Arthroscopic Anchorless Transosseous Rotator Cuff Repair Produces Equivalent Clinical Outcomes and Imaging Results as a Standard Suture Bridge Technique with Anchors.

Purpose: To compare the clinical and imaging outcome of arthroscopic transosseous (TO)-equivalent rotator cuff repair (RCR) with anchors with arthroscopic anchorless TO RCR at a minimum of 2 years postoperatively. Methods: The study population included patients who underwent RCR using either an anchorless TO technique with a TO suture passing device (group A) and those who were matched for tear size and underwent RCR using suture anchors for repair (group B). The inclusion criterion was an easily reducible rotator cuff tear with a sagittal extension of 2 to 4 cm. After a minimum of 2 years, clinical outcome scores and magnetic resonance imaging were obtained. Tendon quality and footprint integration were evaluated using the Sugaya classification. Results: Seventy patients were included. A total of 45 were in group A and 25 were in group B. Group A had 2 bone tunnels and 4 sutures using an X-box configuration, and group B had a suture bridge construct of 4 anchors. Group A and B had identical anteroposterior tear size and were comparable for age. The Constant score improved from 50 ± 17.4 to 88 ± 8.6 in group A versus 48 ± 14.5 to 87 ± 7.2 in B. The Subjective Shoulder Value rose from 47 ± 19.1 to 95 ± 7.4 in group A vs from 47 ± 19.4 to 95 ± 7.6 in B. Neither the preoperative (P ≥ .502) nor postoperative scores (P ≥ .29) showed a significant difference. Magnetic resonance imaging showed 2 small retears in group A and one in B, resulting in an identical 4% retear rate. The mean Sugaya type was 2.02 versus 2.24 (P = .206) for groups A versus B. Conclusions: Anchorless TO RCR is a valid alternative to suture anchor techniques. Clinical outcome data showed comparable results for both techniques after a follow-up of 2 years. The healing results as observed on magnetic resonance imaging were also equivalent for both groups. Level of Evidence: Level III, retrospective comparative study.

Results of Arthroscopic Revision Rotator Cuff Repair for Failed Open or Arthroscopic Repair: A Prospective Multicenter Study on 100 Cases.

BACKGROUND: Retears after rotator cuff repair (RCR) have been associated with poor clinical results. Meaningful data regarding the role of arthroscopic revision RCR are sparse thus far. PURPOSE/HYPOTHESIS: To investigate results after arthroscopic revision RCR. We hypothesized that (1) arthroscopic revision RCR would lead to improved outcomes, (2) the clinical results would be dependent on tendon integrity and (3) tear pattern, tendon involvement, and repair technique would influence clinical and structural results. STUDY DESIGN: Case series; Level of evidence 4. METHODS: During a 40-month period, 100 patients who underwent arthroscopic revision RCR were prospectively enrolled in this multicenter study. Outcomes were evaluated preoperatively, at 6 months (6M), and at 24 months (24M) using the Constant score (CS), the Oxford Shoulder Score (OSS), and the Subjective Shoulder Value (SSV). Tendon integrity at 2 years was analyzed using magnetic resonance imaging. A total of 13 patients (13%) were lost to follow-up, and 14 patients (14%) had a symptomatic retear before the 24M follow-up. RESULTS: All clinical scores improved significantly during the study period (CS: preoperative, 44 ± 16; 6M, 58 ± 22; 24M, 69 ± 19 points; OSS: preoperative, 27 ± 8; 6M, 36 ± 11; 24M, 40 ± 9 points; SSV: preoperative, 43% ± 18%; 6M, 66% ± 24%; 24M, 75% ± 22%) (P < .01). At 2 years, a retear rate of 51.8% (43/83) and a surgical revision rate of 12.6% (11/87) were observed. Mean full-thickness tear size decreased from 5.00 ± 1.61 cm2 to 3.25 ± 1.92 cm2 (P = .041). Although the Sugaya score improved from 4.5 ± 0.9 to 3.7 ± 1.4 (P = .043), tendon integrity did not correlate with better outcome scores. Previous open RCR, involvement of the subscapularis, chondral lesions of Outerbridge grade ≥2, and medial cuff failure were correlated with poorer SSV scores at 2 years (P≤ .047). Patients with traumatic retears had better CS and OSS scores at 2 years (P≤ .039). CONCLUSION: Although arthroscopic revision RCR improved shoulder function, retears were frequent but usually smaller. Patients with retears, however, did not necessarily have poorer shoulder function. Patient satisfaction at 2 years was lower when primary open RCR was performed, when a subscapularis tear or osteoarthritis was present, and when the rotator cuff retear was located at the musculotendinous junction. Patients with traumatic retears showed better functional improvement after revision.

Arthroscopic Suture-Bridge Repair of the Subscapularis Tendon-"Inside and Outside the Box" With Preservation of the Comma Sign.

The subscapularis muscle and its tendon are of major importance in the kinematics of the glenohumeral joint. Therefore, a diligent repair of subscapularis tears is essential. We describe our reliable standardized arthroscopic suture bridge technique to repair subscapularis tears under intra- and extraarticular visualization and with preservation of the "comma sign." This technique provides excellent exposure of the subscapularis tendon, allows its complete release in the subcoracoid space and ensures a safe and stable repair.

A "Comma Sign"-Directed Subscapularis Repair in Anterosuperior Rotator Cuff Tears Yields Biomechanical Advantages in a Cadaveric Model.

BACKGROUND: Additional stabilization of the "comma sign" in anterosuperior rotator cuff repair has been proposed to provide biomechanical benefits regarding stability of the repair. PURPOSE: This in vitro investigation aimed to investigate the influence of a comma sign-directed reconstruction technique for anterosuperior rotator cuff tears on the primary stability of the subscapularis tendon repair. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 18 fresh-frozen cadaveric shoulders were used in this study. Anterosuperior rotator cuff tears (complete full-thickness tear of the supraspinatus and subscapularis tendons) were created, and supraspinatus repair was performed with a standard suture bridge technique. The subscapularis was repaired with either a (1) single-row or (2) comma sign technique. A high-resolution 3D camera system was used to analyze 3-mm and 5-mm gap formation at the subscapularis tendon-bone interface upon incremental cyclic loading. Moreover, the ultimate failure load of the repair was recorded. A Mann-Whitney test was used to assess significant differences between the 2 groups. RESULTS: The comma sign repair withstood significantly more loading cycles than the single-row repair until 3-mm and 5-mm gap formation occurred (P≤ .047). The ultimate failure load did not reveal any significant differences when the 2 techniques were compared (P = .596). CONCLUSION: The results of this study show that additional stabilization of the comma sign enhanced the primary stability of subscapularis tendon repair in anterosuperior rotator cuff tears. Although this stabilization did not seem to influence the ultimate failure load, it effectively decreased the micromotion at the tendon-bone interface during cyclic loading. CLINICAL RELEVANCE: The proposed technique for stabilization of the comma sign has shown superior biomechanical properties in comparison with a single-row repair and might thus improve tendon healing. Further clinical research will be necessary to determine its influence on the functional outcome.

Intratendinous Strain Variations of the Supraspinatus Tendon Depending on Repair Technique: A Biomechanical Analysis Regarding the Cause of Medial Cuff Failure.

BACKGROUND: Double-row (DR) and transosseous-equivalent (TOE) techniques for rotator cuff repair offer more stability and promote better tendon healing compared with single-row (SR) repairs and are preferred by many surgeons. However, they can lead to more disastrous retear patterns with failure at the medial anchor row or the musculotendinous junction. The biomechanics of medial cuff failure have not been thoroughly investigated thus far. PURPOSE: To investigate the intratendinous strain distribution within the supraspinatus tendon depending on repair technique. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve fresh-frozen cadaveric shoulders were used. The intratendinous strain within the supraspinatus tendon was analyzed in 2 regions-(1) at the footprint at the greater tuberosity and (2) medial to the footprint up to the musculotendinous junction-using a high-resolution 3-dimensional camera system. Testing was performed at submaximal loads of 40 N, 60 N, and 80 N for intact tendons, after SR repair, after DR repair, and after TOE repair. RESULTS: The tendon strain of the SR group differed significantly in both regions from that of the intact tendons and the TOE group at 40 N (P≤ .043) and from the intact tendons, the DR group, and the TOE group at 60 N and 80 N (P≤ .048). SR repairs showed more tendon elongation at the footprint and less elongation medial to the footprint. DR and TOE repairs did not provide significant differences in tendon strain when compared with the intact tendons. However, the increase in tendon strain medial to the footprint from 40 N to 80 N was significantly more pronounced in the DR and TOE group (P≤ .029). CONCLUSION: While DR and TOE repair techniques more closely reproduced the strains of the supraspinatus tendon than did SR repair in a cadaveric model, they showed a significantly increased tendon strain at the musculotendinous junction with higher loads in comparison with the intact tendon. CLINICAL RELEVANCE: DR and TOE rotator cuff reconstructions lead to a more anatomic tendon repair. However, their use has to be carefully evaluated whenever tendon quality is diminished, as they lead to a more drastic increase in tendon strain medial to the footprint, putting these repairs at risk of medial cuff failure.

Arthroscopic Transosseous Anchorless Rotator Cuff Repair Using the X-Box Technique.

We describe a reproducible, step-by-step arthroscopic technique for anchorless transosseous rotator cuff repair using an X-box configuration with the Arthrotunneler device. The technique uses 2 bone tunnels and 4 high-strength sutures and is suitable for medium to large tears of the supra- and infraspinatus that would alternatively need a double-row repair with 4 anchors. Biomechanically, results appear to be similar as for anchored transosseous equivalent techniques. Enhanced biological healing and lower material costs are the possible benefits of this appealing arthroscopic approach that mimics the previous gold standard.

Arthroscopic Revision of Medial Rotator Cuff Failure Augmented With a Bioabsorbable Patch.

When revising failed double-row and suture-bridge rotator cuff repairs medial failures represent a potential feature. In the presence of a compromised healing environment, patch augmentation becomes a logical adjunct from a mechanical and biological point of view. A reproducible step-by-step revision technique is described that reinforces the weak central cuff area with an absorbable synthetic scaffold.

The risk of suprascapular and axillary nerve injury in reverse total shoulder arthroplasty: An anatomic study.

PURPOSE: Implantation of a reverse total shoulder arthroplasty (rTSA) places the axillary and suprascapular nerves at risk. The aim of this anatomic study was to digitally analyse the location of these nerves in relation to bony landmarks in order to predict their path and thereby help to reduce the risk of neurological complications during the procedure. METHODS: A total of 22 human cadaveric shoulder specimens were used in this study. The axillary and suprascapular nerves were dissected, and radiopaque threads were sutured onto the nerves without mobilizing the nerves from their native paths. Then, 3D X-ray scans of the specimens were performed, and the distance of the nerves to bony landmarks at the humerus and the glenoid were measured. RESULTS: The distance of the inferior glenoid rim to the axillary nerve averaged 13.6mm (5.8-27.0mm, ±5.1mm). In the anteroposterior direction, the distance between the axillary nerve and the humeral metaphysis averaged 8.1mm (0.6-21.3mm, ±6.5mm). The distance of the glenoid centre to the suprascapular nerve passing point under the transverse scapular ligament measured 28.4mm (18.9-35.1mm, ±3.8mm) in the mediolateral direction and 10.8mm (-4.8 to 25.3mm, ±6.1mm) in the anteroposterior direction. The distance to the spinoglenoid notch was 16.6mm (11.1-24.9mm, ±3.4mm) in the mediolateral direction and -11.8mm posterior (-19.3 to -4.7mm, ±4.7mm) in the anteroposterior direction. CONCLUSIONS: Implantation of rTSA components endangers the axillary nerve because of its proximity to the humeral metaphysis and the inferior glenoid rim. Posterior and superior drilling and extraosseous screw placement during glenoid baseplate implantation in rTSA place the suprascapular nerve at risk, with safe zones to the nerve passing the spinoglenoid notch of 11mm and to the suprascapular notch of 19mm.

Posteroinferior shoulder instability: clinical outcome of arthroscopic stabilization in 32 shoulders and categorization based on labral mapping.

INTRODUCTION: Posterior shoulder instability is rare, appears in varying clinical patterns and can be the main symptom in patients with instability in more than one direction. The purpose was to analyze and categorize our patients and to report on the results of operative treatment by arthroscopy. MATERIALS AND METHODS: A consecutive series of 32 shoulders in 31 patients from a 7-year period was chosen for retrospective clinical evaluation with VAS for pain, Rowe Score, Constant Score and Simple Shoulder Test. Follow-up rate was 100 %, the mean FU period was 28 months (range 13-58). Allocation based on clinical and intraoperative criteria resulted in the 4 groups A to D characterized by an increasing traumatic impact. Patients received a posterior Bankart repair with bone anchors in 21 or capsular plication to the intact labrum in 11 cases. RESULTS: The clinical outcome scores were generally good and all showed a trend towards better results from A to D, but without significance. Pain on VAS pre- and postoperatively showed a significant (p < 0.0001) overall decline from 7.4 to 1.8. The Rowe Score increased significantly (p < 0.0001) from a mean value of 41.4 to 89.5 points. Three patients were reoperated and satisfied, four patients (12.5 %) not satisfied at follow-up. The drive-through sign was significantly (p = 0.003) more distinct in the less traumatic groups A and B than groups C and D. Subgroup allocation resulted in the following distribution: 7 patients qualified for group A (PPM = predominantly posterior multidirectional), 13 for B (RPS = recurrent posterior subluxation), 7 for C (unidirectional) and 5 patients for group D (bi-directional). Graphic display of labral lesions, called "labral mapping", revealed typical patterns for the groups. CONCLUSION: In patients with posteroinferior shoulder instability, good results can be obtained with the arthroscopic treatment of all identified pathologies. Categorization into one of four subgroups might be a valuable tool regarding the choice of the operative treatment options.

Rupturas parciales del espesor del manguito de los rotadores, diagnóstico y tratamiento artroscópico / Partial-thickness rotator cuff tear: diagnosis and arthroscopic treatment

Introducción: las rupturas parciales del espesor del manguito rotador (tendones del supraespinoso, infraespinoso) se consideran dos veces más frecuente que las rupturas completas del espesor. Los estudios utilizan la artroscopia como método de elección para su diagnóstico y la convierten en la regla de oro. Numerosos cirujanos consideran conservar intactas la parte sana de las fibras del tendón y reparar el área de ruptura; principio posible de cumplir con las técnicas de reparación artroscópicas.Objetivo: evaluar los resultados de la aplicación de la técnica artroscópica para el diagnóstico y la reparación de las rupturas parciales del espesor del manguito de los rotadores, conservando la parte sana del tendón. Métodos: se repararon rupturas parciales del manguito rotador con técnica artroscópica de sutura y anclaje sin completar la ruptura del tendón del supraespinoso e infraespinoso desde enero 2008 hasta mayo de 2009. El estudio incluyó 47 hombros, 34 rupturas parciales de la superficie articular, 7 rupturas parciales de la superficie bursal y 6 rupturas parciales intratendinosas. Se realizó un seguimiento promedio de 14,5 meses (rango de 12 a 17 meses), la distribución según el sexo 34 masculinos (72,3 por ciento) y 13 femeninos (27,7 por ciento) y un promedio de edad de 47,5 años. El miembro dominante estuvo afectado en 38 pacientes (80,9 por ciento). Resultados: se obtuvo resultados excelentes y buenos en 91,5 por ciento de los pacientes y 95,8 por ciento resultados excelentes, buenos y regulares evaluados según la escala de Constant-Murley.Conclusiones: la reparación artroscópica utilizando técnica de sutura y anclaje sin completar la ruptura ofrece ventajas. Se conserva la anatomía, preservando la parte sana del tendón y evitando la progresión a defectos completos del espesor(AU)

Introduction: partial-thickness rotator cuff tears (supraspinatus tendon, infraspinatus) are considered twice as frequent as full thickness tears. Studies using arthroscopy as a method of choice for diagnosis and they turn it in the golden rule. Many surgeons consider fully maintain the healthy part of the tendon fibers and repair the rupture area; which is possible to comply with arthroscopic repair techniques. Objective: evaluate the results of the application of arthroscopic technique for the diagnosis and repair of partial-thickness rotator cuff ruptures, preserving the healthy part of the tendon.Methods: partial rotator cuff tears were repaired with arthroscopic suture anchor technique without completing the supraspinatus and infraspinatus tendon rupture from January 2008 to May 2009. The study included 47shoulders, 34 partial tears of the joint surface, seven partial teras of bursal surface and 6 intratendinous partial tears. An average follow-up of 14.5 months (range 12-17 months) was conducted. Distribution by sex 34 male (72.3 percent) and 13 female (27.7 percent) and an average age of 47.5 years was performed. The dominant limb was affected in 38 patients (80.9 percent). Results: excellent results were obtained in 95.8 percent of patients and good results in 91.5 percent. Results were assessed as excellent, good, regular according to the Constant-Murley scale results. Conclusions: arthroscopic repair using suture anchor technique without completing rupture offers advantages. Anatomy is conserved, while preserving the healthy part of the tendon and preventing progression to full thickness defects(AU)

Rupturas parciales del espesor del manguito de los rotadores, diagnóstico y tratamiento artroscópico / Partial-thickness rotator cuff tear: diagnosis and arthroscopic treatment / Ruptures partielles de la coiffe des rotateurs, diagnostic et traitement sous arthroscopie

INTRODUCCIÓN: las rupturas parciales del espesor del manguito rotador (tendones del supraespinoso, infraespinoso) se consideran dos veces más frecuente que las rupturas completas del espesor. Los estudios utilizan la artroscopia como método de elección para su diagnóstico y la convierten en la regla de oro. Numerosos cirujanos consideran conservar intactas la parte sana de las fibras del tendón y reparar el área de ruptura; principio posible de cumplir con las técnicas de reparación artroscópicas. OBJETIVO: evaluar los resultados de la aplicación de la técnica artroscópica para el diagnóstico y la reparación de las rupturas parciales del espesor del manguito de los rotadores, conservando la parte sana del tendón. MÉTODOS: se repararon rupturas parciales del manguito rotador con técnica artroscópica de sutura y anclaje sin completar la ruptura del tendón del supraespinoso e infraespinoso desde enero 2008 hasta mayo de 2009. El estudio incluyó 47 hombros, 34 rupturas parciales de la superficie articular, 7 rupturas parciales de la superficie bursal y 6 rupturas parciales intratendinosas. Se realizó un seguimiento promedio de 14,5 meses (rango de 12 a 17 meses), la distribución según el sexo 34 masculinos (72,3 %) y 13 femeninos (27,7 %) y un promedio de edad de 47,5 años. El miembro dominante estuvo afectado en 38 pacientes (80,9 %). RESULTADOS: se obtuvo resultados excelentes y buenos en 91,5 % de los pacientes y 95,8 % resultados excelentes, buenos y regulares evaluados según la escala de Constant-Murley. CONCLUSIONES: la reparación artroscópica utilizando técnica de sutura y anclaje sin completar la ruptura ofrece ventajas. Se conserva la anatomía, preservando la parte sana del tendón y evitando la progresión a defectos completos del espesor.

INTRODUCTION: partial-thickness rotator cuff tears (supraspinatus tendon, infraspinatus) are considered twice as frequent as full thickness tears. Studies using arthroscopy as a method of choice for diagnosis and they turn it in the golden rule. Many surgeons consider fully maintain the healthy part of the tendon fibers and repair the rupture area; which is possible to comply with arthroscopic repair techniques. OBJECTIVE: evaluate the results of the application of arthroscopic technique for the diagnosis and repair of partial-thickness rotator cuff ruptures, preserving the healthy part of the tendon. METHODS: partial rotator cuff tears were repaired with arthroscopic suture anchor technique without completing thesupraspinatus and infraspinatus tendon rupture from January 2008 to May 2009. The study included 47shoulders, 34 partial tears of the joint surface, seven partial teras of bursal surface and 6 intratendinous partial tears. An average follow-up of 14.5 months (range 12-17 months) was conducted. Distribution by sex 34 male (72.3 %) and 13 female (27.7 %) and an average age of 47.5 years was performed. The dominant limb was affected in 38 patients (80.9 %). RESULTS: excellent results were obtained in 95.8% of patients and good results in 91.5 %. Results were assessed as excellent, good, regular according to the Constant-Murley scale results. CONCLUSIONS: arthroscopic repair using suture anchor technique without completing rupture offers advantages. Anatomy is conserved, while preserving the healthy part of the tendon and preventing progression to full thickness defects.

INTRODUCTION: les ruptures partielles de la coiffe de rotateurs (tendons du sus-épineux, du sous-épineux) sont considérées deux fois plus fréquentes que les ruptures complètes. Dans les études, l'arthroscopie est utilisée comme méthode de choix pour le diagnostic des ruptures de la coiffe des rotateurs, et dévient alors un gold standard. Plusieurs chirurgiens tendent à laisser intacte la partie saine des fibres tendineuses et à réparer seulement la zone de la rupture, ce qui est tout à fait possible grâce aux techniques de réparation sous arthroscopie. OBJECTIF: le but de cette étude est d'évaluer les résultats de la mise en application d'une technique de diagnostic et de réparation sous arthroscopie dans le traitement des ruptures partielles de la coiffe des rotateurs. MÉTHODES: depuis janvier 2008 jusqu'à mai 2009, on a éprouvé une technique de suture et d'ancrage sous arthroscopie pour la réparation des ruptures partielles de la coiffe des rotateurs. Cette étude a compris 47 épaules (34 ruptures partielles des capsules articulaires, 7 déchirures partielles de la bourse glénoïdale, et 6 ruptures partielles des tendons). On a réalisé un suivi de 14.5 mois en moyenne (12 à 17 mois), avec une distribution par sexes de 34 hommes (72.3 %) et 13 femmes (27.7 %), et une moyenne de 47.5 ans. Le membre supérieur dominant a été affecté chez 38 patients (80.9 %). RÉSULTATS: on a obtenu des résultats excellents et bons chez 91.5% des patients, et les résultats ont été évalués d'excellents, de bons et de moyens chez 95.8% des patients selon l'échelle de Constant-Murley. CONCLUSIONS: cette technique de suture et d'ancrage sous arthroscopie, sans compléter la rupture, montre des bénéfices; on protège l'anatomie en préservant la partie saine du tendon et en évitant l'évolution complète des anomalies au niveau de la coiffe.

Outcome of arthroscopic rotator cuff repair in large tears: the exposed footprint.

The purpose of this retrospective study was to evaluate the clinical results of arthroscopic single-row repair in large rotator cuff tears. Selection was based on the extent of the "exposed footprint" (EFP) obtained by adding up the width of the subscapularis tear and the width of the supra/infraspinatus tear. Three groups were studied: Type I had an EFP of less than 5 cm; Type II had an EFP of 5 cm or more; tears allowing only partial repair were studied separately. During a period of nearly three years (in 2002-04) 49 shoulders complied with our selection. There were 25 type I and 24 type II tears. Subscapularis tears were found in 32/49 shoulders (65%); 10 shoulders (20%) had only partial repair. At an average follow-up of 33 months, all patients were subjected to an outcome assessment using the VAS, the Simple Shoulder Test (SST), Constant score (CS) and strength measurement. A near normal shoulder function (11-12 Yes-answers in the SST) was obtained in 68% of the patients with type I tears, compared to 33% of type II tears (p = 0.02). The adjusted CS for patients with a type I tear was 88%, compared to 77% for patients with a type II (p = 0.01); strength was 69% for type I and 36% for type II shoulders (p = 0.001). After arthroscopic single-row and margin-convergence repair, a near normal shoulder function was obtained in two-thirds of the shoulders with an EFP of up to 5 cm. When the EFP was larger, this outcome was achieved in only one-third of the shoulders.

A comparative clinical evaluation of arthroscopic single-row versus double-row supraspinatus tendon repair.

Cadaveric studies and commercial pressure have initiated a strong trend towards double-row repair in arthroscopic cuff surgery. The objective of this study was to evaluate if the biomechanical advantages of a double-row supraspinatus tendon repair would result in superior clinical outcome and higher abduction strength. A retrospective study of two groups of 32 single-row and 33 double-row repairs of small to medium cuff tears was performed. The Simple Shoulder Test (SST) and a visual analog scale for pain were used to evaluate the outcome. The participation rate was 100%. A subset of patients was further investigated with the Constant Score (CS) including electronic strength measurement. The double-row repair patients had significantly more (p = 0.01) yes answers in the SST than the single-row group, and pain reduction was slightly better (p = 0.03). No difference was found for the relative CS (p = 0.86) and abduction strength (p = 0.74). Patient satisfaction was 100% for double-row and 97% for single-row repair. Single- and double-row repairs both achieved excellent clinical results. Evidence of superiority of double-row repair is still scarce and has to be balanced against the added complexity of the procedure and higher costs.

Humeral osteochondroma causing a subscapularis tear: a rare source of shoulder dysfunction.

The proximal humerus is a well-known site of predilection for the solitary osteochondroma-the most common benign bone tumor. Subscapularis tears were underreported in the pre-arthroscopic era. Literature about rotator cuff impairment caused by osteochondromas is almost non-existent. We will present the case of a young man, who had a complete non-traumatic subscapularis tear, where the tendon had been peeled off the lesser tuberosity by an osteochondroma. Diagnostic features such as MRI and arthroscopy are emphasized. The patient was successfully treated by open resection of the tumor and reattachment of the tendon with suture anchors.

Simplified single-portal V-shaped SLAP repair.

We present a simplified and cost-effective method for repair of a type II SLAP lesion that requires only 1 working portal in the rotator interval-the lateral anterosuperior portal (LASP)-which is about 3 cm more lateral than the standard ASP. The rotator cuff tendon or muscle are not violated when using this portal, which provides an unproblematic 30 degrees angle for the drill hole. The biceps root can be firmly reattached anteriorly and posteriorly using 1 double-loaded absorbable bone anchor with a suture eyelet. The first stitch is performed using a straight suture hook to pierce the anterior biceps root from the front. A PDS utility suture helps to shuttle the braided suture in a retrograde manner through the labrum. We then tie a sliding knot seating solidly on top of the labrum. The second stitch is placed with a 45 degrees curved suture hook allowing us to pierce the labrum posteriorly to the biceps from above. Again, a sliding knot will be seated on top of the posterior biceps root, pressing it firmly onto the previously abraded bone. The completed repair looks like a V and produces secure fixation of the biceps, thus eliminating the peel-back phenomenon.

Open versus arthroscopic rotator cuff repair: a comparative view of 96 cases.

PURPOSE: This study was performed to review and compare the outcome of a consecutive series of 96 rotator cuff repairs performed with an open versus arthroscopic technique. The arthroscopic repairs include the beginning of the learning curve. TYPE OF STUDY: Case series. METHODS: In a 24-month period from 1999 to 2001, 95 patients underwent a cuff repair with bony reattachment by 1 surgeon; 4 patients had surgery on both shoulders. We present subjective outcome data from 96 of 99 operated shoulders by the use of a visual analog scale (VAS), the Simple Shoulder Test (SST), and the question of overall patient satisfaction. Thirty shoulders undergoing surgery before February 2000 had open cuff repair (12 classic open, 18 mini-open) and 66 shoulders undergoing surgery after February 2000 had an arthroscopic cuff repair with suture anchors. All but 3 shoulders had the supraspinatus/infraspinatus tendon refixed, 32% had a subscapularis reattachment, and 21% an additional SLAP repair. RESULTS: Groups A (30 shoulders, open repair) and B (66 shoulders, arthroscopic repair) were comparable concerning tear size, cause of the tear, professional shoulder strain, and preoperative pain intensity. At follow-up evaluation (15-40 months after surgery), group B had significantly better pain relief on the VAS (P < .05), more yes answers in the SST (9.7 vs. 8.7, not significant), and a higher patient satisfaction rate of 92.4% versus 80% (not significant). From the 12 questions of the SST, all but 1 showed a higher percentage of yes answers in group B; for 3 questions concerning mobility the difference was significant (P < .07). There was no correlation between tear size and outcome in the SST. CONCLUSIONS: Arthroscopic cuff repair yielded equal or better results than open repair, even at the beginning of the learning curve. Patients with an arthroscopic repair had a significantly better decrease in pain and a better functional result concerning mobility. Arthroscopic repair is successful for large and small tears. Biomechanically, large tears might even benefit more than small ones. LEVEL OF EVIDENCE: Level IV.

Partial-thickness articular surface supraspinatus tears: a new transtendon suture technique.

The standard technique for repairing partial-thickness tears of the supraspinatus tendon includes completion of the lesion to a full-thickness tear. Partial articular-side supraspinatus tendon avulsions (PASTA) form a subgroup deserving special consideration. We present a transtendon suture technique that is able to preserve the intact tendon fibers and to achieve firm attachment of the tendon to the humeral footprint using 1 double-loaded bone anchor. The surgical technique is described in detail, and pitfalls and complications are noted. The clinical results of the first 22 consecutive patients are reported, showing an increase in the UCLA score from 17.1 to 31.2 points and a patient satisfaction rate of 91%.