Complications in Elbow Arthroscopy: Management and Prevention.

With advances in the understanding of elbow anatomy, pathologies of the elbow, arthroscopic instrumentation, and surgical techniques over recent decades, elbow arthroscopy has become a valuable treatment modality for a variety of conditions. Elbow arthroscopy has gained utility for treating problems such as septic arthritis, osteoarthritis, synovitis, osteophyte and loose body excision, contracture release, osteochondral defects, select fractures, instability, and lateral epicondylitis. Accordingly, precise knowledge of the neurovascular anatomy, safe arthroscopic portal placement, indications, and potential complications are required to maximize patient outcomes and assist in educating patients. This comprehensive review provides the reader an understanding of the potential complications associated with arthroscopic procedures of the elbow and to describe strategies for prevention and management.

Editorial Commentary: Silly Biceps, Tenodesis Is for Kids!

There is now a strong consensus that the best surgical treatment of a SLAP lesion is often something different from a primary direct repair, especially in older patients in whom postoperative stiffness and persistent pain have led most of us to perform a biceps tenodesis instead. However, treatment of younger patients and especially the overhead athlete group is more problematic and thus controversial. This study demonstrates that biceps tenodesis in these patients can be more successful and have a higher return to sport than SLAP repair alone. There may also be a role for biceps tenodesis AND a SLAP repair but the numbers presented in this paper preclude an analysis of exactly who that group is. When it comes to the treatment of patients with SLAP lesions for whom a very well executed rehabilitation program has failed, understanding the symptoms and demographics of your patients is critical to surgical decision making. The pendulum may swing toward tenodesis, but beware: The correct answer is usually near the center of the arc!

Editorial Commentary: Put Down Your Saw and Pick Up Your Scope! Or, Why Burn Down the Bridge When the Road Ahead Is Full of Potholes? Reverse Total Shoulder Replacement Versus Arthroscopic Rotator Cuff Repair.

Are we doing too many reverse total shoulder replacements and not fixing enough repairable rotator cuff tears? A convincing argument can be made for attempting to repair most, not all, very large rotator cuff tears in patients who do not have a significant arthritic change in the shoulder. My experience over more than 25 years of arthroscopic rotator cuff repair (ARCR) is that the only good way to know if it is repairable is to try. But some patients really do not pass my "eyeball test" as to whether they can rehabilitate and heal enough to make an ARCR reasonable. Magnetic resonance imaging scans are useful, mostly to help me with tear pattern recognition, how much time and skill I might need for the repair, and to help me council my patients as to their ultimate functional recovery. I have had surprises both ways: some ARCRs that I thought would be easy turned out to be very challenging and others that I thought would be "mission impossible" turned out to be "mission accomplished"! The rationale for jumping ahead primarily to reverse total shoulder replacements reminds me of certain tax cut plans I have heard talk of lately. Sounds great now (well, maybe the complication rate is a little high) but there might be a price to pay down the road.

Subpectoral Biceps Tenodesis Using an Expanding PEEK Device.

In this Technical Note, we describe a method of mini-open long head biceps subpectoral tenodesis. The implant used is a threadless expanding PEEK (polyether ether ketone) interference device that fixes the biceps tendon in a drill hole in the humerus under the inferior border of the pectoralis major tendon. The diameter of the drill hole varies between 6 and 8 mm depending on the width of the tendon. The procedure can be performed through a 3-cm incision centered on the inferior border of the pectoralis tendon. Based on our experience, it is a quick, safe, and reliable tenodesis procedure.

Shoulder stiffness.

Shoulder stiffness is commonly encountered in clinical practice but varies greatly in severity and etiology. Loss of shoulder range of motion can be a patient's primary complaint or may be a secondary finding. Possible causes of stiffness include guarding due to pain or secondary gain issues (nonanatomic), true mechanical blockage due to acute or chronic trauma, adhesive capsulitis, rotator cuff disease, or surgery on or near the shoulder. This review includes a more detailed discussion of these causes as well as the appropriate history and physical and diagnostic testing recommended for each. Finally, treatment strategies for each group of patients will be presented.

Stiffness and rotator cuff tears: incidence, arthroscopic findings, and treatment results.

PURPOSE: Although stiffness of the shoulder has been evaluated after rotator cuff repair, it has not been studied in patients with cuff tears that occurred before repair. The primary purpose of this study was to determine whether preoperative stiffness persists after cuff repair. We also evaluated the incidence and possible causes of stiffness in patients who underwent arthroscopic rotator cuff repair. METHODS: This was a retrospective evaluation of 72 arthroscopic patients who underwent rotator cuff repair. Preoperative range-of-motion (ROM) deficits in abduction, forward flexion, external rotation, and internal rotation were recorded and were added together to determine the total ROM deficit (TROMD). Patients were then divided into 3 groups on the basis of TROMD. Group 1 comprised 42 patients with 0 degrees to 20 degrees TROMD. Group 2 consisted of 24 patients with 25 degrees to 70 degrees TROMD, and group 3 included 6 patients with a TROMD greater than 70 degrees. Preoperative medical history, intraoperative condition of the capsule and bursa, and cuff tear size were recorded. RESULTS: Capsular and bursal abnormalities were more common in stiffer patients, but arthroscopic evidence of adhesive capsulitis was found only in group 3 (3 of 6 patients). Postoperatively, average TROMD deficit decreased from 10 degrees to 4 degrees in group 1, from 36 degrees to 12 degrees in group 2, and from 89 degrees to 31 degrees in group 3. No reoperations or postoperative manipulations were reported in group 1 or 2. In group 3, 3 patients (the only 3 with adhesive capsulitis) showed no or minimal improvement in postoperative ROM. These 3 patients required a secondary arthroscopic capsular release. After all 3 repairs had completely healed, the TROMD averaged 35 degrees in this subgroup. CONCLUSIONS: Preoperative stiffness is common in patients who undergo rotator cuff repair. Mild and moderate stiffness generally resolve after surgery followed by routine therapy. Patients with a TROMD of 70 degrees or more may have adhesive capsulitis as well as a cuff tear and may not do well with cuff repair alone. LEVEL OF EVIDENCE: Level IV, case series.

Arthroscopic biceps tenodesis.

Arthroscopic biceps tenodesis is indicated for the treatment of severe biceps tendonopathy, partial- or full-thickness tendon tears, or biceps instability typically associated with rotator cuff tear, although there has been considerable debate on tenotomy versus tenodesis. We advocate tenodesis, for the following reasons: to re-establish the resting muscle length so as to avoid scaring and spasm, to allow biceps use for complex elbow motion, and to avoid cosmetic defects in cases in which deformity can sometimes equal disability. This technical note provides illustrations and detailed descriptions of our arthroscopic tenodesis technique using a Arthrex (Naples, FL) biotenodesis system.

Arthroscopic repair of large rotator cuff tears using the interval slide technique.

PURPOSE: In some cases of larger and chronic rotator cuff tears, the supraspinatus tendon may be held in a retracted position by the contracted tissue of the rotator interval and the attached coracohumeral ligament. This study was performed to evaluate the utility and clinical effectiveness of an arthroscopic release of the rotator interval from the supraspinatus tendon combined with repair of the rotator cuff. TYPE OF STUDY: Prospective clinical follow-up study. METHODS: Forty-three arthroscopic rotator cuff repairs were performed and followed up for an average of 32 months. All of these patients had large, contracted tears that could not be adequately mobilized without a rotator interval release. In each case, an arthroscopic rotator interval release and superior capsular release were performed to improve cuff mobility. End-to-bone and side-to-side repair was performed depending on the configuration of the tear. Postoperatively, the patients were evaluated using a modified University of California Los Angeles (UCLA) rating system. RESULTS: Forty-two repairs were available for at least 2-year follow-up. No cases of deltoid morbidity or progressive superior migration of the humeral head were seen. The average overall preoperative score was 17.4 (range, 9-26). The average postoperative score was 36.4 (range, 20-45). We saw 21 excellent, 6 good, 11 fair, and 4 poor results based on prior criteria established for smaller tears. All of the average postoperative scoring categories were improved from preoperative scores. Only 3 patients were not satisfied with their results. CONCLUSIONS: The use of the interval slide technique greatly improves supraspinatus mobility in the case of large retracted tears. Although average improvements were less than in our previous study of smaller tears, complete or partial repair of these tears yields good results and high patient satisfaction.