Arthroscopic Bankart repair. Operative technique and surgical pitfalls

The American Society of Shoulder and Elbow Therapists' consensus rehabilitation guideline for arthroscopic anterior capsulolabral repair of the shoulder

This manuscript describes the consensus rehabilitation guideline developed by the American Society of Shoulder and Elbow Therapists. The purpose of this guideline is to facilitate clinical decision making during the rehabilitation of patients following arthroscopic anterior capsulolabral repair of the shoulder. This guideline is centered on the principle of the gradual application of stress to the healing capsulolabral repair through appropriate integration of range of motion, strengthening, and shoulder girdle stabilization exercises during rehabilitation and daily activities. Components of this guideline include a 0- to 4-week period of absolute immobilization, a staged recovery of full range of motion over a 3-month period, a strengthening progression beginning at postoperative week 6, and a functional progression for return to athletic or demanding work activities between postoperative months 4 and 6. This document represents the first consensus rehabilitation guideline developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients following arthroscopic anterior capsulolabral repair of the shoulder.

Relationships of the musculocutaneous nerve and the coracobrachialis during coracoid abutment procedure (Latarjet procedure)

PURPOSE

The aim of this study was first to define first the anatomical relationships between the musculocutaneous nerve and the coracobrachialis, and then the induced modifications of these relationships by a preglenoid transposition of the vertical part of the coracoid process.

MATERIALS AND METHODS

Twenty-one embalmed adult trunks and upper limb were dissected. First the coracobrachialis and the musculocutaneous nerve were identified through a deltopectoral approach. We measured the distances between the lateral cord of the brachial plexus and the entry point of the nerve, between the inferior tip of the tip of the coracoid process and the penetration of the nerve or its twigs, and finally the angle between the general axis of the coracobrachialis and the axis of the musculocutaneous nerve. The same measures were performed after the coracoid bone block abutment.

RESULTS

Proximal motor branches destined to the coracobrachialis varied from 0 to 3. Mean distance between the lateral cord of the brachial plexus and entry point of the nerve into the muscle was 47.2 mm before and 48.43 mm after the coracoid transfer. Mean angulations between the nerve and the muscle was 121 degrees before and 136 degrees after the transfer of the coracoid process. Mean distance between the inferior tip of the coracoid process and entry point of the nerve into the muscle was 55.7 mm, reduced to 48.6 mm after the coracoid transposition. Finally, the distance between the tip of the coracoid and the first motor twig entering the coracobrachialis was less than 50 mm in 75% of the cases with a mean value of 40.6 mm.

CONCLUSIONS

Lesion of the musculocutaneous nerve is a known complication of the coracoid bone block abutment procedure (Latarjet-Bristow). From this study we know that they are due to lengthening of the nerve and modification of the penetration angle of the nerve into the coracobrachialis. We also infer that some motor nerve destined to the coracobrachialis might be damaged during the proximal medial release of the muscle after the detachment of the pectoralis minor muscle.

Computerized assessment of Bankart lesions under tension with magnetic resonance arthrography

Accurate anatomic depiction of Bankart lesions based on magnetic resonance imaging (MRI) is crucial for the treatment of posttraumatic recurrent dislocation of the glenohumeral joint. MR arthrography, the intraarticular injection of dilute gadolinium before MR imaging, improves sensitivity in the detection of shoulder pathology. Abduction and external rotation (ABER) of the shoulder places dynamic stress on the inferior capsular pouch and anterior labroligamentous complex, important structures for anterior shoulder stability. This study sought to determine whether MR arthrography, by use of computerized image analysis, can visualize Bankart lesions better with the shoulder in the neutral position or in ABER. We evaluated 12 shoulders after traumatic anterior dislocation. The MR images were analyzed with image-analyzing software. We compared 3 parameters at 5 levels of the glenoid in the neutral position and in ABER: detachment (the length of detachment between the anterior glenoid rim and the anterior periosteal attachment), displacement (the distance between the anterior glenoid rim and the tip of the displaced labrum), and Bankart area (the area bounded by the detachment line, the displacement line, and the anterior aspect of the Bankart lesion). MR images revealed that Bankart lesions were under tension in ABER and lax and redundant with the shoulder in the neutral position. All 3 parameters were greater in ABER than in the neutral position in all cases (P = .012, P = .0006, and P = .012). Computerized image assessment of MR arthrography with the shoulder in ABER provides excellent visualization and evaluation of Bankart lesions.

Electrothermal assisted shoulder capsulorraphy--monopolar

Monopolar electrothermal stabilization of the shoulder shows considerable promise as a treatment alternative in athletes and patients with recurrent instability. Range of motion is preserved, recovery is faster than with open procedures, there is little disruption or alteration of inherent anatomy, and, most importantly, results at 2 years appear comparable to other surgical procedures in high-demand populations. The procedure is technically easy to perform, and the complication rate is low. Success depends on surgeon's understanding of the applications of RF energy, the use of proper surgical technique, careful patient selection, attention to the rehabilitation program, and the patient's compliance with postoperative protocol. Long-term follow-up is necessary to determine if results for this procedure deteriorate over time, especially in patients with multidirectional instability.

Arthroscopic shoulder stabilization with suture anchors: technique, technology, and pitfalls

Arthroscopic treatment of anterior shoulder instability has evolved significantly during the past decade. Currently, most techniques include the use of suture and suture anchors. A successful outcome is highly dependent on accurate patient selection. Preoperative evaluation, examination with the patient under anesthesia, and defining the pathoanatomy by a thorough arthroscopic examination determine the most effective treatment strategy. Technical skills include the surgeon's ability to accomplish anchor placement, suture passage, and arthroscopic knot tying. Various instruments and techniques are available to facilitate arthroscopic reconstruction. In properly selected patients and with good surgical technique, outcomes should approximate or exceed traditional open stabilization techniques.