Biceps-based 3-layer reconstruction of the irreparable rotator cuff: a technical note on biceps tendon as a common local graft for in-situ superior capsular reconstruction, partial cuff repair, and middle trapezius tendon transfer.

BACKGROUND: For irreparable rotator cuff tears, 3-layer tendon reconstruction (in which in-situ superior capsular reconstruction-reinforced partial rotator cuff repair was augmented with hamstring-sheet-lengthened middle trapezius tendon transfer) was recently reported to achieve satisfactory postoperative outcomes. To avoid hamstring graft-related drawbacks, the current note describes a technical modification of that reconstruct; wherein long head of biceps tendon is used as a cornerstone structure for simultaneously reconstructing the superior capsule; lengthening the transferred middle trapezius tendon; and augmenting the partially-repaired rotator cuff. METHODS: Via sub-pectoral approach, long head of biceps tendon is distally-tenotomized. Through McKenzie approach, proximal stump of the tenotomized long head of biceps is retrieved to the sub-acromial space where double-row biceps tenodesis (into a trough at the greater tuberosity) is performed for reconstructing the superior capsule. Next, postero-superior rotator cuff is partially repaired, and side-to-side sutured to the reconstructed capsule. Through a 7-8-cm skin incision over the medial scapular spine, middle trapezius tendon is released. Portion of long head of biceps tendon distal to the tenodesis site is retrieved via a sub-trapezius/sub-acromial corridor to the scapular wound where it is re-attached to the released middle trapezius tendon. RESULTS: Use of long head of biceps tendon as a common local graft (for simultaneously reconstructing the superior capsule, lengthening the transferred middle trapezius tendon, and augmenting the partially-repaired rotator cuff) is technically feasible provided that the harvested tendon stump is at least 10 cm in length. CONCLUSION: While avoiding hamstring graft-related complications, the currently-reported biceps-based 3-layer rotator cuff tendon reconstruction might offer the advantages of reproducibility, safety, simplicity and quickness; however, it should be validated via further studies. Trial registration The present study was approved by the Institutional Committee of Scientific Research and Ethics (3-2023Orth10-1).

Middle Trapezius Tendon Transfer for Augmentation of In Situ Superior Capsular Reconstruction-Reinforced Partial Rotator Cuff Repair: Short-term Outcomes of a Prospective Cohort Study.

Background: Middle trapezius tendon (MTT) transfer has been described for dynamic reproduction of supraspinatus function. For management of irreparable rotator cuff (RC) tears, this procedure can be coupled with in situ (long head of the biceps tendon-based) superior capsular reconstruction (SCR) and partial RC repair. Purpose: To investigate the functional outcomes of augmentation of in situ SCR-reinforced partial RC repair with MTT transfer for the management of irreparable posterosuperior RC tears. Study Design: Cohort study; Level of evidence, 3. Methods: Conducted between September 2014 and March 2022, this study included 24 patients with irreparable posterosuperior RC tears who were allocated into 2 groups: patients managed with 2-layer tendon construct (in situ SCR-reinforced partial RC repair) (group A; n = 15) and patients managed with 3-layer tendon construct (MTT transfer-augmented, in situ SCR-reinforced partial RC repair) (group B; n = 9). Outcome measures included 2-year postoperative pain, range of motion (ROM) in forward flexion and external rotation, and the American Shoulder and Elbow Surgeons (ASES) and the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. For data comparison, independent and paired t tests were used for parametric quantitative variables, and Mann-Whitney and Wilcoxon signed-rank tests were used for nonparametric quantitative variables; Fisher exact and McNemar tests were used for qualitative variables. Results: The mean age of the patients was 58.40 ± 4.54 years in group A and 59.22 ± 4.46 years in group B; there were no between-group differences in baseline patient characteristics. Patients in both groups had significant preoperative to postoperative improvement on all outcome measures (P < .05 for all). Group B had a significantly higher magnitude of postoperative improvement compared with group A in forward flexion ROM (88.88° ± 29.34° vs 46.66° ± 20.93°; P = .001), external rotation ROM (32.22° ± 14.81° vs 16.0° ± 9.10°; P = .002), ASES score (71.07 ± 8.26 vs 57.87 ± 8.39; P = .001), and QuickDASH score (-70.20 ± 6.95 vs -58.34 ± 12.52; P = .007). Conclusion: Augmentation of in situ SCR-reinforced partial RC repair with MTT transfer in a 3-layer tendon construct led to significantly greater improvement in postoperative ROM and functional scores compared with a 2-layer construct.

Elderly unstable distal radius fractures a prospective cohort study of bone substitutes-augmented percutaneous pinning.

BACKGROUND: Based on debatable recommendations of using bone substitutes for filling of metaphyseal void in elderly unstable distal radius fractures; this study investigated the following question "Do bone substitutes effectively contribute to postoperative stability of k-wire fixation construct and accelerate healing in elderly unstable distal radius fractures?". METHODS: This prospective cohort study was conducted from October 2014 to April 2021. According to use of bone substitutes, 40 patients of elderly unstable distal radius fractures were alternately allocated into; group-(A) of bone substitutes-augmented percutaneous pinning (19 patients); and group-(B) of non-augmented percutaneous pinning (21 patients). Groups were compared for preoperative patients' demographics and postoperative ROM, Quick-DASH and Mayo Wrist scores, radiographic parameters (palmar tilt, radial height and inclination, ulnar variance and intra-articular step-off) and duration until radiographic fracture healing. RESULTS: Statistically, augmented and non-augmented groups were matched in terms of patients' demographics (mean age; 58.7 vs. 62.0 years respectively, P-value = 0.25). All included fractures have healed with insignificantly longer duration in augmented group (7.1 vs. 6.8 weeks, P-value = 0.26). At 12-week postoperative evaluation, radiographic parameters of both groups were comparably well-maintained except for intra-articular step-off which showed significantly less secondary displacement in augmented group (0.1 vs. 0.4 mm, P-value = 0.01). There were insignificant differences in 6-month postoperative ROM, and Quick-DASH and Mayo Wrist scores. CONCLUSION: Compared to its bone substitutes-augmented counterpart; non-augmented percutaneous pinning of elderly unstable distal radius fractures can offer advantages of comparable healing rates and functional and radiographic outcomes, less-invasive approach, shorter operative time and lower cost. LEVEL OF EVIDENCE: III.

Chronic locked posterior gleno-humeral dislocation: technical note on fibular grafting for restoration of humeral head sphericity.

BACKGROUND: Reconstruction of reverse Hill-Sachs defect using osteo-chondral allograft has the advantages of spherical re-contouring and provision of smooth biological articular surface of the reconstructed humeral head. However, worldwide availability and risk of disease transmission of osteo-chondral allograft remain points of increasing concerns. As an alternative to lacking osteo-chondral allograft, the current technical note describes a reconstructive technique of reverse Hill-Sachs defect using autologous fibular grafting. METHODS: Following open reduction of the dislocated humeral head, reverse Hill-Sachs defect was reconstructed using 3-4 autologous fibular pieces (each is of 10 mm in length) fixed in flush with the articular cartilage using 4-mm cancellous screws. Defect reconstruction was then followed by modified McLaughlin's transfer and posterior capsulorrhaphy. RESULTS: Spherical contour of the humeral head and gleno-humeral range of motion were restored. Intra-operative dynamic testing of the reconstruct revealed no residual posterior gleno-humeral instability. CONCLUSION: Currently reported technique might offer advantages of graft availability, technical simplicity, familiarity and reproducibility, safety (i.e. no disease transmission) and bone preservation facilitating future revision management (if needed). Nevertheless, long-term outcomes of this technique should be investigated via further cohort clinical studies.

Rotator cuff irreparability or failure of repair (re-tear): technical note on middle trapezius tendon transfer for reproduction of supraspinatus function.

PURPOSE: Based on its close anatomic features and nearly-collinear force vector to those of supraspinatus muscle, the current article describes a technique of middle trapezius tendon transfer for reproduction of supraspinatus function in the context of rotator cuff irreparability/re-tear management. METHODS: While seating the patient in beach-chair position, arthroscopic gleno-humeral examination and sub-acromial decompression are initially performed. Hamstring tendons are harvested and fashioned as flattened quadruple sheet. Through McKenzie approach, infraspinatus and subscapularis tendons are repaired. Then, medial half of middle trapezius insertion tendon is harvested from most medial 5-6 cm of the scapular spine. Through McKenzie approach, hamstring sheet is retrieved via a sub-trapezius/sub-acromial corridor from the scapular wound. Hamstring sheet is re-attached to cuff footprint by double row/suture bridge repair configuration. While retracting the scapula and placing gleno-humeral joint in 45O-abduction/45O-external rotation, hamstring sheet is re-attached to released middle trapezius tendon by non-absorbable sutures. Finally, tendon reconstruct is dynamically-tested in different positions of range of motion. RESULTS: Transfer of medial portion of middle trapezius insertion tendon (lengthened by interposition hamstring tendon sheet) to cuff footprint was technically feasible. Dynamic testing showed smooth sub-acromial gliding motion of the tendon reconstruct. CONCLUSION: For reproduction of supraspinatus function, hamstring tendon augmented-middle trapezius tendon transfer to cuff footprint heralds a number of technical and biomechanical advantages; thus offering a potential effective modality of cuff irreparability/re-tear management in relatively young patients of high functional demands. However, current description should be investigated in further biomechanical and clinical studies to validate its long-term outcomes.

Soft Arthroscopic Latarjet Procedure: Technical Note on Biceps Tendon as a Modified Sling for Restoration of Glenohumeral Stability.

As an alternate to sling glenohumeral restabilization mechanism of Latarjet procedure, recent different arthroscopic soft-tissue reconstructive techniques have been described for the management of glenohumeral instability. One of these techniques is trans-subscapularis bony tenodesis of long head of biceps (instead of coracoid graft transfer) to the anteroinferior glenoid. For simplification of the latter technique, the current article reports an alternative arthroscopic technique for management of glenohumeral instability in patients with type V SLAP lesion or poor soft-tissue quality of the anterior capsulolabral complex. In this technique, Bankart repair is followed by soft-tissue tenodesis of long head of biceps to upper border of subscapularis tendon by 2 simple stitches of non-absorbable sutures. Compared with previous ones, the currently reported technique is versatile, quick, technically simple, entirely intra-articular, and cost-saving; however, it is nonanatomic and should be investigated in biomechanical and cohort clinical studies to clarify its long-term validity.

Type V superior labral anterior-posterior (SLAP) lesion in recurrent anterior glenohumeral instability.

BACKGROUND: The literature has reported debatable diagnostic accuracy of clinical provocative tests for a type II superior labral anteroposterior (SLAP) lesion, especially in the context of a type V SLAP (concurrent Bankart and type II SLAP) lesion. This study was conducted to determine whether the investigated provocative tests offer reliable predictive values in the diagnosis of type II SLAP lesions in patients with recurrent anterior glenohumeral (GH) instability. METHODS: This prospective case-control study carried out between September 2014 and September 2018 included 51 patients with post-traumatic recurrent anterior GH instability. Patients were prospectively evaluated for type II SLAP lesions by 9 provocative tests: Jobe relocation test, abduction-external rotation test, anterior slide test, biceps load test I, biceps load test II, pain provocation test, labral tension test, crank test, and the O'Driscoll dynamic labral shear test. The results of these tests were compared with findings of diagnostic arthroscopic GH examinations (control). RESULTS: Statistical analysis revealed the mean age of the studied group to be 26.1 ± 7.56 years, with male predominance (50 patients; 98.04%). Arthroscopic examination revealed a Bankart lesion in isolation and in association with a type II SLAP lesion (ie, a type V SLAP lesion) in 15 (29.4%) and 36 (70.6%) patients, respectively. The anterior slide test yielded the highest positive and lowest negative likelihood ratios (2.91 and 0.52, respectively). CONCLUSION: Except for the anterior slide test, which can be validated for the clinical diagnosis of type II SLAP lesions in patients with traumatic recurrent anterior GH instability, the investigated tests offer poor predictive values and should be cautiously used in clinical practice.

Biceps femoris tenodesis revisited A prospective cohort study of concurrent anterior cruciate and postero-lateral corner reconstruction.

PURPOSE: When tendon allograft is not an option, knee posterolateral corner reconstruction by biceps femoris tenodesis gains increasing interest. This study investigated such question; "Does biceps femoris tenodesis result in clinical and functional outcomes comparable to Larsen fibular-based sling in concurrent posterolateral corner and anterior cruciate reconstruction? PATIENTS & METHODS: From October 2014 till December 2018, 19 patients of concurrent anterior cruciate and posterolateral corner injury were prospectively categorized according to posterolateral reconstruction technique into group-(A) of 10 patients managed by Larsen sling and group-(B) of 9 patients managed by biceps femoris tenodesis. Patients were evaluated for preoperative and 2-year postoperative knee range of motion, varus stress and prone dial tests, Lysholm and IKDC scores, return to work, and instability recurrence. RESULTS: Statistical analysis revealed matched demographics between groups. At mean of 29months postoperatively, average knee flexion was 146°; while extension loss didn't exceed 1° in both groups. There was no significant difference between groups in Lysholm and IKDC scores; (P-value= 0.710 and 0.210 respectively). CONCLUSION: Despite it is non-anatomic technique, biceps femoris tenodesis can achieve clinical and functional outcomes comparable to Larsen fibular-based sling in concurrent posterolateral corner and anterior cruciate reconstruction; while offering advantages of simplicity and quickness and overcoming tendon graft unavailability.

Intra-operative patellar fracture during chronic patellar tendon rupture reconstruction: salvage and prophylactic modified techniques.

Management of chronic neglected patellar tendon rupture represents a challenging condition for the orthopedic surgeons to deal with due to many factors such as quadriceps muscle atrophy, superior migration of the patella, e.g., patella alta, peri-patellar adhesions and patellar tendon atrophy. Such difficulties might be further complicated by intra-operative patellar fracture during patellar tendon reconstruction. In the current article, the authors report (1) a salvage procedure for such devastating intra-operative complication, based on bypassing the patella and gaining the advantage of the quadriceps tendon for structural and functional restoration of the knee extensor mechanism, and (2) prophylactically a technical modification of patellar tendon reconstruction guarding against such inadvertent patellar fracture.