Arthroscopic debridement and biological resurfacing of the glenoid in glenohumeral arthritis.

The purpose of this study was to analyse the intermediate-term results of an arthroscopic procedure to debride and resurface the arthritic glenoid, in a middle-aged population, using an acellular human dermal scaffold. Between 2003 and 2005, thirty-two consecutive patients underwent an arthroscopic debridement and biological glenoid resurfacing for glenohumeral arthritis. The diagnoses included primary osteoarthrosis (28 patients), arthritis after arthroscopic reconstruction for anterior instability (1 patient) and inflammatory arthritis (3 patients). All shoulders were assessed clinically using the Constant and Murley score, and results graded according to Neer's criteria. Statistical analysis was performed to determine significant parameters and associations. A significant improvement (P < 0.0001) in each parameter of the subjective evaluation component (severity of pain, limitation in daily living and recreational activities) of the Constant score was observed. The Constant and Murley score increased significantly (P < 0.0001) from a median of 40 points (range 26-63) pre-operatively to 64.5 (range 19-84) at the final assessment. Overall, the procedure was considered as "successful outcome" in 23 patients (72%) and as a "failure" in 9 patients (28%). According to Neer's criteria, the result was categorized as excellent in 9 (28%), satisfactory in 14 (44%) and unsatisfactory in 9 (28%). Within the unsatisfactory group, there were five conversions to prosthetic arthroplasty. A standard magnetic resonance imaging was performed on 22 patients in the successful outcome group; glenoid cartilage was identified in 12 (thick in 5, intermediate in 1, thin in 6) and could not be identified in 10 patients (complete/incomplete loss in 5, technical difficulties in 5). Overall, five complications included transient axillary nerve paresis, foreign-body reaction to biological material, inter-layer dissociation, mild chronic non-specific synovitis and post-traumatic contusion. Dominance of affected extremity and generalized disease (diabetes, rheumatoid arthritis, generalized osteoarthritis) was associated with an unsatisfactory outcome (P < 0.05). Arthroscopic debridement and biological resurfacing of the glenoid is a minimally invasive therapeutic option for pain relief, functional improvement and patient satisfaction, in glenohumeral osteoarthritis, in the intermediate-term.

The "subscapularis-sparing" approach: a new mini-open technique to repair a humeral avulsion of the glenohumeral ligament lesion.

Anterior approaches to the shoulder involve partial or complete detachment of the subscapularis muscle. We have developed a new technique that permits adequate access to the humeral attachment of the inferior glenohumeral ligament (IGHL) without any detachment of the subscapularis, and have used this to successfully repair humeral avulsions of glenohumeral ligament lesions. Preliminary diagnostic arthroscopy using air insufflation of the glenohumeral joint is used to identify and grade the lesion. A 1-inch axillary incision is used to access the subscapularis tendon through the deltopectoral approach. Thereafter, anatomic landmarks are identified to expose the lateral aspect of the inferior border of the subscapularis muscle. Blunt dissection is used to separate the musculocapsular plane, and the subscapularis is retracted in an anterosuperior direction. Adequate exposure for visualization and repair of the avulsed IGHL is possible in a majority of cases where this approach is attempted. The use of arthroscopic instruments and suture anchors facilitates suture passage through the mid and posterior regions of the IGHL. If exposure is inadequate, the approach can be easily converted to a conventional L-shaped tenotomy approach through the lower or upper region of the subscapularis.

Direct arthroscopy of the bicipital groove: a new approach to evaluation and treatment of bicipital groove and biceps tendon pathology.

Assessment of the intra-articular and intertubercular regions of the long tendon of the biceps forms an important aspect of routine glenohumeral arthroscopic examination. We describe a new technique of direct visualization of the bicipital groove and tendon by positioning the arthroscope in linear alignment with the bicipital groove. A 4.5-mm cannula is introduced through a superior-medial (Neviaser) portal, into the glenohumeral joint, parallel and adjacent to the superior aspect of the biceps tendon, and is used as a viewing portal. The arm is then positioned in abduction, external rotation, and forward flexion, to align the groove with the arthroscope, thereby attempting to "look down the groove." The biceps tendon, as well as the structures forming its medial and lateral pulleys, can be evaluated from the glenohumeral and intertubercular aspects. A greater length of the medial and lateral lips and the floor and roof of the bicipital groove can be visualized by advancing the arthroscope deeper within the groove. A fat pad along the lateral wall of the groove serves as an anatomic landmark to limit dissection in this region, thereby preventing damage to the anterolateral ascending branch of the anterior circumflex artery. An extension of this technique, to facilitate instrumentation for arthroscopic biceps tenodesis, is described.

The bony partial articular surface tendon avulsion lesion: an arthroscopic technique for fixation of the partially avulsed greater tuberosity fracture.

The partial articular surface tendon avulsion (PASTA) is a common lesion that involves the supraspinatus tendon in most cases. We present an arthroscopic fixation technique for a previously undescribed lesion that may be considered a variant of the PASTA. The lesion involves a partial avulsion of the greater tuberosity with an intact deep insertion of the supraspinatus tendon into the fractured bone fragment and an intact superficial insertion of the supraspinatus into the unavulsed lateral aspect of the greater tuberosity: a "bony PASTA" lesion. The surgical technique involves the use of a 70 degree arthroscope to provide an "end-on" view of the pathology. A superior-medial transmuscular portal is used for anchor insertion and suture management; the portal avoids damage to the intact tendinous insertion of the supraspinatus, which can occur during transtendon anchor/screw insertion. Abduction of the arm to 50 degrees, after creation of the portal and passage of the cannula, permits an optimal "deadman" angle of anchor placement. An angled suture grasper is used to retrieve the 4 suture strands from the double-loaded suture anchor through the intact superficial and deep supraspinatus tendon fibers along the length of the fracture; these are tied as 2 mattress sutures over the tendon fibers in the subacromial space by use of sliding-locking knots. Adequacy of reduction is confirmed by intra-articular arthroscopic observation during movement of the extremity through its complete range of motion.

Arthroscopic rotator cuff repair with double-row fixation.

BACKGROUND: The treatment of rotator cuff tears has evolved from open surgical repairs to complete arthroscopic repairs over the past two decades. In this study, we reviewed the results of arthroscopic rotator cuff repairs with the so-called double-row, or footprint, reconstruction technique. METHODS: Between 1998 and 2002, 264 patients underwent an arthroscopic rotator cuff repair with double-row fixation. The average age at the time of the operation was fifty-nine years. Two hundred and thirty-eight patients (242 shoulders) were available for follow-up; 210 were evaluated with a full clinical examination and thirty-two, with a questionnaire only. Preoperative and postoperative examinations consisted of determination of a Constant score and a visual analogue score for pain as well as a full physical examination of the shoulder. Ultrasonography was done at a minimum of twelve months postoperatively to assess the integrity of the cuff. RESULTS: The average score for pain improved from 7.4 points (range, 3 to 10 points) preoperatively to 0.7 point (range, 0 to 3 points) postoperatively. The subjective outcome was excellent or good in 220 (90.9%) of the 242 shoulders. The average increase in the Constant score after the operation was 25.4 points (range, 0 to 57 points). Ultrasonography demonstrated an intact rotator cuff in 83% (174) of the shoulders overall, 47% (fifteen) of the thirty-two with a repair of a massive tear, 78% (thirty-two) of the forty-one with a repair of a large tear, 93% (113) of the 121 with a repair of a medium tear, and 88% (fourteen) of the sixteen with a repair of a small tear. Strength and active elevation increased significantly more in the group with an intact repair at the time of follow-up than in the group with a failed repair; however, there was no difference in the pain scores. CONCLUSIONS: Arthroscopic rotator cuff repair with double-row fixation can achieve a high percentage of excellent subjective and objective results. Integrity of the repair can be expected in the majority of shoulders treated for a large, medium, or small tear, and the strength and range of motion provided by an intact repair are significantly better than those following a failed repair. LEVEL OF EVIDENCE: Therapeutic Level IV.

The "paraglider-wing" sign: an arthroscopic indicator of partial-thickness bursal-surface tears of the supraspinatus tendon.

Partial-thickness bursal-surface tears of supraspinatus tendon may be missed on preoperative investigations and can be overlooked at surgery if not specifically sought. The authors describe an arthroscopic sign to detect these tears, when they involve more than half the tendon fibres, from the articular-side of the joint. The "paraglider-wing" sign, visualized during diagnostic glenohumeral arthroscopy, is demonstrated as an upward bulge of the capsulo-tendinous layer through the bursal-surface tear, under pressure of the inflow fluid. A positive sign indicates (1) presence of a partial-thickness bursal-side tear of the supraspinatus tendon, (2) significant depth (stage II or III) of the tear, and (3) the medial extent of the tear along the length of the tendon. A meticulous subacromial bursoscopy and excision of the bursa is then performed to visualize the tear from the subacromial space. Repair of the tear is performed with a double-row suture anchor fixation technique; the medial row of sutures is passed through the intact region of the tendon using the "paraglider-wing" sign as a guide.

The "bench-presser's shoulder": an overuse insertional tendinopathy of the pectoralis minor muscle.

BACKGROUND: Tendinopathies of the rotator cuff muscles, biceps tendon and pectoralis major muscle are common causes of shoulder pain in athletes. Overuse insertional tendinopathy of pectoralis minor is a previously undescribed cause of shoulder pain in weightlifters/sportsmen. OBJECTIVES: To describe the clinical features, diagnostic tests and results of an overuse insertional tendinopathy of the pectoralis minor muscle. To also present a new technique of ultrasonographic evaluation and injection of the pectoralis minor muscle/tendon based on use of standard anatomical landmarks (subscapularis, coracoid process and axillary artery) as stepwise reference points for ultrasonographic orientation. METHODS: Between 2005 and 2006, seven sportsmen presenting with this condition were diagnosed and treated at the Cape Shoulder Institute, Cape Town, South Africa. RESULTS: In five patients, the initiating and aggravating factor was performance of the bench-press exercise (hence the term "bench-presser's shoulder"). Medial juxta-coracoid tenderness, a painful active-contraction test and bench-press manoeuvre, and decrease in pain after ultrasound-guided injection of a local anaesthetic agent into the enthesis, in the absence of any other clinically/radiologically apparent pathology, were diagnostic of pectoralis minor insertional tendinopathy. All seven patients were successfully treated with a single ultrasound-guided injection of a corticosteroid into the enthesis of pectoralis minor followed by a period of rest and stretching exercises. CONCLUSIONS: This study describes the clinical features and management of pectoralis minor insertional tendinopathy, secondary to the bench-press type of weightlifting. A new pain site-based classification of shoulder pathology in weightlifters is suggested.

Arthroscopic suprascapular nerve decompression at the suprascapular notch.

The suprascapular notch is a common location for entrapment of the suprascapular nerve. Open surgical procedures for excision of the transverse scapular ligament are associated with pain relief and functional improvement. Arthroscopic procedures have been described for decompressing ganglion cysts, which compress the nerve at the spinoglenoid notch. However, there is no description of an arthroscopic procedure for decompression of the nerve at the suprascapular notch, and this is probably related to unfamiliarity with the complex anatomy of the region. The technique described herein is based on standard anatomic landmarks and utilization of these as reference points for arthroscopic orientation and reproducibility. The acromioclavicular joint, conoid ligament, and coracoid process are stepwise reference landmarks leading to the suprascapular notch. Arthroscopic identification of structures around the notch is necessary before ligament resection. A new suprascapular portal, in combination with an accessory portal, is described for retraction, blunt dissection, nerve stimulation, and ligament resection. Key instruments include a 4-mm arthroscope of standard length (160 mm), with a 70 degree angled lens for adequate visualization and a calibrated probe to guide and limit dissection.

Surgical treatment of comminuted, displaced fractures of the greater tuberosity of the proximal humerus: a new technique of double-row suture-anchor fixation and long-term results.

Conventional techniques of internal fixation of displaced fractures of the greater tuberosity may be insufficient in presence of comminution. A new surgical technique of internal fixation using a double-row of suture-anchors is described. Long-term results of this technique are evaluated in 21 patients with an isolated, displaced and comminuted greater tuberosity fracture at an average of 3.5 years (range 1-5 years) after surgery. The average age of the patients in the study was 51 years (range 17-93 years). Twenty fractures healed without post-operative displacement. The result was rated as excellent in 8, good in 10, satisfactory in 2 and unsatisfactory in 1 patient. Post-operative bicipital impingement in two patients and reaction to fixation material in one patient resulted in persistent, severe pain in the rehabilitation period, necessitating additional surgery.

Arthroscopic technique of interposition arthroplasty of the glenohumeral joint.

Arthroscopic glenohumeral interposition arthroplasty is performed with the patient placed in the lateral decubitus position. Standard posterior, anterior, and anterosuperior portals are created, a routine diagnostic arthroscopy is performed, and the joint is débrided with the use of an arthroscopic shaver. An arthroscopic burr is used to resect prominent osteophytes, to alter the version of the glenoid if necessary, and to create microfractures on the glenoid surface. Next, 3 absorbable sutures are passed percutaneously with a 30 degrees angled suture grasper from 3 different sites posteriorly through the posterior capsular-labral tissue and into the anterior portal cannula, where they are isolated by means of the suture saver kit. The prepared interposition membrane/tissue (GRAFTJACKET Regenerative Tissue Matrix, Wright Medical Technology, Inc., Arlington, TN) is tagged with the 3 sutures in the anterior cannula before it is introduced into the joint. Three additional sutures are attached to the membrane anteriorly at 1, 3, and 5 o'clock positions and are isolated with suture savers. The membrane is next introduced into the joint through the anterior cannula and is aligned with the glenoid rim. The anterior sutures are rerouted through the anterior capsular-labral tissue with a 70 degrees angled suture grasper, and they are retrieved through the anterior cannula. Intra-articular nonsliding knots are used anteriorly to anchor the interposition tissue to the anterior glenoid labrum and capsule. The posterior sutures are knotted intra-articularly, or they may be tied extra-articularly; the proximal and distal posterior sutures are retrieved subcutaneously out through the skin tract of the posterior portal and are knotted with the suture present in this portal, with the use of nonsliding knots. Stability of the interposition tissue is assessed by movement of the glenohumeral joint through its entire range of motion. The postoperative protocol consists of early passive exercises, active exercises after 3 weeks, and muscle-strengthening exercises after 6 weeks.