Atiba A Nelson

Complications following arthroscopic fixation of acromioclavicular separations: a systematic review of the literature.

Purpose Over the past decade, a number of arthroscopic or arthroscopically assisted reconstruction techniques have emerged for the management of acromioclavicular (AC) separations. These techniques provide the advantage of superior visualization of the base of the coracoid, less soft tissue dissection, and smaller incisions. While these techniques have been reported to provide excellent functional results with minimal complications, discrepancies exist within the literature. This systematic review aims to assess the rate of complications following these procedures. Methods Two independent reviewers completed a search of Medline, Embase, PubMed, and the Cochrane Library entries up to December 2013. The terms “Acromioclavicular Joint (MeSH)” OR “acromioclavicular* (text)” OR “coracoclavicular* (text)” AND “Arthroscopy (MeSH)” OR “Arthroscop* (text)” were used. Pooled estimates and 95% confidence intervals were calculated assuming a random-effects model. Statistical heterogeneity was quantified using the I2 statistic. Level of evidence IV Results A total of 972 abstracts met the search criteria. After removal of duplicates and assessment of inclusion/exclusion criteria, 12 articles were selected for data extraction. The rate of superficial infection was 3.8% and residual shoulder/AC pain or hardware irritation occurred at a rate of 26.7%. The rate of coracoid/clavicle fracture was 5.3% and occurred most commonly with techniques utilizing bony tunnels. Loss of AC joint reduction occurred in 26.8% of patients. Conclusion Arthroscopic AC reconstruction techniques carry a distinct complication profile. The TightRope/Endobutton techniques, when performed acutely, provide good radiographic outcomes at the expense of hardware irritation. In contrast, graft reconstructions in patients with chronic AC separations demonstrated a high risk for loss of reduction. Fractures of the coracoid/clavicle remain a significant complication occurring predominately with techniques utilizing bony tunnels.

Partial Thickness Rotator Cuff Tears: Current Concepts

Partial thickness rotator cuff tears are a common cause of pain in the adult shoulder. Despite their high prevalence, the diagnosis and treatment of partial thickness rotator cuff tears remains controversial. While recent studies have helped to elucidate the anatomy and natural history of disease progression, the optimal treatment, both nonoperative and operative, is unclear. Although the advent of arthroscopy has improved the accuracy of the diagnosis of partial thickness rotator cuff tears, the number of surgical techniques used to repair these tears has also increased. While multiple repair techniques have been described, there is currently no significant clinical evidence supporting more complex surgical techniques over standard rotator cuff repair. Further research is required to determine the clinical indications for surgical and nonsurgical management, when formal rotator cuff repair is specifically indicated and when biologic adjunctive therapy may be utilized.

The rotator cuff quality-of-life index predicts the outcome of nonoperative treatment of patients with a chronic rotator cuff tear.

BACKGROUND Chronic rotator cuff tears are prevalent and can be disabling. The existing literature is unclear regarding the effectiveness of nonoperative treatment. The purposes of this study were to determine whether the outcome of nonoperative treatment can be predicted on the basis of the presenting clinical characteristics and whether the outcome achieved at three months after treatment can be maintained at two years. METHODS The prospective cohort included ninety-three patients with a documented chronic full-thickness rotator cuff tear. Patients underwent a three-month supervised program of nonoperative treatment and were then evaluated by an orthopaedic surgeon. The treatment outcome was defined as a success if surgical treatment was no longer deemed appropriate by both patient and surgeon because the patient had improved considerably and was predominantly asymptomatic. The outcome was defined as a failure if the patient elected to have surgery after failing to improve and remaining symptomatic. The presenting clinical characteristics that were analyzed included age, sex, smoking status, hand dominance, duration of symptoms, onset (traumatic etiology or insidious onset), shoulder motion, external rotation strength, tear size as documented by ultrasonography or magnetic resonance imaging, and the Rotator Cuff Quality-of-Life Index (RC-QOL). RESULTS Seventy (75%) of the patients were successfully treated. Logistic regression analysis showed that the baseline RC-QOL score was a significant predictor of outcome (p = 0.017). Eighty-nine percent of patients maintained their three-month outcome at two years of follow-up. CONCLUSIONS The RC-QOL was predictive of the outcome of nonoperative treatment of patients with a chronic full-thickness rotator cuff tear. Patients in whom the nonoperative treatment was deemed successful at the conclusion of three months of treatment had a very high chance of ongoing success at two years after the initiation of treatment.

Transtendon rotator-cuff repair of partial-thickness articular surface tears can lead to medial rotator-cuff failure

Purpose The purpose of this study was to evaluate clinical and anatomic outcomes of patients following transtendon rotator-cuff repair of partial articular supraspinatus tendon avulsion (PASTA) lesions. Patients and methods Patients in the senior author’s practice who had isolated PASTA lesions treated by transtendon rotator-cuff repair were included (n=8) and retrospectively reviewed. All patients were evaluated preoperatively and at a mean of 21.2 months (±9.7 months) postoperatively using standardized clinical evaluation (physical exam, American Shoulder and Elbow Surgeons, and Simple Shoulder Test). All patients underwent postoperative imaging with a magnetic resonance imaging arthrogram. Results There was a significant improvement in American Shoulder and Elbow Surgeons (42.7±17.5 to 86.9±25.2) and Simple Shoulder Test (4.6±3.2 to 10.1±3.8) scores from pre- to postoperative, respectively. Postoperative imaging demonstrated full-thickness medial cuff tearing in seven patients, and one patient with a persistent partial articular surface defect. Conclusion Transtendon repair of PASTA lesions may lead to improvements in clinical outcome. However, postoperative imaging demonstrated a high incidence of full-thickness rotator-cuff defects following repair.

Long-term outcomes of the Bankart and Latarjet repairs: a systematic review

The most common surgical techniques for the treatment of recurrent anterior shoulder instability include the arthroscopic Bankart repair, the open Bankart repair and the open Latarjet procedure. The purpose of this study was to evaluate and compare the long-term outcomes following these procedures. A systematic review of modern procedures with a minimum follow-up of 5 years was completed. The objective outcome measures evaluated were post-operative dislocation and instability rate, the Rowe score, radiographic arthritis and complications. Twenty-eight studies with a total of 1652 repairs were analyzed. The estimated re-dislocation rate was 15.1% following arthroscopic Bankart repair, 7.7% following open Bankart repair and 2.7% following Latarjet repair, with the comparison between arthroscopic Bankart and open Latarjet reaching statistical significance (p<0.001). The rates of subjective instability and radiographic arthritis were consistently high across groups, with no statistical difference between groups. Estimated complication rates were statistically higher in the open Latarjet repair (9.4%) than in the arthroscopic Bankart (0%; p=0.002). The open Latarjet procedure yields the most reliable method of stabilization but the highest complication rate. There are uniformly high rates of post-operative subjective instability symptoms and radiographic arthritis at 5 years regardless of procedure choice.

Magnetic resonance imaging arthrography following type II superior labrum from anterior to posterior repair: interobserver and intraobserver reliability

Background Arthroscopic repair of type II superior labrum from anterior to posterior (SLAP) lesions is a common surgical procedure. However, anatomic healing following repair has rarely been investigated. The intraobserver and interobserver reliability of magnetic resonance imaging arthrography (MRA) following type II SLAP repair has not previously been investigated. This is of particular interest due to recent reports of poor clinical results following type II SLAP lesion repair. Purpose To evaluate the MRA findings following arthroscopic type II SLAP lesion repair and determine its intraobserver and interobserver reliability. Study design Cohort study (diagnosis), Level of Evidence, 2. Methods Twenty-five patients with an isolated type II SLAP lesion (confirmed via diagnostic arthroscopy) underwent standard suture anchor-based repair. At a mean of 25.2 months post-operatively, patients underwent a standardized MRA protocol to investigate the integrity of the repair. MRAs were independently reviewed by two radiologists and a fellowship trained shoulder surgeon. The outcomes were classified as healed SLAP repair or re-torn SLAP repair. Results On average, 54% of MRAs were interpreted as healed SLAP repairs while 46% of MRAs were interpreted as having a re-torn SLAP repair. Overall, only 43% of the studies had 100% agreement across all interpretations. The intraobserver reliability ranged from 0.71 to 0.81 while the interobserver reliability between readers ranged from 0.13 to 0.44 (Table 1). Conclusion The intraobserver agreement of MRA in the evaluation of type II SLAP repair was substantial to excellent. However, the interobserver agreement of MRA was poor to fair. As a result, the routine use of MRA in the evaluation of type II SLAP lesion repair should be utilized with caution. A global evaluation of the patient, including detailed history and physical examination, is paramount in determining the cause of failure and one should not rely on MRA alone.

Arthroscopic repair of type II SLAP lesions: Clinical and anatomic follow-up

Aims: The aim was to evaluate the clinical and anatomic outcome of arthroscopic repair of type II SLAP lesions. Materials and Methods: The senior author performed isolated repairs of 25 type II SLAP lesions in 25 patients with a mean age of 40.0 ± 12 years. All tears were repaired using standard arthroscopic suture anchor repair to bone. All patients were reviewed using a standardized clinical examination by a blinded, independent observer, and using several shoulder outcome measures. Patients were evaluated by magnetic resonance imaging arthrogram at a minimum of 1-year postoperatively. Statistical Analysis Used: Two-tailed paired t-test were used to determine significant differences in preoperative and postoperative clinical outcomes scores. In addition, a Fishers exact test was used. Results: At a mean follow-up of 54-month, the mean American Shoulder and Elbow Surgeons Shoulder Index (ASES) scores improved from 52.1 preoperatively to 86.1 postoperatively (P < 0.0001) and the Simple Shoulder Test (SST) scores from 7.7 to 10.6 (P < 0.0002). Twenty-two out of the 25 patients (88%) stated that they would have surgery again. Of the 21 patients who had postoperative magnetic resonance imaging arthrographys (MRAs), 9 patients (43%) demonstrated dye tracking between the labrum bone interface suggestive of a recurrent tear and 12 patients (57%) had a completely intact repair. There was no significant difference in ASES, SST, and patient satisfaction scores in patients with recurrent or intact repairs. Conclusions: Arthroscopic repair of type II SLAP lesions demonstrated improvements in clinical outcomes. However, MRA imaging demonstrated 43% of patients with recurrent tears. MRA results do not necessarily correlate with clinical outcome.

Knotless anchors with sutures external to the anchor body may be at risk for suture cutting through osteopenic bone

Objectives This study evaluated the mechanical performance, under low-load cyclic loading, of two different knotless suture anchor designs: sutures completely internal to the anchor body (SpeedScrew) and sutures external to the anchor body and adjacent to bone (MultiFIX P). Methods Using standard suture loops pulled in-line with the rotator cuff (approximately 60°), anchors were tested in cadaveric bone and foam blocks representing normal to osteopenic bone. Mechanical testing included preloading to 10 N and cyclic loading for 500 cycles from 10 N to 60 N at 60 mm/min. The parameters evaluated were initial displacement, cyclic displacement and number of cycles and load at 3 mm displacement relative to preload. Video recording throughout testing documented the predominant source of suture displacement and the distance of ‘suture cutting through bone’. Results In cadaveric bone and foam blocks, MultiFIX P anchors had significantly greater initial displacement, and lower number of cycles and lower load at 3 mm displacement than SpeedScrew anchors. Video analysis revealed ‘suture cutting through bone’ as the predominant source of suture displacement in cadaveric bone (qualitative) and greater ‘suture cutting through bone’ comparing MultiFIX P with SpeedScrew anchors in foam blocks (quantitative). The greater suture displacement in MultiFIX P anchors was predominantly from suture cutting through bone, which was enhanced in an osteopenic bone model. Conclusions Anchors with sutures external to the anchor body are at risk for suture cutting through bone since the suture eyelet is at the distal tip of the implant and the suture directly abrades against the bone edge during cyclic loading. Suture cutting through bone may be a significant source of fixation failure, particularly in osteopenic bone. Cite this article: Y. Ono, J. M. Woodmass, A. A. Nelson, R. S. Boorman, G. M. Thornton, I. K. Y. Lo. Knotless anchors with sutures external to the anchor body may be at risk for suture cutting through osteopenic bone. Bone Joint Res 2016;5:269–275. DOI: 10.1302/2046-3758.56.2000535.

What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears

The purpose of this study was to examine five-year outcomes of patients previously enrolled in a non-operative rotator cuff study. Patients with chronic, full-thickness rotator cuff tears (demonstrated on imaging) who were referred to one of two senior shoulder surgeons were enrolled in the study between October 2008 and September 2010. Patients participated in a comprehensive non-operative, home-based treatment program. After three months patients were defined as “successful” or “failed”. “Successful” patients were essentially asymptomatic and did not require surgery. “Failed” patients were symptomatic and consented to surgical repair. All patients were followed up at one year, two years, and five-plus years. Original results of our study showed that 75% of patients were treated successfully with non-operative treatment, while 25% went on to surgery. These numbers were maintained at two-year follow-up (previously reported) and five-year follow-up. At five+ years, 88 patients were contacted for follow-up. Fifty-eight (66%) responded. The non-operative success group had a mean RC-QOL score of 80 (SD 18) at previously reported two-year follow-up. At five-year follow-up this score did not decrease (RCQOL = 82 (SD 16)). Furthermore, between two and five years, only two patients who had previously been defined as “successful” became more symptomatic and underwent surgical rotator cuff repair. From the original cohort of patients, those who failed non-operative treatment and underwent surgical repair had a mean RC-QOL score of 89 (SD 12) at five-year follow-up. The operative and non-operative groups at five-year follow-up were not significantly different (p = 0.07). Non-operative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. While some may argue that non-operative treatment delays inevitable surgical fixation, our study shows that patients can do extremely well over time.

Lateral releases of the subscapularis tendon

The technique of arthroscopic subscapularis repair continues to evolve. A three-sided subscapularis release (e.g. anterior, posterior, superior) is commonly advocated for improving tendon excursion to bone. However, a lateral release is commonly required as well, particularly for full thickness, upper subscapularis tears and full thickness, complete subscapularis tears. We describe the techniques to identify and release the lateral subscapularis border, which aids in the completion of other releases.