Glenoid Cartilage Lesions Compromise Outcomes of Surgical Treatment for Posterior Shoulder Instability.

BACKGROUND: Posterior shoulder instability is associated with nonspecific symptoms, including pain, subluxation, and functional impairment, which complicate its diagnosis and management. Owing to the rarity of the condition, there are no present decision tools for its diagnosis and treatment. PURPOSE: To investigate demographic, lesional, and surgical factors that influence functional outcomes in patients treated for posterior shoulder instability. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We analyzed the clinical and radiographic records of 150 patients treated surgically for isolated posterior shoulder instability at 10 centers between 2000 and 2015, of which 144 were eligible for inclusion: 114 men (79%) and 30 women (21%) (mean ± SD age, 28.7 ± 9.6 years). The mean time between onset of symptoms and surgery was 66 ± 75 months. Shoulder instability was of traumatic origin in 115 patients (80%). The primary treatment was bone-block procedures for 65 patients (45%), posterior Bankart repair for 67 (47%), and capsular plication for 12 (8%). Patients were assessed with the Constant and Walch-Duplay scores at a mean follow-up of 51 ± 32 months (range, 12-159 months). Uni- and multivariable regression analyses were performed to determine associations between clinical scores and sex, age, traumatic origin, type of lesion, type of procedure, and follow-up. RESULTS: At final follow-up, subluxations or dislocations recurred in 24 patients (17%). The overall Constant score was 86.2 ± 14.5, with a pain component of 12.6 ± 3.5. The Walch-Duplay score was 79.8 ± 24.2. Multivariable regressions revealed that the presence of a glenoid cartilage lesion was the only factor associated with worse Constant score (beta = -10; P = .013) and Walch-Duplay score (beta = -16.7; P = .024) across all subcomponents. CONCLUSION: The only factor that jeopardized functional outcomes of posterior instability surgery was the presence of glenoid cartilage lesions. Knowing that shoulders with glenoid cartilage lesions are at greater risk of residual pain or instability could help manage patient expectation and justify faster intervention before lesions deteriorate.

Arthroscopic suture-bridge repair for small to medium size supraspinatus tear: healing rate and retear pattern.

PURPOSE: The purpose of the study was to assess the repair site integrity after transosseous equivalent/suture-bridge (TOE/SB) repair with the use of magnetic resonance imaging (MRI). METHODS: One hundred seven consecutive shoulders with a small to medium-size full-thickness supraspinatus tear were repaired arthroscopically with use of the TOE/SB technique. There were 64 men and 41 women, and mean age at the time of surgery was 54.8 years (range, 21 to 74 years). All patients underwent postoperative MRI and clinical examination. Mean follow-up was 16.1 months (range, 12 to 28 months). RESULTS: The mean Constant score improved from 54.5 ± 12.5 points preoperatively to 80 ± 12.1 points postoperatively (P < .0001). The mean pain score improved from 7 ± 2 points preoperatively to 13 ± 2.5 postoperatively (P < .0001). The mean active forward flexion improved from 151° ± 37° preoperatively to 169° ± 14° postoperatively (P < .0001). The mean Constant score was 81 points when repaired tendon had healed and it was 72.6 points when repaired tendon was unhealed (P = .02). Smoking status was found to have detrimental influence on the tendon healing (P = .04). Postoperative MRI showed a healed repair in 96 (89.7%) of 107 shoulders. Among 11 retears, 10 occurred at the greater tuberosity and 1 occurred at the musculotendinous junction. CONCLUSIONS: Arthroscopic TOE/SB repair of full-thickness supraspinatus tendon led to a healing rate of 89.7%. Patients with healed tendons according to MRI had significant better functional and subjective outcome. Smoking habit was found to be detrimental on healing. Retears occurred mainly at tendon-bone interface at the greater tuberosity, whereas medial cuff failure was observed in only one case in the mean time of follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic posterior bone block procedure: a new technique using suture anchor fixation.

We present a novel all-arthroscopic technique of posterior shoulder stabilization that uses suture anchors for both bone block fixation and capsulolabral repair. The bone graft, introduced inside the glenohumeral joint through a cannula, is fixed with 2 suture anchors. The associated posteroinferior capsulolabral repair places the bone block in an extra-articular position. In this article we present the detailed arthroscopic technique performed in a consecutive series of 15 patients and report the early results. We also report the positioning, healing, and remodeling of the bone block using postoperative 3-dimensional computed tomography. The benefits of this new technique are as follows: (1) it is all arthroscopic, preserving the posterior deltoid and posterior rotator cuff muscles; (2) it is accurate, resulting in appropriate bone block positioning; (3) it is efficient, allowing for consistent bone graft healing; (4) it is anatomic, both restoring the glenoid bone stock and repairing the injured posterior labrum; and (5) it is safe, limiting hardware-related complications and eliminating the risk of injury to vital structures associated with drilling or screw insertion from posterior to anterior. We believe that this technique is advantageous because it does not use screws for fixation and may be safer for the patient.

Clinical and structural results of arthroscopic repair of isolated subscapularis tear.

BACKGROUND: Even though the frequency of arthroscopic repair of isolated lesions of the subscapularis tendon has increased, few studies have presented clinical and anatomical outcomes of this treatment. We hypothesized that, after an arthroscopic repair, structural outcomes in the muscle have an influence on functional results. METHODS: A retrospective study was performed on twenty-two patients who had undergone arthroscopic repair of an isolated tear of the subscapularis tendon and had a mean follow-up of thirty-six months. Patients were evaluated preoperatively and postoperatively with use of the Constant-Murley score, a subjective shoulder value, the lift-off test, the belly-press test, and magnetic resonance imaging or computed tomography arthrography. The results were compared with those of a cohort of thirteen patients who underwent open repair of the subscapularis tendon tear. RESULTS: In the arthroscopic group, the Constant-Murley score improved from a mean of 66 points preoperatively to a mean of 85 points postoperatively (p < 0.05). The subscapularis tendon was healed in 86% of the patients. Three patients (14%) had a partial rupture limited to the superior tendon. Postoperatively, progression of fatty infiltration of the subscapularis muscle was observed in 55% of the patients. Ten patients (45%) had a severe but localized fatty infiltration area of the subscapularis muscle related to the larger tears. Subjective and functional outcomes were not influenced by tendon-healing or postoperative fatty infiltration (p > 0.05). Clinical testing was significantly improved, but incomplete corrections remained frequent. Although open repair resulted in higher subjective shoulder scores and better strength scores, most other clinical parameters, postoperative subscapularis testing results, and structural outcomes were comparable between the arthroscopic repair and the open repair group. CONCLUSIONS: Arthroscopic repair of isolated subscapularis tears was associated with improved shoulder function and improved results on clinical testing. The tendon-healing rate was high but resulted in incomplete correction of the results of clinical testing. Progression of fatty infiltration in the subscapularis muscle was observed on magnetic resonance imaging but did not influence the clinical outcomes.