Anterior Approach to Retracted Anterosuperior Cuff Tear With Biceps Superior Capsular Reconstruction and Subscapularis Release and Repair With Transosseous Equivalent Double-Row Repair.

The incidence of a subscapularis tear combined with any other rotator cuff tear is around 19% to 49% among all rotator cuff lesions. On the contrary, less attention has been given to the treatment of anterosuperior rotator cuff tears, particularly by arthroscopic methods. Subscapularis lesions are hard to access and require advanced surgical technique along with optimum visualization to achieve an anatomic repair. Use of an anterior portal helps in obtaining a good visualization with a 30° arthroscope in viewing the tendon along its axis as well as the posterior, superior, and anterior sides. Incorporation of the biceps tendon along with supraspinatus repair helps strengthen the supraspinatus repair as well as preserve the acromiohumeral index. Double-row repair of both subscapularis and supraspinatus ensures an adequate bone bed for tendon healing.

Clinical and radiological outcome following arthroscopic Latarjet with cerclage FiberTape fixation with a minimum 1-year follow-up.

Background: The rates of implant-related complications are significant following the Latarjet procedure using metal screws in patients with recurrent shoulder dislocation and bone loss. The purpose of this study is to evaluate the short-term outcome following the arthroscopic Latarjet procedure using cerclage FiberTape (Arthrex, Naples, FL, USA) combined with remplissage and capsulolabral repair. It was hypothesized that performing the procedure with cerclage FiberTape would provide sturdy fixation, comparable to the conventional method of using metal screws, while averting hardware-related complications attributed to the latter in published literature. Methods: A prospective study was performed in a single institution between 2020 and 2022, with all surgeries performed by a single fellowship-trained shoulder surgeon who has ample experience in performing arthroscopic screw Latarjet procedures. Patient demographics, number of dislocations before surgery, arm dominance, ligamentous laxity, type of sporting activity, Instability Severity Index Score, and percentage of bone loss on the glenoid and humeral sides were recorded. The patients were followed up with visual analog scale, American Shoulder and Elbow Surgeons score, Rowe score, and Walch-Duplay score preoperatively and postoperatively. The coracoid graft position, healing, and remodeling were assessed with computed tomography scans at 3 months postoperatively. Minimum clinical follow-up was for a period of one year. Results: Overall, 10 patients (all males, average age 28 ± 8.8 years) were operated on with an arthroscopic Latarjet procedure using cerclage FiberTape. The minimum follow-up period was 12 months, and the mean follow-up was 13.2 months. The median and individual visual analog scores during arm motion, American Shoulder and Elbow Surgeons scores, Rowe scores, and Walch-Duplay scores improved in the follow-up period. Computed tomography scans at 3 months showed flushed graft position in 5 patients, medial graft position in two patients, and three patients showed graft nonunion with migration. Out of 10 patients, seven had good graft union in follow-up scans. None of the patients required revision surgery. All three patients with graft nonunion were kept under follow-up beyond the study period for recurrence of instability. Conclusion: Our study demonstrated that arthroscopic Latarjet using cerclage FiberTape fixation combined with remplissage and capsulolabral repair resulted in high rate of graft loosening and migration (30%). Nonetheless, patients in whom the coracoid graft had united, as well as those in whom it had not, all had good to excellent functional and clinical outcomes, no complications, and did not require any revision surgery.

Challenges and Solutions: Total Knee Replacement in Patients with Chronic Lymphatic Filariasis: A Case Report.

CASE: A 59-year-old woman with a history of left knee pain exacerbated by lymphatic filariasis underwent successful total knee replacement (TKR) for advanced osteoarthritis. Postoperatively, diligent adherence to compression bandaging, physiotherapy, and lymphatic flow promotion resulted in no lymphedema progression. During the 5-year follow-up, the patient showed improved Knee injury and Osteoarthritis Outcome Score and stable implant. CONCLUSIONS: Currently, there are no established protocols or formulated guidelines for TKR in patients with chronic filariasis. The preoperative lymphedema prevention must be tailor-made for each patient in the context of advanced osteoarthritis based on the functional lymphatic vessel status.

Chronic Distal Biceps Tendon Rupture: A Case Report of Single-Incision Repair With Tightrope and Flexor Carpi Radialis Autograft Augmentation.

A 48-year-old male presented with weakness in right upper limb flexion and supination three months post-road traffic accident and was diagnosed with a complete distal bicep tendon rupture. Urgent single-incision surgical repair augmented with the flexor carpi radialis tendon was performed using the tightrope reconstruction method for stability. This case underscores the importance of prompt recognition and intervention for distal biceps tendon tears to prevent long-term functional impairment, emphasizing the critical role of surgical reattachment. Delayed medical care may compromise work capabilities and surgical success.

Arthroscopic Fixation of Acute Large Bony Bankart with Suture-assisted Reduction and Screw Fixation - Surgical Technique.

Introduction: Glenoid rim fractures with Bankart lesions are called bony Bankart lesions and are associated with persistent glenohumeral joint instability. Acute bony Bankart lesions can be treated by various arthroscopic techniques. Here, we present a technique of arthroscopic bony Bankart repair using suture-assisted reduction and screw fixation. Discussion: The conventional suture anchor repair does not provide compression of the fractured fragment, and the bony piece may tilt because of the single-point fixation. Conclusion: This procedure can achieve firm compression between the bony fragments and prevent rotation of fragment during screw fixation to the glenoid. The capsular plication distributes the loads to the surrounding soft tissues. Hence, this procedure should be offered to all patients presenting acutely with a large bony Bankart of size >25% of glenoid width, as it is minimally invasive as well as provides excellent outcomes and anatomical union.

Diagnosis and treatment approach of delayed presentation of anterior branch axillary nerve injury following shoulder dislocation: case report.

In this case report, a unique instance of delayed isolated anterior branch axillary nerve injury following shoulder dislocation is highlighted. The patient, a 55-year-old manual laborer, presented with severe deltoid wasting and reduced power 18 months postdislocation, necessitating a specialized treatment approach. The use of axillary nerve neurolysis and an innovative upper trapezius to anterior deltoid transfer via a subacromial path posterior to the clavicle, facilitated by an autologous semitendinosus graft, resulted in significant improvement with 160 degrees of abduction and Grade 4+ power Medical Research Council grading (MRC) at the 5-year follow-up.

Arthroscopic Double-Row Rotator Cuff Repair With Biceps Augmentation.

Arthroscopic repair of chronic retracted rotator cuff tears remains challenging to shoulder arthroscopy surgeons. With the recent technical advances, most of the massive rotator cuff tears are managed successfully. The biceps tendon is highly vascular and a rich source of tenocytes and fibroblasts, which can promote biological healing. In massive degenerate rotator cuff tears in which the rotator cuff tissue can be released and fixed onto the footprint without much tissue tension, long head of the biceps tendon can act as an augment providing structural support to the poor-quality rotator cuff tissue and also enhancing the healing process. In this Technical Note, we describe arthroscopic rotator cuff repair using biceps augmentation for a massive degenerate rotator cuff tear with the excursion of the cuff onto the footprint with minimal tissue tension.

Arthroscopic double row partial articular supraspinatus tendon avulsion bridge repair technique for shoulder: A transtendinous approach.

Partial articular supraspinatus tendon avulsion (PASTA) lesions, a subset of partial rotator cuff tears, pose a surgical challenge, disrupting the integrity of the supraspinatus tendon. Transtendinous repair is the preferred choice in young individuals for limiting tear progression and preserving intact, high-quality cuff tissue, thus preventing tendon shortening, as compared to the tear completion and repair technique. Our approach leverages these advantages, specifically those indicated for Ellman's Grade 3 tears and cases where conservative treatments have failed. In our technique, we employ progressive dilation, anchor drill sleeve insertion to facilitate medial row anchor placement, followed by percutaneous spinal needles for suture shuttling, and finally locking sliding knots for compressive medial row repair, followed by lateral row fixation for additional stability. This method accelerates rehabilitation and restores optimal shoulder function.

All Arthroscopic Salvage Technique for Intraoperative Vertical Split Coracoid Graft Fracture in Latarjet Procedure-Technical Note.

Intraoperative vertical coracoid graft fractures during the Latarjet procedure are well-described complications, which typically have a poor prognosis or may necessitate further iliac crest bone grafting for stabilization. The vertical split coracoid fractures are reasoned to be caused by excessive tightening of the screws, poor bone quality, especially in females and the smaller dimension of the coracoid graft. In this technical note, we propose an arthroscopic salvage technique for salvaging the fractured coracoid graft and to avoid the need for additional bone graft, thereby reducing morbidity to the patient. We use two double-loaded, all-suture anchors (Stryker, India) on either side of the split coracoid graft, and double-pulley configuration of suture tightening is done, providing compression and stability to the fractured graft.

Arthroscopic Superior Capsular Reconstruction Using Hybrid Autologous Fascia Lata and the Long Head of Biceps Tendon Graft: the Central Beam Concept.

Superior capsular reconstruction is a joint salvage treatment option for retracted irreparable rotator cuff tears in relatively young patients. Various graft options have been described in the literature, including autologous fascia lata graft, synthetic graft, and dermal patches. Superior capsular reconstruction using long head of biceps tendon autograft alone has also been described by few authors. In this technical note, we describe a modified technique of performing arthroscopic superior capsular reconstruction using both fascia lata graft and the intra articular portion of the long head of biceps tendon. Our technique resembles central beam concept over which the fascia lata graft is anchored, providing good structural support to the graft and enabling graft healing and improved clinical outcomes.

All-arthroscopic versus mini-open double row rotator cuff repair - A prospective randomised control study based on functional and radiological outcomes.

Purpose: In an era where arthroscopic rotator cuff repair is dominant in the United States (77.9 % preference) compared to open surgery (53.33 %), a shift towards minimally invasive All-Arthroscopic (AA) techniques over classical Mini-Open (MO) repair is emerging. This study explores current trends in shoulder procedures in India and compares functional outcomes and radiological repair integrity between AA and MO techniques, which are understudied in the Indian context. Methodology: In this prospective study, 60 patients (30 in the AA group and 30 in the MO group) with rotator cuff tears underwent assessment. Pre/post-operative clinical evaluations and 12-month follow-ups using UCLA and Oxford Shoulder Score, along with preoperative MRI and postoperative USG, were conducted. Results: At one-year follow-up, the AA group showed better functional outcomes (53.3 % excellent/good vs. 30.0 % in MO). No significant radiological differences (Sugaya grading) were found. Tear size was comparable with no association with functional/radiological outcomes. Conclusion: The AA group demonstrated favourable functional outcomes, matched to MO group findings, which is in accordance with global studies. Despite higher costs, the increasing popularity of AA in India is justified by enhanced results and reduced postoperative discomfort.

Arthroscopic Salvage Procedure for Iatrogenic Conjoint Tendon Avulsion Fracture Following Arthroscopic Latarjet Procedure Using Double Sling Fixation Technique - A Case Report.

Introduction: We present a case report of an iatrogenic conjoint tendon avulsion fracture following arthroscopic Latarjet and salvage technique to address the complication with a novel double sling technique. Case Report: A 16-year-old male patient who presented with recurrent instability of the right shoulder was counseled for an arthroscopic Latarjet procedure, taking account of critical glenoid bone loss and his contact sporting activities. An intraoperative coracoid tip fracture occurred, which was managed with the double sling technique. At 1-year follow-up, the patient has made a good recovery with a full range of movements and a stable shoulder; the CT scans showed a well-approximated coracoid tip fragment. Conclusion: Iatrogenic intraoperative coracoid graft fractures during arthroscopic Latarjet can be managed depending on the site of the fracture and quality of the bone. The double sling fixation technique helps in maintaining the sling action of the conjoint tendon in patients with recurrent instability.

Arthroscopic Subscapularis Tendon Repair Using the Lasso-Loop Technique Through Anterolateral Viewing Portal.

The subscapularis is the strongest muscle among the rotator cuff muscles, and it provides a coupled balanced force across the glenohumeral joint by resisting the infraspinatus in axial plane and the shearing force of deltoid in the coronal plane. It is important to repair subscapularis tears to maintain the coupled balanced force. Subscapularis tendon tears are difficult to diagnose and treat. Only a small portion of the subscapularis tendon is visualized during routine arthroscopy, as it is largely covered by the middle and inferior glenohumeral ligaments. Various repair techniques have been described in the literature. Here, we describe the anterolateral viewing portal for better visualization of subscapularis and our preferred technique, the lasso-loop technique, which provides better tissue grip and improved functional outcome.

Dynamic Anterior Stabilization Using Transosseous Bone Tunnel Technique With the Adjustable Loop Length Cortical Button Incorporating High-Strength Suture Augmentation for Recurrent Shoulder Instability.

Dynamic anterior stabilization using the long head of the biceps tendon is a recently described technique in the management of recurrent shoulder dislocation with subcritical bone loss. This technique involves the transfer of the long head of the biceps to the glenoid, providing sling and hammock effect. The long head of the biceps (LHB) tendon fixation can be accomplished with a variety of implants. We present a modified fixation technique of LHB tendon using transosseous bone tunnel with the adjustable loop length cortical button, incorporating high-strength suture augmentation device in a patient with recurrent glenohumeral instability with limited glenoid bone loss and an engaging Hill-Sachs defect in the humeral head.

Trans-cuff portals heal by 6 weeks: an ultrasonography-based study.

BACKGROUND: Various arthroscopic portals have been described for repair of superior labrum anterior-posterior (SLAP) lesions. The difficulty in doing repair through the rotator interval and the problems in direction and placement of anchors still persist. Functional outcomes of the patients after treating them using trans-cuff portal are well established in literature, but the actual healing of the portal is not clear. We made a sincere effort to identify healing of the trans-cuff portal with ultrasound guidance and functional outcome using American Shoulder and Elbow Surgeons Shoulder Score (ASES score), Constant Shoulder Score, and Oxford Shoulder Score. MATERIAL AND METHODS: Twenty-two patients with SLAP or labral tears and normal contralateral shoulders were included. Surgery was performed using the trans-cuff portal as a viewing or working portal for biceps repair and labral repair. Rehabilitation was initiated from day 1 and followed up on 6 weeks, 3 months and, 6 months with a maximum follow-up duration of 2 years. Ultrasound was used to measure the depth of healing and graded at 6 weeks of follow-up postoperatively. Functional outcomes were measured using ASES score, Constant Shoulder Score, and Oxford Shoulder Score measured at 6 months. RESULTS: Seventeen patients were of grade 1 (complete healing); 1 patient was of grade 2 (more than 50% healing); 1 of grade 3 (less than 50% healing), and 3 were lost to follow-up. Fourteen patients out of 19 had excellent ASES scores, 4 patients had good scores, and 1 patient was considered as poor with an average ASES score of 84.51 (range 93-48) and standard deviation of 10.37. The ASES score indicated that healing of the rotator cuff portal is directly related to the functional outcome of the shoulder. The Constant Shoulder Score and Oxford Shoulder Score on the contrary were statistically not significant indicating no relation of the Oxford and Constant scores with healing of the rotator cuff portals. CONCLUSION: Trans-cuff portal is safe, gives proper angle for insertion of anchors, and can be used for repair of SLAP lesions with ease. Ultrasonography helps in confirming the healing of portal.

Tubercular infection after arthroscopic rotator cuff repair.

Tubercular septic arthritis after shoulder arthroscopy has not been reported in the English literature to our knowledge. A case of Tubercular septic arthritis of the shoulder following arthroscopic rotator cuff repair is presented. The sinus and the wound healed well, and laboratory parameters returned to normal, which suggests that the infection was well controlled with the treatment follow-up of 1 year. But the functional score was poor due to repeated surgeries; long-standing infection and the arthritic changes developed. Tubercular infection can occur after arthroscopic shoulder surgery especially in healthcare workers in zones endemic for Tuberculosis. Level of evidence V.

Correlation of visual analogue scale foot and ankle (VAS-FA) to AOFAS score in malleolar fractures using Indian language questionnare.

BACKGROUND: Visual analogue scale foot and ankle (VAS-FA score) is a new score, validated in previous studies, but never compared to AOFAS score. OBJECTIVE: Analysis of the two scores using Indian language questionnaire. METHODS: Fifty patients with Malleolar fractures were assessed for functional outcome, time for calculation of scores, difficulty in correlation and comprehension of the questionnaire, in Malayalam language. The score parameters were compared by SSPSS. RESULTS: There was similarity in pattern of score values in both systems but also a difference between values in each category, with VAS-FA having lower values, reflecting its efficacy. There was significant correlation, similar sensitivity and agreement between the scoring systems. VAS-FA correlated better with patient's outcome and required less time for assessment. CONCLUSION: This study shows that Indian language VAS-FA has a similar pattern of extracting scores as AOFAS and can be an efficient tool in ankle outcome assessment in Indian patients.