Subpectoral, Suprapectoral, and Top-of-Groove Biceps Tenodesis Procedures Lead to Similar Good Clinical Outcomes: Comparison of Biceps Tenodesis Procedures.

Purpose: To determine whether there is a difference in clinical results among open subpectoral (SB), arthroscopic low-in-groove suprapectoral (SP), and arthroscopic top-of-groove (TOG) locations in terms of patient-reported outcome measures for biceps tenodesis (BT) procedures using a global, self-reporting registry. Methods: We identified patients who underwent BT surgery in the Surgical Outcomes System registry. The inclusion criteria were isolated primary surgical procedures for BT, excluding patients with rotator cuff and labral repairs. Additional search requirements included repair location and 100% compliance with pretreatment and 2-year follow-up surveys. This study measured clinical outcomes comparing the 3 aforementioned techniques using the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, and Single Assessment Numeric Evaluation (SANE) score before treatment and at 3 months, 6 months, 1 year, and 2 years postoperatively. In addition, postoperative VAS pain scores were collected at 2 and 6 weeks. Statistical analysis was conducted using analysis of variance (Kruskal-Wallis test) and the Wilcoxon test. Results: A total of 1,923 patients from the Surgical Outcomes System registry qualified for the study; of these, 879 underwent the SB technique, 354 underwent the SP technique, and 690 underwent the TOG technique. There was no statistically significant difference in the demographic characteristics among the groups except that the TOG group was older: 60.76 years versus 54.56 years in the SB group and 54.90 years in the SP group (P < .001). In all groups, the ASES score statistically improved from before treatment (mean, 49.29 ± 0.63) to 2 years postoperatively (mean, 86.82 ± 0.80; P < .05). There were no statistically significant differences among the 3 groups in the VAS, ASES, and SANE scores at all time points (P > .12) except for the VAS score at 1 year (P = .032) and the ASES score at 3 months (P = .0159). At 1 year, the mean VAS score in the SB group versus the TOG group was 1.146 ± 1.27 versus 1.481 ± 1.62 (P = .032), but the minimal clinically important difference (MCID) was not met. The 3-month ASES Index scores in the SB, SP, and TOG groups were 68.991 ± 18.64, 66.499 ± 17.89, and 67.274 ± 16.9, respectively (P = .0159), and similarly, the MCID was not met. At 2 years, the ASES scores in the SB, SP, and TOG groups improved from 49.986 ± 18.68, 49.54 ± 16.86, and 49.697 ± 7.84, respectively, preoperatively to 86.00 ± 18.09, 87.60 ± 17.69, and 86.86 ± 16.36, respectively, postoperatively (P > .12). Conclusions: The SB, SP, and TOG BT procedures each resulted in excellent clinical improvement based on patient-reported outcome measures from a global registry. On the basis of the MCID, no technique was clinically superior to the other techniques in terms of VAS, ASES, or SANE scores at any time point up to 2 years. Level of Evidence: Level III, retrospective comparative study.

Biomechanical properties of repairs for dislocated AC joints using suture button systems with integrated tendon augmentation.

PURPOSE: To evaluate the biomechanical performance of different techniques for CC reconstruction using suture button systems with integrated tendon augmentation. Hypothesis was that (1) reconstructions using a cortical button combined with a biological augmentation (semitendinosus allograft) will demonstrate improved stability than a modified Weaver-Dunn procedure and (2) constructs using two tunnels at the clavicle for fixation will show superior horizontal stability than single-tunnel constructs. METHODS: The acromioclavicular joints of 47 cadaveric shoulders were tested for anterior, posterior, and superior translations (70 N load) and maximal load to failure (superior). Shoulders were assigned to 4 groups: (1) native (n = 18) and after sectioning the AC and CC ligaments; (2) CC reconstruction with 1 clavicular and 1 coracoid tunnel (GR-ST) augmented with semitendinosus graft (n = 15); (3) CC reconstruction augmented with semitendinosus tendon (GR-DT) with 2 clavicular and 1 coracoid tunnel (n = 8); and (4) modified Weaver-Dunn reconstruction (n = 6). RESULTS: The Weaver-Dunn demonstrated statistically more translation than the native joint for posterior direction (P = 0.038). The GR-ST had significantly less translation than the Weaver-Dunn for anterior and posterior translations (P = 0.003, P = 0.004) and compared to the native for superior translation (P = 0.028). The GR-DT differed significantly in anterior and posterior translations compared to the Weaver-Dunn (P = 0.002, P = 0.001). The modified Weaver-Dunn failed at significantly less load to failure compared to all other groups (P = 0.002, P = 0.002, P = 0.005). There was no significant difference between the native and the other reconstructions. CONCLUSION: The evaluated techniques for isolated CC ligament reconstruction (GR-ST) in AC joint dislocation showed biomechanical stability superior to the modified Weaver-Dunn procedure and obtained similar measures compared to the native control. A modified technique (GR-DT), which used two fixation points at the clavicle, did not result in decreased horizontal or vertical translation and therefore no superiority of the GR-DT technique could be shown compared to the GR-ST. LEVEL OF EVIDENCE: Controlled laboratory study.

Biomechanical comparison of arthroscopic repairs for acromioclavicular joint instability: suture button systems without biological augmentation.

BACKGROUND: Arthroscopic procedures for reconstruction of acromioclavicular (AC) joint separations are increasingly used in clinical practice. Multiple surgical techniques exist, but there are still few data on biomechanical performances of commonly used arthroscopic techniques and fixation methods. HYPOTHESIS: Single and double clavicular tunnel reconstructions show comparable primary stability with a modified Weaver-Dunn procedure, and double tunnel constructs show superior horizontal stability. STUDY DESIGN: Controlled laboratory study. METHODS: The AC joints of 40 cadaveric shoulders were tested for anterior, posterior, and superior translation (70-N load) and maximal load to failure (superior) with the MTS 858 Bionix II Servohydraulic testing system. Shoulders were assigned to 4 groups: (1) native (n = 18), (2) coracoclavicular (CC) reconstruction with 1 clavicular and 1 coracoid tunnel (SCT) fixed with a suture pulley and 2 buttons (n = 8), (3) CC reconstruction with 2 clavicular and 1 coracoid tunnel (DCT) fixed with a suture pulley and 3 buttons (n = 8), and (4) modified Weaver-Dunn reconstruction (n = 6). RESULTS: Native specimens showed a mean anterior translation of 7.92 mm (±1.69 mm), a mean posterior translation of 7.84 mm (±2.09 mm), and a superior translation of 4.28 mm (±1.81 mm). Maximal load to failure was 579.44 N (±148.01 N). The SCT technique showed a mean anterior translation of 5.81 mm (±1.16 mm), posterior translation of 8.30 mm (±1.94 mm), and a superior translation of 2.28 mm (±0.52 mm). The maximal load to failure was 591.35 N (±231.17 N). Anterior and superior translations were significantly less compared with the native specimen (P = .005 and P = .003). The DCT technique had an anterior translation of 4.68 mm (±0.6 mm), posterior translation of 6.85 mm (±0.83 mm), and superior translation of 2.09 mm (±0.86 mm). The mean maximal load to failure was 651.16 N (±226.93 N). Anterior and superior translations were significantly less compared with the native specimens (P = .000 and P = .001). No statistically significant differences were shown between SCT and DCT reconstruction for all measurements (P > .05). One reconstruction of the modified Weaver-Dunn procedure failed directly after mounting it into the testing device. The remaining 5 showed a mean anterior translation of 11.36 mm (±3.17 mm), a mean posterior translation of 13.51 mm (±2.21 mm), and a mean superior translation of 3.31 mm (±0.47 mm). Anterior and posterior translations were significantly increased compared with the native specimen (P = .019 and P = .000). The mean maximal load to failure measured 311.13 N (±52.2 N) and was significantly less compared with the native specimen (P = .000). The Weaver-Dunn technique showed significantly less maximal load to failure and more anterior and posterior translation compared with SCT and DCT (P ≤ .05). CONCLUSION: Isolated reconstruction of the CC ligaments using single and double clavicular tunnel techniques results in a high load to failure for superior translation, which is equal to the native stability, and less translation in all 3 directions as well as higher superior stability when compared with the modified Weaver-Dunn procedure. A potential drawback is the risk of coracoid fracture, as the high load to failure of the device may exceed load to failure of cortical bone prior to device breakage. CLINICAL RELEVANCE: Single clavicular tunnel arthroscopic reconstructions of the coracoacromial ligaments show good biomechanical results.

Arthroscopic excision of the os trigonum: using the posteromedial portal safely.

The os trigonum is an accessory ossicle that, though usually asymptomatic, can become a chronic source of pain, particularly in dancers and athletes. Surgical intervention is sometimes necessary, with arthroscopy having the theoretical advantages of less pain, inflammation, and scarring. Presented here is an example of chronic posterior ankle pain in an athlete successfully treated with arthroscopic os trigonum resection using posteromedial and posterolateral portals. We review the technical features and surgical technique of safe placement of the posteromedial portal and associated advantages.

Management of the failed AC joint reconstruction: causation and treatment.

With recent studies showing improved biomechanical behavior of anatomic acromioclavicular joint reconstructions, these techniques are more frequently being performed. With both the more historic methods of fixation such as coracoacromial ligament transfer along with the newer anatomic reconstruction, potential for failure exists. However, there is a paucity of literature addressing these failures and possible treatment options. The purpose of this review is to report cases of failed reconstructions, describe failure mechanisms, and propose treatment options.