Kim's lesion: an incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder.

PURPOSE: The purpose of this article is to report a new clinical entity of posterior instability of the shoulder and the results of its treatment. TYPE OF STUDY: Case series. METHODS: The Kim's lesion, which is an incomplete and concealed avulsion of the posteroinferior labrum, was arthroscopically identified in 15 patients who presented with posterior or multidirectional posteroinferior instability. Patients were treated by arthroscopic labroplasty and capsular shift. At a minimum follow-up of 2 years, the outcome was evaluated using subjective (pain and function visual analogue scale) and objective (UCLA, ASES, and Rowe scores) measurements. RESULTS: When visualized under an arthroscope, Kim's lesion apparently had an intact labral attachment and appeared to have a superficial crack at the junction between the articular cartilage of the glenoid and the posteroinferior labrum. However, probing of the lesion revealed detachment of the deep portion of the posteroinferior labrum. The posteroinferior labrum was flat with loss of normal height, which resulted in the retroversion of the chondrolabral glenoid. Incision of the superficial portion of the lesion exposed a loose deep portion of the labrum. Labroplasty was performed to restore the labral height, as well as capsular shift with or without rotator interval closure. The surgical outcome was satisfactory in 14 patients and unsatisfactory in 1 patient. Shoulders were stable in all patients with unidirectional posterior instability. There was 1 recurrence of multidirectional posteroinferior instability. CONCLUSIONS: Kim's lesion is an incomplete avulsion of the posteroinferior labrum, which is concealed by apparently intact superficial portion. The clinical significance of this lesion is the need for surgeons to convert this concealed incomplete lesion to a complete tear and repair it with the posterior band of the inferior glenohumeral ligament. A failure to address this lesion may result in persistent posterior instability. LEVEL OF EVIDENCE: Level IV, therapeutic, Case Series.

Accelerated rehabilitation after arthroscopic Bankart repair for selected cases: a prospective randomized clinical study.

PURPOSE: Increased stress within a certain limit enhances ligament healing and improves joint function. In this prospective randomized clinical trial, we compared the clinical results of early motion versus conventional immobilization after arthroscopic Bankart repair in a selected patient population. TYPE OF STUDY: Prospective randomized clinical trial. METHODS: We performed an arthroscopic Bankart repair using suture anchors in 62 patients with traumatic recurrent anterior instability of the shoulder. Patients were randomized into 2 groups; group 1 (28 patients; mean age, 28 years) was managed with 3 weeks of immobilization using an abduction sling and conventional rehabilitation program, and group 2 (34 patients; mean age, 29 years) was managed with an accelerated rehabilitation program that consisted of staged range of motion and strengthening exercises from the immediate postoperative day. Selection criteria were nonathletes with recurrent anterior shoulder dislocation and a classic Bankart lesion with a robust labrum limited to 1 cm from the midglenoid notch. The patients were followed up for a mean of 31 months (range, 27 to 45 months; standard deviation, 9 months). Analysis of outcome included pain scores at 6 weeks and at final follow-up evaluation, range of motion, return to activity, recurrence rate, patient satisfaction with each rehabilitation program, and shoulder scores assessed by the American Shoulder and Elbow Surgeons Shoulder Index, the rating system of the University of California at Los Angeles, and another scoring system. RESULTS: The recurrence rate was not different between the 2 groups (P =.842). None of the groups developed recurrent dislocation. Two patients from each group were positive for anterior apprehension signs. Patients who underwent accelerated rehabilitation resumed functional range of motion faster (P <.001) and returned earlier to the functional level of activity (P <.001). Accelerated rehabilitation decreased postoperative pain (P =.013), and more patients were satisfied with this program (P <.001). Shoulder scores, return to activity, pain score, and range of motion were not different between the 2 groups at the final follow-up evaluation (P >.05). CONCLUSIONS: Early mobilization of the operated shoulder after arthroscopic Bankart repair does not increase the recurrence rate in a selected group of patients. Although the final outcomes are approximately the same for both groups, the accelerated rehabilitation program promotes functional recovery and reduces postoperative pain, which allows patients an early return to desired activities.

Arthroscopic versus mini-open salvage repair of the rotator cuff tear: outcome analysis at 2 to 6 years' follow-up.

PURPOSE: The purpose of this study was to compare the outcomes of arthroscopic repair of medium and large rotator cuff tears with the outcomes for mini-open repair of similar tears in which arthroscopic repair was technically unsuccessful. TYPE OF STUDY: Retrospective case series. METHODS: We evaluated 76 patients who were treated for full-thickness rotator cuff tears either by all-arthroscopic (42 patients) or mini-open salvage of technically unsuccessful arthroscopic repair (34 patients). Patients who had acromioclavicular arthritis, subscapularis tear, or instability were excluded. There were 39 men and 37 women, with a mean age of 56 years (range, 42 to 75 years). At a mean follow-up of 39 months (range, 24 to 64 months), the results of both groups were compared using the University of California Los Angeles and American Shoulder and Elbow Surgeons shoulder rating scales. RESULTS: Shoulder scores improved in all ratings in both groups (P <.05). Overall, 66 patients showed excellent or good and 10 patients showed fair or poor scores by the University of California Los Angeles scale. Seventy-two patients satisfactorily returned to previous activity, and 4 showed unsatisfactory returns. The range of motion, strength, and patient satisfaction were improved postoperatively. No differences were seen in shoulder scores, pain, and activity return between the arthroscopic and mini-open salvage groups (P >.05). However, patients with larger tears showed lower shoulder scores and less predictable recovery of strength and function (P <.05). Postoperative pain was not different with respect to the size of the tear (P =.251). CONCLUSIONS: Arthroscopic repair of medium and large full-thickness rotator cuff tears had an equal outcome to technically unsuccessful arthroscopic repairs, which were salvaged by conversion to a mini-open repair technique. Surgical outcome depended on the size of the tear, rather than the method of repair.

Arthroscopic posterior labral repair and capsular shift for traumatic unidirectional recurrent posterior subluxation of the shoulder.

BACKGROUND: The purpose of this study was to evaluate the results of arthroscopic treatment of traumatic unidirectional recurrent posterior subluxation of the shoulder. METHODS: We treated twenty-seven patients who had traumatic unidirectional recurrent posterior subluxation of the shoulder with arthroscopic labral repair and posterior capsular shift, and we evaluated them at a mean of thirty-nine months postoperatively. Patients who had posteroinferior instability, multidirectional instability, or an atraumatic onset or who were undergoing revision were excluded. There were twenty-five male and two female patients with a mean age of twenty-one years (range, fourteen to thirty-three years). All patients were involved in sports activity, and all had had a substantial injury prior to the onset of the instability. Results were assessed on the basis of stability, motion, and UCLA (University of California at Los Angeles), ASES (American Shoulder and Elbow Surgeons), and Rowe scores. Pain and function were also evaluated with visual analog scales. RESULTS: All patients had one or more lesions in the posteroinferior aspect of the labrum and capsule. The most common finding was incomplete stripping of the posteroinferior aspect of the labrum (eighteen patients). At the arthroscopy, the posteroinferior aspect of the capsule appeared to be stretched in twenty-two patients. At the time of follow-up, all patients had improved shoulder function and scores (p < 0.01). All patients also had a stable shoulder according to subjective and objective measurements, except for one patient who had recurrent subluxation. Except for that patient, all patients were able to return to their prior sports activity with little or no limitation. Shoulder function was graded as >90% of the preinjury level in twenty-four patients. There were twenty-one excellent UCLA scores, five good scores, and one fair score. The average pain score improved from 4.5 points preoperatively to 0.2 point at the time of follow-up (p < 0.0001). The mean loss of internal rotation was one vertebral level. There were no operative complications. CONCLUSIONS: Arthroscopic posterior labral repair and capsular shift to treat traumatic unidirectional recurrent posterior subluxation is a reliable procedure with respect to providing stability, pain relief, and functional restoration.

Arthroscopic anterior stabilization of the shoulder: two to six-year follow-up.

BACKGROUND: The purpose of this study was to evaluate prospectively the surgical outcomes of arthroscopic repair of anterior capsulolabral lesions with use of suture anchors in a large series of patients who were followed for two to six years. METHODS: We evaluated the results of arthroscopic Bankart repair with use of suture anchors and nonabsorbable sutures in 167 patients with traumatic recurrent anterior instability of the shoulder. The mean age at the time of the operation was twenty-five years. Preoperatively and at the time of follow-up (at a mean of forty-four months), the patients were assessed with three objective outcome measurement tools (the Rowe score, the University of California at Los Angeles [UCLA] shoulder rating scale, and the American Shoulder and Elbow Surgeons [ASES] score) and two subjective measurement tools (pain and function visual analog scales). The recurrence rate, range of motion, and risk factors for postoperative recurrence were evaluated. RESULTS: All shoulder scores improved after surgery (p < 0.001). According to the Rowe scale, 130 patients (78%) had an excellent score; twenty-nine (17%), a good score; six (4%), a fair score; and two (1%), a poor score. Overall, the rate of postoperative recurrence of instability was 4% (one dislocation, two subluxations, and four positive results on the anterior apprehension test). Postoperative recurrence was related to an osseous defect of >30% of the entire glenoid circumference. In the patients with recurrent postoperative instability, the episodes were less frequent than they had been preoperatively and shoulder function was related to activity level. A revision arthroscopic Bankart repair stabilized three of the four shoulders in which it was performed. One hundred and fifty-two patients (91%) returned to >/=90% of their preinjury activity level. The mean loss of external rotation (and standard deviation) was 2.0 degrees +/- 4.0 degrees. CONCLUSIONS: We found that, in contrast to previous reports on the results of arthroscopic repair, arthroscopic capsulolabral repair with use of suture anchors can provide satisfactory outcomes in terms of recurrence rate, activity, and range of motion.

Differential arthroscopic portal placement for rotator cuff repair.

We report an effective technique of arthroscopic portal placement for rotator cuff repair of the shoulder. The differential portals are placed depending on the location of the tear. After the glenohumeral arthroscopic examination, the subacromial bursoscopy is performed through the same posterior skin portal. With the rotator cuff tear in view, a spinal needle is inserted to the center of the tear, 3 cm from the lateral margin of the acromion (middle working portal). Another spinal needle is then inserted into the posterior lip of the tear, 1 cm from the lateral margin of the acromion (rear viewing portal). The rear viewing portal provides a good downward en-face view of the tear, and the middle working portal allows better access to the anterior and posterior margins of the cuff tear than the usual posterior and lateral portals do. This differential portal placement with respect to the location of the rotator cuff tear ensures superior access for arthroscopic repair of rotator cuff tears.

Bankart repair in traumatic anterior shoulder instability: open versus arthroscopic technique.

PURPOSE: The purpose of this study was to compare the results of open and arthroscopic Bankart repair using suture anchors in traumatic anterior glenohumeral instability. Variables measured were recurrence rate, range of motion, and return to preinjury activity. TYPE OF STUDY: Case control study. METHODS: Eighty-nine shoulders in 88 patients with traumatic unilateral anterior shoulder instability were evaluated using Rowe and University of California Los Angeles scores, recurrence, return to activity, and range of motion by an independent examiner at an average of 39 months after either an arthroscopic or open Bankart repair using suture anchors. The arthroscopic technique included a minimum of 3 anchors in most patients and a routine incorporation of capsular plication and proximal shift. Of the 89 shoulders, 30 shoulders (30 patients) underwent open Bankart repair and 59 shoulders (58 patients) underwent arthroscopic Bankart repair. RESULTS: Twenty-six shoulders (86.6%) in the open repair group showed excellent or good results, and 54 (91.5%) shoulders in the arthroscopic repair group showed excellent or good results. The arthroscopic group revealed slightly higher scores in the Rowe (P =.041) and UCLA scores (P =.026). Two patients (6.7%) in the open repair group and 2 (3.4%) in the arthroscopic repair group had experienced at least 1 episode of redislocation after the surgery. One patient (3.3%) in the open repair group and 4 (6.8%) in the arthroscopic repair group demonstrated mild apprehension. The overall residual instability was 10% in the open repair group and 10.2% in the arthroscopic repair group. There were no significant differences in the loss of external rotation and return to prior activity between the 2 groups (P >.05). Residual instability occurred more frequently in patients with fewer anchors. CONCLUSIONS: Arthroscopic suture anchor capsulorraphy showed similar results to the open Bankart procedure.

Results of arthroscopic treatment of superior labral lesions.

BACKGROUND: The purpose of this study was to evaluate the results of arthroscopic repair of isolated superior labral lesions of the shoulder. METHODS: We evaluated thirty-four patients at a mean of thirty-three months (range, twenty-four to forty-nine months) following arthroscopic repair of an isolated superior labral lesion of the shoulder with suture anchors. The outcome of treatment was evaluated with the University of California at Los Angeles shoulder score and on the basis of the patient's ability to return to prior activities. There were thirty male patients and four female patients with a mean age of twenty-six years (range, sixteen to thirty-five years). Thirty patients were involved in athletic activities, and eighteen of them were engaged in overhead sports. RESULTS: Repair of the superior labral lesion resulted in a satisfactory University of California at Los Angeles shoulder score for thirty-two patients (94%) and an unsatisfactory score for two. Thirty-one patients (91%) regained their preinjury level of shoulder function. The shoulder score and the return to activity were correlated with the type of sports activity (r = 0.291, p < 0.0001 and r = 0.373, p = 0.010, respectively. Patients participating in overhead sports had significantly lower shoulder scores and a lower percentage of return to their preinjury level of shoulder function compared with patients who were not engaged in overhead activity (p = 0.024 and 0.015, respectively). CONCLUSIONS: Arthroscopic repair of an isolated superior labral lesion is successful in a majority of patients. However, the results in patients who participate in overhead sports are not as satisfactory as those in patients who are not involved in overhead sports.

Arthroscopic revision Bankart repair: a prospective outcome study.

PURPOSE: The clinical outcome of the revision surgery for the failed Bankart repair is not well known. The purpose of this study was to prospectively analyze a series of patients with recurrent instability after primary Bankart repair that were revised arthroscopically using a suture-anchor technique. TYPE OF STUDY: Prospective, nonrandomized outcome study. METHODS: Twenty-three patients with failed Bankart repair were treated with arthroscopic surgery and were followed up for a mean of 36 months (range, 24-52 months; SD, 9 months). There were 21 men and 2 women with the mean age of 24 years (range, 17-34 years; SD, 4.4 years). Eight patients had previously received an open Bankart repair (5 transosseous-suture technique, 3 suture-anchor technique), and 15 had received an arthroscopic repair (10 transglenoid multiple-suture technique, 5 suture-anchor technique). The revision surgery included repair of the anterior labrum using suture anchors and nonabsorbable sutures, capsular plication, and proximal shift of the inferior capsule with or without closure of the rotator interval. The characteristics of the patients, possible modes of failure, surgical findings, shoulder scores (University of California at Los Angeles [UCLA] scale, Simple Shoulder Test, and Rowe score), and clinical outcome were evaluated. RESULTS: Recurrent instability developed at a mean of 21 months (range, 11-39 months; SD, 8 months) after the initial stabilization. A possible cause of failure in 5 patients was a nonanatomic repair, with the labral tissue fixed proximal or medial to the glenoid margin. At the follow-up, 15 patients had excellent results, 4 good, 3 fair, and 1 poor, according to the UCLA scale. The mean Rowe score improved from 87.3 (range, 30-100; SD, 12.6) to 91.2 (range, 40-100; SD, 14.2) (P =.023). The Simple Shoulder Test responses improved from 8 yes responses preoperatively to 11 postoperatively. Eighteen patients achieved an activity return of more than 90% of preinjury level. Five patients had recurrence after revision surgery (1 frank dislocation, 2 subluxation, 2 positive anterior apprehension sign). Engagement in contact sports was correlated with the recurrence (r =.683, P =.003). With the number available, no significant difference could be detected in the outcome between the types of the primary surgery. Arthroscopic revision Bankart repair did not result in any additional loss of external rotation compared with the contralateral side (P =.723). The most predictable factor for the functional return was preoperative range of external rotation (r =.793, P =.001). CONCLUSIONS: Arthroscopic revision Bankart surgery using suture anchors can provide a satisfactory outcome, including a low recurrence rate and reliable functional return, in carefully selected patients.

A water-infusion system with two reservoirs at different levels.

To provide a continuous supply of fluid during arthroscopic surgery, we suggest an infusion system with 2 reservoirs placed at different heights. The lower bag serves as a water reservoir, which allows more time for the circulating nurse to complete the task of exchanging the emptied water bag.

A cannula for non-slip knots.

In this article, we introduce a modified cannula that has 1 process and 2 notches. We believe that this will allow a surgeon to complete tying of a non-slip knot without any slippage.