Biceps Smash Technique: Biceps Tendon Autograft Augmentation for Arthroscopic Rotator Cuff Reconstruction

The proportion of postoperative retears after arthroscopic rotator cuff reconstruction remains constant despite advancement of suture techniques and improved anchor implants. The commonly degenerative nature of rotator cuff tears can carry the risk of compromised tissue. Several techniques have been developed to biologically enhance rotator cuff repair, and a considerable number of autologous, allogeneic, and xenogenous augmentation methods have been described. This article introduces the biceps smash technique, an arthroscopic augmentation procedure for posterosuperior rotator cuff reconstruction using an autograft patch of the long head of the biceps tendon.

Arthroscopic Posterior Articular Coverage and Shift (PACS) Procedure for Treatment of Preosteoarthritic Constitutional Static Posterior Shoulder Instability (Type C1)

BACKGROUND

Different joint-preserving techniques for treatment of preosteoarthritic, constitutional static (type C1) posterior shoulder instability (PSI) have been proposed, including posterior glenoid open wedge osteotomy and bone graft augmentation. However, the techniques are demanding, the reported complication and reoperation rates are high, and posterior decentering cannot reliably be reversed.

PURPOSE

To assess the clinical and radiological longitudinal outcomes of patients with type C1 PSI after arthroscopic posterior articular coverage and shift (PACS) surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We performed a retrospective analysis of a prospective database with longitudinal follow-up including 14 shoulders in 13 patients who underwent an arthroscopic PACS procedure for symptomatic preosteoarthritic constitutional static posterior instability (type C1) with previous failed nonoperative treatment. Patients were clinically evaluated before surgery and at 3, 6, 12, and 24 months postoperatively in terms of satisfaction and pain levels as well as standardized physical examination, Subjective Shoulder Value (SSV), Western Ontario Shoulder Instability Index (WOSI) score, Constant score, and Rowe score. Preoperative, postoperative, and follow-up magnetic resonance imaging scans were obtained in all patients. A paired 2-sample t test was used to compare changes in continuous variable parameters over time. Correlation analyses were performed using the Pearson correlation coefficient.

RESULTS

All outcome scores and the pain level improved significantly from preoperatively to postoperatively, and the improvement was sustained over the follow-up period of 2 years (pain level, 6.4 preoperatively vs 3.3 at 2 years, P < .001; SSV, 40 vs 70, P = .001; WOSI, 33 vs 56, P = .001; Constant, 70 vs 79, P = .049; Rowe, 52 vs 76, P < .001). The mean glenohumeral and scapulohumeral subluxation indices were significantly lower in the early postoperative period compared with preoperative measurements (glenohumeral, 52% ± 6% vs 58% ± 10%, P = .02; scapulohumeral, 70% ± 8%; vs 77% ± 9%, P = .002, respectively); however, they returned to baseline values at follow-up (57% ± 7% vs 58% ± 10%, P = .7; 75% ± 6% vs 77% ± 9%, P = .4, respectively). A high scapulohumeral subluxation index, excessive glenoid retroversion, and increased posterior positioning of the humeral head in relation to scapular blade axis and older age were correlated with worse clinical outcomes.

CONCLUSION

Over the follow-up period of 2 years, the PACS procedure significantly improved outcome scores in patients who had preosteoarthritic constitutional static posterior shoulder instability, especially in younger patients with less severe glenoid retroversion and posterior decentering of the humeral head. However, similar to other techniques, the PACS procedure needs to be considered a symptomatic therapy that does not reverse the underlying cause or stop the progressive pathology.

A Systematic Review of Long-term Clinical and Radiological Outcomes of Arthroscopic and Open/Mini-open Rotator Cuff Repairs

BACKGROUND

Arthroscopic rotator cuff repair (aRCR) has shown similar midterm functional results and retear rates as open/mini-open rotator cuff repair (oRCR). A pooled analysis of long-term results of both techniques is yet missing.

PURPOSE

To evaluate the long-term results of aRCR and oRCR for full-thickness rotator cuff tears.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The CENTRAL (Cochrane), MEDLINE (PubMed), and Embase databases were searched for studies that reported on long-term clinical and radiographic outcomes of full-thickness aRCR and oRCR with a minimum follow-up of 9 years.

RESULTS

Eleven studies were included: 5 studies on aRCR and 6 studies on oRCR. Studies were based on 550 shoulders (539 patients) with a mean patient age of 56.3 years (range, 25-77). After a mean follow-up of 14.0 years (range, 9-20), the mean preoperative absolute Constant score (CS) and American Shoulder and Elbow Surgeons (ASES) shoulder score were significantly improved postoperatively (CS, 44 to 78 points; ASES, 52% to 91%; both comparisons, P < .001). The retear rate was 41% (141 of 342 shoulders) without a significant difference between groups (aRCR, 43%; oRCR, 39%) (P = .364). A retear was associated with significantly reduced CS as compared with a healed repair (P = .004). No significant differences were found in postoperative functional scores, complications, and retear rates after failed cuff repairs between the arthroscopic and open/mini-open repair groups.

CONCLUSION

Pooled analysis of arthroscopic and open rotator cuff repairs demonstrated sustained improvement in long-term shoulder scores and pain with a substantial retear rate in both groups, which was associated with inferior shoulder function. There were no significant differences in long-term functional outcomes, retear rates, and complications. Both surgical techniques may be used on the basis of factors such as patient or surgeon preference and cost. Further studies using a more robust randomized controlled trial or larger cohort design are recommended to ascertain whether one surgical repair technique is superior to the other.

REGISTRATION

CRD42020180448 (PROSPERO).

The subjective knee value is a valid single-item survey to assess knee function in common knee disorders

INTRODUCTION

The patient's perspective plays a key role in judging the effect of knee disorders on physical function. We have introduced the Subjective Knee Value (SKV) to simplify the evaluation of individual's knee function by providing one simple question. The purpose of this prospective study was to validate the SKV with accepted multiple-item knee surveys across patients with orthopaedic knee disorders.

MATERIALS AND METHODS

Between January through March 2020, consecutive patients (n = 160; mean age 51 ± 18 years, range from 18 to 85 years, 54% women) attending the outpatient clinic for knee complaints caused by osteoarthritis (n = 69), meniscal lesion (n = 45), tear of the anterior cruciate ligament (n = 23) and focal chondral defect (n = 23) were invited to complete a knee-specific survey including the SKV along with the Knee Injury Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee subjective knee form (IKDC-S). The Pearson correlation coefficient was used to evaluate external validity between the SKV and each patient-reported outcome measure (PROM) separately. Furthermore, patient's compliance was assessed by comparing responding rates.

RESULTS

Overall, the SKV highly correlated with both the KOOS (R = 0.758, p < 0.05) and the IKDC-S (R = 0.802, p < 0.05). This was also demonstrated across all investigated diagnosis- and demographic-specific (gender, age) subgroups (range 0.509-0.936). No relevant floor/ceiling effects were noticed. The responding rate for the SKV (96%) was significantly higher when compared with those for the KOOS (81%) and the IKDC-S (83%) (p < 0.05).

CONCLUSION

At baseline, the SKV exhibits acceptable validity across all investigated knee-specific PROMs in a broad patient population with a wide array of knee disorders. The simplified survey format without compromising the precision to evaluate individual's knee function justifies implementation in daily clinical practice.

LEVEL OF EVIDENCE

II, cohort study (diagnosis).

Joint Preserving Treatment of Chronic Locked Posterior Shoulder Dislocation by Means of Combined Humeral Allograft Reconstruction and Posterior Glenoid Autograft Augmentation

Chronic locked posterior shoulder dislocations are challenging to treat and often warrant total shoulder arthroplasty. While joint preserving treatment is preferable in young patients, surgical techniques to treat this pathology have rarely been described in the literature. This technical note presents the treatment of a 30-year-old male patient with a chronic locked posterior shoulder dislocation by means of combined humeral allograft reconstruction and posterior glenoid autograft augmentation. Restoration of the spheric humeral head surface was obtained using a fresh-frozen femoral allograft fixed with two reabsorbable screws. Due to the intraoperatively persistent posterior instability after humeral reconstruction, the posterior glenoid was augmented with a tricortical iliac crest autograft, which was fixed with two metal screws. This treatment strategy resulted in a full range of motion and a centered stable shoulder joint at one-year follow-up. Therefore, the procedure of segmental reconstruction of the humeral head with a fresh-frozen allograft combined with a posterior glenoid augmentation with an iliac crest bone autograft is a joint-preserving treatment alternative to shoulder arthroplasty in young patients when humeral head reconstruction alone does not suffice.

Middle trapezius transfer for treatment of irreparable supraspinatus tendon tears- anatomical feasibility study

Purpose

The purpose of this study was to investigate the anatomical feasibility of a middle trapezius transfer below the acromion for treatment of irreparable supraspinatus tendon tears.

Methods

This study involved 20 human cadaveric shoulders in 10 full-body specimens. One shoulder in each specimen was dissected and assessed for muscle and tendon extent, force vectors, and distance to the neurovascular structures. The opposite shoulder was used to evaluate the surgical feasibility of the middle trapezius transfer via limited skin incisions along with an assessment of range of motion and risk of neurovascular injury following transfer.

Results

The harvested acromial insertion of the middle trapezius tendon showed an average muscle length of 11.7 ± 3.0 cm, tendon length of 2.7 ± 0.9 cm, footprint length of 4.3 ± 0.7 cm and footprint width of 1.4 ± 0.5 cm. The average angle between the non-transferred middle trapezius transfer and the supraspinatus was 33 ± 10° in the transversal plane and 34 ± 14° in the coronal plane. The mean distance from the acromion to the neurovascular bundle was 6.3 ± 1.3 cm (minimum: 4.0 cm). During surgical simulation there was sufficient excursion of the MTT without limitation of range of motion in a retracted scapular position but not in a protracted position. No injuries to the neurovascular structures were noted.

Conclusion

Transfer of the acromial portion of the middle trapezius for replacement of an irreparable supraspinatus seems to be feasible in terms of size, vector, excursion, mobility and safety. However, some concern regarding sufficiency of transfer excursion remains as scapula protraction can increase the pathway length of the transfer.

Level of evidence

Basic Science Study/Anatomical Study

Clinical midterm results of arthroscopic rotator cuff repair in patients older than 75 years

BACKGROUND

The effect of patient age on functional improvement after arthroscopic rotator cuff repair (ARCR) is still a matter of debate. The purpose of this study was to evaluate the clinical midterm results after ARCR in patients who were 75 years or older at the time of surgery.

METHODS

A total of 31 shoulders in 30 patients older than 75 years at the time of surgery underwent ARCR for a degenerative full-thickness rotator cuff tear (RCT) between 2010 and 2016. Among those, 23 shoulders in 22 patients (74%) with a mean age at time of surgery of 77 ± 2 years (range, 75-82 years) were followed up after a mean of 7 ± 2 years (range, 3-9 years). Clinical assessment included the Western Ontario Rotator Cuff (WORC) index as well as patient satisfaction, the Subjective Shoulder Value (SSV), Simple Shoulder Test (SST), and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score.

RESULTS

Overall, patient satisfaction was excellent, as everybody stated to be very satisfied with the surgery. Neither any complication nor revision surgery occurred during the study period. At final follow-up, the mean WORC index was 88% ± 15%. The mean SSV was comparable between the affected shoulder (90% ± 15%) and the contralateral side (87% ± 15%) (P = .235). The mean SST score was 10 ± 2 points and the mean ASES score was 89 ± 17 points.

CONCLUSION

ARCR for symptomatic RCTs without advanced muscle degeneration in patients older than 75 years at the time of surgery provided good clinical results and high patient satisfaction at midterm follow-up.

Long-term Results of Arthroscopic Rotator Cuff Repair: A Follow-up Study Comparing Single-Row Versus Double-Row Fixation Techniques

BACKGROUND

Arthroscopic rotator cuff repair (RCR) with suture anchor-based fixation techniques has replaced former open and mini-open approaches. Nevertheless, long-term studies are scarce, and lack of knowledge exists about whether single-row (SR) or double-row (DR) methods are superior in clinical and anatomic results.

PURPOSE

To analyze long-term results after arthroscopic RCR in patients with symptomatic rotator cuff tears and to compare functional and radiographic outcomes between SR and DR repair techniques at least 10 years after surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between 2005 and 2006, 40 patients with a symptomatic full-thickness rotator cuff tear (supraspinatus tendon tear with or without a tear of the infraspinatus tendon) underwent arthroscopic RCR with either an SR repair with a modified Mason-Allen suture-grasping technique (n = 20) or a DR repair with a suture bridge fixation technique (n = 20). All patients were enrolled in a long-term clinical evaluation, with the Constant score (CS) as the primary outcome measure. Furthermore, an ultrasound examination was performed to assess tendon integrity and conventional radiographs to evaluate secondary glenohumeral osteoarthritis.

RESULTS

A total of 27 patients, of whom 16 were treated with an SR repair and 11 with a DR repair, were followed up after a mean ± SD period of 12 ± 1 years (range, 11-14 years). Five patients underwent revision surgery on the affected shoulder during follow-up period, which led to 22 patients being included. The overall CS remained stable at final follow-up when compared with short-term follow-up (81 ± 8 vs 83 ± 19 points; P = .600). An increasing number of full-thickness retears were found: 6 of 22 (27%) at 2 years and 9 of 20 (45%) at 12 years after surgery. While repair failure negatively affected clinical results as shown by the CS (P < .05), no significant difference was found between the fixation techniques (P = .456). In general, progressive osteoarthritic changes were observed, with tendon integrity as a key determinant.

CONCLUSION

Arthroscopic RCR with either an SR or a DR fixation technique provided good clinical long-term results. Repair failure was high, with negative effects on clinical results and the progression of secondary glenohumeral osteoarthritis. While DR repair slightly enhanced tendon integrity at long-term follow-up, no clinical superiority to SR repair was found.