Augmentation of Massive Rotator Cuff Repairs Using Biceps Transposition Without Tenotomy Improves Clinical and Patient-Reported Outcomes: The Biological Superior Capsular Reconstruction Technique.

PURPOSE: To evaluate the outcomes of a consecutive series of patients after transposition of the biceps without tenotomy (biological superior capsular reconstruction [bio-SCR] technique) to augment massive rotator cuff repairs. METHODS: Thirty massive rotator cuff tears repaired and augmented using the bio-SCR technique between June 2018 and July 2021 were identified and retrospectively reviewed. American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale pain scores, supraspinatus and infraspinatus strength, and range of motion were collected preoperatively and postoperatively. RESULTS: The average age of patients undergoing bio-SCR augmentation was 67.0 years (range, 28.4-81.9 years), and the mean clinical follow-up period was 2.9 years (range, 1.8-4.5 years). The average ASES score improved from 33.2 preoperatively to 80.8 at 6 months postoperatively, 92.0 at 1 year, and 87.0 at 2 years (P < .001). The minimal clinically important difference for the ASES score was exceeded at all postoperative intervals. Active forward flexion improved from 120.6° to 156.8° (P < .001). The pain score improved from 7.1 to 0.9 (P < .001). Postoperatively, 1 complication (3.3%) occurred: a proximal biceps rupture. CONCLUSIONS: Incorporating a transposed biceps tendon into the repair of a massive rotator cuff tear using the bio-SCR technique resulted in significant clinical improvements with a low complication rate. LEVEL OF EVIDENCE: Level IV, case series.

Techniques and Tips to Arthroscopically Remove Prominent and Loose Shoulder Joint Hardware.

The number of arthroscopic shoulder operations has continued to steadily increase in recent years, with a projection of over 500,000 rotator cuff operations in 2023. Although the incidence of anchor pullout, hardware failure, and aberrant hardware placement is relatively low, this increased volume of shoulder operations has inevitably resulted in a consequent increase in the number of patients who experience such hardware complications. These hardware issues can cause significant pain, limit shoulder function, and cause permanent damage to the shoulder articular cartilage. The described arthroscopic techniques are presented to provide tools and strategies to safely and effectively remove prominent and loose shoulder joint hardware.

"Double Row Rip-Stop" Arthroscopic Repair Technique for Acute, Retracted Rotator Cuff Tears.

Acute, retracted rotator cuff tendon tears are important to recognize and can present unique technical challenges to repair. Various arthroscopic techniques and suture configurations have been proposed for repair of acute tears with aims to maximize the repair footprint and optimize tendon fixation. The double row rip-stop configuration was designed and has been used for rotator cuff repair due to its potential advantages related to suture pullout, footprint reapproximation and load sharing. The purpose of this article is to present the author's arthroscopic technique for repair of acute, retracted rotator cuff tendon tears using a double-row, rip-stop suture configuration. The indications and authors' preferred arthroscopic technique for biceps tenodesis are also discussed.

Arthroscopic Techniques to Recognize and Quantify Subtle Medial and Lateral Elbow Instability.

The diagnosis and treatment of elbow instability can be challenging for surgeons. Although history, physical examination, radiographs, and advanced imaging such as stress ultrasound scanning and magnetic resonance imaging are helpful, diagnostic arthroscopy is a valuable tool in the armamentarium of an elbow surgeon. Elbow arthroscopy is not only a diagnostic tool but also has the added therapeutic benefits that are not available with other diagnostic modalities. The purpose of this article and associated video is to present 3 arthroscopic techniques to help elbow surgeons arthroscopically recognize and quantify medial and lateral elbow instability.

Limited Arthroscopic Deltoid Fasciectomy Increases Subacromial Visualization and Characterization of Rotator Cuff Tears.

Adequate arthroscopic visualization in the subacromial space is a necessity to appropriately characterize rotator cuff tears and to subsequently develop a suture construct that best reduces the cuff tear with the least tissue tension possible for optimal healing. The purpose of this article and corresponding video is to demonstrate a technique for carrying out a limited deltoid fasciectomy, resulting in enhanced visualization of the rotator cuff through the lateral viewing portal.

Medialized Rip-Stop Convergence Technique for Retracted Rotator Cuff Tears.

Attempts to restore the anatomical footprint during rotator cuff repair for retracted, relatively immobile tears can be difficult. In some cases, it can lead to excessive tension of the repair. Previous studies have noted improved clinical outcomes when repair tension is not excessive, and medialization of the anatomical footprint has been suggested as a technique that can help surgeons repair large, retracted tears without excessive tension and achieve improved clinical outcomes. Of note, excessive tension when restoring the rotator cuff tendon to the anatomical footprint is not limited to large, retracted tears. In some cases, restoring small- and medium-sized tears to the anatomical footprint also can lead to excessive tension. Therefore, it is not uncommon for the authors to employ some degree of footprint medialization even for repair of small- or medium-sized tears if repair to the anatomical footprint will lead to excess tension. The purpose of this article and video demonstration is to provide instruction for a reproducible rotator cuff technique using a medialized single-row rip-stop construct combined with convergence.

Arthroscopic Techniques to Stabilize Glenoid Bony Bankart Fragments.

A bony Bankart lesion is an avulsion of the labroligamentous complex associated with an anterior glenoid rim fracture. Bony Bankart lesions can be seen in up to 70% of traumatic shoulder dislocations. With such a high prevalence, the development of an optimal repair technique is important. Selection of the most appropriate repair method depends heavily on the individual hard- and soft-tissue characteristics of the presenting lesion, as well as surgeon experience with the various repair options. We describe 3 arthroscopic Bankart fixation techniques (labrum alone, transosseous, and double row) to address a range of presenting Bankart pathologies.

Arthroscopic Management Strategies for Glenohumeral Articular Cartilage Lesions and Defects.

Glenoid articular cartilage lesions are a source of shoulder pain and can occur in the setting of glenohumeral instability and degenerative shoulder disease. Glenolabral articular disruption lesions have been reported to be associated with worse outcomes after arthroscopic repair of labral tears. There are relatively few published studies evaluating outcomes after surgical treatment of glenoid articular lesions; however, it is generally accepted that management should consist of restoring the glenoid articular surface, minimizing exposed articular defect, and re-establishing capsulolabral integrity to achieve stability. We present arthroscopic strategies to manage these glenoid articular defects through debridement, abrasion, microfracture, capsulolabral advancement and labral interposition.

Arthroscopic Identification and Management of Hourglass Biceps.

The hourglass biceps is a condition in which the intra-articular portion of the biceps tendon becomes inflamed and hypertrophies relative to the remaining tendon. This condition can be seen in association with rotator cuff and labral pathology and may lead to anterior shoulder pain. Diagnosis requires careful visualization and inspection of the biceps tendon during shoulder arthroscopy, as the presentation may be subtle. Surgical treatment includes tenotomy or tenodesis, depending on patient factors and surgeon preference.

The Arthroscopic "Bellows" Sign Identifies Hidden Rotator Cuff Tears.

The intraoperative recognition of rotator cuff tears continues to be a challenge in some cases, despite clinical suspicion, a physical examination suggesting a rotator cuff tear, and detection on preoperative imaging studies. Intraoperative identification can be elusive in partial tears including intratendinous tears and obscured full-thickness tears. The purpose of this Technical Note, and the associated technique video, is to discuss a visual sign for the detection of various rotator cuff tear pathologies. Derived from the dynamic fluid expansion and contraction of the affected tissues, this indicator is termed the arthroscopic "bellows" sign.

"Triple-Fix" Arthroscopic Biceps Tenodesis: Indications and Technique.

Pathology of the long head of the bicep tendon is a common cause of anterior shoulder pain and frequently is treated surgically using either tenodesis or tenotomy. Tenodesis often is the preferred technique for younger, more active patients and laborers, especially when cosmesis and preservation of function are clinical priorities. However, the security of the tenodesis varies with fixation methods and techniques, and failure of the tenodesis can have both cosmetic and symptomatic consequences. Traditional arthroscopic tenodesis also can be technically challenging, as it usually requires extra-articular identification of the bicep tendon within the bicipital groove. The arthroscopic surgical technique described is an approach that has been routinely employed by the senior author for approximately 8 years that allows for accurate and reproducible exposure of the biceps tendon within the bicipital groove along with secure, anatomic tenodesis of the long head of the bicep tendon.

Arthroscopically Assisted Humeral Head Decompression for Avascular Necrosis: Lateral Cortical Perforation Technique.

Avascular necrosis (AVN) of the humeral head is debilitating condition that, when left untreated, can progress to humeral head collapse and end-stage arthritis of the glenohumeral joint. Core decompression is widely regarded as a first-line surgical treatment for early-stage AVN, and when performed on the appropriate patient, core decompression is an effective treatment for improving symptoms and preventing progression and humeral head collapse. This article discusses operative indications and presents a relatively simple and effective arthroscopic method for core decompression of humeral head avascular necrosis.

Editorial Commentary: Elbow Lateral Epicondylitis Treatment Using Platelet-Rich Plasma.

The best treatment for elbow lateral epicondylitis is controversial. Multiple treatment interventions are used commonly, including physical therapy, corticosteroid injections, nonsteroidal anti-inflammatory drugs, bracing, acupuncture, ultrasound-guided percutaneous tenotomy, open or arthroscopic surgical debridement, and recently, platelet-rich plasma (PRP) or autologous blood injections. Patients in whom more traditional conservative measures have failed may benefit from PRP injections, although long-term outcomes after such injections are unclear. The complication rates of PRP injections are low. One PRP injection, if successful, could be a cost-effective alternative to surgery, but multiple injections are often recommended and third-party payers have historically rarely paid those medical claims, thus placing an increased financial burden on the patient.

Revision Rotator Cuff Repair: A Comprehensive Approach and Stepwise Technique.

The indications for and techniques to accomplish revision rotator cuff repair continue to be challenging problems that surgeons face. Complexity of tears, poor tissue quality, retained hardware, and adhesions are routinely encountered during surgical intervention for failed rotator cuff repairs. A successful outcome for any revision rotator cuff repair is determined, in part, by the surgeon's ability to address these intraoperative issues in an optimum manner. The surgical technique described in this article outlines a comprehensive and stepwise approach that can aid the surgeon in developing an effective strategy to accomplish revision rotator cuff repair.

Combined Intra-articular and Extra-articular Visualization for Repair of a Complete Subscapularis Tear: The "Blended View" Technique.

Repair of subscapularis tendon tears can be a challenging task, even for an experienced arthroscopist. The complexity results not only from the difficulty in identifying these tears accurately but also because establishing orientation for visualization and repair of this often distorted anatomy can be difficult. Even after a subscapularis tear is identified and mobilized, restoration of the footprint can prove demanding due to the limited view of the subscapularis tendon's lesser tuberosity insertion site, especially from the traditional posterior portal. Such visualization limitations often necessitate switching back and forth between 30° and 70° arthroscopes. A "blended view" technique is used routinely because it offers optimal visualization and access to the subscapularis tendon and the lesser tuberosity during full-thickness subscapularis repair.

"Ninja Technique" for Percutaneous Completion of Partial-Thickness, Articular-Sided Rotator Cuff Tears.

Rotator cuff tears are a common source of shoulder pain and dysfunction. Owing to the multifaceted nature of these injuries, various viable methodologies exist for their surgical and nonsurgical management. Among surgically managed patients, those with PASTA (partial articular supraspinatus tendon avulsion) lesions require careful consideration of technique. Both transtendinous repair and tear completion with subsequent repair have been described. Both techniques offer unique benefits. In this publication, we offer an expedient and minimally invasive technique for tear completion and subsequent repair. The "ninja technique" uses localization via a spinal needle and tear completion with an arthroscopically manipulated scalpel blade. Conversion of partial tears to full-thickness tears using the ninja technique allows for technically simplified repairs while maximizing available tendon length.

Arthroscopic "Wallow" Procedure for Resection of Symptomatic Os Acromiale Pseudoarthrosis.

Os acromiale is a relatively common anatomic variant that can occasionally be associated with shoulder pain. Several surgical options to address a symptomatic os acromiale that has failed nonoperative treatment have been described. Published techniques, however, are often very invasive, technically challenging, and carry the risk of potential complications that can be difficult to manage. The technique presented here describes a relatively simple arthroscopic alternative, coined by the authors as the "Wallow technique" due to the fact that the arthroscopic shaver is used to rotate within and resect the os site, that results in complete resection of the os acromiale pseudoarthrosis and avoids the need for an open approach or the use of implants.

Arthroscopic Management of Displaced Greater Tuberosity Fractures.

Displaced greater tuberosity fractures of the humerus require anatomic reduction with stable fixation to optimize rotator cuff function and prevent subacromial impingement. A wide variety of surgical approaches and fixation constructs have been reported, largely with favorable results. Arthroscopic management of these fractures allows excellent visualization with strong suture anchor fixation while minimizing soft tissue disruption, blood loss, and radiation exposure. The purpose of this article is to describe an arthroscopic technique for reduction and suture-anchor fixation of displaced greater tuberosity fractures.

Partial Rotator Cuff Repair for Massive Tears Rarely Require Revision Surgery.

PURPOSE: To determine the significance of initial and residual rotator cuff tear defect size on the need for revision surgery or additional nonsurgical therapy, in a consecutive group of patients undergoing partial repair of massive rotator cuff tears. METHODS: A retrospective chart review was carried out for all arthroscopic rotator cuff repairs performed by a single surgeon between January of 2013 and December of 2016. All patients with massive rotator cuff tears (>30 cm2) who underwent partial repair were included in the study. Outcomes for the surgical procedure were measured based on the necessity for revision surgery or adjunct therapy, including steroid injections or additional physical therapy after initial release from care. RESULTS: In total, 1954 patients who underwent arthroscopic rotator cuff repair were identified. Thirty-eight of these met the inclusion criteria. Those patients undergoing revision surgery represented 5.2% (2/38) of the series and had an average initial/residual tear defect area of 45.0/7.0 cm2. Patients requiring adjunct therapy represented 7.9% (3/38) of the series and possessed an average initial/residual tear defect size of 40.0/16.0 cm2. The remaining 33 (86.9%) patients did not require revision surgery or adjunct therapy at a minimum follow-up of 2 years. There was no significance between initial and/or residual rotator cuff tear defect size and the need for revision surgery. However, there was a significant difference in the mean residual defect size in the patients requiring additional nonoperative treatment after initial release from care (P = .012). CONCLUSIONS: There was no relationship between residual defect size after partial repair and the need for revision surgery. Patients who returned for additional nonoperative treatment after being released from care were noted to have a statistically larger residual defect size at the time of index surgical intervention. Only 5% of patients underwent subsequent surgery at an average of more than 4 years' follow-up, suggesting that partial repair of massive rotator cuff tears can provide a durable, joint-preserving intervention. LEVEL OF EVIDENCE: Level IV, Therapeutic Case Series.

Techniques and Tips for Identification of Comma Tissue in Subscapularis Tears.

Identifying and repairing subscapularis tears can be challenging for the arthroscopic surgeon and is commonly related to the difficulty in accurately recognizing the distorted anatomy that may be encountered. Defining and differentiating this anterior glenohumeral joint anatomy are often made even more challenging in clinical situations in which large, retracted subscapularis and anterosuperior tears are present. Identifying the "comma tissue" during the initial arthroscopic assessment is very helpful because it provides an important anatomic landmark that not only serves to orient the surgeon but also facilitates reduction and repair of these tears. Identification of the comma tissue is sometimes a critical surgical step in subscapularis repair, and we provide tips and techniques that can aid the surgeon in reliably and reproducibly recognizing and incorporating the comma tissue.