Complications observed following labral or rotator cuff repair with use of poly-L-lactic acid implants.

BACKGROUND: A variety of complications associated with the use of poly-L-lactic acid (PLLA) implants, including anchor failure, osteolysis, glenohumeral synovitis, and chondrolysis, have been reported in patients in whom these implants were utilized for labral applications. We report on a large series of patients with complications observed following utilization of PLLA implants to treat either labral or rotator cuff pathology. METHODS: Patients who had undergone arthroscopic debridement to address pain and loss of shoulder motion following index labral or rotator cuff repair with PLLA implants were identified retrospectively with use of our research database. A total of forty-four patients in whom macroscopic anchor debris had been observed and/or biopsy samples had been obtained during the debridement were included in the study. Synovial biopsy samples taken at the time of the arthroscopic debridement were available for thirty-eight of the forty-four patients and were analyzed by a board-certified pathologist. Magnetic resonance imaging (MRI) scans acquired after the index procedure and data from the arthroscopic debridement were available for all patients. RESULTS: Macroscopic intra-articular anchor debris was observed in >50% of the cases. Giant cell reaction was observed in 84%; the presence of polarizing crystalline material, in 100%; papillary synovitis, in 79%; and arthroscopically documented Outerbridge grade-III or IV chondral damage, in 70%. A significant correlation (rho = 0.36, p = 0.018) was observed between the time elapsed since the index procedure and the degree of chondral damage. A recurrent rotator cuff tear that was larger than the tear documented at the index procedure was observed in all patients whose index procedure included a rotator cuff repair. CONCLUSIONS: Clinically important gross, histologic, and MRI-visualized pathology was observed in a large cohort of patients in whom PLLA implants had been utilized to repair lesions of the labrum or rotator cuff.

Coracoid impingement: diagnosis and treatment.

Coracoid impingement is a controversial, well-known diagnosis that results in anterior shoulder pain. Idiopathic, traumatic, and iatrogenic etiologies have been identified. Proper diagnosis requires a focused clinical examination of the anterior shoulder and adjacent structures. MRI and CT are helpful in evaluating coracoid morphology as well as the integrity of the rotator cuff and long head of the biceps. Imaging is an essential diagnostic tool. Initial management consists of physical therapy and injection therapies. Surgery may be required when nonsurgical methods are unsuccessful. Successful functional and subjective outcomes have been reported with both open and arthroscopic techniques.

Treatment of glenohumeral osteoarthritis.

This clinical practice guideline is based on a systematic review of published studies on the treatment of glenohumeral osteoarthritis in the adult patient population. Of the 16 recommendations addressed, nine are inconclusive. Two were reached by consensus-that physicians use perioperative mechanical and/or chemical venous thromboembolism prophylaxis for shoulder arthroplasty patients and that total shoulder arthroplasty not be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear. Four options were graded as weak: the use of injectable viscosupplementation; total shoulder arthroplasty and hemiarthroplasty as treatment; avoiding shoulder arthroplasty by surgeons who perform fewer than two shoulder arthroplasties per year (to reduce the risk of immediate postoperative complications); and the use of keeled or pegged all-polyethylene cemented glenoid components. The single moderate-rated recommendation was for the use of total shoulder arthroplasty rather than hemiarthroplasty. Management of glenohumeral osteoarthritis remains controversial; the scientific evidence on this topic can be significantly improved.

Typical and atypical shoulder impingement syndrome: diagnosis, treatment, and pitfalls.

The cause of shoulder impingement syndrome usually is considered to be compression of the rotator cuff and subacromial bursa against the anterolateral aspect of the acromion. The typical symptom is anterolateral shoulder pain that worsens at night and with overhead activity. However, the pain may be caused by factors other than a hooked acromion. Atypical impingement syndrome most commonly results from an os acromiale, a subcoracoid disorder, acromioclavicular joint undersurface hypertrophy, a deconditioned rotator cuff, or scapular dyskinesis. The correct diagnosis is made through the patient history and physical examination, with appropriate diagnostic imaging. Nonsurgical treatment is successful for most types of impingement syndrome; if it is not successful, all structural causes of mechanical impingement must be corrected.

Computed tomography analysis of the coracoid process and anatomic structures of the shoulder after arthroscopic coracoid decompression: a cadaveric study.

The purpose of this anatomic study is to define the morphologic changes of the coracoid and surrounding soft tissue after arthroscopic coracoid decompression. We obtained 5 fresh-frozen forequarter cadaveric specimens, 3 female and 2 male, with a mean age of 86.2 years. Arthroscopic coracoid decompression was performed, and intraarticular pathology was documented. Preoperative and postoperative measures of coracoid overlap, coracoid index, and coracohumeral distance were made on limited-cut axial computed tomography scans. Dissection was performed to assess anatomic relationships after coracoid decompression. Arthroscopic findings revealed subscapularis pathology and glenohumeral arthritis in all specimens, long head of biceps pathology in 3, and supraspinatus pathology in 2. Gross dissection confirmed the pathologic findings. Arthroscopic coracoid decompression effectively improves coracoid overlap, coracoid index, and coracohumeral distance. The adjacent major neurovascular structures are at a safe distance from the decompression site.

Nonoperative management for in-season athletes with anterior shoulder instability.

BACKGROUND: Acute or recurrent anterior shoulder instability is a frequent injury for in-season athletes. Treatment options for this injury include shoulder immobilization, rehabilitation, and shoulder stabilization surgery. PURPOSE: To determine if in-season athletes can be returned to their sports quickly and effectively after nonoperative treatment for an anterior instability episode. METHODS: Over a 2-year period, 30 athletes matched the inclusion criteria for this study. Nineteen athletes had experienced anterior dislocations, and 11 had experienced subluxations. All were treated with physical therapy and fitted, if appropriate, with a brace. These athletes were followed for the number of recurrent instability episodes, additional injuries, subjective ability to compete, and ability to complete their season or seasons of choice. RESULTS: Twenty-six of 30 athletes were able to return to their sports for the complete season at an average time missed of 10.2 days (range, 0-30 years). Ten athletes suffered sport-related recurrent instability episodes (range, 0-8 years). An average of 1.4 recurrent instability episodes per season per athlete occurred. There were no further injuries attributable to the shoulder instability. Sixteen athletes underwent surgical stabilization for their shoulders during the subsequent off-season. CONCLUSIONS: Most of the athletes were able to return to their sport and complete their seasons after an episode of anterior shoulder instability, although 37% experienced at least 1 additional episode of instability during the season.

Poly-L-lactic acid tack synovitis after arthroscopic stabilization of the shoulder.

BACKGROUND: Progress has been made in the design of bioabsorbable implants, with reduced complication rates and slower degradation times. PURPOSE: To report on complications related to use of poly-L-lactic acid implants after arthroscopic shoulder stabilization procedures. STUDY DESIGN: Retrospective cohort study. METHODS: Between 1997 and 1999, 52 patients underwent arthroscopic stabilization at one institution with an average of 2.2 poly-L-lactic acid tacks. Ten patients (19%), with an average age of 30 years, developed delayed onset of symptoms at an average of 8 months after surgery, including pain in all 10 and progressive stiffness in 6. The patients underwent magnetic resonance imaging and arthroscopic evaluation and debridement. RESULTS: Nine patients had gross implant debris. Evidence of glenohumeral synovitis was seen arthroscopically in all 10 patients. Three patients had significant full-thickness chondral damage on the humeral head. All preexisting labral lesions were healed. One year after arthroscopic debridement, loose body removal, and synovectomy, seven patients reported no or minimal pain and full return of motion. Two patients continued to have persistent pain and stiffness, and one patient reported discomfort with overhand throwing; all three had chondral lesions. CONCLUSIONS: Patients with symptoms of delayed pain and progressive stiffness after arthroscopic stabilization with poly-L-lactic acid implants should be evaluated for synovitis and chondral injury. Arthroscopic treatment provides a significant decrease in symptoms and increased range of motion.

Anteromedial capsular redundancy and labral deficiency in shoulder instability.

BACKGROUND: Redundancy of the anteromedial capsule of the shoulder may persist despite proper tensioning of the capsule and repair of a Bankart lesion during an anteroinferior capsular shift procedure. HYPOTHESIS: A barrel-stitch suture technique incorporated into a capsular shift procedure is effective in achieving satisfactory shoulder stability. STUDY DESIGN: Uncontrolled retrospective review. METHODS: A barrel-stitch technique was used for patients identified as having anteromedial capsular redundancy during a capsular shift procedure for anteroinferior instability. RESULTS: The incidence of anteromedial capsular redundancy and labral deficiency was 49% (38 of 78). Patients with anteromedial capsular redundancy had a significantly greater number of dislocations before surgery (16.1 +/- 21.3 versus 7.4 +/- 7.4) and a greater duration of symptoms (79.8 +/- 84.2 versus 31.6 +/- 32.2 months). The mean postoperative Rowe score of patients with anteromedial capsular redundancy was 88.7 +/- 14.8, with 92% having excellent or good results, compared with 88.9 +/- 14.8 in the remaining patients and 93% excellent or good results. CONCLUSIONS: Anteromedial capsular redundancy is associated with longer preoperative duration of symptoms and more dislocations, but effective treatment can be achieved with a capsular shift procedure augmented with medial capsular imbrication with a barrel stitch.