Augmentation of Massive Rotator Cuff Repairs Using Biceps Transposition Without Tenotomy Improves Clinical and Patient-Reported Outcomes: The Biological Superior Capsular Reconstruction Technique.

PURPOSE: To evaluate the outcomes of a consecutive series of patients after transposition of the biceps without tenotomy (biological superior capsular reconstruction [bio-SCR] technique) to augment massive rotator cuff repairs. METHODS: Thirty massive rotator cuff tears repaired and augmented using the bio-SCR technique between June 2018 and July 2021 were identified and retrospectively reviewed. American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale pain scores, supraspinatus and infraspinatus strength, and range of motion were collected preoperatively and postoperatively. RESULTS: The average age of patients undergoing bio-SCR augmentation was 67.0 years (range, 28.4-81.9 years), and the mean clinical follow-up period was 2.9 years (range, 1.8-4.5 years). The average ASES score improved from 33.2 preoperatively to 80.8 at 6 months postoperatively, 92.0 at 1 year, and 87.0 at 2 years (P < .001). The minimal clinically important difference for the ASES score was exceeded at all postoperative intervals. Active forward flexion improved from 120.6° to 156.8° (P < .001). The pain score improved from 7.1 to 0.9 (P < .001). Postoperatively, 1 complication (3.3%) occurred: a proximal biceps rupture. CONCLUSIONS: Incorporating a transposed biceps tendon into the repair of a massive rotator cuff tear using the bio-SCR technique resulted in significant clinical improvements with a low complication rate. LEVEL OF EVIDENCE: Level IV, case series.

Editorial Commentary: Elbow Lateral Epicondylitis Treatment Using Platelet-Rich Plasma.

The best treatment for elbow lateral epicondylitis is controversial. Multiple treatment interventions are used commonly, including physical therapy, corticosteroid injections, nonsteroidal anti-inflammatory drugs, bracing, acupuncture, ultrasound-guided percutaneous tenotomy, open or arthroscopic surgical debridement, and recently, platelet-rich plasma (PRP) or autologous blood injections. Patients in whom more traditional conservative measures have failed may benefit from PRP injections, although long-term outcomes after such injections are unclear. The complication rates of PRP injections are low. One PRP injection, if successful, could be a cost-effective alternative to surgery, but multiple injections are often recommended and third-party payers have historically rarely paid those medical claims, thus placing an increased financial burden on the patient.

Elbow Arthroscopy Made Simple: Indications and Techniques.

Elbow arthroscopy is a technically demanding procedure. A comprehensive understanding of the elbow neurovascular anatomy combined with a very detail-oriented technique for portal placement helps to minimize risk and facilitates performing elbow arthroscopic procedures effectively and safely for the appropriate indications. The technique for establishing all portals is critical regardless of which portals are used. Care should be taken to thoroughly palpate the bony landmarks before establishing any portal site, and only blunt trocars should be used for elbow arthroscopy. Identification of the ulnar nerve is critical to avoid nerve injuries. In addition, only the skin should be incised, with a hemostat used to dissect through deeper tissues, in an effort to protect the superficial nerves. Likewise, although accurately measuring distances from the bony landmarks is important when planning portal-site locations, elbow sizes and shapes are highly variable. Therefore, recognition of an individual patient's body size and habitus is a key step before establishing portals. The use of anterior proximal portals also allows for improved visualization of anterior structures in a safe manner (distant from nerves). Finally, insufflating the elbow joint before establishing the initial anterior compartment portal has been reported to increase the distances of the nerves from the portal-site cannulas. An additional reason to consider insufflating the joint before portal placement is that insufflation increases anterior capsular tension, making penetration of the capsule with the blunt trocars easier and more reliable. In summary, elbow arthroscopy is a reliable procedure that requires a clear understanding of the anatomy to be able to safely access the joint.

Editorial Commentary: Dealer's Choice for Arthroscopic Versus Open Lateral Epicondylitis Release? It's Not That Simple.

The most efficacious treatment for patients with persistent lateral epicondylitis who have not adequately improved despite undergoing extended nonoperative measures may be arthroscopic. One advantage is the capability of the surgeon to fully assess the elbow intra-articularly. Second, the incision is often considered less appealing to both patients and surgeons than portal-site incisions. A final potential benefit is the opportunity for the occasional elbow arthroscopist to take advantage of a "best-case" clinical setting to perform a thorough arthroscopic diagnostic evaluation of both the anterior and posterior elbow compartments and improve his or her elbow arthroscopic skills, because patients with lateral epicondylitis rarely have advanced arthritis or capsular contractures and have infrequently undergone prior elbow surgery. Moreover, if technical difficulties arise during an arthroscopic release, the procedure can be easily converted to a standard open release technique without compromising the patient's condition or the procedure.

Editorial Commentary: Beware the Radial Nerve: More Elbow Arthroscopy Portals, More Options.

Elbow arthroscopy is a challenging procedure due, in part, to the technical demands of portal placement as a consequence of the close proximity of the neurovascular structures. The radial nerve and its branches are especially at risk during lateral elbow arthroscopic portal placement. Two newly described (proximal) anterolateral elbow arthroscopy portals may be safer than the distal anterolateral portal location with regard to proximity to the radial nerve. These portals provide a new angle of approach, compared with the traditional and more posterior (but still safely proximal) anterolateral portals.

Editorial Commentary: The Needle or the Knife? Platelet-Rich Plasma Versus Surgery for Lateral Epicondylitis.

The most efficacious treatment for patients with lateral epicondylitis who have not adequately improved despite being treated for extended periods with commonly used nonoperative measures is controversial. Are locally applied platelet-rich plasma (PRP) injections more effective than a surgical procedure, such as arthroscopic lateral epicondylitis debridement, in reducing symptoms for such patients? Level II evidence shows that long-term clinical benefits are much less likely to occur in patients receiving PRP injections. Moreover, in patients treated with PRP injection, progressively worsening pain is more likely to develop during activity at 1 and 2 years of follow-up in contradistinction to arthroscopically managed patients.

Editorial Commentary: To Move or Not to Move the Shoulder, That Is the Question.

Whether to use an immediate range of motion exercise protocol or, rather, to delay the initiation of rehabilitation exercises for patients after arthroscopic rotator cuff repair presents a significant dilemma for the treating surgeon. The study "The Effect of Early Range of Motion on Quality of Life, Clinical Outcome, and Repair Integrity After Arthroscopic Rotator Cuff Repair" by Mazzocca, Arciero, Shea, Apostolakos, Solovyova, Gomlinski, Wojcik, Tafuto, Stock, and Cote reveals that no differences in quality of life scores or rotator cuff healing were identified after comparing 2 groups of patients undergoing either immediate (within 3 days) or delayed (after 28 days) postoperative rehabilitation protocols. These results underscore the fact that little data has been published to date that demonstrates an optimum time period for initiating postoperative rehabilitation after rotator cuff repair.

Traumatic full-thickness transtendinous rotator cuff tears: a case series.

HYPOTHESIS: Our purpose was to describe an arthroscopic repair technique for and outcomes of traumatic transtendinous rotator cuff tears affecting the supraspinatus tendon. MATERIALS AND METHODS: A retrospective review was performed on a series of patients between January 2009 and January 2012. Demographic data, as well as preoperative and postoperative clinical data including strength, visual analog scale pain score, Subjective Shoulder Value, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score, were obtained. RESULTS: Seven patients were identified with magnetic resonance imaging showing full-thickness, transtendon supraspinatus tears with extension into the infraspinatus, which were consistent with physical examination and arthroscopic findings. The mechanism of injury was traumatic in all cases, usually a fall with the arm abducted. The mean remaining stump of tendon measured 1.3 cm. All patients underwent open or arthroscopic repair by a side-to-side (tendon-to-tendon) technique with additional suture anchor augmentation. At an average follow-up of 41.5 months (range, 33-50 months), all patients had postoperative improvements in strength and visual analog scale pain scores (range, 0-1), as well as Subjective Shoulder Value, Simple Shoulder Test, and American Shoulder and Elbow Surgeons scores greater than 90. CONCLUSION: We have described the occurrence of a rare rotator cuff tear in the purely tendinous portion of the muscle, leaving at least 1 cm of tendon attached to an intact footprint. We also have presented an arthroscopic side-to-side repair technique and postoperative outcomes. To our knowledge, this is the first article describing this uncommon rotator cuff tear.

Arthroscopic Management of Anterior, Posterior, and Multidirectional Shoulder Instabilities.

Arthroscopic shoulder stabilization offers several potential advantages compared with open surgery, including the opportunity to more accurately evaluate the glenohumeral joint at the time of diagnostic assessment; comprehensively address multiple pathologic lesions that may be identified; and avoid potential complications unique to open stabilization, such as postoperative subscapularis failure. A thorough understanding of normal shoulder anatomy and biomechanics, along with the pathoanatomy responsible for anterior, posterior, and multidirectional shoulder instability patterns, is very important in the management of patients who have shoulder instability. The treating physician also must be familiar with diagnostic imaging and physical examination maneuvers that are required to accurately diagnose shoulder instability.

A Proficiency-Based Progression Training Curriculum Coupled With a Model Simulator Results in the Acquisition of a Superior Arthroscopic Bankart Skill Set.

PURPOSE: To determine the effectiveness of proficiency-based progression (PBP) training using simulation both compared with the same training without proficiency requirements and compared with a traditional resident course for learning to perform an arthroscopic Bankart repair (ABR). METHODS: In a prospective, randomized, blinded study, 44 postgraduate year 4 or 5 orthopaedic residents from 21 Accreditation Council for Graduate Medical Education-approved US orthopaedic residency programs were randomly assigned to 1 of 3 skills training protocols for learning to perform an ABR: group A, traditional (routine Arthroscopy Association of North America Resident Course) (control, n = 14); group B, simulator (modified curriculum adding a shoulder model simulator) (n = 14); or group C, PBP (PBP plus the simulator) (n = 16). At the completion of training, all subjects performed a 3 suture anchor ABR on a cadaveric shoulder, which was videotaped and scored in blinded fashion with the use of previously validated metrics. RESULTS: The PBP-trained group (group C) made 56% fewer objectively assessed errors than the traditionally trained group (group A) (P = .011) and 41% fewer than group B (P = .049) (both comparisons were statistically significant). The proficiency benchmark was achieved on the final repair by 68.7% of participants in group C compared with 36.7% in group B and 28.6% in group A. When compared with group A, group B participants were 1.4 times, group C participants were 5.5 times, and group C(PBP) participants (who met all intermediate proficiency benchmarks) were 7.5 times as likely to achieve the final proficiency benchmark. CONCLUSIONS: A PBP training curriculum and protocol coupled with the use of a shoulder model simulator and previously validated metrics produces a superior arthroscopic Bankart skill set when compared with traditional and simulator-enhanced training methods. CLINICAL RELEVANCE: Surgical training combining PBP and a simulator is efficient and effective. Patient safety could be improved if surgical trainees participated in PBP training using a simulator before treating surgical patients.

Primary versus revision arthroscopic reconstruction with remplissage for shoulder instability with moderate bone loss.

PURPOSE: This study aims to evaluate our outcomes of arthroscopic remplissage in this setting. METHODS: A retrospective review was performed to identify patients who underwent arthroscopic remplissage of an engaging Hill-Sachs lesion along with anterior capsulolabral reconstruction for anterior glenohumeral instability with moderate glenohumeral bone loss at our institution. Thirty-five patients, with a minimum of 2 years' follow-up, were identified. We assessed the American Shoulder and Elbow Surgeons score, incidence of recurrent instability, and postoperative Rowe instability score. RESULTS: Follow-up was available for 30 patients (31 shoulders). The mean age was 24.6 years, with a mean follow-up period of 41 months. Prior instability surgery had failed in 11 patients, and they underwent capsulolabral reconstruction and remplissage ("revision surgery"). The failure rate in revision cases (36%) was significantly higher than the failure rate in primary surgery cases (0%) (P = .01). Failure resulted from trauma in all 4 patients, and none required further surgery. The mean American Shoulder and Elbow Surgeons score for all patients improved from 50 preoperatively to 91 postoperatively (P < .001), with no significant postoperative difference between primary and revision patients (P = .13). The patients with clinical failure showed nonsignificant improvement from 41 preoperatively to 72 postoperatively (P = .08). The mean postoperative Rowe score for the entire cohort was 90. The Rowe score was significantly lower in the 4 cases of failure than in the 27 non-failure cases (51 v 96, P < .001). CONCLUSIONS: In our experience, aggressive capsulolabral reconstruction with remplissage in traumatic instability patients with moderate bone loss and engaging humeral Hill-Sachs lesions yields acceptable outcomes for primary instability surgery. However, a significantly higher failure rate occurred when arthroscopic reconstruction with remplissage was performed in the revision setting. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Limited Arthroscopic Deltoid Fasciectomy Increases Subacromial Visualization and Characterization of Rotator Cuff Tears.

Adequate arthroscopic visualization in the subacromial space is a necessity to appropriately characterize rotator cuff tears and to subsequently develop a suture construct that best reduces the cuff tear with the least tissue tension possible for optimal healing. The purpose of this article and corresponding video is to demonstrate a technique for carrying out a limited deltoid fasciectomy, resulting in enhanced visualization of the rotator cuff through the lateral viewing portal.

Medialized Rip-Stop Convergence Technique for Retracted Rotator Cuff Tears.

Attempts to restore the anatomical footprint during rotator cuff repair for retracted, relatively immobile tears can be difficult. In some cases, it can lead to excessive tension of the repair. Previous studies have noted improved clinical outcomes when repair tension is not excessive, and medialization of the anatomical footprint has been suggested as a technique that can help surgeons repair large, retracted tears without excessive tension and achieve improved clinical outcomes. Of note, excessive tension when restoring the rotator cuff tendon to the anatomical footprint is not limited to large, retracted tears. In some cases, restoring small- and medium-sized tears to the anatomical footprint also can lead to excessive tension. Therefore, it is not uncommon for the authors to employ some degree of footprint medialization even for repair of small- or medium-sized tears if repair to the anatomical footprint will lead to excess tension. The purpose of this article and video demonstration is to provide instruction for a reproducible rotator cuff technique using a medialized single-row rip-stop construct combined with convergence.

Techniques and Tips to Arthroscopically Remove Prominent and Loose Shoulder Joint Hardware.

The number of arthroscopic shoulder operations has continued to steadily increase in recent years, with a projection of over 500,000 rotator cuff operations in 2023. Although the incidence of anchor pullout, hardware failure, and aberrant hardware placement is relatively low, this increased volume of shoulder operations has inevitably resulted in a consequent increase in the number of patients who experience such hardware complications. These hardware issues can cause significant pain, limit shoulder function, and cause permanent damage to the shoulder articular cartilage. The described arthroscopic techniques are presented to provide tools and strategies to safely and effectively remove prominent and loose shoulder joint hardware.

"Double Row Rip-Stop" Arthroscopic Repair Technique for Acute, Retracted Rotator Cuff Tears.

Acute, retracted rotator cuff tendon tears are important to recognize and can present unique technical challenges to repair. Various arthroscopic techniques and suture configurations have been proposed for repair of acute tears with aims to maximize the repair footprint and optimize tendon fixation. The double row rip-stop configuration was designed and has been used for rotator cuff repair due to its potential advantages related to suture pullout, footprint reapproximation and load sharing. The purpose of this article is to present the author's arthroscopic technique for repair of acute, retracted rotator cuff tendon tears using a double-row, rip-stop suture configuration. The indications and authors' preferred arthroscopic technique for biceps tenodesis are also discussed.

Arthroscopic Techniques to Recognize and Quantify Subtle Medial and Lateral Elbow Instability.

The diagnosis and treatment of elbow instability can be challenging for surgeons. Although history, physical examination, radiographs, and advanced imaging such as stress ultrasound scanning and magnetic resonance imaging are helpful, diagnostic arthroscopy is a valuable tool in the armamentarium of an elbow surgeon. Elbow arthroscopy is not only a diagnostic tool but also has the added therapeutic benefits that are not available with other diagnostic modalities. The purpose of this article and associated video is to present 3 arthroscopic techniques to help elbow surgeons arthroscopically recognize and quantify medial and lateral elbow instability.

Acute radial ulno-humeral ligament injury in patients with chronic lateral epicondylitis: an observational report.

PURPOSE: Lateral elbow pain has multiple etiologies; most common is lateral epicondylitis. Radio-capitellar arthritis, posterolateral rotatory instability (PLRI), plica and radial tunnel syndromes may produce similar pain. The purpose of this study is to report on a rare subset of patients who had an acute injury during treatment for chronic lateral epicondylitis, exacerbating symptoms and lessening function. Indications for surgery were a failure of another round of nonoperative management and diagnosis of a new injury to the lateral ligaments in addition to the lateral epicondylitis. Surgical intervention revealed the acute injury to the radial ulno-humeral ligament (RUHL) complex, superimposed on chronic lateral epicondylitis, which we believe caused worsening of symptoms. Surgical repair of both lesions provided satisfactory results. MATERIALS AND METHODS: Seven patients (range, 29-46 years; mean, 40.7) being treated for chronic lateral epicondylitis each sustained an acute elbow injury resulting in PLRI. Study data, including Andrews-Carson Elbow Score (ACES) and Mayo Elbow Performance Score (MEPS), were collected in the initial evaluation and at regular postoperative intervals, with a follow-up period of 12-24 months. Indications for surgery were pain, functional impairment, and failure of other treatments. All surgeries were performed on an outpatient basis under general anesthesia in the prone position. RESULTS: All patients showed arthroscopic evidence of chronic lateral epicondylitis and acute RUHL injury. All showed significant improvement in total ACES and MEPS after repair of both lesions, full range of motion, and objective improvement in strength and function, with no adverse effects or complications. CONCLUSION: Patients with chronic lateral epicondylitis who sustain an acute injury may damage the RUHL complex. Early recognition of this additional injury may allow surgical repair of both injuries with satisfactory results.

Arthroscopic Identification and Management of Hourglass Biceps.

The hourglass biceps is a condition in which the intra-articular portion of the biceps tendon becomes inflamed and hypertrophies relative to the remaining tendon. This condition can be seen in association with rotator cuff and labral pathology and may lead to anterior shoulder pain. Diagnosis requires careful visualization and inspection of the biceps tendon during shoulder arthroscopy, as the presentation may be subtle. Surgical treatment includes tenotomy or tenodesis, depending on patient factors and surgeon preference.