Percutaneous tensioning of the glenohumeral ligaments during arthroscopic bankart repair

Tensioning of the inferior glenohumeral ligament complex (IGLC) before arthroscopoic repair is a critical step in restoring stability. This article describes a simple surgical technique to tension the IGLC percutaneously before arthroscopic fixation. This technique eliminates the need for grasping instruments and a second anterior portal.     

Detection of Cutibacterium acnes in arthroscopic rotator cuff and bankart repair

BackgroundWe evaluated the detection rate for Cutibacterium acnes (C. acnes) in patients who underwent arthroscopic cuff repair and Bankart repair.MethodsArthroscopic cuff repair was performed in 105 patients (R group) and arthroscopic Bankart repair was performed in 29 patients (B group). Skin swabs prior to antisepsis, intraoperative synovial swabs of the glenohumeral joint (immediately after incision and prior to wound closure), suture of suture anchor, and postoperative swabs from the tip of arthroscope were cultured. Evaluation criteria were compared between groups and included the presence or absence of diabetes mellitus, operation time, frequency of preoperative injections, deep infections, and detection rate of C. acnes in multiple regions of the body.ResultsThere were 14 patients (12.2%) in the R group and one patient in the B group (3.6%) with diabetes mellitus, and no significant difference was found between the two groups. The frequency of injections to the shoulder was significantly greater in the R group at 3.6 ± 4.2 times compared to the B group at 1.6 ± 2.0 times. There were no deep infections in either groups. The detection rate for C. acnes was significantly greater in the synovial swabs alone (skin swabs for R and B groups, 42.3% and 47.6%, respectively; synovial swabs, 10.4% and 1.8%; suture, 8.7% and 0%; tip of arthroscope, 4.3% and 0%).ConclusionsA significantly greater number of C. acnes samples were detected from synovial swabs of cuff tears, suggesting that its presence may be due to preoperative injections to the shoulder.     

Return to sports after arthroscopic bankart repair on the dominant shoulder in overhead athletes

BackgroundArthroscopic Bankart repair (ABR) yields good results in young athletes with anterior shoulder instability. However, the treatment for overhead athletes is challenging because recovery of range of motion is necessary for return to play and repeated shoulder motion may lead to recurrent instability. The aim of this study was to investigate the clinical outcomes and return to sports after ABR on the dominant shoulder in overhead athletes.MethodsThis study included 24 competitive level overhead athletes who underwent ABR on their dominant shoulders. The mean age at surgery was 17.6 years, and the mean follow-up was 39.7 months. The range of bilateral shoulder motion, the Rowe score, the Japanese Shoulder Society Shoulder Instability Score (JSS-SIS), and the Japanese Shoulder Society Shoulder Sports Score (JSS-SSS) were evaluated before the surgery and at the final visit. Recurrent instability, the final level of return to sports, and the duration before returning to sports were confirmed, as well as the pre-, intra- and postoperative factors, which prohibited complete return to play.ResultsThere were no cases of recurrent instability. The Rowe score, JSS-SIS, JSS-SSS, and the range of flexion, abduction, internal rotation significantly improved postoperatively. Fifteen athletes (62.5%) returned to the same or superior levels without any complaint in their shoulders. The mean duration needed for a complete return was 13.3 months. The postoperative external rotation deficit in abduction was larger in the athletes who returned incompletely than those who returned completely, 7.8° and 2.3°, respectively.ConclusionsABR is a reliable surgery for preventing recurrent instability in overhead athletes, however the rate of a complete return to preinjury level was low and a long duration was needed for complete return to play. The postoperative external rotation may be necessary for a complete return to overhead sports.Level of evidenceLevel IV: Retrospective Case Series.     

Functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair

AIM To compare the functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair. METHODS Eighty-seven patients with rotator cuff tears following arthroscopic treatment were divided into traumatic and non-traumatic tear groups. Postoperative muscle strength and outcomes using the modified University of California, Los Angeles score were evaluated. Sex, age, affected limb and dominant limb were correlated between groups. Muscle strength of the repaired and unaffected shoulders was compared. Rotator cuff injury size was measured. RESULTS Of the 87 patients who underwent rotator cuff repairs, 35 had traumatic tears and 52 had non-traumatic tears. In patients with non-traumatic tears, the average age was 59 years, 74.5% were female, 96.1% were righthand dominant and 92.3% had their dominant shoulder affected. Patients with traumatic tears were 59.5 yearsold on average, 51.4% were female, 91.4% were righthand dominant and 88.5% had their dominant shoulder affected. No difference existed in the mean modified University of California, Los Angeles score between patients with traumatic tears(33.7) compared with those with non-traumatic tears(32.8). No strength differences were observed between groups: The strength difference between the non-affected and affected sides was 1.21 kg in the non-traumatic group and 1.39 kg in the traumatic group(P = 0.576), while the strength ratio between the non-affected/affected sides was 0.805 in the nontraumatic group and 0.729 in the traumatic group(P = 0.224). CONCLUSION The functional results of traumatic rotator cuff repairs are similar to non-traumatic tears. Both outcomes are satisfactory.     

Normal variations of the glenohumeral ligament complex: an anatomic study for arthroscopic bankart repair

PurposeThe purpose of this study was to evaluate the prevalence and morphologic characteristics of normal variations in the glenohumeral ligament complex (GHLC).Type of studyAnatomic study in cadavers.MethodsWe investigated 84 cadaver shoulders and recorded visualization of the superior glenohumeral ligament (SGHL), middle glenohumeral ligament (MGHL), and anterior band of the inferior glenohumeral ligament (AIGHL). In cases with an AIGHL, we noted the location of its origin with respect to the anterior glenoid in terms of a clock face as in a right shoulder. If an MGHL was present, the site of its glenoid attachment was recorded. The presence of a cord-like MGHL, the Buford complex, and a sublabral foramen was also investigated.ResultsOf these, 79 (94.1%) manifested an SGHL, 53 (63.1%) an MGHL, and 76 (90.5%) an AIGHL. The AIGHL originated in an area located between the 2- and 5-o’clock position; in 11 (14.5%), the origin was at the 2-o’clock position; in 49 (64.5%) at the 3-o’clock position; in 11 (14.5%), the 4-o’clock position; and in 5 (6.5%) at the 5-o’clock position. Two common variations in the attachment of the MGHL were seen; 30 of 53 MGHL (56.6%) originated from the labrum separate from the origin of the SGHL, and 23 (43.4%) from the labrum at the origin of the SGHL. Of the 84 specimens, 15 (17.9%) manifested a cord-like MGHL, and one (1.2%) the Buford complex. None of the specimens had a sublabral foramen, a finding that requires further investigation.ConclusionsOur results suggest that the Buford complex is a rare variant of the GHLC, and the cord-like MGHL appears to be a relatively common normal variant.Clinical relevanceThe present study provides useful information concerning normal variations of the GHLC to arthroscopists considering Bankart repair.     

Bankart repair in patients aged fifty years or greater: results of arthroscopic and open repairs

Currently, there is little information on the results of Bankart repairs in older patients. Therefore, the purpose of this study was to determine the results, complications, and rates of revision among patients aged 50 years or greater undergoing Bankart repairs. Between 1992 and 1999, 12 Bankart repairs were performed on patients aged 50 years or greater (mean, 57 years) at our institution. Eleven patients with complete clinical records, operative reports, and minimum 3-year follow-up (mean, 6.5 years) were included in the study. All patients had shoulder instability as a result of specific trauma. Six patients underwent open repairs, and five underwent arthroscopic repairs. There were no patients with full-thickness rotator cuff tears. At the most recent follow-up, there were no shoulders with recurrent instability. The mean simple shoulder test score was 10.8 in the open group and 9.8 in the arthroscopic group. The mean American Shoulder and Elbow Surgeons score was 98 in the open group versus 87 in the arthroscopic group. At the most recent follow-up, mean elevation in the open group was 178 degrees versus 174 degrees in the arthroscopic group. Mean external rotation was 70 degrees in the open group and 72 degrees in the arthroscopic group. The data from this study suggest that Bankart repair in older patients is associated with a low recurrence rate, and similar results may be obtained with either open or arthroscopic procedures.     

Atrium Proloop~（TM）三维网塞治疗腹股沟疝的围手术期处理探讨

随着无张力疝修补术迅速普及和推广,越来越多的患者能接受该手术方式,但疝修补材料和手术方式层出不穷,究竟选择什么术式或材料,还应针对具体疝类型、个体化与微创相结合,是腹壁疝治疗的最佳模式[1]。     

Functional outcomes after arthroscopic treatment of lateral epicondylitis

Background  The purpose of this study was to evaluate surgical outcomes of arthroscopic débridement for lateral epicondylitis using a validated, patient-assessed scoring system as well as conventional outcome measures. We also wanted to identify potential predictive factors that may be associated with the outcomes. Methods  A total of 20 elbows in 18 patients with chronic lateral epicondylitis who underwent arthroscopic surgery were included. There were nine men and nine women with a mean age of 54 years (range 42–71 years). Operative treatment consisted of débridement of the extensor carpi radialis brevis (ECRB) origin and resection of the radiocapitellar synovial plica interposed in the joint. Outcomes were assessed using a patient rating, visual analogue scale (VAS) pain score, the Japanese Orthopaedic Association (JOA) elbow score, and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. The average length of follow-up was 28 months (range 24–40 months). Results  After surgery, according to the patients’ reports, 14 of 20 elbows were much better, and 6 elbows were better. A mean preoperative VAS pain score at rest of 3.9 points improved to 0.3 points (P < 0.0001), and that during activity improved from 7.8 points to 0.9 points (P < 0.0001). The mean preoperative JOA elbow score of 29 points was improved to 90 points (P < 0.0001). The mean postoperative DASH score was 10.6 (range 0–50). Absent of T2-weighted high signal focus of the ECRB origin on preoperative magnetic resonance imaging (MRI) (P = 0.02) and receiving public assistance (P = 0.01) were significantly associated with worse DASH scores. Conclusions  Arthroscopic release was a satisfactory procedure for chronic lateral epicondylitis. Preoperative MRI of the ECRB origin and socioeconomic factors were significantly associated with postoperative residual symptoms evaluated with the DASH score.     

脱细胞组织基质材料生物补片治疗6至18岁腹股沟疝患者的疗效分析

目的 探讨脱细胞组织基质材料生物补片在6～18岁腹股沟疝患者治疗中应用的价值.方法 选择2009年6月至12月间60例符合人选标准的6～18岁腹股沟疝患者,随机分为试验组和对照组,每组各30例.试验组应用脱细胞组织基质材料生物补片行腹股沟疝Lichtenstein平片无张力修补术,对照组行传统的单纯疝囊高位结扎术治疗.记录两组患者手术前后的临床参数,观察并分析术后并发症发生情况及疝复发情况.结果 试验组手术时间(39±4) min,术后24h目测类比疼痛评分法(VAS)评分为(2.8±0.9)分,术后留院时间(31±8)h;对照组手术时间(36 ±4) min,术后24 h VAS评分(2.6±1.0)分,术后留院时间(34±11)h.试验组手术时间长于对照组(t=3.357,P=0.001),而两组术后24 h VAS评分和术后留院时间无差异(P＞0.05).两组随访观察14～20个月,未出现生物材料过敏病例,未出现伤口感染、慢性疼痛或局部异物感.试验组术后出现阴囊积液3例,无复发;对照组出现阴囊积液2例,复发2例.结论 在6～18岁儿童和青少年腹股沟疝患者的治疗中,应用生物补片行平片无张力疝修补手术效果良好,不增加术后相关并发症.     

老年肩袖撕裂关节镜下修复方式再探讨

目的：探讨关节镜下锚钉改良植入,单排缝合修复老年肩袖撕裂方法及疗效。方法：回顾性分析2016年3月至2020年2月96例符合纳入标准的老年肩袖撕裂患者,其中男29例,女67例,年龄65~85（68.8±3.9）岁。采用关节镜下锚钉改良植入,单排缝合修复撕裂肩袖。手术前后采用美国加州大学洛杉矾分校（University of California Los Angeles,UCLA）评分,美国肩肘外科协会（American Shoulder and Elbow Surgeons,ASES）评分评估肩关节功能,采用视觉模拟评分（visual analogue scale,VAS）评估疼痛情况。其中32例术后1年患肩接受MRI检查。结果：所有病例完成关节镜下手术,随访时间11~42（21.4±7.5）个月,UCLA评分由术前的12.22±3.30提高至末次随访时的31.30±2.49（t=45.21,P<0.01）;ASES评分由术前的8.60±1.88提高至末次随访时的12.60±0.84（t=19.05,P<0.01）;VAS中位数由术前的5.00（2.00~8.00）分改善至末次随访的1.00（0.00~3.00）分（Z=-12.22,P<0.05）。术后1年32例接受MRI检查的患者中,1例显示修复肩袖再撕裂,但不影响正常生活,未再手术。未发现植入锚钉拔出病例。结论：关节镜下锚钉改良植入,单排缝合修复老年肩袖撕裂可取得较满意的疗效,能有效降低锚钉拔出并发症。     

Modes of failure of knotted and knotless suture anchors in an arthroscopic bankart repair model with the capsulolabral tissues intact

The purpose of this study was to assess failure modes of knotless and knotted anchors in a Bankart repair model with the capsulolabral soft tissues intact. Previous reports used a model stripped of soft tissues. In 8 matched pairs of cadaver shoulders, a Bankart lesion was repaired arthroscopically using either 2 Bio-SutureTak anchors (Arthrex, Naples, Florida) or 2 Bioknotless anchors (Mitek, Westwood, Massachusetts). The shoulders were mounted with the repaired capsulolabral tissues attached to a custom sinusoidal clamp, and were tested in cyclic loading (20-80 N, 100 cycles, 0.5 mm/s) and then load to failure (1.25 mm/s). Cut-through at the suture-tissue interface (23/32 anchors) was more common than pullout at the anchor-bone interface (9/32) as a mode of failure (P = .02). Failure at the suture-tissue interface occurred in 10/16 knotted and 13/16 knotless anchors. Mean (SD) ultimate load of knotted vs knotless anchors was 125.3 (67.4) N and 96.9 (95.1) N, respectively. Mean (SD) stiffness of knotted vs knotless anchors was 20.9 (6.4) N/mm and 19.8 (8.6)N/mm, respectively. We concluded that both knotted and knotless anchors fail most often at the suture-tissue interface. The tested model with the capsulolabral tissues intact is distinct from previous models, which tested the anchor-bone interface only.     

小肠黏膜下层材料在青少年（14-18岁）腹股沟疝修补术中应用的初步探讨

目的　探讨小肠黏膜下层材料生物补片在14~18岁青少年腹股沟疝患者治疗中的应用价值。方法　采用前瞻性研究方法,将入组的47例患者分为2组：对照组与治疗组。治疗组使用小肠黏膜下层材料行腹股沟疝平片无张力修补术,对照组采用传统的疝囊高位结扎术治疗。观察并分析术后并发症及复发情况。结果　治疗组平均手术时间51.6±12.7min,高于对照组的38.2±7.5min（P<0.05）,治疗组平均住院时间3.4±1.1d,低于对照组5.1±1.3d（P<0.05）。术中出血量14.4±6.5mL,与对照组13.0±5.9mL比较,无统计学差异（P>0.05）。在术后的并发症的发生情况、复发率、术后疼痛评分上,两组无明显差异。结论　对于14~18岁的青少年腹股沟疝患者,使用小肠黏膜下层材料行无张力疝修补术效果良好,能够缩短住院时间,不会增加术后的疼痛不适与并发症的发生率,安全有效。     

Functional evaluation of patient after arthroscopic repair of rotator cuff tear

BackgroundRotator cuff tear is a common problem either after trauma or after degenerative tear in old age group. Arthroscopic repair is the current concept of rotator cuff repair. Here, we are trying to evaluate the functional outcome after arthroscopic repair of full thickness rotator cuff tear (single row) in Indian population.Materials and methodsTwenty five patients (14 males and 11 females) who underwent arthroscopic repair of full thickness rotator cuff tear at a single institution were included in the study. Postoperatively patient's shoulder was rated according to UCLA score, pain was graded according to the visual analog score. The range of motion was analysed and documented.ResultsThe mean age of the patients were 50.48 years. The preoperative VAS score mode was 7 and post operative VAS was 1 (p value <0.001). The UCLA grading was good in 80% (n = 20), fair in 12% (n = 3), excellent in 8% (n = 2) and poor results were seen in none of the patients.The mean UCLA improved from a score of 15.84 to 30.28 with a p value <0.001. Mean postoperative forward flexion was 161.6°, mean abduction was 147.6° and mean external rotation was 45.4°.ConclusionArthroscopic repair is a good procedure for full thickness rotator cuff tear with minimal complications. The newer double row repair claims to be biomechanically superior with faster healing rates without functional advantages, hence we used a single row repair considering the Indian population and the cost effectiveness of the surgery with good to excellent results.     

The TOTS (temporary outside traction suture): a new technique to allow easy suture placement and improve capsular shift in arthroscopic bankart repair

We describe a new technique to allow easy placement of anterior sutures and to improve the proximal capsular shift in arthroscopic anterior stabilization of the shoulder, which we call the temporary outside traction suture (TOTS). Two standard portals are used: posterior and anterosuperior. Using a curved suture hook, both the capsule and the labrum are perforated at approximately the 5-o’clock position, and a monofilament suture is passed through the tissues. The suture is first retrieved through the anterior canula and then placed outside the canula. After labrum detachment and glenoid preparation, 1 or 2 further inferior sutures can be placed before the first suture is retrieved inside the canula and used. The technique of the TOTS has many advantages. (1) It allows easy placement of the first suture before the anterior capsule and labrum have been released. This makes this step much more difficult due to the lack of tension in the anterior tissues and anterior subluxation of the humeral head. (2) It allows the surgeon to choose, with accuracy, the amount of capsule taken, according to the severity of the capsular lesions and the degree of capsular laxity. It can also allow anatomic recreation of the anterior band of the inferior glenohumeral ligament (IGHL). (3) By placing tension on the suture, it avoids damaging the anterior capsule and labrum with the shaver and burr while preparing the scapula neck and can aid with haemostasis. (4) Tension on the suture also allows one to easily place 1 or 2 further sutures in a lower position. (5) It avoids entangling the sutures in the canula. (6) It allows one to perform a capsular shift of approximately 10 to 15 mm when the traction suture is retrieved and implanted with an anchor in the 3- or even 2-o’clock position.     

Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears

BACKGROUND: Isolated tears of the subscapularis occur less commonly than those involving the superior and posterior components of the rotator cuff. The purpose of the present study was to evaluate the structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. METHODS: A prospective study of seventeen consecutive patients who were managed with an all-arthroscopic repair of the subscapularis tendon was performed. The study group included thirteen men and four women who had an average age of forty-seven years at the time of surgery. The average interval from the onset of symptoms to the time of surgery was twenty-four months. Thirteen tears were traumatic, and four were degenerative. Seven patients had a tear involving the superior third of the tendon, six had a tear involving the superior two-thirds of the tendon, and four had complete separation of the subscapularis from its insertion on the lesser tuberosity. Clinical findings were assessed for all patients preoperatively and postoperatively with use of the Constant and University of California at Los Angeles scoring systems, and all patients had postoperative computed tomographic arthrography studies to evaluate the structural integrity of the repair. RESULTS: The average duration of follow-up was twenty-nine months. When the preoperative findings were compared with the most recent findings, the average relative Constant score had improved from 58% to 96% (p < 0.05), the average University of California at Los Angeles score had improved from 16 to 32 points (p < 0.05), the average pain score had improved from 5.9 to 13.5 points (p < 0.05), the average forward flexion had improved from 146 degrees to 175 degrees (p < 0.05), the average external rotation had improved from 50 degrees to 60.3 degrees (p < 0.05), the average internal rotation had improved from the level of the sacrum to L1-L2 (p < 0.05), and the average abduction strength had improved from 7.4 to 15.6 points (p < 0.05). The structural integrity of the repair was completely intact in fifteen patients and was partially reruptured in two patients on the basis of computed tomographic arthrography. Progression of fatty infiltration of the subscapularis was not observed in any patient. Subjectively, twelve patients were very satisfied with the result, four were satisfied, and one was not satisfied. CONCLUSIONS: Arthroscopic repair of an isolated subscapularis tear can yield marked improvements in shoulder function, can significantly reduce pain, and can result in a durable structural repair. LEVEL OF EVIDENCE: Therapeutic Level IV.