Superior Capsular Reconstruction With Arthroscopic Rotator Cuff Repair in a "Functional Biologic Augmentation" Technique to Treat Massive Atrophic Rotator Cuff Tears.

Surgical treatment of patients with massive rotator cuff tears is unpredictable because of a low healing rate and high incidence of clinical failure. Arthroscopic superior capsular reconstruction has emerged as a promising technique in treating younger, active patients with massive irreparable rotator cuff tears. Superior capsular insufficiency has been theorized to be a factor in the higher failure rate for repairs of massive tears, and there have been proposals of superior capsular repair in addition to rotator cuff repair to facilitate better healing of massive rotator cuff tears. This article presents our technique of functional rotator cuff augmentation, which is concomitant superior capsular reconstruction with arthroscopic rotator cuff repair, to treat massive, atrophic rotator cuff tears. This technique is used in patients with massive rotator cuff tears and superior capsular insufficiency.

Arthroscopic Superior Capsular Reconstruction With Acellular Dermal Allograft Using Push-In Anchors for Glenoid Fixation.

Massive irreparable rotator cuff tears in the younger, active patient can be one of the most challenging pathologies to treat in shoulder surgery. Over the last few years, the superior capsular reconstruction (SCR) technique, which has shown favorable initial clinical results, has emerged as a promising new technique that aims to restore glenohumeral mechanics and improve patient function. SCR can be technically challenging, and improvements have been made consistently to the technique. In this Technical Note, we present our knotless technique of glenoid fixation using push-in anchors and suture tapes. We believe that our procedure offers an improvement to current SCR techniques.

Arthroscopic Superior Capsular Reconstruction With Acellular Dermal Allograft for the Treatment of Massive Irreparable Rotator Cuff Tears: Short-Term Clinical Outcomes and the Radiographic Parameter of Superior Capsular Distance.

PURPOSE: This outcome analysis presents 88 consecutive shoulders presenting with irreparable rotator cuff tears that we treated with arthroscopic superior capsular reconstruction (SCR) using an acellular dermal allograft. We also present the concept of superior capsular distance to quantitatively measure the decreased distance present upon restoration of superior capsular integrity. METHODS: A retrospective review was conducted of patients treated with arthroscopic SCR with a minimum 12-month follow-up. Outcome analysis was performed via an internet-based outcome-tracking system to evaluate visual analog scale (VAS) and American Shoulder and Elbow Surgeons (ASES) scores. Radiographic analysis of anteroposterior radiographs analyzed acromiohumeral interval and superior capsular distance. Digital dynamometric strength and functional range of motion assessments were also obtained. The main inclusion criteria for patients in this analysis was all patients who underwent superior capsular reconstruction during the time period of this report. RESULTS: Eighty-six patients with an average age of 59.4 years presented with massive rotator cuff tears (Cofield >5 cm). Outcome data revealed improvement in VAS (4.0-1.5), and ASES (52-82) scores at 1 year (P = .005). Radiographic analysis showed increase in acromiohumeral interval (mean 7.1 mm preoperatively to mean 9.7 mm at 1 year) (P = .049) and superior capsular distance (mean 52.9 mm preoperatively to mean 46.2 mm at 1 year) (P = .011). Strength improved significantly (forward flexion/abduction/external rotation of 4.8/4.1/7.7 lb preoperatively to 9.8/9.2/12.3 lb at 1 year) as well as range of motion (forward flexion/abduction of 120°/103° preoperatively to 160°/159° at 1 year) (P = .044/P = .007/P = .02). At follow-up, 90% of patients were satisfied. CONCLUSIONS: This analysis reveals that arthroscopic SCR with acellular dermal allograft has been successful in decreasing pain and improving function in this patient subset. Radiographic analysis has also shown a consistent and lasting decrease in superior capsular distance and increase in acromiohumeral interval, indicating maintenance of superior capsular stability. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Comparative analysis of single-row versus double-row repair of rotator cuff tears.

PURPOSE: Our goal in this analysis was to compare clinical outcomes and radiographic healing rates of double-row (DR) transosseous-equivalent versus single-row (SR) Mason-Allen configuration (MAC) arthroscopic repair techniques. METHODS: A prospective, nonrandomized assessment of 132 arthroscopic rotator cuff repair patients included 78 SR repair patients and 54 with DR repair. Tears measured between 1.5 and 4.5 cm. Patients were evaluated with a visual analog scale; University of California, Los Angeles score; American Shoulder and Elbow Surgeons score; active range of motion; and dynamometric strength. Scores and measurements were obtained preoperatively and at 3, 6, 12, and 24 months postoperatively. The SR repairs were performed with the arthroscopic MAC. For DR repairs, two 5.5-mm fully threaded Bio-Corkscrew anchors (Arthrex, Naples, FL), single loaded with FiberWire (Arthrex), were used for the medial row. The lateral row was secured with PushLock bioabsorbable anchors (Arthrex). Forty-four patients in the SR group and 37 patients in the DR group returned for magnetic resonance imaging (MRI) evaluation of repair integrity between 12 and 28 months postoperatively. RESULTS: DR repairs resulted in higher outcome scores, though not significantly. Patient satisfaction rates were 95% in the SR group and 92% in the DR group. MRI showed a statistically significantly improved healing rate with SR repair compared with DR repair in our entire patient population (P ≤ .017). A more homogeneous subset of patients with tears between 2.5 and 3.5 cm showed a significantly improved healing rate for the DR repair (P ≤ .03). CONCLUSIONS: Our short-term results suggest that SR MAC repair provides comparable clinical results to DR repair. Although our MRI data suggest improved healing rates in our SR repairs in the entire patient population, when similar-sized tears were compared, the DR repair group showed improved radiographic healing. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Arthroscopic posterior labral repair in athletes: Outcome analysis at 2-year follow-up.

PURPOSE: The purpose of this outcome analysis was to evaluate the clinical presentation of isolated posterior labral tears resulting from athletic injury and to use multiple outcome measurements to evaluate postoperative results after arthroscopic repair with respect to satisfaction, function, and return to sport. METHODS: Seventy-five consecutive patients injured during athletic activity were treated surgically during the 2-year period from 2005 to 2006 for labral pathologies. Twenty-eight patients were treated for isolated posterior labral tears. Of these, all underwent arthroscopic repair of their tears. The mechanism of injury was trauma to a previously asymptomatic shoulder during sports. The patients' mean age was 21 years, and they were evaluated with American Shoulder and Elbow Surgeons; University of California, Los Angeles; Rowe; and visual analog scale scores, as well as active motion and dynamometric strength testing. Scores and measurements were obtained preoperatively and postoperatively at 3, 6, and 12 months and yearly thereafter. RESULTS: In our athletic population undergoing surgical management for labral pathology, 37% of patients (28 of 75) were found to have purely posterior labral lesions after an athletic injury. On intraoperative examination, an element of posterior laxity was seen in only 29% of patients with these tears. At 24 months, significant improvements were observed in the American Shoulder and Elbow Surgeons; University of California, Los Angeles; Rowe; and visual analog scale scores. Increases in forward flexion and external rotation strength were also noted. Return to sport was achieved in 26 of 28 patients (93%). A 93% patient satisfaction rate was observed for arthroscopic posterior labral repairs at more than 24 months. CONCLUSIONS: Our patient-athletes presented with painful, dysfunctional shoulders that inhibited performance in their chosen sport. Arthroscopic evaluation and repair of these posterior labral lesions resulted in 26 of 28 patients (93%) returning to sport and 23 of 28 (82%) returning without any limitations. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic coracoclavicular ligament reconstruction using biologic and suture fixation.

Presented in this report is a modified arthroscopic approach to acromioclavicular joint reconstruction via suture and allograft fixation. An arthroscopic approach is used to expose the base of the coracoid by use of electrocautery. After an open distal clavicle excision is performed, clavicular and coracoid tunnels are created under arthroscopic visualization as previously described by Wolf and Pennington. The myotendinous end of a semitendinosus allograft is sutured to a Spider plate (Kinetikos Medical, San Diego, CA). The tendinous end of the graft is prepared with a running baseball stitch. A Nitinol wire with a loop end (Arthrex, Naples, FL) is used to pass 2 free FiberTape sutures (Arthrex) and the leading sutures from the tendinous end of the graft through the clavicular and coracoid tunnels, exiting out the anterior portal. One of the FiberTape sutures is retrieved with a grasper and passed over the anterior aspect of the distal clavicle. The second FiberTape suture and the allograft are passed over the distal end of the resected clavicle. While the acromioclavicular joint is held reduced, the FiberTape sutures are tied to the plate and the allograft is tensioned medially until the plate is embedded against the superior surface of the clavicle. The tendinous end of the graft is secured to the superior surface of the clavicle with a Bio-tenodesis screw (Arthrex) medial to the clavicular tunnel.

Arthroscopic glenoid resurfacing with meniscal allograft: a minimally invasive alternative for treating glenohumeral arthritis.

The chronically painful arthritic glenohumeral joint recalcitrant to nonsurgical treatment modalities generally has been treated with an open arthroplasty type of procedure. Certain patients may benefit from a less invasive surgical technique in which a meniscal allograft is used to resurface the glenoid, resulting in decreased pain and increased function. We describe an arthroscopic method of glenoid resurfacing with a meniscal allograft to aid in the restoration of function by providing pain relief to patients debilitated by arthritic conditions of the glenohumeral joint.