Comprehensive arthroscopic management without axillary nerve release or subacromial decompression achieves satisfactory and durable results in young patients with glenohumeral osteoarthritis.

PURPOSE: The comprehensive arthroscopic management (CAM) procedure is a useful joint-preserving option for young or active patients with glenohumeral osteoarthritis (GHOA). Our objective was to evaluate the results and prognostic factors of the CAM procedure without direct axillary nerve release or subacromial decompression. METHODS: A retrospective observational study among patients with GHOA who underwent the CAM procedure was conducted. Neither axillary nerve neurolysis nor subacromial decompression was performed. Both primary and secondary GHOA were considered; the latter was defined as a history of shoulder pathology (mainly instability or proximal humerus fracture). The American Shoulder and Elbow Surgeons scale, Simple Shoulder Test, Visual Analogue Scale, activity level, Single Assessment Numeric Evaluation, EuroQol 5 Dimensions 3 Levels, Western Ontario Rotator Cuff Index, and active range of motion (aROM) were analysed. RESULTS: Twenty-five patients who underwent the CAM procedure met the inclusion criteria. After a mean follow-up of 42.4 ± 22.9 months, we found improvement (p < 0.001) in all postoperative values of the different scales. The procedure increased aROM overall. Patients with arthropathy due to instability showed worse results. The rate of CAM failures, defined as conversion to shoulder arthroplasty, was 12%. CONCLUSIONS: This study showed that the CAM procedure without direct axillary nerve neurolysis or subacromial decompression might be a valid alternative in active patients with advanced GHOA to improve shoulder function (aROM and scores), decrease pain, and delay arthroplasty. This technique showed good subjective functional scores, high patient satisfaction, and a low rate of complications. LEVEL OF EVIDENCE: IV.

Technical Guide and Tips to Posterior Arthroscopic Latissimus Dorsi Transfer for Irreparable Posterosuperior Rotator Cuff Tears.

Latissimus dorsi (LD) transfer is a reliable treatment option for irreparable posterosuperior (PS) rotator cuff tears in young and active patients that need to recover the range of motion for their daily living activities. The technique starts with an arthroscopic assessment of the tear. The next step is the mini-open stage for muscle release from the subcutaneous layer of the skin, the teres major (TM), the triceps, and the lateral border and inferior angle of the scapula. Later, the scope is used to prepare the footprint (arthroscopy) and for the release and the harvest of the tendon (endoscopy), taking care not to detach the TM and not to damage the radial nerve. A grasper is used to push the LD to its correct path medial to the triceps. After that the same instrument is placed from the anterolateral and the anterior arthroscopic portals toward the mini-open incision to catch the sutures previously loaded on the LD tendon with Krackow stitches. The LD is transferred to the greater tuberosity and is attached with one medial and one lateral knotless anchors. A third point of fixation enables a partial RC repair and ensures a surface of bone to tendon healing.

Lower trapezius transfer for massive posterosuperior rotator cuff defects.

OBJECTIVE: To present the arthroscopically assisted lower trapezius transfer technique that restores shoulder external rotation and forward elevation, with low complication rates and fast recovery. INDICATIONS: Massive irreparable posterosuperior rotator cuff tears in active young patients with fatty infiltration ≥ III, osteoarthrosis Hamada ≤ 3, normal function of lower trapezius, and without glenohumeral stiffness. CONTRAINDICATIONS: Absolute: Active soft tissue infection and trapezius muscle paralysis. Relative: medical comorbidities, inability to follow postoperative recommendations, advanced age, advanced degenerative changes (Hamada > 3), deltoid deficiency, and forward elevation < 60º. SURGICAL TECHNIQUE: Beach chair position. Lower trapezius harvesting, allograft preparation, arthroscopic evaluation and rotator cuff partial repair, allograft passage, allograft intraarticular arthroscopic attachment, lower trapezius-allograft open attachment and wound closure. POSTOPERATIVE MANAGEMENT: Avoidance of internal rotation with an external rotation brace for 6 weeks. At 6 weeks progressively appropriate physical therapy. Unrestricted activity at 6 months. RESULTS: At mean follow-up of 14 months, good results were reported (pain, range of motion, and Subjective Shoulder Value and Disabilities of the Arm and Shoulder and Hand scores). Long-term symptoms, Hamada 3 rotator cuff arthropathy, and true pseudo paralysis were associated with negative clinical outcomes, but subscapularis pathology and teres minor fatty atrophy were not. A low complication rate was described. Arthroscopically assisted lower trapezius transfer may restore motion and strength in external rotation. Good results with low complication rates have been reported. It has become the authors' procedure of choice in young active patients with irreparable massive rotator cuff tears.