Arthroscopic lasso-loop technique for subscapularis repair with anterolateral viewing portal yields better clinical outcomes for Lafosse grade 3 and 4 tears: a prospective study with minimum 2 years of follow-up.

Background: Contracted subscapularis tears, especially Lafosse grade 3 and 4, pose a significant challenge in surgical repair due to the need for extensive release of retracted tendon and the risk of cut-through due to poor tissue quality. The posterior viewing portal may hinder adequate visualization and extensive release of retracted tendons, particularly in addressing the bursal surface of the tears. Tension-free robust repair is critical to prevent retears and for achieving successful outcomes for these massive and complex retracted tears. This study investigates the clinical outcomes of the Lasso-Loop technique with an anterolateral viewing portal, aiming to enhance tendon release, improve footprint fixation, and optimize tissue grip, particularly in cases of chronic retracted Lafosse 3 and 4 tears. This innovation also eliminates the need for arthroscope switching and serves as a crucial measure for averting axillary nerve injuries during the procedure. Methods: The study included 40 patients with isolated subscapularis or combined anterosuperior rotator cuff tears (Lafosse grade 3 and 4) that underwent arthroscopic subscapularis repair using a Lasso-Loop technique through an anterolateral viewing portal. Evaluations were conducted both preoperatively and at predefined postoperative intervals: 6 weeks, 3 months, 6 months, 1 year, and 2 years. The evaluations in this study encompassed a comprehensive range of clinical assessments, which included a complete range of movements, specialized tests for subscapularis muscle functionality (specifically the lift-off test and belly press test), the utilization of the University of California at Los Angeles and Oxford shoulder scoring systems, and a postoperative ultrasonography conducted at the 6-month mark to assess the presence of any retear. Clinical outcomes were compared with that of the opposite normal shoulder. Results: There was considerable improvement in the active painless range of motion postoperatively. During the 2-year follow-up, the positive belly press test decreased from 50% (n = 20) to 2.5% (n = 1), while the positive lift-off test decreased from 100% (n = 40) to 5% (n = 2). The modified University of California at Los Angeles score increased significantly from 10.15 preoperatively to 30.17 at 2 years postoperatively (P value = .001). Oxford's Shoulder Score increased significantly from 15.6 preoperatively to 40.64 at 2 years postoperatively (P value = .001). Conclusion: This technique has produced positive functional outcomes, in cases categorized as massive subscapularis tears and chronic tears indicating the superiority over other conventional techniques of subscapularis repair described in the literature.

Challenges and Solutions: Total Knee Replacement in Patients with Chronic Lymphatic Filariasis: A Case Report.

CASE: A 59-year-old woman with a history of left knee pain exacerbated by lymphatic filariasis underwent successful total knee replacement (TKR) for advanced osteoarthritis. Postoperatively, diligent adherence to compression bandaging, physiotherapy, and lymphatic flow promotion resulted in no lymphedema progression. During the 5-year follow-up, the patient showed improved Knee injury and Osteoarthritis Outcome Score and stable implant. CONCLUSIONS: Currently, there are no established protocols or formulated guidelines for TKR in patients with chronic filariasis. The preoperative lymphedema prevention must be tailor-made for each patient in the context of advanced osteoarthritis based on the functional lymphatic vessel status.

Arthroscopic Double-Row Rotator Cuff Repair With Biceps Augmentation.

Arthroscopic repair of chronic retracted rotator cuff tears remains challenging to shoulder arthroscopy surgeons. With the recent technical advances, most of the massive rotator cuff tears are managed successfully. The biceps tendon is highly vascular and a rich source of tenocytes and fibroblasts, which can promote biological healing. In massive degenerate rotator cuff tears in which the rotator cuff tissue can be released and fixed onto the footprint without much tissue tension, long head of the biceps tendon can act as an augment providing structural support to the poor-quality rotator cuff tissue and also enhancing the healing process. In this Technical Note, we describe arthroscopic rotator cuff repair using biceps augmentation for a massive degenerate rotator cuff tear with the excursion of the cuff onto the footprint with minimal tissue tension.

All-arthroscopic versus mini-open double row rotator cuff repair - A prospective randomised control study based on functional and radiological outcomes.

Purpose: In an era where arthroscopic rotator cuff repair is dominant in the United States (77.9 % preference) compared to open surgery (53.33 %), a shift towards minimally invasive All-Arthroscopic (AA) techniques over classical Mini-Open (MO) repair is emerging. This study explores current trends in shoulder procedures in India and compares functional outcomes and radiological repair integrity between AA and MO techniques, which are understudied in the Indian context. Methodology: In this prospective study, 60 patients (30 in the AA group and 30 in the MO group) with rotator cuff tears underwent assessment. Pre/post-operative clinical evaluations and 12-month follow-ups using UCLA and Oxford Shoulder Score, along with preoperative MRI and postoperative USG, were conducted. Results: At one-year follow-up, the AA group showed better functional outcomes (53.3 % excellent/good vs. 30.0 % in MO). No significant radiological differences (Sugaya grading) were found. Tear size was comparable with no association with functional/radiological outcomes. Conclusion: The AA group demonstrated favourable functional outcomes, matched to MO group findings, which is in accordance with global studies. Despite higher costs, the increasing popularity of AA in India is justified by enhanced results and reduced postoperative discomfort.

Arthroscopic Bankart repair with inferior glenohumeral ligament tightening using the antegrade suture passer.

Arthroscopic repair is the gold standard for treating Bankart lesions, with commonly used portals including the posterior, anterosuperior, and anteroinferior portals. The two anterior portals are established through a safe triangle created by the superior margin of the subscapularis, the inferior margin of the biceps tendon, and the anterior superior edge of the glenoid cavity. However, the disadvantage of this conventional method is that it can lead to crowding of the instruments at the rotator interval, making it difficult to handle. The inferior glenohumeral ligament (IGHL) and its bands play a major role in the pathophysiology of glenohumeral instability. Restoration of the capsular tension by tightening the anterior band of the IGHL is an integral part of a successful Bankart repair, achieved by suturing the labrum at the 6 o'clock position to an anchor placed at the 5 o'clock position of the glenoid, creating a south-to-north capsulolabral shift. Traditionally, this is done using a curved suture passer (Lasso). However, taking a bite using the Lasso through the anteroinferior portal is difficult.

Arthroscopic Subscapularis Tendon Repair Using the Lasso-Loop Technique Through Anterolateral Viewing Portal.

The subscapularis is the strongest muscle among the rotator cuff muscles, and it provides a coupled balanced force across the glenohumeral joint by resisting the infraspinatus in axial plane and the shearing force of deltoid in the coronal plane. It is important to repair subscapularis tears to maintain the coupled balanced force. Subscapularis tendon tears are difficult to diagnose and treat. Only a small portion of the subscapularis tendon is visualized during routine arthroscopy, as it is largely covered by the middle and inferior glenohumeral ligaments. Various repair techniques have been described in the literature. Here, we describe the anterolateral viewing portal for better visualization of subscapularis and our preferred technique, the lasso-loop technique, which provides better tissue grip and improved functional outcome.