Subacromial bone erosion due to suture-knots in arthroscopic rotator cuff repair: A report of two cases

Knotless versus knotted arthroscopic Bankart repairs for anterior shoulder instability: a systematic review and meta-analysis

BACKGROUND

Arthroscopic Bankart repair can be performed via a more contemporary knotless procedure or a more traditional knotted procedure. Nonetheless, comparisons between these two techniques remain controversial.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search of PubMed, EMBASE, Cochrane Library, Scopus, and Web of Science was conducted. Randomized controlled trials (RCTs) and cohort studies directly comparing the knotless and knotted arthroscopic Bankart procedures were included. The primary outcomes were rates of recurrent instability and revision surgeries. Secondary outcomes encompassed number of anchors, operative time, improvements in functional scores including Rowe score and Constant-Murley score (CMS), pain level assessed by the visual analogue scale (VAS) score, range of motion (ROM), adverse events, and radiological results. Quality assessment was performed using RoB2 and MINORS tools. Meta-analysis pooled RCT data using Review Manager 5.4.1, and non-pooled outcomes from cohort studies or limited RCT data were reported separately.

RESULTS

This meta-analysis included nine studies with a total of 729 patients. Pooled data from three RCTs demonstrated no significant differences between the two techniques in terms of re-dislocation (P = 0.78), recurrent anterior subluxation and positive apprehension test (P = 0.78), revision surgery (P = 0.94), number of anchors used (P = 0.26), or improvements in Rowe score (P = 0.15). For outcomes not suitable for pooling, qualitative analysis of trends indicated comparable outcomes between the groups, except a slightly reduced operative time in the knotless repair group. Adverse events were infrequently reported and occurred at similar rates in both groups. Limited radiological data from one RCT showed no significant differences in MRI parameters at the 24-month follow-up.

CONCLUSION

Both techniques demonstrate comparable clinical outcomes. The only potential advantage of the knotless technique is a possible reduction in operative time, though its clinical significance remains uncertain. Given the limitations of the evidence, these findings should be interpreted cautiously.

CLINICAL TRIAL NUMBER

Not applicable.

PROSPERO REGISTRATION ID

CRD42024586135.

Arthroscopic V-Shaped Double-Pulley Suture-Bridge Repair of Massive Rotator Cuff Tear

At present, suture bridge is a feasible choice in the treatment of massive rotator cuff tears (MRCTs). However, high tension on the repair site and medial tension during suture tightening and after medial knotting are unavoidable problems in MRCT repair with a suture bridge. Arthroscopic V-shaped double-pulley suture-bridge repair is a pragmatic surgical technique for the repair of MRCTs. The unique parallel design of medial- and lateral-row anchors can minimize tendon tension on the apex portion; 6 sets of double-pulley suture bridges can not only provide sufficient tendon-bone contact area but also reduce the tendon retear rate. Moreover, medial knotless techniques can reduce tendon tension.

The High Resistance Loop (H-Loop) Technique for Arthroscopic Repair of Subscapularis

The subscapularis tendon is more challenging and riskier to repair than the posterior upper rotator cuff. The knotless anchor suture in subscapularis repair simplified the repair process and had an excellent postoperative effect. We describe a new knotless anchor stitching method, the H-Loop technique. The simplicity and efficiency of the technique make it particularly suitable for small subscapular tendon tears.

Superior capsular reconstruction using hybrid graft for irreparable massive rotator cuff tear

PURPOSE

To evaluate the clinical and radiological outcomes of arthroscopic superior capsular reconstruction (SCR) using hybrid grafts composed of tensor fascia lata autografts and human dermal allografts.

METHODS

This study included 30 patients with chronic irreparable posterosuperior rotator cuff tears (RCTs) who underwent arthroscopic SCR using a hybrid graft composed of tensor fascia lata autograft and human dermal allograft. Clinical outcomes were evaluated using the pain visual analogue scale score, shoulder range of motion, American Shoulder and Elbow Surgeons score, constant score, University of California-Los Angeles score, and simple shoulder test score preoperatively and at least 2 years after surgery. Radiographic analysis included the Hamada classification grade, acromiohumeral distance (AHD), and graft integrity at 2 years after surgery.

RESULTS

All patients exhibited significant clinical improvement in all functional outcome measurements, except external rotation (all P < 0.05). The number of patients who exhibited pseudoparalysis decreased from 7 (23.3%) to 2 (6.7%) postoperatively. Complications were not observed. Radiologically, the mean postoperative AHD increased significantly from 6.9 ± 1.6 cm to 8.8 ± 2.1 cm at 2 years postoperatively (P < 0.001). Twenty five out of the 30 (83.3%) patients showed successful graft healing, and all healing failures occurred on the humeral side. The differences between the healed-graft and failed-graft groups were significantly lower graft thickness (P = 0.001) and smaller AHD (P < 0.001) in the failed-graft group. Every functional outcome scores were not statistically different between healed-graft and failed-graft groups.

CONCLUSIONS

An arthroscopic SCR technique using a hybrid graft consisting of a tensor fascia lata autograft and human dermal allograft showed satisfactory clinical outcomes in patients with irreparable RCTs.

LEVEL OF EVIDENCE

IV.

Knot impingement after arthroscopic rotator cuff repair mimicking infection: A case report

BACKGROUND

Knot impingement as a complication after arthroscopic rotator cuff repair (ARCR) has been suggested as a cause of persistent pain with limited motion. We report on a case involving a patient who developed knot impingement after ARCR who complained of acute onset of pain with limited motion, which was confused with infection.

CASE SUMMARY

A 55-year-old female who complained of severe pain with limited motion of the right shoulder visited our emergency room. Passive range of motion could not be evaluated due to the patient’s severe pain. The patient had undergone ARCR using a suture-bridge technique at a local clinic four months ago for treatment of a small supraspinatus tear of the right shoulder. An erosive change of the undersurface of the acromion was observed on plain radiographs of the right shoulder, and a moderate amount of bursal fluid and synovial thickening with enhancement was observed by magnetic resonance imaging. Results of an analysis of the aspirated fluid showed that the WBC count was 3960 with 90% neutrophils. The arthroscopic view showed healing of the repaired supraspinatus tendon and loose suture threads and knots with severe subacromial bursitis were observed. Debridement of inflammatory tissues of the glenohumeral joint and subacromial space was performed for the removal of all suture materials. The patient’s symptoms subsided immediately after the surgical procedure.

CONCLUSION

Although the incidence of knot impingement is rare, the possibility of knot impingement after ARCR should be a consideration.