Arthroscopic Repair of Medium to Large Rotator Cuff Tears With a Triple-Loaded Medially Based Single-Row Technique Augmented With Marrow Vents.

PURPOSE: The primary purpose of this study was to evaluate the repair integrity on magnetic resonance imaging (MRI), and secondarily, clinical outcomes, of medium to large (2-4 cm) rotator cuff tears treated using an arthroscopic triple-loaded medially based single-row repair technique augmented laterally with bone marrow vents. METHODS: This is a retrospective outcomes study of patients with full-thickness medium to large (2-4 cm) rotator cuff tears repaired by 4 surgeons at a single institution over a 2-year period with a minimum of 24 months' follow-up. A single-row repair with tension-minimizing medially based triple-loaded anchors and laterally placed bone marrow vents was used. Patients completed a satisfaction and pain survey, the Western Ontario Rotator Cuff index questionnaire, and a Short Form-36 version 2 survey to evaluate clinical outcomes. MRI was obtained at a minimum of 24 months follow-up to assess repair integrity. RESULTS: A total of 64 males and 27 females with a mean age of 59.7 (range, 34-82) were included. The mean tear size was 2.6 cm in anteroposterior dimension, treated with a mean of 2.2 anchors. Eighty-three of 91 shoulders (91%) reported being completely satisfied with their result. The median Western Ontario Rotator Cuff score was 95.2% of normal, with a significant difference found between those with an intact repair and those with a full-thickness recurrent defect (median, 95.9% vs. 73.8%; P = .003). Postoperative MRI obtained at a median of 32 months (range, 24-48) demonstrated an intact repair in 84 of 91 shoulders (92%), with failure defined as a full-thickness defect of the tendon. CONCLUSIONS: Arthroscopic repair of medium to large rotator cuff tears using triple-loaded medially based single-row repair augmented with marrow vents resulted in a 92% healing rate by MRI and excellent patient-reported outcomes LEVEL OF EVIDENCE: Level IV, retrospective case series.

Outcomes of arthroscopic revision rotator cuff repair with acellular human dermal matrix allograft augmentation.

BACKGROUND: The purpose was to assess the minimum 2-year patient-reported outcomes and failure rate of patients who underwent revision arthroscopic rotator cuff repair augmented with acellular human dermal matrix (AHDM) allograft for repairable retears. METHODS: From 2008-2014, patients who underwent revision rotator cuff repair augmented with AHDM with greater than 2 years' follow-up by a single surgeon were retrospectively reviewed. Data regarding surgical history, demographic characteristics, and medical comorbidities were collected. Outcome data included American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores, as well as rotator cuff healing on magnetic resonance imaging or ultrasound. Retears and subsequent surgical procedures were characterized. RESULTS: A total of 28 patients met our inclusion criteria, and 23 (82%) were available for follow-up at 2 years. The mean age was 60.1 ± 9.3 years (range, 43-79 years), with a mean follow-up period of 48 ± 23 months. All patients had at least 1 prior rotator cuff repair. Of the 23 patients, 13 (56%) underwent postoperative imaging, and 4 of these 13 (31%) had a retear. A reoperation was performed in 3 of 23 patients (13%). Among the 6 patients with both preoperative and postoperative outcome scores, we saw improvement in the ASES score from 56 to 85 (P = .03) and in the SANE score from 42 to 76 (P = .03). The full cohort's mean postoperative ASES and SANE scores were 77 and 69, respectively. CONCLUSION: AHDM allograft augmentation is a safe and effective treatment method for patients with full-thickness rotator cuff retears. Further research is needed with larger studies to confirm these findings from our small cohort of patients.

All-Arthroscopic Suprapectoral Versus Open Subpectoral Tenodesis of the Long Head of the Biceps Brachii Without the Use of Interference Screws.

PURPOSE: To compare patient-reported outcomes and healing rates after open subpectoral and all-arthroscopic suprapectoral biceps tenodesis without the use of interference screws in patients with more than 2 years of follow-up. METHODS: Patients with at least 2 years of follow-up who underwent open subpectoral biceps tenodesis or all-arthroscopic suprapectoral biceps tenodesis without concomitant rotator cuff repair, labral repair, or Mumford procedure were considered for enrollment in the study. They were evaluated for visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and satisfaction with function and biceps contour. Ultrasonography was performed to evaluate the integrity of the tenodesis site and measure biceps muscle diameters on each arm. RESULTS: Forty-nine patients were eligible for our study and of these, 38 were able to participate. Twenty-three patients had open subpectoral biceps tenodesis and 15 received all-arthroscopic suprapectoral biceps tenodesis. The average follow-up time was 4.5 years (range 2-9.1 years). There were no significant differences in anterior shoulder pain VAS, ASES scores, or satisfaction rates. The average anterior shoulder VAS was 0.7 ± 1.1 for the open group and 0.9 ± 1.8 for the arthroscopic group (P = .74). The mean ASES score for the open group was 90.6 ± 11.4 and 91.4 ± 13.9 for the arthroscopic group (P = .69). All patients had an intact tenodesis site on ultrasonography and the ratio of operative to nonoperative biceps diameters was 100.2% ± 12.8% for the open group and 99.1% ± 10.8% for the arthroscopic group (P = .66). There were no infections and no brachial plexus injuries in either group. CONCLUSIONS: Open subpectoral biceps tenodesis and all-arthroscopic suprapectoral biceps tenodesis are both successful surgeries with consistently positive outcomes. Tenodesis can be performed in either location without interference screw fixation with durable, reliable results. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair.

PURPOSE: To prospectively evaluate the safety and effectiveness of arthroscopic acellular human dermal matrix augmentation of large rotator cuff tear repairs. METHODS: A prospective, institutional review board-approved, multicenter series of patients undergoing arthroscopic repair of 2-tendon rotator cuff tears measuring greater than 3 cm were randomized by sealed envelopes opened at the time of surgery to arthroscopic single-row rotator cuff repair with GraftJacket acellular human dermal matrix (Wright Medical Technology, Arlington, TN) augmentation (group 1) or without augmentation (group 2). Preoperative and postoperative functional outcome assessments were obtained by use of the American Shoulder and Elbow Surgeons (ASES), Constant, and University of California, Los Angeles scales. Gadolinium-enhanced magnetic resonance imaging (MRI) evaluation of these repairs was obtained at a mean of 14.5 months (range, 12 to 24 months). Adverse events were recorded. RESULTS: There were 22 patients in group 1 and 20 in group 2 with a mean age of 56 years. The mean follow-up was 24 months (range, 12 to 38 months). The ASES score improved from 48.5 to 98.9 in group 1 and from 46.0 to 94.8 in group 2. The scores in group 1 were statistically better than those in group 2 (P = .035). The Constant score improved from 41.0 to 91.9 in group 1 and from 45.8 to 85.3 in group 2. The scores in group 1 were statistically better than those in group 2 (P = .008). The University of California, Los Angeles score improved from 13.3 to 28.2 in group 1 and from 15.9 to 28.3 in group 2 (P = .43). Gadolinium-enhanced MRI scans showed intact cuffs in 85% of repairs in group 1 and 40% in group 2 (P < .01). No adverse events were attributed to the presence of the matrix grafts. CONCLUSIONS: Acellular human dermal matrix augmentation of large (>3 cm) cuff tears involving 2 tendons showed better ASES and Constant scores and more frequent intact cuffs as determined by gadolinium-enhanced MRI. Intact repairs were found in 85% of the augmented group and 40% of the nonaugmented group (P < .01). No adverse events related to the acellular human dermal matrix were observed. LEVEL OF EVIDENCE: Level II, lesser-quality randomized controlled trial.

Arthroscopic rotator cuff repair in patients younger than fifty years of age.

Thirty-seven patients (41 shoulders) younger than 50 years of age (mean age, 43.7 years) underwent all-arthroscopic repairs of rotator cuff tears between 1994 and 2002. With a minimum 3-year follow-up (average 69 months, range 37-161 months), postoperative function was assessed by means of a UCLA scoring system, range of motion measurements, strength exam, and VAS pain score. Tears were categorized into 4 groups by type and size: partial undersurface tears, complete tears that were small (<1 cm), medium (1-3 cm), or large/massive (4-5 cm). All but 1 patient (97%) was subjectively satisfied and felt to be improved postoperatively. Average postoperative UCLA score improved significantly, and 95% of the shoulders achieved good or excellent postoperative results. Postoperative pain scores and strength evaluation also improved significantly. There was no significant loss of motion postoperatively and outcomes were independent of tear size and type. To date, there have been no revisions. These treatment results suggest that arthroscopic management in patients younger than 50 can achieve predictably good to excellent results regardless of tear size.

Adolescent baseball pitching technique: a detailed three-dimensional biomechanical analysis.

PURPOSE: Document the biomechanics of the pitching motion to help provide insight about the etiology of common injuries seen in adolescent baseball pitchers. METHODS: Kinematic and kinetic data for the upper and lower extremities, thorax, and pelvis were collected from 24 adolescent pitchers, using modern three-dimensional computerized motion-analysis techniques. RESULTS: Original information regarding forearm and wrist motion was reported in this study and were consistent with expected motions for the fastball pitch. Average excursion of motion was: pronation/supination 63 +/- 15 degrees, wrist flexion/extension 44 +/- 14 degrees, and ulnar/radial deviation 12 +/- 4 degrees. Explosive forearm motion occurred between ball release (BR) and maximal glenohumeral internal rotation (GH-MIR) with a peak pronation velocity of 2051 +/- 646 degrees.s(-1). The majority of internal/external and abduction/adduction shoulder motion was attributed to the glenohumeral motion. Internal glenohumeral rotation range of motion was 125 +/- 13 degrees and mean peak internal glenohumeral rotation velocity was 3343 +/- 453 degrees.s(-1). Thorax and pelvic motion peak velocities and accelerations occurred before the peak elbow varus moment, which occurred at 59% of the pitch cycle (PC). The peak shoulder, elbow, and wrist velocities and accelerations occurred after the peak elbow varus moment. The pelvis squared to the plate at 51 +/- 10% PC and the thorax at 59 +/- 7% PC with maximal glenohumeral external rotation (GH-MER) at 65% PC and BR at 78 +/- 3% PC. The data collected in this study were consistent with the literature, with the exception of joint velocities and moments, which were lower than those in one published study. CONCLUSION: We have established the kinematic and kinetic parameters of the adolescent baseball pitch. These measured parameters and the differences between adolescent pitchers and their adult counterparts can be used to examine and help determine the causes of the rapid increase in adolescent pitching injuries.

Arthroscopic Iliac Crest Bone Grafting to the Anterior Glenoid.

Failed arthroscopic soft-tissue stabilization and anterior glenoid bone loss have been shown to have high failure rates after standard arthroscopic stabilization techniques. For patients with recurrent glenohumeral instability, the Bristow-Latarjet procedure is currently the standard of care. It is predominantly performed through an open deltopectoral approach but has recently been described arthroscopically. Although providing excellent clinical outcomes, the Bristow-Latarjet procedure violates the subscapularis muscle, has a steep learning curve with a high complication rate, and permanently changes the anterior shoulder anatomy, making any future revision surgery more challenging. We describe a technique for arthroscopic anterior glenoid augmentation using iliac crest bone graft that does not violate the subscapularis, by creating a far anterior-medial portal that traverses superior to the subscapularis and lateral to the conjoint tendon. The graft is passed through this portal and secured with rigid fixation. An arthroscopic Bankart capsulolabral repair is then performed, making the graft extra-articular. A remplissage can easily be added as indicated, allowing this procedure to arthroscopically address all 3 major components of structural instability: glenoid bone loss, capsulolabral tearing, and humeral bone loss.

In Vivo Measurement of Rotator Cuff Tear Tension: Medial Versus Lateral Footprint Position.

We conducted a study to evaluate in vivo tension applied to the rotator cuff tendon positioned at the medial versus lateral footprint during arthroscopic rotator cuff repair. We evaluated 20 consecutive patients who underwent arthroscopic rotator cuff repair. During repair, a grasper was inserted through a lateral portal, and a digital weigh scale was attached. The tendon was grasped and translated to the medial footprint, and tension recorded. After a relaxation period, the tendon edge was translated to the lateral footprint, and tension recorded. Mean (SD) tension was 0.41 (0.33) pound when tendons were positioned at the medial footprint and 2.21 (1.20) pounds when they were positioned at the lateral footprint, representing a 5.4-fold difference (P < .0001). For smaller tears (≤ 20 mm anterior-posterior), 7.6 times less tension was applied to the tendons when pulled to the medial versus lateral footprint. For larger tears, 4.1 times less tension was applied to the tendons when pulled to the medial versus lateral footprint. This study demonstrated a significant, 5.4-fold increase in tension when the tendon edge was reduced to the lateral as opposed to the medial footprint in vivo.

Arthroscopic transosseous bony bankart repair.

Restoration of glenoid bony integrity is critical to minimizing the risk of recurrence and re-creating normal kinematics in the setting of anterior glenohumeral instability. We present an arthroscopic suture anchor-based technique for treating large bony Bankart fractures in which the fragment is secured to the intact glenoid using mattress sutures placed through the bony fragment and augmented with soft-tissue repair proximal and distal to the bony lesion. This straightforward technique has led to excellent fragment reduction and good outcomes in our experience.