All-endoscopic approach for distal biceps tendon pathology: analysis of long-term outcomes in partial and complete ruptures.

BACKGROUND: Distal biceps tendon (DBT) pathology is a spectrum that ranges from tendinopathy to complete retracted ruptures, and surgical treatment is usually performed via open approaches. The purpose of this study was to analyze safety and long-term outcomes of all-endoscopic surgery for entire spectrum of primary DBT pathology. The hypothesis was that at an all-endoscopic technique would result in satisfactory clinical outcomes and a low complication rate. METHODS: Consecutive patients who underwent all-endoscopic surgery for primary isolated DBT pathology (bursitis, partial and acute/chronic complete tears) between January 2013 and December 2021 were assessed and analyzed retrospectively. Refractory bursitis and low-grade partial tears underwent endoscopic débridement, and high-grade partial tears and complete ruptures underwent all-endoscopic repair or graft reconstruction. Preoperative and follow-up assessment included functional assessment using Mayo Elbow Performance Score and a Patient-Reported Distal Biceps Score, and radiological assessment was performed using plain biplanar radiographs and sonography. Pre- and postoperative scores for the overall group, and for partial and complete tears, were compared using a paired t test. RESULTS: Overall, 26 male patients underwent an all-endoscopic surgery for DBT tears; the pathology was classified by endoscopic findings into 6 types, and follow-up period ranged from 21 to 125 months (mean 79.4 months). Nine chronic partial tears (35%) included predominantly bursitis (type I, n = 2) and predominantly partial tears (type IIA and B, n = 7). The complete tear group (65%) included isolated short or long head tears (type IIIA and IIIB, n = 2) and complete tendon ruptures (types IV, V, and VIA-C, n = 15). Endoscopic débridement of the bursitis/low-grade tears and repair of the high-grade and complete ruptures resulted in complete resolution of symptoms and significant improvement in both Mayo Elbow Performance Score and Patient-Reported Distal Biceps Score (P < .001). Autografts were necessary in 35% (6/17) of complete tears, and no significant difference was found in functional scores in this group as compared to those where primary repairs were possible. There were 2 minor complications (7.6%) that involved transient lateral antebrachial cutaneous nerve neuropraxia. Follow-up sonography and radiographs showed an intact tendon and absence of heterotopic ossification or synostosis. CONCLUSIONS: An all-endoscopic approach for treating DBT pathology was safe and reliable and was associated with significant improvement in subjective and functional outcomes in the long-term. The dual-anchor onlay repair technique showed long-term radiologically demonstrable structural integrity of the tendon and was associated with a low minor complication rate and absence of heterotopic ossification.

How does dynamic arthroscopic tracking compare with radiologic glenoid track for identification of on- and off-track lesions in anterior shoulder instability?

BACKGROUND: Current treatment paradigms for anterior shoulder instability are based on radiologic measurements of glenohumeral bone defects, and mathematical calculation of the glenoid track (GT) is used to classify lesions into on-track and off-track morphology. However, radiologic measurements have shown high variability, and GT widths under dynamic conditions have been reported to be significantly smaller than those under static radiologic conditions. The purpose of this study was to assess the reliability, reproducibility, and diagnostic validity of dynamic arthroscopic standardized tracking (DAST) in comparison to the gold-standard radiologic track measurement method for the identification of on- and off-track bony lesions in patients with anteroinferior shoulder instability. METHODS: Between January 2018 and August 2022, 114 patients with traumatic anterior shoulder instability were evaluated using 3-T magnetic resonance imaging or computed tomography scans; glenoid bone loss, Hill-Sachs interval, GT, and Hill-Sachs occupancy ratio (HSO) were measured, and defects were classified as on-track or off-track defects and peripheral-track defects (based on HSO percentage) by 2 independent researchers. During arthroscopy, a standardized method (DAST method) was used by 2 independent observers to classify defects into on-track defects (central and peripheral) and off-track defects. Interobserver reliability of the DAST and radiologic methods was calculated using the κ statistic and reported as percentage agreement. Diagnostic validity (sensitivity, specificity, positive predictive value, and negative predictive value) of the DAST method was calculated using the radiologic track (HSO percentage) as the gold standard. RESULTS: The radiologically measured mean glenoid bone loss percentage, Hill-Sachs interval, and HSO in off-track lesions were lower with the arthroscopic method (DAST) as compared with the radiologic method. The DAST method showed nearly perfect agreement between the 2 observers for the on-track/off-track classification (κ = 0.96, P < .001) and the on-track central or peripheral /off-track classification (κ = 0.88, P < .001). The radiologic method showed greater interobserver variability (κ = 0.31 and κ = 0.24, respectively) with only fair agreement for both classifications. Inter-method agreement varied between 71% and 79% (95% confidence interval, 62%-86%) between the 2 observers, and reliability was assessed as slight (κ = 0.16) to fair (κ = 0.38). Overall, for identification of an off-track lesion, the DAST method showed maximum specificity (81% and 78%) when radiologic peripheral-track lesions (HSO percentage of 75%-100%) were considered off-track and showed maximum sensitivity when arthroscopic peripheral-track lesions were classified as off-track. CONCLUSION: Although inter-method agreement was low, a standardized arthroscopic tracking method (DAST method) showed superior interobserver agreement and reliability for lesion classification in comparison to the radiologic track method. Incorporating DAST into current algorithms may help reduce variability in surgical decision making.

How does anterior glenoid bone loss affect shoulder stability? A cadaveric analysis of glenoid concavity and bony shoulder stability ratio.

BACKGROUND: Concavity compression is an important glenohumeral stabilizing factor, and recent studies have suggested that peripheral glenoid bone loss creates the most relevant change in stability. This study analyzed changes in the bony shoulder stability ratio (BSSR) with sequential anterior glenoid bone loss (0%-40% width) and with reconstructive bone graft procedures. The aim was to quantify the critical bone defect size that would significantly alter the BSSR and determine restoration of the BSSR with the Latarjet procedure. METHODS: Anterior glenoid defects were created with sequential osteotomies (10%-40%), and defects were reconstructed using 2 Latarjet modifications (classic Latarjet procedure and congruent-arc Latarjet [CAL] procedure). We obtained 108 computed tomography scans of (1) intact scapulae (n = 12), (2) after each bone defect (n = 48), and (3) after each reconstruction (n = 48). The glenoid concavity depth and concavity radius were measured, and the BSSR was determined using a validated mathematical formula. Statistical analysis was performed to determine significant differences between the intact state and each of the deficient and reconstructed glenoids. RESULTS: The glenoid concavity radius increased by approximately 30% (14 mm) and the glenoid concavity depth decreased by 50% (1.5 mm) from the 0% to 40% defect. The maximal sequential change in depth (1.2 mm, 44%; P < .001) and radius (6 mm, 12%; P < .001) occurred at the 10% glenoid defect. The overall BSSR decreased by approximately 40% (0.15) from the intact glenoid to the 40% defect. This change in the BSSR was most profound (0.11, 30%; P < .001) at the 10% glenoid defect and was only marginal thereafter between the 20% and 40% defects (0.24, 0.22, and 0.21). The Latarjet procedure adequately restored glenoid concavity; however, the CAL procedure significantly overcorrected all 3 parameters at 10% defect. CONCLUSION: The glenoid concavity depth and BSSR undergo progressive deformation with sequential bone loss, and 90% of this change occurs with a 10% glenoid defect. Articular concavity and the BSSR are adequately restored with the Latarjet procedure, and the CAL procedure significantly overcorrects concavity in mild (0%-10%) defects.

Endoscopic anatomy of distal biceps tendon insertion and bicipitoradial bursa: a cadaveric study.

BACKGROUND: Distal biceps endoscopy has emerged as a minimally invasive alternative to open procedures for distal biceps tendon (DBT) pathology. The purpose of this study was to systematically describe the static and dynamic appearance and variations of the DBT insertional region using a standardized endoscopic technique and dissection in healthy cadaveric elbows. METHODS: Endoscopic assessment of the DBT insertional region was performed using a standard proximal parabiceps portal in 20 fresh frozen cadaveric upper extremities. A 6-point endoscopic evaluation of the DBT and bicipitoradial bursa was performed in a static supination position and with dynamic rotation. Anatomic variations in the DBT insertional characteristics, as well as the extent and appearance of the intrabursal space, were documented. Each cadaver was then dissected to correlate endoscopic findings with gross anatomic structures. RESULTS: A bare oval tuberosity area (n = 20) bounded by the supinator and DBT was observed. The DBT inserted ulnar to the bare area (n = 16) and the presence of an intervening wide (n = 1) or narrow (n = 3) tuberosity sulcus were documented. The dorsoradial DBT surface was consistently intrabursal and was differentiated into 2-5 fiber bundles (n = 15). The volar-ulnar DBT surface was always extrabursal and was associated with endoscopically identifiable proximal and distal fat pads. The bicipitoradial bursa formed a bursal sac that was attached to the dorsoradial (n = 13) or volar (n = 7) aspect of the tuberosity and extended proximally along the DBT for 3-5 cm (parabiceps space). A distinct ligament-like band (transverse radioulnar ligament) extended transversely across the proximal radioulnar space and appeared to form a sling that provided ulnar support to the DBT during dynamic rotation. The intact DBT surface was robust and could not be breached, even with firm pressure using a probe. CONCLUSIONS: The bare tuberosity area, the bursal sac, and the parabiceps space are consistent anatomic landmarks that can be used during DBT endoscopy. An insertional tuberosity sulcus and DBT surface differentiation are normal anatomic variations. The transverse radioulnar ligament provides ulnar support for the DBT during pronation and forms a pulley mechanism for smooth tendon gliding motion.

Bone defect-induced alteration in glenoid articular surface geometry and restoration with coracoid transfer procedures: a cadaveric study.

BACKGROUND: This study analyzed the alteration in glenoid articular geometry with increasing anterior bone loss, as well as its subsequent correction with 2 modifications of the Latarjet procedure. METHODS: Anterior defects were simulated by creating glenoid osteotomies (10%, 20%, 30%, and 40%), and defects were reconstructed using 2 Latarjet modifications (classic and congruent arc). A total of 108 computed tomography scans were performed (1) on intact scapulae (n = 12), (2) after each bone defect (n = 48), and (3) after each reconstruction (n = 48). Glenoid parameters (width, area, arc length, and version) were analyzed on computed tomography scans. Statistical analysis was used to determine significant differences between intact, deficient, and reconstructed glenoids. RESULTS: All parameters were reduced with every 10% defect increment (mean change in width, 2.5 mm; area, 64 mm2; version, 2.2°; and arc length, 2.2 mm). Width correction with the classic Latarjet procedure was not statistically significant in 30% and 40% defects. Area correction in 30% defects was not significant with the classic Latarjet procedure and was significantly undercorrected in 40% defects. Version correction was not significant after the classic Latarjet procedure in 20%, 30%, and 40% defects. Arc-length correction was not significant in 20% and 30% defects with the classic Latarjet procedure and was significantly undercorrected in 40% defects. The congruent-arc Latarjet procedure overcorrected glenoid parameters in all defects; however, area and arc length were not significantly different from intact glenoids in 40% defects (P < .05). CONCLUSION: Glenoid articular geometry is progressively altered with a sequential increase in anterior bone defects from 0% to 40%. The classic Latarjet procedure provided significant correction in bone defects of 10% and 20%. The congruent-arc Latarjet procedure restored and overcorrected most parameters even in 40% glenoid defects.

Analysis of technical feasibility and neurovascular safety of endoscopic distal biceps repair: a cadaveric study.

BACKGROUND: This cadaveric study was designed to analyze the safety of endoscopic repair of distal biceps tendon (DBT) tears using 2 reattachment techniques. We evaluated the proximity of neurovascular structures to endoscopy portals; iatrogenic injury to neurovascular, musculotendinous, and osseous structures; and changes in compartment pressures. We hypothesized that an all-endoscopic repair of the ruptured DBT would be technically safe and the risk of iatrogenic injury would be low. METHODS: A 2-portal endoscopic tendon repair was performed in 28 fresh-frozen cadaveric elbows with button devices (with or without interference screws) (n = 17) and suture anchors (n = 11). Dissection was performed, and neurovascular, musculotendinous, and osseous structures were assessed for iatrogenic injury. The repair construct (tendon-tuberosity contact area and implant placement site) was evaluated, and compartment pressures were measured. Statistical analysis was performed to determine significant differences in iatrogenic injury, compartment pressure changes, and tendon-bone contact area between different devices. RESULTS: The lateral cutaneous nerve, cephalic vein, and radial artery were in close proximity to the portals. The button group showed a significantly higher number of iatrogenic injuries than the anchor group (P = .036). All-suture anchor repair showed a significantly higher contact area (mean, 85 mm2) than repairs with all other devices (P < .001). Compartment pressures increased by 2-4 mm in each of the 3 compartments tested (P < .001). CONCLUSION: Endoscopic DBT repair was technically feasible with both fixation techniques. Button devices were associated with a significantly higher number of iatrogenic injuries. Endoscopic repair with dual suture anchors was safe in cadavers; however, further clinical results are necessary to establish the clinical safety of this technique.

Cadaveric Study of Insertional Anatomy of Distal Biceps Tendon and its Relationship to the Dynamic Proximal Radioulnar Space.

PURPOSE: To quantify and assess the relationship between the insertional dimensions of the distal biceps tendon (DBT) and radioulnar space (RUS) in 3 rotational positions. We hypothesized that in all positions RUS would be adequate for the DBT and would remain adequate even after an incremental increase (1 to 3 mm) in tendon thickness. METHODS: Eleven fresh-frozen cadaveric elbows were dissected; DBT dimensions and bicipital tuberosity measurements were performed and insertional footprints were quantified using a distal biceps footprint index. The RUS was measured at 3 levels of the bicipital tuberosity and in 3 positions of forearm rotation. We performed statistical analysis to analyze differences in RUS (positional and inter-level). In addition, significant differences between DBT thickness (native and incremental) and RUS were analyzed to identify potential sites of radioulnar impingement. RESULTS: The DBT had a mean length of 92 mm; thickness ranged from 2.9 to 6.1 mm. Three variations in DBT insertional footprint were observed and quantified. The RUS linear distance reduced significantly from a supinated to a pronated position at each of 3 bicipital tuberosity levels; the reduction was statistically significant at the lower tuberosity level (45%). Pronation RUS distance was adequate for native DBT thickness and was significantly less when DBT thickness increased by 2 and 3 mm. CONCLUSIONS: Radioulnar space reduces significantly from the supinated to the pronated position and is most evident in the lower aspect of the tuberosity. In addition, the RUS in pronation is inadequate for incremental increases in DBT thickness. CLINICAL RELEVANCE: Postoperative DBT impingement in the RUS may be prevented by avoiding techniques that increase the thickness of the tendon and by using a reattachment site at the proximal aspect of the tuberosity.

Endoscopic Repair of Acute and Chronic Retracted Distal Biceps Ruptures.

Distal biceps tendon (DBT) ruptures are infrequent injuries that result in pain, weakness, and cosmetic deformity. Severe retraction of the ruptured DBT can occur at the time of injury, or in chronic neglected ruptures, and surgical exposure is performed using a single incision or a 2-incision technique. The technique presented here describes an endoscopic approach using 3 portals that provide access to the retracted DBT, biceps sheath, and radial tuberosity. Preoperative sonographic localization of the retracted DBT and neurovascular structures is used to guide portal placement. The parabiceps portal is used for visualization of the biceps sheath remnant, and the midbiceps portal is used to visualize and retrieve the retracted tendon in the arm. The retracted DBT is shuttled through the biceps sheath into the upper forearm, and 2 suture anchors are passed into the radial tuberosity under direct endoscopic vision. The DBT is whipstitched via the distal anterior portal, and nonsliding knots are tied to securely reattach the DBT to the prepared radial tuberosity.

Cadaveric study of anterior and posterior elbow endoscopy portals for endoscopic distal biceps repair: comparative anatomy-at-risk.

PURPOSE: The purpose of this study was to describe neurovascular structures-at-risk during establishment of five portals for access to distal biceps tendon (DBT) in cubital fossa, and to establish relative safety of these portal sites for such access. We hypothesized that all five portals are safe for endoscopic DBT exploration. METHODS: Ten fresh frozen cadaveric elbows were dissected after placement of portals at five potential sites (four anterior, one posterior). Nine neurovascular structures (CV, cephalic vein; LCN, lateral cutaneous nerve; LV, leash of vessels; RN, radial nerve; SRN, superficial radial nerve; PIN, posterior interosseous nerve; RA, radial artery; BA, brachial artery; MN, median nerve) were dissected, and their distances from portal sites were measured. Statistical analysis was performed to determine relative portal safety, and risk of injury to neurovascular structures in relation to each portal was analyzed. RESULTS: Structures that were significantly "at risk" were RA (p = 0.006), SRN (p = 0.002), and PIN (p = 0.004). RA was significantly "at risk" of injury from portal 4 (p = 0.009). Similarly, SRN was "at risk" from portal 3 (p = 0.036), and the PIN was "at risk" from portal 2 (p = 0.003). CONCLUSIONS: Portal 1 (parabiceps portal) was safe for all neurovascular structures, however, portals 2-4 were significantly closer to neurovascular structures. RA, SRN, and PIN were significantly "at risk" as compared to other structures amongst the portals studied. Portal 5 was relatively safe for SRN and PIN. CLINICAL RELEVANCE: Portals 1 (parabiceps portal) and 5 (distal posterior) can be safely placed for endoscopic access to the DBT. Portal 4 (open distal anterior) may be used after careful open dissection and under direct vision. Portals 2 and 3 are not recommended for elbow endoscopy.

Endoscopic anterior capsulectomy for severe elbow contractures.

Elbow stiffness secondary to trauma or surgical reconstruction can sometimes result in a severe contracture with restricted joint space, and arthroscopic access to the joint is difficult. Previous surgery and severe stiffness can also alter the position of neurovascular structures and iatrogenic injury is possible with an inside-out arthroscopic approach. To overcome these technical difficulties, an endoscopic approach to the anterior capsule can be performed as an alternative to open approach. The endoscopic approach utilises the sub-brachialis space for an outside-in capsular resection under vision. Identification of standard anatomic landmarks is useful as a guide for safe resection in a central to peripheral direction.

Surgical treatment of significant glenoid bone defects and associated humeral avulsions of glenohumeral ligament (HAGL) lesions in anterior shoulder instability.

PURPOSE: Combined occurrence of humeral avulsion of glenohumeral ligament (HAGL) lesion and a significant glenoid bone defect is an unusual and previously undescribed association in traumatic anterior shoulder instability. The purpose of this study was (1) to report a retrospective case series of seven anterior bony instability patients who were diagnosed with this unusual association and (2) to evaluate the results of a modified Latarjet procedure and simultaneous HAGL repair using a new subscapularis-sparing approach. METHODS: A retrospective review of the records of 64 anterior shoulder instability patients who underwent bony stabilization surgery was performed, and patients who underwent a combined reconstruction for significant glenohumeral bone defects (glenoid loss >20 %) and an associated HAGL lesion were identified. Pre- and postoperative follow-up clinical parameters and functional scores were documented (Oxford shoulder instability score [OSIS], Western Ontario shoulder instability index [WOSI]), Rowe score). Radiological assessment included measurement of the glenoid bone defect (CT scan) and evaluation of soft tissue lesions (MR arthrogram). RESULTS: Radiological and arthroscopic evaluation confirmed the combined lesion complex in 7 (11 %) patients. Follow-up evaluation (mean 20.6 months) suggested an excellent outcome (Rowe score: median 95, range 95-100); a statistically significant improvement was seen in the follow-up OSIS (median 12, range 12-14, p = 0.018) and WOSI score (median 28, range 17-102, p = 0.018) as compared to the preoperative score (median OSIS 50, range 32-53; median WOSI 1,084, range 919-1,195). Clinical tests for subscapularis function revealed a functional subscapularis muscle; no significant differences were detected in pre- versus postoperative internal rotation strength and in the operated versus normal contralateral shoulder (ns). The dual-window subscapularis-sparing approach provided adequate exposure for combined reconstruction of the humeral and glenoid lesions, and no complications were encountered. CONCLUSIONS: Significant glenoid defects are associated with HAGL lesions in approximately 1/10th of patients with bony instability. Combined reconstruction of these lesions via a subscapularis-sparing approach results in an excellent outcome and significant improvement in functional scores at a medium-term follow-up. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

Surgical correction of the "Popeye biceps" deformity: dual-window approach for combined subpectoral and deltopectoral access and proximal biceps tenodesis.

"Popeye biceps" deformity represents the appearance of a distally retracted biceps muscle resulting from either a traumatic long biceps tendon (LBT) rupture or an iatrogenic LBT tenotomy. Cosmetic and functional problems associated with the deformity may necessitate surgical correction, and surgical exposure using multiple incisions is recommended. The technique presented here describes a novel mini-open approach using a single 1-in incision that provides access to 3 peripectoral anatomical zones. Preoperative sonographic localization of the ruptured and retracted LBT is used to guide incision placement, and facilitates intraoperative tendon retrieval via a limited incision and minimal dissection. Inferolateral retraction of the mini-incision window permits infrapectoral and subpectoral LBT mobilization and dissection. Deltopectoral access via superomedial retraction of the same skin window is used to expose the suprapectoral zone and is employed for LBT retrieval and proximal tenodesis. Technical tips for safe dissection via a mini-incision, and methods for biological LBT augmentation are discussed.

"All-Endoscopic" Management of Refractory Elbow Bicipitoradial Bursitis and Partial Distal Biceps Tendon Tears.

Elbow bicipitoradial bursitis and partial distal biceps tendon (DBT) tears are a result of chronic overuse or other infective/inflammatory pathology and may be refractory to conservative treatment. The all-endoscopic approach provides minimally invasive access to the bursal space and DBT, and diagnostic and therapeutic procedures can be performed under direct endoscopic vision. The technique uses 2 portals, the proximal parabiceps portal and distal anterior portal, and the bursa is insufflated to create a working space. Tissue biopsies are obtained under direct endoscopic visualization, and debridement along 6 bursal zones can be effectively performed. An endoscopic probe test is demonstrated for assessment of partial DBT tears, and low-grade tears are debrided to stable tissue. The all-endoscopic technique is safe and reproducible, and it is a stepping-stone in the learning curve of all-endoscopic repair and reconstruction of distal biceps ruptures.

Arthroscopic Bursa-Augmented Rotator Cuff Repair: A Vasculature-preserving Technique for Subacromial Bursal Harvest and Tendon Augmentation.

Rotator cuff repairs are associated with suboptimal outcomes and possibly greater incidence of retears if the biological healing environment is compromised. Strategies to optimize tendon-bone healing include the use of bioinductive scaffolds and regenerative stem cell therapy. The subacromial bursa has been shown to have significant pluripotent stem cell potency for tendon healing and has the advantage of easy accessibility and no added cost. However, a reproducible surgical technique for bursal mobilization, harvest, and vascularity preservation has not been described. We describe our technique for vasculature-preserving bursal mobilization and harvest of the entire posterosuperior and lateral subacromial bursa, and its use in rotator cuff repair augmentation is presented. The technique involves mobilization of the bursa as a continuous layer by maintain its medial and lateral vascularity. The bursa is advanced laterally, and the "vascular bursal duvet" and cuff tendons are repaired together as a tendon-bursa unit.

Arthroscopic Biological Augmentation for Massive Rotator Cuff Tears: The Biceps-Cuff-Bursa Composite Repair.

Surgical repair of massive and chronic rotator cuff tears is difficult due to tendon retraction and severe atrophy, and the resultant retear rate in the structurally weak tendons is high. Commercially available patches and bioinductive scaffolds have been used to provide strength and superior healing environment in partial and complete rotator cuff tears. Biological biceps autograft has been used for superior capsular reconstruction, and the subacromial bursa has been shown to have significant pluripotent stem cell potency for tendon healing. We describe our technique for combined use of the long biceps tendon (LBT) and vasculature-preserved subacromial bursa as autografts in rotator cuff repair augmentation. The technique involves obtaining a LBT graft of sufficient length using a "traction and tenodesis" technique. The subacromial bursa is mobilized as a continuous layer (vascular bursal duvet) by maintaining its medial and lateral vascularity. All-suture anchors are used to minimize the insertion apertures (3 mm) in tuberosity. The bursa is advanced laterally, and the mobilized cuff is repaired together as a biceps-cuff-bursa composite unit. Combined use of the biceps and bursa as biological autografts has the advantage of structural and regenerative augmentation, and the autografts are easily accessible without added cost.

Arthroscopic repair of a chondrolabral lesion associated with anterior glenohumeral dislocation.

Chondrolabral lesions are uncommon after anteroinferior glenohumeral dislocations. This report describes a new dual-lesion complex that involved an avulsion of the anteroinferior glenoid labrum and a flap tear of the adjacent articular cartilage [glenoid labral tear and articular cartilage flap (GLAF) lesion]. The chondral component involved a large undermined region of the anterior half of the lower glenoid articular cartilage, and the labral component involved an avulsion from the 2.30-6 o'clock position on the glenoid. The labral tear was reconstructed with 3 suture anchors to form a neo-labrum in an attempt to overlap and stabilize the periphery of the chondral flap. A meniscal repair device was used to place a mattress stitch in the cartilage periphery to further stabilize the flap. This technique resulted in a secure repair without any chondral damage, and this remained intact on an MRI performed at a 3-month follow-up. A final 12-month follow-up showed complete recovery, as assessed by the Oxford shoulder instability score and Rowe score, and by a return to the pre-injury sporting level.

Arthroscopic debridement and biological resurfacing of the glenoid in glenohumeral arthritis.

The purpose of this study was to analyse the intermediate-term results of an arthroscopic procedure to debride and resurface the arthritic glenoid, in a middle-aged population, using an acellular human dermal scaffold. Between 2003 and 2005, thirty-two consecutive patients underwent an arthroscopic debridement and biological glenoid resurfacing for glenohumeral arthritis. The diagnoses included primary osteoarthrosis (28 patients), arthritis after arthroscopic reconstruction for anterior instability (1 patient) and inflammatory arthritis (3 patients). All shoulders were assessed clinically using the Constant and Murley score, and results graded according to Neer's criteria. Statistical analysis was performed to determine significant parameters and associations. A significant improvement (P < 0.0001) in each parameter of the subjective evaluation component (severity of pain, limitation in daily living and recreational activities) of the Constant score was observed. The Constant and Murley score increased significantly (P < 0.0001) from a median of 40 points (range 26-63) pre-operatively to 64.5 (range 19-84) at the final assessment. Overall, the procedure was considered as "successful outcome" in 23 patients (72%) and as a "failure" in 9 patients (28%). According to Neer's criteria, the result was categorized as excellent in 9 (28%), satisfactory in 14 (44%) and unsatisfactory in 9 (28%). Within the unsatisfactory group, there were five conversions to prosthetic arthroplasty. A standard magnetic resonance imaging was performed on 22 patients in the successful outcome group; glenoid cartilage was identified in 12 (thick in 5, intermediate in 1, thin in 6) and could not be identified in 10 patients (complete/incomplete loss in 5, technical difficulties in 5). Overall, five complications included transient axillary nerve paresis, foreign-body reaction to biological material, inter-layer dissociation, mild chronic non-specific synovitis and post-traumatic contusion. Dominance of affected extremity and generalized disease (diabetes, rheumatoid arthritis, generalized osteoarthritis) was associated with an unsatisfactory outcome (P < 0.05). Arthroscopic debridement and biological resurfacing of the glenoid is a minimally invasive therapeutic option for pain relief, functional improvement and patient satisfaction, in glenohumeral osteoarthritis, in the intermediate-term.

The "subscapularis-sparing" approach: a new mini-open technique to repair a humeral avulsion of the glenohumeral ligament lesion.

Anterior approaches to the shoulder involve partial or complete detachment of the subscapularis muscle. We have developed a new technique that permits adequate access to the humeral attachment of the inferior glenohumeral ligament (IGHL) without any detachment of the subscapularis, and have used this to successfully repair humeral avulsions of glenohumeral ligament lesions. Preliminary diagnostic arthroscopy using air insufflation of the glenohumeral joint is used to identify and grade the lesion. A 1-inch axillary incision is used to access the subscapularis tendon through the deltopectoral approach. Thereafter, anatomic landmarks are identified to expose the lateral aspect of the inferior border of the subscapularis muscle. Blunt dissection is used to separate the musculocapsular plane, and the subscapularis is retracted in an anterosuperior direction. Adequate exposure for visualization and repair of the avulsed IGHL is possible in a majority of cases where this approach is attempted. The use of arthroscopic instruments and suture anchors facilitates suture passage through the mid and posterior regions of the IGHL. If exposure is inadequate, the approach can be easily converted to a conventional L-shaped tenotomy approach through the lower or upper region of the subscapularis.

Direct arthroscopy of the bicipital groove: a new approach to evaluation and treatment of bicipital groove and biceps tendon pathology.

Assessment of the intra-articular and intertubercular regions of the long tendon of the biceps forms an important aspect of routine glenohumeral arthroscopic examination. We describe a new technique of direct visualization of the bicipital groove and tendon by positioning the arthroscope in linear alignment with the bicipital groove. A 4.5-mm cannula is introduced through a superior-medial (Neviaser) portal, into the glenohumeral joint, parallel and adjacent to the superior aspect of the biceps tendon, and is used as a viewing portal. The arm is then positioned in abduction, external rotation, and forward flexion, to align the groove with the arthroscope, thereby attempting to "look down the groove." The biceps tendon, as well as the structures forming its medial and lateral pulleys, can be evaluated from the glenohumeral and intertubercular aspects. A greater length of the medial and lateral lips and the floor and roof of the bicipital groove can be visualized by advancing the arthroscope deeper within the groove. A fat pad along the lateral wall of the groove serves as an anatomic landmark to limit dissection in this region, thereby preventing damage to the anterolateral ascending branch of the anterior circumflex artery. An extension of this technique, to facilitate instrumentation for arthroscopic biceps tenodesis, is described.

An anatomic study of inferior glenohumeral recess portals: comparative anatomy at risk.

PURPOSE: The purpose of this study was to describe the musculotendinous relations and neurologic structures at risk during establishment of posterior portals for access to the inferior glenohumeral recess (IGHR). METHODS: Three 18-gauge spinal needles were used to establish 2 posteroinferior portals and 1 axillary pouch portal in 14 embalmed cadaveric shoulders, without joint distention and arthroscopic visualization. At dissection, musculotendinous structures traversed by the needles were recorded, and distances from the (1) axillary nerve (at the deltoid undersurface, quadrangular space, and capsule), (2) nerve to teres minor (at the inferior border of the teres minor muscle and at the capsule), and (3) suprascapular nerve were measured. Additional parameters studied included the vertical distances between the acromion and IGHR and between the acromion and axillary nerve. Statistical analysis (multiple comparisons procedure) was performed to compare relative portal safety. RESULTS: The mean distance of the axillary pouch portal to the 3 nerves, at each level, was greater than that of the posteroinferior portals. In 1 specimen (7.1%), the posteroinferior portal tracts were in close proximity (within 2 mm) to the axillary nerve and its branch to the teres minor. The distance of the axillary pouch portal to the nerves was significantly greater (P < .05) at every level, except at the deltoid undersurface. CONCLUSIONS: Our study suggests that posterior portal techniques described for access to the IGHR are safe; the risk of axillary nerve injury with posteroinferior portals is low, though possible. The axillary pouch portal is relatively farther away from the neurologic structures and provides safer access to the same region. CLINICAL RELEVANCE: Arthroscopic procedures that require access to the IGHR can be safely performed with posteroinferior and axillary pouch portals. The axillary pouch portal may be used preferentially for this access because it is placed farthest from the neurologic structures.