Fluoroscopically Guided Subacromial Spacer Implantation for Massive Rotator Cuff Tears: Two Years of Prospective Follow-up.

BACKGROUND: Massive rotator cuff tears (MRCTs) are common and have been estimated to account for nearly 40% of all rotator cuff tears. An evolving strategy for management of MRCTs has been the implantation of a degradable subacromial spacer balloon that attempts to restore normal shoulder biomechanics. PURPOSE: To assess the safety and efficacy of fluoroscopically guided balloon spacer implantation under local anesthesia in a cohort of patients with 2 years of postoperative follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The safety and efficacy of using fluoroscopically guided subacromial spacer implantation was assessed in 46 patients. Follow-up visits were scheduled according to routine clinical practice. Shoulder function was evaluated using Constant and American Shoulder and Elbow Society (ASES) scores. RESULTS: Overall, 87.5% (35/40) of patients saw clinically significant improvement in the total Constant and ASES scores from 6 weeks postoperatively, with improvement maintained up to 24 months postoperatively. CONCLUSION: The data suggest that fluoroscopically guided subacromial spacer implantation under local anesthesia is a low-risk, clinically effective option, especially for the elderly population and those patients who have multiple comorbidities or a contraindication to general anesthesia. Patients undergoing subacromial spacer implantation for the treatment of MRCTs had satisfactory outcomes at 2-year follow-up, with a low rate of complications.

Anatomic Reduction and Fixation for Glenoid Fractures: The Kissing Anchor Technique.

Up to one fifth of glenoid fractures are intra-articular and associated with recurrent anterior dislocation. Surgery is often the indicated treatment, and as with many other articular fractures, it aims for a perfectly congruent and flush reconstruction of the articular surface to avoid the onset of secondary degenerative joint diseases. The purpose of this paper is to describe a reproducible, simple arthroscopic technique that uses suture anchors to fix the glenoid fragment with a strong and stable construct called "kissing anchors." This method provides the advantages of both direct and indirect stabilizing effects. It applies 2 anchors, one inside the fragment and the other inside the fracture bed, to stabilize and fix the fragment, and is adequately associated with labrum refixation, which provides the construct with increased stability. However, a surgeon willing to apply it should already be confident with basic shoulder arthroscopy and should have performed an appropriate amount of arthroscopic shoulder stabilizations.

Multidirectional Shoulder Instability: Arthroscopic Labral Augmentation.

Capsulolabral augmentation is one of the most used arthroscopic techniques to address multidirectional instability of the shoulder. Given the thin and weak capsule seen in the affected patients, reconstruction in this subset of patients can be particularly challenging. This arthroscopic technique aims to reduce the capsular volume and deepen the glenoid socket through the creation of a particularly voluminous "bumper" along the glenoid bone. Increasing the depth of the glenoid facilitates a concavity-compression stabilizing effect and, therefore, shoulder stability, especially midrange stability. This technique aims to augment the bump of the standard capsulolabral reconstruction by using a resorbable surgical mesh derived from porcine skin.

Arthroscopic treatment of the atraumatic shoulder instability: a case series with two-year follow-up evaluation.

BACKGROUND: The purpose of this work is to evaluate the results of arthroscopic capsulolabroplasty in patients affected by atraumatic shoulder instability (ASI). METHODS: A retrospective review was performed of 10 patients (7 women and 3 men) who underwent arthroscopic treatment of symptomatic ASI. Mean age at evaluation was 27.9 (19-35) years and the mean follow-up was 23.3 (12-37) months. We evaluated recurrence rate, range of movement, apprehension and relocation tests, hyperlaxity, and sport activity. The ASES score, the Rowe score, the Simple Shoulder Test (SST) and Visual Analogue Scale (VAS) were also used as outcomes measure. RESULTS: None of the patients experienced episodes of dislocation or subluxation after surgery. The apprehension and relocation tests produced positive results in 2 patients. Six out of 10 patients reported apprehension with the arm in specific positions. The ASES mean score was 93.4 (55-100); the Rowe mean score was 85.5 (70-100); the SST mean score was 9.1 (5.8-10). On average, external rotation is reduced by 10° in adduction, and by 8° in abduction in 6 out of 10 patients; internal rotation is reduced on average by 6.6° in abduction with the arm abducted, and was overall limited in 6 out of 10 patients. CONCLUSIONS: Arthroscopic capsulolabroplasty ensures excellent results in patients showing atraumatic shoulder instability in terms of recurrence. Still, an underlying insecurity persists and the risk of residual stiffness is tangible. LEVEL OF EVIDENCE: V.

No-holes transpectoral tenodesis technique vs tenotomy of the long head of the biceps brachii.

BACKGROUND: There is no univocal consensus regarding Long Head of the Biceps (LHB) best treatment between tenotomy and tenodesis. There is no consensus regarding the best location to perform the tenodesis. The LHB tenodesis performed by the proximal tendon excision as first step can miss the proper tension to the muscle belly. Fixations proximal to the pectoralis major can lead to groove pain. This study aims to test the efficacy of a new LHB tenodesis technique by comparing its results with the tenotomy. METHODS: We retrospectively evaluated patients who underwent surgery between May 2014 and May 2015. The mean follow up was 14.7 months. Sixteen patients underwent mini-open tenodesis to the Pectoralis Major tendon by the use of a resorbable suture (TD group); sixteen underwent tenotomy (TT group). The mean age of the TD group was 54 years; the mean age of the TT group was 56 years. We evaluated pain, subjective perception of the patient of possible aesthetic and strength differences between the two biceps, "Popeye sign", and tests to stimulate the LHB. We administered three evaluation questionnaires: the ASES score, the SPADI score, and the SST. RESULTS: 32 consecutive patients were evaluated. The clinical scores did not record statistically significant differences: the mean ASES score was 92.9 (TD) and 90.8 (TT); the mean SPADI score was 92.5 (TD), and 89.7 (TT); the mean SST was 8.9 (TD), and 8.4 (TT). Compared to the TD group, in the TT group we registered with greater frequency the "Popeye sign" with a P value < 0.05 (9 cases vs 1), and spasms in the biceps muscle belly (5 cases vs 1). All other signs or symptoms evaluated were more frequent in the TT group, except the strength difference perceived by the patient (3 patients in the TT group, and 2 in the TD group). No complications were recorded. CONCLUSIONS: This new Long Head of the Biceps (LHB) tenodesis technique is valuable and reliable, and provided better results than tenotomy. LEVEL OF EVIDENCE: IV.

Fluoroscopy-guided implantation of subacromial "biodegradable spacer" using local anesthesia in patients with irreparable rotator cuff tear.

Treatment of massive rotator cuff tears can be challenging, especially when tears are considered irreparable or, when repaired, at significant risk of retear. A surgical technique is described using a biodegradable subacromial balloon-shaped spacer (InSpace; Ortho-Space, Caesarea, Israel) that, when implanted between the humeral head and acromion, permits smooth, frictionless gliding, supporting shoulder biomechanics. The specific insertion technique described herein is a simple procedure that can be performed in a day-care or outpatient setting with patients under local anesthesia, thus providing a treatment option for patients with multiple comorbidities complicating or contraindicating surgery, such as reverse arthroplasty under general anesthesia.

Locked bilateral posterior fracture-dislocation of the shoulder in an epileptic patient: case report.

Bilateral posterior dislocation of the shoulder, often secondary to seizures, is uncommon, while bilateral posterior fracture-dislocations is rarer still: 0.6 cases among a population of 100,000 people per year. The scientific literature contains very few published reports of cases of bilateral posterior fracture-dislocation of the shoulder, a condition that tends to be sustained by epileptic patients during seizures. The authors presented a case of bilateral posterior fracture-dislocation of the shoulder secondary to a first epileptic seizure episode treated by humeral head replacement with stem less implants on both shoulders, with satisfactory radiographic and clinical outcome.

Arthroscopic latissimus dorsi transfer.

The patient is placed in lateral decubitus. A 6-cm incision made in the axilla allows access to the latissimus dorsi tendon and its neurovascular pedicle. Holding the arm in internal rotation, the surgeon detaches sharply the tendon off the humeral shaft and then reinforces it with wrapping sutures. Pulling the free limbs of the sutures exposes the under surface of the muscle and helps to identify the neurovascular pedicle. Special lighting retractors suited for a large diameter scope are helpful. Mobilization is completed when 2 cm of the tendon crosses the posterior edge of the acromion. The standard lateral portal is used for visualization. A silicon drain tube stiffened by a Wissinger rod is advanced from the posterior portal under direct visualization in the space between teres minor and deltoid, exiting in the auxiliary incision. A suture loop passed down the tube retrieves the tendon sutures out the posterior portal. These are then moved out the anterior portal, thus pulling the tendon over the tuberosity. The first anchor is inserted at the anterior aspect of the greater tuberosity, close to the articular cartilage and long head of the biceps tendon. Two to 3 anchors are inserted fixing the tendon to the tuberosity until it is stable.