 2 knots are tied. Knot tying is facilitated by the placement of suture strands in the prosthesis so that strands of the same color are tied together, as shown in Figure 5A. The tying sequence begins by tying the superiormost strand of the medial 8 strands (blue) to 1 of the superior strands from the lateral fin (also blue), as shown in Figure 5B. Next the inferiormost strand of the medial 7 strands (tiger stripe) is tied to 1 of the inferior strands from the lateral fin (also tiger stripe), as shown in Figure 5C. Next the remaining inferior suture from the lateral fin (tiger stripe) is tied to the third strand from the top of the remaining 6 medial strands (also tiger stripe), as shown in Figure 5D. Then the final superior suture from the lateral fin (blue) is tied to the third strand from the bottom of the remaining 5 medial strands (also blue), as shown in Figure 5E. Finally, the top 2 and bottom 2 medial strands are tensioned to tighten the construct and then they are tied together. These final 2 knots break the rule of matching suture colors, as shown in Figure 5F. The final construct should have secure knots that are evenly spaced about the tendon footprint (Figure 6).


Initial layout of the 12 strings of sutures (A). Superior knot tying (B). Inferior knot tying (C). First lateral to medial knot tying (D). Second lateral to medial knot tying (E). Medial row knot tying and final knot configuration (F).

Figure 5:

Initial layout of the 12 strings of sutures (A). Superior knot tying (B). Inferior knot tying (C). First lateral to medial knot tying (D). Second lateral to medial knot tying (E). Medial row knot tying and final knot configuration (F).


The final subscapularis repair should have secure knots that are evenly spaced about the tendon footprint.

Figure 6:

The final subscapularis repair should have secure knots that are evenly spaced about the tendon footprint.

Cadaveric Study

To test the strength of subscapularis repair performed with a through-implant technique, the authors obtained 20 matched pairs of fresh frozen cadaveric shoulders with overlying soft tissues removed, an intact rotator cuff, and a potted humerus. Cadavers were all male, with a mean±SD age of 58.1±10.6 years and no previous shoulder injury or surgery. An uncemented short-stemmed humeral prosthesis that facilitates through-implant repair (Univers Apex; Arthrex) was implanted in all specimens. Cadavers were prospectively randomized to side (right vs left) and surgical technique (lesser tuberosity osteotomy vs subscapularis peel). For each cadaver, the subscapularis was repaired with a lesser tuberosity osteotomy with standard suture technique10 on 1 side, whereas the contralateral subscapularis was repaired with a novel through-implant suture repair and subscapularis peel technique. Specimens that received lesser tuberosity osteotomy repair constituted the control group, and those that received the subscapularis peel technique and through-implant suture repair constituted the experimental group. Lesser tuberosity osteotomy repairs were made with 4 No. 5 FiberWire sutures (Arthrex) that were passed through bone tunnels in the lateral bicipital groove and around the humeral stem before implantation. The free suture tail was then passed through the tendon with a modified Mason-Allen stitch and tied over the lesser tuberosity osteotomy.11 The same technique as described earlier was used for all through-implant subscapularis suture repairs in the experimental group. Using a hydraulic testing system (Instron, Canton, Massachusetts), each specimen was cycled at 10 to 100 N for 500 cycles and then pulled to failure at 33 mm/s. Displacement of the subscapularis footprint was measured from its original position after 10 cycles and again after 500 cycles. Ultimate load to failure of each construct was quantified, and the mechanism of failure was documented. The stiffness of each construct was calculated as force/displacement at the bone-tendon junction. Statistical analysis was performed with Student's t test to compare mean and SD, with significance set at alpha=0.05.

Results

Mean±SD displacement for the control group was 0.75±0.94 mm at 10 cycles and 2.24±2.76 mm at 500 cycles (Figure 7). Mean±SD load to failure was 612±185 N, and mean±SD ultimate stiffness was 119±32 N/mm. No significant differences were found between the control group and the experimental group in mean±SD displacement at 10 cycles (1.09±1.30 mm, P=.31), mean±SD displacement at 500 cycles (2.85±2.43 mm, P=.26), mean±SD load to failure (683±274 N, P=.31), or mean±SD ultimate stiffness (117±37 N/mm, P=.88) (Figures 89). Individual data, including mode of failure, are shown in Table 1 and Table 2.


Comparison of cyclic displacement of the subscapularis tendon from bone after 10 cycles and 500 cycles showed no difference between lesser tuberosity osteotomy with standard suture configuration and subscapularis peel with a suture-incorporating humeral prosthesis.

Figure 7:

Comparison of cyclic displacement of the subscapularis tendon from bone after 10 cycles and 500 cycles showed no difference between lesser tuberosity osteotomy with standard suture configuration and subscapularis peel with a suture-incorporating humeral prosthesis.


Comparison of ultimate load to failure showed no difference between lesser tuberosity osteotomy with standard suture configuration and subscapularis peel with a suture-incorporating humeral prosthesis.

Figure 8:

Comparison of ultimate load to failure showed no difference between lesser tuberosity osteotomy with standard suture configuration and subscapularis peel with a suture-incorporating humeral prosthesis.


Comparison of construct stiffness showed no difference between lesser tuberosity osteotomy with standard suture configuration and subscapularis peel with a suture-incorporating humeral prosthesis.

Figure 9:

Comparison of construct stiffness showed no difference between lesser tuberosity osteotomy with standard suture configuration and subscapularis peel with a suture-incorporating humeral prosthesis.


Displacement, Load to Failure, Stiffness, and Failure Mode Data for the Control Group

Table 1:

Displacement, Load to Failure, Stiffness, and Failure Mode Data for the Control Group


Displacement, Load to Failure, Stiffness, and Failure Mode Data for the Experimental Group

Table 2:

Displacement, Load to Failure, Stiffness, and Failure Mode Data for the Experimental Group

Discussion

Failure of subscapularis repair negatively affects subjective and objective results after TSA. Liem et al9 performed tenotomy with transosseous repair and showed partial repair defects in 30% of patients with ultrasound at a mean follow-up of 43 months. In addition, 25% of their study cohort showed both subjective and objective signs of diminished function. Miller et al12 reported that subscapularis rupture after TSA results in delayed rehabilitation and a possible need for additional surgery and produces inferior outcomes, even with adequate treatment. Use of the humeral prosthesis as an anchoring device is a novel approach. The current biomechanical study showed that subscapularis repair through a humeral prosthesis specifically designed for subscapularis repair options allows subscapularis peel repair to achieve equivalent strength to lesser tuberosity osteotomy.

This study used subscapularis peel and lesser tuberosity osteotomy as fixation techniques in biomechanical testing. If suture incorporation through the humeral prosthesis could be shown to make subscapularis peel as strong as the current gold standard of lesser tuberosity osteotomy with a nonincorporating device, this would theoretically provide equivalent potential for healing with a simplified surgical technique. Despite the theoretical advantage of osseous healing after lesser tuberosity osteotomy, the results of biomechanical and clinical studies comparing the techniques have been mixed. Fishman et al3 found more gapping at the repair site with cyclic loading with the use of tenotomy rather than lesser tuberosity osteotomy to access the glenohumeral joint, with equivalent load to failure. Krishnan et al7 observed superior load to failure with lesser tuberosity osteotomy compared with tenotomy. Jandhyala et al6 showed superior strength to belly press testing in patients who underwent lesser tuberosity osteotomy compared with those who underwent tenotomy during TSA. Giuseffi et al4 found that tenotomy produced less displacement to cyclic loading and equivalent load to failure compared with lesser tuberosity osteotomy. Other authors8,13 found no clear superiority of 1 technique.

Subscapularis peel and tenotomy are simple techniques that are favored by many surgeons for their ease of use and because they avoid the possibility of lesser tuberosity nonunion that may occur after lesser tuberosity osteotomy.2 In older patients, the subscapularis tendon insertion may have degeneration or partial tears. In patients with surgery involving the subscapularis tendon, the insertion may have been lateralized or compromised. This may affect the ability to perform lesser tuberosity osteotomy or tenotomy, and peel-off can preserve maximal tendon length and allow for repair of the tendon to the lesser tuberosity. The authors prefer to use subscapularis peel and have found that it produces excellent results. However, Ahmad et al1 showed that this technique alters the anatomy of the subscapularis insertion, compromising the strength of repair. Subscapularis repair with the use of the humeral prosthesis as an anchoring device does not produce a more anatomic fixation, but it appears to provide better initial strength during the healing period. The technique, as designed, allows for dynamic equalization of tension across the suture construct by the nature of the sliding suture holes and the practice of tying each suture strand to a strand from another suture. This attribute is unique to this technique and the use of this specifically designed device. The authors use this device because it provides superior initial fixation strength and also may reduce the risk of tuberosity fracture with subscapularis peel. The superior initial fixation provided by incorporating sutures through the humeral prosthesis may reduce the incidence of lesser tuberosity nonunion when lesser tuberosity osteotomy is used, but further clinical studies with advanced imaging techniques are needed to determine whether this benefit exists. Avoiding the devastating complication of subscapularis failure will improve patient outcomes and reduce revision rates.

Limitations

Limitations of the study include its short-term nature. Biomechanical studies and short-term clinical outcome studies do not provide information on the ultimate healing potential of this construct. However, this study was conducted similarly to other studies of subscapularis repair.4,7,10,13 Further clinical study of the suture-incorporating humeral prosthesis is needed to determine whether it offers a true benefit in terms of shorter operative time and improved patient outcomes.

Conclusion

The results of this biomechanical study show that a through-implant suture technique allows subscapularis peel to achieve similar strength to lesser tuberosity osteotomy in terms of displacement to cyclic loading, ultimate load to failure, and stiffness. The authors have begun to use this device in clinical practice and are monitoring the early outcomes of patients treated with the device to determine whether there is a true clinical benefit when the subscapularis is fixed with a through-implant suturing technique.

References

  1. Ahmad CS, Wing D, Gardner TR, Levine WN, Bigliani LU. Biomechanical evaluation of subscapularis repair used during shoulder arthroplasty. J Shoulder Elbow Surg. 2007; 16(suppl 3):S59–S64. doi:10.1016/j.jse.2006.09.002 [CrossRef]
  2. Caplan JL, Whitfield B, Neviaser RJ. Subscapularis function after primary tendon to tendon repair in patients after replacement arthroplasty of the shoulder. J Shoulder Elbow Surg. 2009; 18(2):193–196. doi:10.1016/j.jse.2008.10.019 [CrossRef]
  3. Fishman MP, Budge MD, Moravek JE Jr, et al. Biomechanical testing of small versus large lesser tuberosity osteotomies: effect on gap formation and ultimate failure load. J Shoulder Elbow Surg. 2014; 23(4):470–476. doi:10.1016/j.jse.2013.06.024 [CrossRef]
  4. Giuseffi SA, Wongtriratanachai P, Omae H, et al. Biomechanical comparison of lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty. J Shoulder Elbow Surg. 2012; 21(8):1087–1095. doi:10.1016/j.jse.2011.07.008 [CrossRef]
  5. Jackson JD, Cil A, Smith J, Steinmann SP. Integrity and function of the subscapularis after total shoulder arthroplasty. J Shoulder Elbow Surg. 2010; 19(7):1085–1090. doi:10.1016/j.jse.2010.04.001 [CrossRef]
  6. Jandhyala S, Unnithan A, Hughes S, Hong T. Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder replacement: a comparison of patient outcomes. J Shoulder Elbow Surg. 2011; 20(7):1102–1107. doi:10.1016/j.jse.2011.03.019 [CrossRef]
  7. Krishnan SG, Stewart DG, Reineck JR, Lin KC, Buzzell JE, Burkhead WZ. Subscapularis repair after shoulder arthroplasty: biomechanical and clinical validation of a novel technique. J Shoulder Elbow Surg. 2009; 18(2):184–192. doi:10.1016/j.jse.2008.09.009 [CrossRef]
  8. Lapner PL, Sabri E, Rakhra K, Bell K, Athwal GS. Healing rates and subscapularis fatty infiltration after lesser tuberosity osteotomy versus subscapularis peel for exposure during shoulder arthroplasty. J Shoulder Elbow Surg. 2013; 22(3):396–402. doi:10.1016/j.jse.2012.05.031 [CrossRef]
  9. Liem D, Kleeschulte K, Dedy N, Schulte TL, Steinbeck J, Marquardt B. Subscapularis function after transosseous repair in shoulder arthroplasty: transosseous subscapularis repair in shoulder arthroplasty. J Shoulder Elbow Surg. 2012; 21(10):1322–1327. doi:10.1016/j.jse.2011.09.022 [CrossRef]
  10. Van Thiel GS, Wang VM, Wang FC, et al. Biomechanical similarities among subscapularis repairs after shoulder arthroplasty. J Shoulder Elbow Surg. 2010; 19(5):657–663. doi:10.1016/j.jse.2010.01.014 [CrossRef]
  11. Scheibel MT, Habermeyer P. A modified Mason-Allen technique for rotator cuff repair using suture anchors. Arthroscopy. 2003; 19(3):330–333. doi:10.1053/jars.2003.50079 [CrossRef]
  12. Miller BS, Joseph TA, Noonan TJ, Horan MP, Hawkins RJ. Rupture of the subscapularis tendon after shoulder arthroplasty: diagnosis, treatment, and outcome. J Shoulder Elbow Surg. 2005; 14(5):492–496. doi:10.1016/j.jse.2005.02.013 [CrossRef]
  13. Ponce BA, Ahluwalia RS, Mazzocca AD, Gobezie RG, Warner JJ, Millett PJ. Biomechanical and clinical evaluation of a novel lesser tuberosity repair technique in total shoulder arthroplasty. J Bone Joint Surg Am. 2005; 87(suppl 2):1–8. doi:10.2106/JBJS.E.00441 [CrossRef]

Displacement, Load to Failure, Stiffness, and Failure Mode Data for the Control Group

SpecimenDisplacement at 10 Cycles, mmDisplacement at 500 Cycles, mmUltimate Load, NStiffness, N/mmFailure Mode
C120430L0.190.96586.49179.47Bone fractured, implant pulled out
C121212R1.002.67649.8881.42Suture tore through tendon
C131040R0.270.63495.00100.15Bone fractured, implant pulled out
C131344L0.400.69450.5784.28Suture broke
C131420R0.572.16216.15105.87Knot failure
L130716R1.36Not applicable832.24111.38Suture broke, knot failure
S131778R0.310.63663.67213.34Bone fractured, implant pulled out
C121966L0.231.11703.77109.55Bone fractured, implant pulled out
S120195R0.541.98606.97132.44Knot failure, bone fractured, implant pulled out
S120757R0.341.32666.91118.42Knot failure, suture slipped under implant
S121187R0.641.95917.21121.61Knot failure, bone fractured, implant pulled out
S121660R0.892.68467.25135.53Knot failure, bone fractured, implant pulled out
F130694R0.210.58958.44116.45Knot failure, implant pulled out
F140040R0.593.21835.9587.89Knot failure, implant pulled out
F140131L0.971.30510.85107.96Implant pulled out
F140134L0.983.72324.0695.88Knot failure, bone fractured, implant pulled out
F140214L0.220.44677.52116.83Knot failure, implant pulled out
F140303L0.533.08559.3685.98Knot failure, suture slipped under implant
C140351L4.5012.82542.38126.18Knot failure, bone fractured, implant pulled out
C140403L0.220.64584.91144.30Knot failure, bone fractured, implant pulled out
Mean0.752.24612119
SD0.942.7618532

Displacement, Load to Failure, Stiffness, and Failure Mode Data for the Experimental Group

SpecimenDisplacement at 10 Cycles, mmDisplacement at 500 Cycles, mmUltimate Load, NStiffness, N/mmFailure Mode
C120430R0.681.97894.54136.01Suture broke, knot failure
C121212L0.421.93493.4081.66Suture broke
C131040L0.601.97595.94141.99Suture tore through tendon, knot failure
C131344R0.130.231388.44168.81Suture broke
C131420L0.361.64441.4879.19Suture tore through tendon, knot failure
L130716L0.381.541105.96116.71Suture tore through tendon, knot failure
S131778L0.351.39475.5298.76Bone fractured, implant pulled out
C121966R0.270.371010.3862.36Suture tore through tendon
S120195L1.324.23420.84129.79Suture broke, implant pulled out
S120757L1.492.901064.80134.17Knot failure, implant pulled out
S121187L0.761.95646.26141.25Suture broke, implant pulled out
S121660L1.062.90672.94160.69Knot failure, implant pulled out
F130694L1.253.18530.75133.53Suture broke, implant pulled out
F140040L0.161.28731.98124.85Suture broke, implant pulled out
F140131R0.712.06425.7399.51Knot failure, suture broke, implant pulled out
F140134R4.9410.08438.3890.38Knot failure, implant pulled out
F140214R0.501.84741.9984.55Knot failure, implant pulled out
F140303R4.387.21582.0484.56Suture broke, implant pulled out
C140351R1.546.39490.5670.96Bone fractured, implant pulled out
C140403R0.461.97505.30204.37Suture broke, implant pulled out
Mean1.092.85683117
SD1.302.4327437
Authors

The authors are from The Orthopedic Clinic Association and University of Arizona (EL), College of Medicine, Phoenix, Arizona; University Hospitals Case Medical Center (JS), Cleveland, Ohio; and the Cleveland Shoulder Institute (JI, YS, RG), Beachwood, Ohio.

Drs Shishani and Gobezie are previous Blue Ribbon Article Award recipients (Orthopedics, July/August 2016).

Drs Streit, Idoine, and Shishani have no relevant financial relationships to disclose. Dr Lederman is a paid consultant for and receives grants and royalties from Arthrex Inc. Dr Gobezie is a paid consultant for and receives grants and royalties from Arthrex Inc.

Correspondence should be addressed to: Reuben Gobezie, MD, Cleveland Shoulder Institute, 3999 Richmond Rd, Ste 200, Beachwood, OH 44122 ( drg@clevelandshoulder.com).

Received: May 06, 2015
Accepted: September 23, 2015
Posted Online: July 12, 2016

10.3928/01477447-20160623-09

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