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.

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.

Arthroscopic Treatment of Cartilage Lesions With Microfracture and BST-CarGel.

Bone marrow stimulation techniques for the treatment of articular cartilage defects such as microfracture so far have solely reproduced mechanically inferior fibrous cartilage tissue, which might result in unsatisfactory clinical results at midterm follow-up. A recent study has shown an improvement in repair tissue quality by enhancing microfracture with a chitosan-based biomaterial (BST-CarGel; Piramal, Laval, Quebec, Canada). BST-CarGel so far has only been applied by arthrotomy, which might lead to increased scar tissue formation and thus compromise recovery time and clinical outcome. We describe a surgical technique for an arthroscopic treatment of cartilage defects of the knee with microfracture in combination with BST-CarGel to benefit from improved repair tissue quality and to reduce arthrotomy-related morbidity.

Matrix-associated chondroplasty: a novel platelet-rich plasma and concentrated nucleated bone marrow cell-enhanced cartilage restoration technique.

Bone marrow stimulation techniques such as microfracture for the treatment of articular cartilage defects so far solely reproduce mechanically inferior fibrous cartilage tissue, which might result in unsatisfactory clinical results at midterm. The combination of microfracture and biomaterials-for example, autologous matrix-induced chondrogenesis technology-has not yet proved that the disadvantages of the marrow stimulation techniques can be overcome. At present, only laboratory-cultivated autologous chondrocytes are able to restore a biomechanically superior cartilage layer and might lead to superior functional results. However, the costs are high and the patient must undergo a 2-stage procedure. By selecting the appropriate cell fraction in conjunction with a controlled release of differentiating growth factors, sufficient cartilage regeneration might be achievable on the basis of bone marrow aspirate as well. We thus describe an advanced surgical technique for the treatment of articular cartilage defects based on platelet-rich plasma and bone marrow aspirate concentrate to overcome these drawbacks.

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.

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%.