A biomechanical comparison of new techniques for distal clavicular fracture repair versus locked plating.

BACKGROUND: Unstable distal clavicular fractures treated surgically are associated with high failure rates and hardware-related complications. Newer techniques have shown promising early clinical results with fewer hardware complications; however, their biomechanical performance has not been assessed. This study biomechanically compared a distal-third locking plate with 3 newer techniques that incorporate coracoid fixation into the construct. METHODS: The study randomized 36 adult fresh frozen cadaveric shoulders to 4 groups: (1) distal-third locking plate (P); (2) distal-third locking plate with a coracoid button augmentation (P + CB); (3) coracoclavicular button (CB); and (4) coracoclavicular button with coracoclavicular ligament reconstruction using semitendinosus allograft (CB + CC). After fixation, each specimen was stressed in the coronal plane. Cyclic displacement, load at 10-mm displacement, and ultimate load to failure were measured. RESULTS: All 3 experimental groups biomechanically outperformed the locking plate. Mean load to failure was significantly higher in the CB (343 ± 76 N) and CB + CC (349 ± 94 N) groups compared with the P group (193 ± 52 N). There was also significantly less cyclic displacement in the CB (4.3 ± 1.9 mm) and CB + CC (4.4 ± 1.9 mm) groups compared with the P group (8.2 ± 2.9 mm). With respect to load at 10 mm of displacement, which essentially measures a clinical failure, the P + CB (235 ± 112 N), CB (253 ± 111 N), and CB+CC (238 ± 76 N) experimental groups significantly outperformed the P group (96 ± 29 N). CONCLUSIONS: CB and CB + CC techniques demonstrated more than 75% greater strength than the traditional locking plate alone. Coupled with greater overall construct strength and lower-profile hardware, these newer techniques may result in improved clinical outcome and fewer hardware-related complications.

Preliminary Results of Arthroscopic Superior Capsule Reconstruction with Dermal Allograft.

PURPOSE: The purpose of this study was to evaluate the short-term outcomes of arthroscopic superior capsule reconstruction (SCR) with dermal allograft for the treatment of irreparable massive rotator cuff tears (MRCTs). METHODS: A multicenter study was performed on patients undergoing arthroscopic SCR for irreparable MRCTs. The minimum follow-up was 1 year. Range of motion and functional outcome according to visual analog scale (VAS) pain, American Shoulder and Elbow Surgeons (ASES) score, and subjective shoulder value (SSV) score were assessed preoperatively and at final follow-up. Radiographs were used to evaluate the acromiohumeral interval (AHI). RESULTS: Fifty-nine patients with a mean age of 62.0 years had a minimum follow-up of 1 year. Twenty-five patients (42.4%) had a prior rotator cuff repair. Forward flexion improved from 130° preoperative to 158° postoperative, and external rotation improved from 36° to 45°, respectively (P < .001). Compared with preoperative values, the VAS decreased from 5.8 to 1.7, the ASES score improved from 43.6 to 77.5, and the SSV score improved from 35.0 to 76.3 (P < .001). The AHI was 6.6 mm at baseline and improved to 7.6 mm at 2 weeks postoperatively but decreased to 6.7 mm at final follow-up. Based on postoperative magnetic resonance imaging, 45% (9 of 20) of the grafts demonstrated complete healing. Forty-six (74.6%) cases were considered a success. Eleven patients (18.6%) underwent a revision procedure including 7 reverse shoulder arthroplasties. CONCLUSIONS: Arthroscopic SCR using dermal allograft provides a successful outcome in approximately 70% of cases in an initial experience. The preliminary results are encouraging in this difficult to manage patient population, but precise indications are important and graft healing is low in our initial experience. LEVEL OF EVIDENCE: Level IV, case series.

Arthroscopic proximal biceps tenodesis at the articular margin: evaluation of outcomes, complications, and revision rate.

PURPOSE: The purpose of this study was to evaluate the incidence of residual pain, outcomes, and the revision rate of arthroscopic proximal biceps tenodesis high in the groove at the articular margin of the humeral head by interference screw fixation. METHODS: Seven surgeons pooled data on patients who underwent an arthroscopic biceps tenodesis at the articular margin by interference screw fixation. All patients had a minimum of 50 weeks' follow-up. Preoperative and postoperative patient data including visual analog scale scores (obtained by all surgeons), objective shoulder scores (Simple Shoulder Test and University of California, Los Angeles scores obtained by 2 and 4 surgeons, respectively), and need for revision surgery (obtained by all surgeons) were retrospectively analyzed, the results are reported, and statistical analysis was performed. RESULTS: After the application of our exclusion criteria, 1,083 patients were included in the analysis. The mean follow-up period was 136 weeks. The overall revision surgery rate for this group was 4.1% (44 of 1,083). Revision for biceps tenodesis-related issues was needed in only 4 cases (for a biceps tenodesis-related revision rate of 0.4%). Pain scores improved from 6.47 preoperatively to 1.08 postoperatively (P < .0001). University of California, Los Angeles scores improved from 14.9 preoperatively to 30.1 postoperatively (P < .0001), and Simple Shoulder Test scores improved from 2.7 preoperatively to 10.2 postoperatively (P < .0001). CONCLUSIONS: Arthroscopic biceps tenodesis performed at the articular margin results in a low surgical revision rate, a low rate of residual pain, and significant improvement in objective shoulder outcome scores. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

70° frontal visualization of lateral compartment of the elbow allows extensor carpi radialis brevis tendon release with preservation of the radial lateral collateral ligament.

PURPOSE: To determine whether the radial component of the lateral collateral ligament (R-LCL) and extensor carpi radialis brevis (ECRB) are consistently visible, using a 70° arthroscope, as parallel structures in the extra-articular space of the elbow, and to evaluate the clinical outcomes of these techniques in a series of patients. METHODS: An arthroscopic ECRB tendon release was performed between 2008 and 2010. Eighteen patients were retrospectively evaluated at a minimum of 24 months' follow-up. The surgeon performed the ECRB release while protecting the R-LCL and viewing the structures extra-articularly with a 70° arthroscope through the anteromedial portal. Patients underwent surgery if they presented with localized tenderness and pain not responding to conservative treatment for 12 months and had magnetic resonance imaging scans indicating tendinopathy or degeneration. Arthritis, posterolateral rotatory instability, trauma, and previous surgeries were exclusion criteria. Intraoperative videos were reviewed and a clinical examination was performed by an independent reviewer at 24 months postoperatively. Patients were also evaluated with the Mayo Elbow Performance Score; Andrews-Carson score; and shortened Disabilities of the Arm, Shoulder and Hand questionnaire. Direct varus stress was applied in extension and flexion (40°), and the posterolateral pivot-shift and chair tests were performed. RESULTS: Visualization with the 70° arthroscope through the anteromedial portal was successful in all of the cases (100%). Visualization of the residual ECRB tendon stump, as well as the posterior common extensor tendon, was also achieved 94% of the time. The final mean Mayo Elbow Performance Score and Andrews-Carson score were 82.5 (range, 60 to 100) and 185.3 (range, 125 to 200), respectively. The mean postoperative score on the shortened Disabilities of the Arm, Shoulder and Hand questionnaire was 20.14 (range, 5 to 57.5). Clinical tests showed stability in all the cases. CONCLUSIONS: The 70° arthroscope allows visualization of the ECRB insertion and R-LCL frontally and in parallel. A surgical plane could be created between the structures. The clinical outcome was good or excellent in 78% of the cases. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Associated lesions requiring additional surgical treatment in grade 3 acromioclavicular joint dislocations.

PURPOSE: To evaluate the incidence of associated pathologic shoulder lesions that were addressed surgically in grade 3 acromioclavicular joint (ACJ) dislocations, as well as to compare this incidence between younger and older patients and between acute and chronic cases. METHODS: In this multicenter nonrandomized retrospective study, 98 patients operated on for grade 3 ACJ dislocation underwent concomitant arthroscopic evaluation for the identification and treatment of any associated lesions. The type and treatment of associated lesions were collected in a central database and analyzed. We classified patients according to age (<45 years and ≥ 45 years) and according to the length of time between trauma and surgical treatment (≤ 30 days and ≥ 120 days), obtaining the following stratification: younger acute, older acute, younger chronic, and older chronic. RESULTS: Of the patients, 42 (42.8%) were diagnosed with at least 1 additional pathologic lesion, and 29 (29.5%) required a dedicated additional treatment. Rates of treatment on associated lesions were analyzed: younger versus older groups presented a significant difference, as did younger acute versus older acute groups; SLAP and posterior rotator cuff tear treatments represented 24 of the 35 additional surgeries (68.5%). CONCLUSIONS: The overall rate of associated pathologic lesions requiring additional surgical treatment in patients with ACJ dislocation was 29.5%. Patients aged 45 years or older had a greater risk of presenting with associated lesions that needed to be surgically addressed (odds ratio, 3.01). The overall rates of associated surgical lesions in acute versus chronic cases were not shown to be significantly different. LEVEL OF EVIDENCE: Level IV, prognostic case series.

A systematic approach for diagnosing subscapularis tendon tears with preoperative magnetic resonance imaging scans.

PURPOSE: To determine and propose a systematic approach to evaluating magnetic resonance imaging (MRI) scans for subscapularis tears and compares preoperative MRI interpretations with findings of the same shoulders at arthroscopy. METHODS: The study was composed of 202 patients who underwent shoulder arthroscopy by 1 of 5 orthopaedic surgeons during a 3-month period. All patients had MRI scans performed within 6 months before arthroscopy. RESULTS: Of the 202 patients, 82 had subscapularis tendon tears confirmed at the time of arthroscopy. The orthopaedic surgeons correctly diagnosed 60 of 82 patients (73%) with subscapularis tendon tears on preoperative MRI that were subsequently identified by arthroscopy. The orthopaedic surgeons correctly diagnosed 113 of 120 patients (94%) as not having subscapularis tendon tears. This resulted in an overall sensitivity of 73%, specificity of 94%, positive predictive value of 90%, negative predictive value of 84%, and accuracy of 86%. The frequency of subscapularis tears was highest when the long head of the biceps was displaced from the groove (88%), a combined supraspinatus/infraspinatus tear existed (71%), or the long head of the biceps tendon was torn (69%). CONCLUSIONS: Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with the described systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies. A consistent finding is that larger subscapularis tendon tears are more easily detected using MRI scans whereas smaller tears are more frequently missed. LEVEL OF EVIDENCE: Level III, development of diagnostic criteria with universally applied reference (nonconsecutive patients).

A Technique for a Suture-Based Cable Reconstruction of an Irreparable Posterosuperior Rotator Cuff Tear.

The management of irreparable rotator cuff tears remains challenging. In patients in whom a complete repair cannot be obtained, a partial repair remains an option. The goal of a partial rotator cuff repair is to obtain a stable glenohumeral joint fulcrum by restoring the rotator cable complex. Traditionally, partial repair has been performed with independent reattachment(s) of the rotator cable complex with or without margin convergence medially. This Technical Note describes an alternative approach to a partial rotator cuff repair with a suture-based cable reconstruction.

Addition of Allograft and Acromioclavicular Cerclage Improves Outcomes of Arthroscopic-Assisted Reconstruction of Acromioclavicular Separation With a Single Coracoclavicular Tunnel.

Objective The purpose of this study was to prospectively evaluate the functional outcome and complications of unstable acromioclavicular (AC) joint separations repaired with a single coracoclavicular tunnel utilizing an arthroscopic-assisted curved button technique. Methods Thirty-five patients with a minimum of 12 months follow-up underwent arthroscopic-assisted AC joint reconstruction with suspensory button and 2 mm suture tape fixation using 3 mm tunnels. Functional outcome scores were analyzed preoperatively and at final follow-up with all complications noted. Results Comparing preoperative to postoperative values, all functional outcome scores improved. Three of the 16 (19%) patients that had a supplementary graft looped around the undersurface of the coracoid demonstrated loss of reduction compared to eight of the 19 (42%) that were treated with button and suture fixation alone (p = .138). No loss of reduction occurred in the subset of patients with AC joint supplementation. One (3%) patient sustained a distal clavicle fracture. Conclusion Arthroscopic-assisted AC joint reconstruction with a suspensory button construct demonstrates improved clinical outcomes with high patient satisfaction. While loss reduction remains problematic, smaller bone tunnels appear to lead to a low rate of iatrogenic fractures. The addition of a free tendon graft, as well as AC cerclage, appears to minimize loss of reduction.

Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair.

PURPOSE: The purpose of this study was to determine the incidence of clinically significant postoperative stiffness following arthroscopic rotator cuff repair. This study also sought to determine the clinical and surgical factors that were associated with higher rates of postoperative stiffness. Finally, we analyzed the result of arthroscopic lysis of adhesions and capsular release for treatment of patients who developed refractory postoperative stiffness 4 to 19 months (median, 8 months) following arthroscopic rotator cuff repair. METHODS: A retrospective review of a consecutive series of arthroscopic rotator cuff repairs was conducted. During a 3-year time period, the senior author (S.S.B.) performed 489 arthroscopic rotator cuff repairs. The operative indications, technique of the rotator cuff repair, and the rehabilitation protocol were essentially unchanged during this time period. Demographic data, comorbid medical conditions, rotator cuff tear description, technique of repair, and concomitant surgical procedures were evaluated for their effect on stiffness. All office evaluations were reviewed to determine the pre- and postoperative motion, pain scores, functional strength, and patient satisfaction. Patients who were dissatisfied because of the development of postoperative stiffness underwent secondary arthroscopic lysis of adhesions. The final result of the secondary lysis of adhesions and capsular release were analyzed. RESULTS: In total, 24 patients (4.9%) were dissatisfied with the result of their procedure because of the development of postoperative stiffness, which was more likely (P < .05) to develop in patients with Workers' Compensation insurance (8.6%), patients younger than 50 years of age (8.6%), those with a coexisting diagnosis of calcific tendonitis (16.7%) or adhesive capsulitis (15.0%) requiring additional postoperative therapy, partial articular-sided tendon avulsion (PASTA) type rotator cuff tear (13.5%), or concomitant labral repair (11.0%). Patients with concomitant coracoplasty (2.3%) or tears larger in size and/or involving more tendons were less likely (P < .05) to develop postoperative stiffness. Among 90 patients positive for selected risk factors (adhesive capsulitis, excision of calcific deposits, single-tendon repair, PASTA repair, or any labral repair without a concomitant coracoplasty), 12 (13.3%) developed postoperative stiffness (P < .001). This overall clinical risk factor combined with Workers' Compensation insurance identified 16 of the 24 cases resulting in a sensitivity of 66.7% and a specificity of 64.5%. All 24 patients who experienced postoperative stiffness elected to undergo arthroscopic lysis of adhesions and capsular release, which was performed from 4 to 19 months (median, 8 months) after the rotator cuff repair. During second-look arthroscopy, 23 patients (95.8%) were noted to have complete healing of the original pathology. Following capsular release, all 24 patients were satisfied with the overall result of their treatment. CONCLUSIONS: In a series of 489 consecutive arthroscopic rotator cuff repairs, we found that 24 patients (4.9%) developed postoperative stiffness. Risk factors for postoperative stiffness were calcific tendinitis, adhesive capsulitis, single-tendon cuff repair, PASTA repair, being under 50 years of age, and having Workers' Compensation insurance. Twenty-three of 24 patients (95.8%) showed complete healing of the rotator cuff. Arthroscopic release resulted in normal motion in all cases. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The value of arthroscopy before an open modified latarjet reconstruction.

PURPOSE: The purpose of this study was to identify the presence of intra-articular pathology in patients undergoing shoulder arthroscopy immediately before modified Latarjet reconstruction for recurrent anterior instability with bone deficiency. METHODS: The records of 33 consecutive patients who underwent shoulder arthroscopy immediately before the modified Latarjet reconstruction were analyzed. Arthroscopy was performed just before the open procedure to identify and treat intra-articular pathology that would otherwise have been missed or not well treated during the routine open anterior approach to the shoulder. RESULTS: In 24 of 33 cases (73%) associated pathologic lesions were identified and addressed arthroscopically (lesions not likely to have been discovered and treated optimally during the open deltopectoral approach). We identified and addressed 21 type 2 SLAP lesions (64%) as well as 1 posterior Bankart lesion, 2 loose bodies, 2 rotator cuff tears, and 2 localized areas of grade 4 chondromalacia. CONCLUSIONS: Arthroscopic examination before modified Latarjet reconstruction is recommended because it allows the surgeon to identify and arthroscopically address associated pathologic entities that are present in over two thirds of the cases. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The double-pulley technique for double-row rotator cuff repair.

In an effort to maximize the area of footprint coverage, we developed the "double-pulley technique" for double-row rotator cuff repairs. Two suture anchors are inserted at the articular margin of the greater tuberosity (one anterior and one posterior). All 4 suture strands from each anchor are passed through a single medial point on the torn cuff. In this way, the 4 suture strands from the anteromedial anchor pass through 1 point in the cuff and the 4 strands from the posteromedial anchor pass through a different point in the cuff. A suture strand from 1 anchor is tied extracorporeally to a suture strand of the same color from the other anchor. The other ends of those 2 strands are then pulled, thereby delivering this extracorporeal knot into the joint and over the medial footprint. These 2 free suture strands are then tied together as a static knot. The procedure is repeated with the other sutures. This technique creates a double mattress suture medially, which compresses the intervening tendon bridge against its bone bed. We call this procedure the double-pulley technique because it uses the anchor eyelets as pulleys to deliver the extracorporeal knot into the shoulder. After the lateral row repair is performed, the rotator cuff footprint will be completely reconstituted.

The anatomy and function of the low posterolateral portal in addressing posterior labral pathology.

PURPOSE: A standard posterior portal allows excellent visualization of the glenohumeral joint but is inadequate for anchor placement because of its parallelism to the glenoid surface. The purpose of this study was to describe the low posterolateral portal for glenohumeral arthroscopy, describe the anatomy of the portal and surrounding structures, and discuss the portal's usefulness in addressing posterior and inferior shoulder pathology. METHODS: Five cadaveric shoulders were dissected after placement of a spear through the low posterolateral portal. The location was identified via a spinal needle, 2 to 4 cm lateral and 4 to 5 cm inferior to the posterolateral corner of the acromion. Measurements from the spear to the anatomic structures were recorded with a caliper. Seventeen patients with posterior labral pathology were included in this study. The low posterolateral portal was established while visualizing through the anterosuperolateral or posterior portal. The spear and anchor were inserted through the low posterolateral portal. RESULTS: Five shoulders were dissected, and the neurovascular structures relative to the low posterolateral portal were identified. The portal was 13.8 +/- 1.6 mm from the axillary nerve and 13.4 +/- 1.2 mm from the posterior humeral circumflex artery. In the retrospective review the low posterolateral portal was created without difficulty or complication in all 17 patients. The portal was extremely helpful for anchor insertion in the posteroinferior glenoid. It was useful in suture passage through the posterior and inferior labrum and in suture management. CONCLUSIONS: The low posterolateral portal provides the optimal angle for insertion of instruments and anchors, resulting in a more anatomic repair. CLINICAL RELEVANCE: The standard 3 portals are not optimal for approaching posterior and inferior labral tears, and use of the low posterolateral portal improves access and treatment.

Middle Glenohumeral Ligament Abrasion Causing Upper Subscapularis Tear.

The middle glenohumeral ligament (MGHL) typically contributes partially to the anterior stability of the shoulder. In a very limited number of cases, the MGHL can cause abrasion on the upper edge of the subscapularis causing persistent pain symptoms for patients. The condition is exacerbated by internal rotation of the arm. In this Technical Note, we describe this entity and call it the SAM lesion (Subscapularis Abrasion from the MGHL). We present a technique of addressing this lesion.

Patient-Reported Outcomes of Knotted and Knotless Glenohumeral Labral Repairs Are Equivalent.

We conducted a study to compare the clinical results and operative times of knotted and knotless fixation of anterior and posterior glenohumeral labral repairs and superior labrum anterior to posterior (SLAP) repairs. We retrospectively evaluated data that had been prospectively collected from a Surgical Outcomes System database. Knotted and knotless techniques for 226 repairs (59 isolated anterior labral, 95 posterior labral, 72 SLAP) were compared on patient-reported outcome measures (PROMs), including American Shoulder and Elbow Surgeons (ASES) score, visual analog scale pain score, and Veterans RAND 12-Item Health Survey score, obtained before surgery and 6 months and 1 year after surgery. Operative time was recorded as well. One-year follow-up was available for all 226 repairs. There was no statistically difference in PROMs between knotted and knotless anterior labral or SLAP repairs at any point (P > .05). ASES scores were higher 6 months after surgery in the knotless group (88.6 vs 84.2; P = .022), but scores 1 year after surgery were the same (88.6 vs 89.8; P = .451). Operative time per anchor was shorter for knotless anterior labral repairs (26 vs 31 min; P = .02) and knotless posterior labral repairs (18 vs 21 min; P = .031) and trended shorter for knotless SLAP repairs (26 vs 37 min; P = .080). There is no difference in PROMs between knotted and knotless labral repairs. Operative times were shorter for anterior and posterior knotless anchors than for knotted anchors. Obtaining equivalent outcomes in less operative time may help decrease healthcare costs and minimize potential complications.

The suture-weave technique: a method of reloading a deployed unloaded suture anchor.

Many suture anchors hold 2 sutures per anchor. Occasionally during a procedure, 1 of these sutures may be inadvertently pulled out of the anchor eyelet. We describe the technique of rethreading a deployed suture anchor in the event that 1 of the sutures is inadvertently unloaded from the anchor eyelet. We have evaluated its effectiveness in vivo. The basic steps of the "suture-weave" technique are as follows. If 1 strand remains threaded through the anchor eyelet, it is tensioned so that there is 1 long end and 1 short end. The free suture is threaded into the eye of a graft preparation needle and this needle is then used to pierce the braids of the long end of the threaded suture. The free suture is interwoven through the braids of the threaded suture. The short end of the threaded suture is then pulled while visualizing the anchor eyelet arthroscopically. The free suture passes through the eyelet as the intersection of the 2 woven sutures traverses the eyelet. During this process, 3 suture strands are traversing the eyelet. Finally, the intersecting suture limbs are pulled free from each other such that there are 2 separate suture strands that slide independently and pass through the anchor eyelet once again. This procedure has been successfully used in vivo without complications. It is important to note that this procedure will only work in an anchor eyelet that will allow for the passage of 3 suture strands.

Arthroscopic subscapularis repair: surgical tips and pearls A to Z.

Arthroscopic subscapularis repair can be technically challenging. This article summarizes a number of technical tips that can greatly simplify and expedite what otherwise might be a daunting surgical procedure. Specific tips and pearls include the following: 1. A description of a new clinical test--the bear-hug test--for detecting subscapularis tears on physical examination. 2. How to accurately place portals for precise subscapularis repair. 3. How to safely and accurately perform a coracoplasty. 4. How to identify and mobilize a retracted subscapularis tear. 5. How the comma sign can be used to simplify arthroscopic subscapularis repair. 6. How to securely repair all sizes of subscapularis tear. 7. A description of postoperative immobilization and rehabilitation to optimize results of arthroscopic subscapularis repair.

Evaluation of residual rotator cuff defects after in vivo single- versus double-row rotator cuff repairs.

PURPOSE: As arthroscopic rotator cuff surgery has advanced, new techniques have emerged to maximize the biomechanical strength of the repair construct. The double-row repair has been recommended as a means of increasing the contact area of the repaired rotator cuff to the native bone bed. This study attempts to sequentially examine and measure the rotator cuff footprint (in vivo) before cuff repair, after an initial lateral-row repair (before the medial-row sutures are tied), and finally, after the double-row repair. In this way, the rotator cuff footprint of single- and double-row repairs can be quantified and compared. METHODS: Between October 2004 and February 2005, 26 patients were enrolled in the study. These patients had rotator cuff tears that were amenable to double-row repair by means of performing the lateral-row repair before the medial-row repair. After preparation of the greater tuberosity footprint, the native footprint was measured in the medial-to-lateral direction. Next, the medial-row anchors and sutures were passed through the cuff (but not tied), and then the lateral row was secured via suture anchors and the arthroscope was reinserted into the intra-articular space. A depth gauge was introduced through the repaired cuff (lateral row only), and the residual bare footprint was measured. The medial row was then tied, and the cuff was again visualized from the intra-articular position to measure any remaining bare footprint. RESULTS: The mean footprint measured 17.0 +/- 1.9 mm from medial to lateral. After repair of the lateral row, the mean residual uncovered footprint measured 9.0 +/- 2.0 mm. This constituted a 52.7% +/- 9.2% uncovered area after a single lateral-row repair. After the medial row was secured, there were no remaining residual deficits of the cuff footprint. CONCLUSIONS: After an isolated lateral-row repair, 52.7% +/- 9.2% of the rotator cuff footprint remains uncovered. On average, the double-row repair offered over twice the footprint coverage yielded by a single-row repair. CLINICAL RELEVANCE: The arthroscopic shoulder surgeon should be aware of the enhanced footprint coverage offered by double-row rotator cuff fixation as opposed to single-row rotator cuff fixation.

Calcific tendonitis of the subscapularis tendon causing subcoracoid stenosis and coracoid impingement.

Calcific tendonitis is a common disease of the shoulder which usually responds to conservative treatment. In cases unresponsive to conservative management, arthroscopic treatment is sometimes required. While there are several reports on calcifications within the supraspinatus tendon, documented cases involving the subscapularis tendon are rare. We present a case of a 47 year old farmer with recurrent anterior shoulder pain. An MRI revealed calcium deposits as well as a large subcoracoid cyst. Arthroscopic excision of the multiple calcific deposits left a large defect in the subscapularis tendon which was repaired back to the lesser tuberosity using arthroscopic techniques. A coracoplasty resulted in an increased coracohumeral space. The patient followed a conservative postop rehabilitation protocol and ultimately regained full strength and was pain free at the latest follow-up. We postulate two possible etiologies of subscapularis calcific tendonitis: either an idiopathic calcific tendonitis caused a secondary coracoid impingement or a primary subcoracoid stenosis resulted in an interstitial subscapularis tear which eventually resulted in calcium deposition. This report describes the clinical and technical details of arthroscopic excision of calcific deposits of the subscapularis tendon as well as arthroscopic repair of the resulting subscapularis defect.

What do you do when you have a loose screw?

PURPOSE: This study seeks to compare the pullout strength of various anchor configurations in an osteoporotic bone model. We have tested and present here a technique designed to augment the pullout resistance of an anchor in poor-quality bone with the use of a second anchor as an interference fit; this report describes our in vivo results with this procedure. METHODS: Four groups of suture anchor constructs were tested. These included a single 5.0-mm Bio-Corkscrew (Arthrex, Naples, FL) (group I), a single 5.5-mm Bio-Corkscrew FT (fully threaded; Arthrex, Naples, FL) (group II), a single 6.5-mm Bio-Corkscrew (Arthrex, Naples, FL) (group III), and an interference fit of two 5.0-mm Bio-Corkscrew suture anchors (group IV). Anchors were secured in a 10-lb/ft3 polyurethane foam block to simulate osteoporotic bone. Each construct was cycled, then was pulled to failure with an Instron testing device (Instron, Canton, MA); measurements regarding cyclic displacement, yield load, and extension at yield load were recorded. During the in vivo portion of the study, the interference fit technique was performed in 18 shoulder arthroscopy cases in which a loose screw was a matter of concern. After the technique was performed, both anchors were pulled so their security could be assessed; cuff repair then proceeded normally. RESULTS: Biomechanical study: In terms of yield load, every anchor construct was significantly different from every other construct. Specifically, pullout strength increased significantly as follows: group I was the weakest against pullout (176 +/- 13 N), group III (223 +/- 17 N) was significantly stronger than group I, group II (247 +/- 12 N) was significantly stronger than group III, and, finally, group IV (305 +/- 16 N) was significantly stronger than group II. The only statistically significant difference in terms of cyclic displacement was that group IV (1.4 mm +/- 0.2) had significantly less displacement than group III (1.9 mm +/- 0.3). No significant differences in extension at yield load were observed among any of the groups. In vivo study: The interference anchor technique was used in 18 of 24 loose screw situations over a 6-month period. In all 18 of these cases (100%), a stable dual-anchor construct was achieved. All anchors were stable to the tug test, and none failed during knot tying or at any time during the procedure. CONCLUSIONS: From the perspective of strength against pullout, the strongest suture construct of those tested in the osteoporotic bone model was the dual-anchor-against-an-anchor interference fit construct. The next strongest anchor tested was the 5.5-mm Bio-Corkscrew FT, followed by the 6.5-mm Bio-Corkscrew, and, finally, the 5.0-mm Bio-Corkscrew. Each group was statistically different from every other group in terms of pullout strength. The interference fit construct was not only the strongest in vitro, but it performed well in the in vivo setting, offering the added benefit of additional sutures to be used for securing a cuff defect. This study gives the arthroscopic surgeon important data for use in planning what to do when a loose screw is encountered. CLINICAL RELEVANCE: Data from this study may be useful for the arthroscopic surgeon in choosing the proper anchor construct for osteoporotic bone. This study also lends support to the technique of press-fitting an anchor against an anchor in the loose screw situation.

The Arthroscopic Superior Capsular Reconstruction.

In a subset of patients with rotator cuff tears, the glenohumeral joint has minimal degenerative changes and the rotator cuff tendon is either irreparable or very poor quality and unlikely to heal. Reverse shoulder arthroplasty (RSA) is often considered for these patients despite the lack of glenohumeral arthritis. However, due to the permanent destruction of the glenohumeral articular surfaces, complication rates, and concerns about implant longevity with RSA, we believe the superior capsular reconstruction (SCR) is a viable alternative. In this article, we describe our technique for the SCR.