Daniel D. Buss

Arthroscopic Versus Open Reconstruction of the Shoulder in Patients with Isolated Bankart Lesions

We compared open and arthroscopic stabilizations of true Bankart lesions in patients with traumatic, unidi rectional anterior glenohumeral dislocations. The 27 patients were men (age range, 18 to 56 years) who were involved in recreational sports. One group (15 patients) had elected an arthroscopic Bankart repair; the other group (12 patients) had chosen open stabili zation with a standard deltopectoral approach. Patients were followed up 17 to 42 months after surgery by examination, radiographs, and interviews. In the open repair group, 1 of the 12 patients experienced a sub luxation in the follow-up period, but no patients had dislocations or reoperations. In the arthroscopic group, 5 of 15 patients had experienced subluxation or dislo cation ; of these 5 patients, 2 underwent reoperation. The arthroscopic group had significantly worse results in satisfaction, stability, apprehension, and loss of for ward flexion in the operated limb. In summary, the arthroscopic procedure did not significantly improve function; instead, it produced an increased failure rate compared with the open procedure. Therefore, we be lieve that open stabilization remains the procedure of choice for patients with true Bankart lesions.

Nonoperative Management for In-Season Athletes With Anterior Shoulder Instability

Background Acute or recurrent anterior shoulder instability is a frequent injury for in-season athletes. Treatment options for this injury include shoulder immobilization, rehabilitation, and shoulder stabilization surgery. Purpose To determine if in-season athletes can be returned to their sports quickly and effectively after nonoperative treatment for an anterior instability episode. Methods Over a 2-year period, 30 athletes matched the inclusion criteria for this study. Nineteen athletes had experienced anterior dislocations, and 11 had experienced subluxations. All were treated with physical therapy and fitted, if appropriate, with a brace. These athletes were followed for the number of recurrent instability episodes, additional injuries, subjective ability to compete, and ability to complete their season or seasons of choice. Results Twenty-six of 30 athletes were able to return to their sports for the complete season at an average time missed of 10.2 days (range, 0-30 years). Ten athletes suffered sport-related recurrent instability episodes (range, 0-8 years). An average of 1.4 recurrent instability episodes per season per athlete occurred. There were no further injuries attributable to the shoulder instability. Sixteen athletes underwent surgical stabilization for their shoulders during the subsequent off-season. Conclusions Most of the athletes were able to return to their sport and complete their seasons after an episode of anterior shoulder instability, although 37% experienced at least 1 additional episode of instability during the season.

Suprascapular nerve entrapment caused by supraglenoid cyst compression

Twenty-two cases of suprascapular nerve entrapment caused by supraglenoid cyst compression were reviewed. Pain and weakness were the presenting symptoms in 14 shoulders and pain alone in 8. Twenty of the cysts were diagnosed by magnetic resonance imaging, and two were confirmed at surgical exploration. Electromyography of 20 shoulders was positive for neurologic involvement for both the infraspinatus and supraspinatus in 4 cases, for the infraspinatus only in 12, and negative in 4. Sixteen shoulders were treated by open excision, arthroscopy, or both. Superior labral lesions were diagnosed in 11 of 12 patients who underwent arthroscopy. At follow-up 10 of the patients who underwent surgery had complete resolution of symptoms, 5 had occasional pain or weakness, and 1 recurrence required a second surgery. Of six patients treated without surgery, two improved and four had no change. Supraglenoid ganglion cysts are common and can easily be diagnosed by magnetic resonance imaging. For patients with symptoms arthroscopy with repair of the superior labral lesion and either arthroscopic debridement or direct open decompression and excision of the cyst is recommended.

Poly-l-lactic Acid Tack Synovitis after Arthroscopic Stabilization of the Shoulder*

Background Progress has been made in the design of bioabsorbable implants, with reduced complication rates and slower degradation times. Purpose To report on complications related to use of poly-L-lactic acid implants after arthroscopic shoulder stabilization procedures. Study Design Retrospective cohort study. Methods Between 1997 and 1999, 52 patients underwent arthroscopic stabilization at one institution with an average of 2.2 poly-L-lactic acid tacks. Ten patients (19%), with an average age of 30 years, developed delayed onset of symptoms at an average of 8 months after surgery, including pain in all 10 and progressive stiffness in 6. The patients underwent magnetic resonance imaging and arthroscopic evaluation and debridement. Results Nine patients had gross implant debris. Evidence of glenohumeral synovitis was seen arthroscopically in all 10 patients. Three patients had significant full-thickness chondral damage on the humeral head. All preexisting labral lesions were healed. One year after arthroscopic debridement, loose body removal, and synovectomy, seven patients reported no or minimal pain and full return of motion. Two patients continued to have persistent pain and stiffness, and one patient reported discomfort with overhand throwing; all three had chondral lesions. Conclusions Patients with symptoms of delayed pain and progressive stiffness after arthroscopic stabilization with poly-L-lactic acid implants should be evaluated for synovitis and chondral injury. Arthroscopic treatment provides a significant decrease in symptoms and increased range of motion.

Complications Observed Following Labral or Rotator Cuff Repair with Use of Poly-L-Lactic Acid Implants

BACKGROUND A variety of complications associated with the use of poly-L-lactic acid (PLLA) implants, including anchor failure, osteolysis, glenohumeral synovitis, and chondrolysis, have been reported in patients in whom these implants were utilized for labral applications. We report on a large series of patients with complications observed following utilization of PLLA implants to treat either labral or rotator cuff pathology. METHODS Patients who had undergone arthroscopic debridement to address pain and loss of shoulder motion following index labral or rotator cuff repair with PLLA implants were identified retrospectively with use of our research database. A total of forty-four patients in whom macroscopic anchor debris had been observed and/or biopsy samples had been obtained during the debridement were included in the study. Synovial biopsy samples taken at the time of the arthroscopic debridement were available for thirty-eight of the forty-four patients and were analyzed by a board-certified pathologist. Magnetic resonance imaging (MRI) scans acquired after the index procedure and data from the arthroscopic debridement were available for all patients. RESULTS Macroscopic intra-articular anchor debris was observed in >50% of the cases. Giant cell reaction was observed in 84%; the presence of polarizing crystalline material, in 100%; papillary synovitis, in 79%; and arthroscopically documented Outerbridge grade-III or IV chondral damage, in 70%. A significant correlation (rho = 0.36, p = 0.018) was observed between the time elapsed since the index procedure and the degree of chondral damage. A recurrent rotator cuff tear that was larger than the tear documented at the index procedure was observed in all patients whose index procedure included a rotator cuff repair. CONCLUSIONS Clinically important gross, histologic, and MRI-visualized pathology was observed in a large cohort of patients in whom PLLA implants had been utilized to repair lesions of the labrum or rotator cuff.

Transport and metabolism of pyridoxine in rat liver

Evidence, obtained with in situ perfused rat liver, indicated that pyridoxine is taken up from the perfusate by a non-concentrative process, followed by metabolic trapping. These conclusions were reached on the basis of the fact that at low concentrations (0.125 microM), the 3H of [3H]pyridoxine accumulated against a concentration gradient, but high concentrations (333 microM) of pyridoxine or 4-deoxypyridoxine prevented this apparent concentrative uptake. Under no conditions did the tissue water:perfusate concentration ratio of [3H]pyridoxine exceed unity. The perfused liver rapidly converted the labeled pyridoxine to pyridoxine phosphate, pyridoxal phosphate and pyridoxamine phosphate and released a substantial amount of pyridoxal and some pyridoxal phosphate into the perfusate. Since muscle and erythrocytes failed to oxidize pyridoxine phosphate to pyridoxal phosphate, it is suggested that the liver plays a major role in oxidizing dietary pyridoxine and pyridoxamine as their phosphate esters to supply pyridoxal phosphate which then reaches to other organs chiefly as circulating pyridoxal.

Outpatient shoulder surgery: A prospective analysis of a perioperative protocol

During a 10-month period, 106 consecutive outpatient shoulder procedures were done in 102 patients who were followed up prospectively for a minimum of 6 months. The procedures included arthroscopic surgery alone (60%) and open surgeries with or without associated arthroscopy (40%). The anesthetic protocol included propofol and nitrous oxide, without scalene block augmentation, and local 0.5% bupivacaine. Patients were discharged with oral analgesics. Ninety-five percent of the patients successfully underwent their procedure as an outpatient; only 5% required admission on the day of surgery, and none required readmission. There were no short-or long-term postoperative complications attributable to the protocol. Ninety-six percent of the patients were satisfied with their pain management, and all patients were satisfied with their overall experience.

Cost-benefit comparison: holmium laser versus electrocautery in arthroscopic acromioplasty.

This prospective study was designed to measure the costs and benefits of using a laser rather than electrocautery for soft tissue resection during arthroscopic shoulder decompression. Forty-nine shoulders with refractory Neer stage II impingement (persistent fibrosis and tendinitis) were divided into 2 groups. The composition of the 2 groups was similar with regard to sex, workers compensation status, dominant arm involvement, duration of symptoms, and length of conservative treatment. In one group, electrocautery was used to ablate the bursa and periosteum, release the coracoacromial ligament, and maintain hemostasis. In the other group, a laser was used in place of electrocautery. Patients had been evaluated preoperatively with 2 functional scoring systems. The patients were reexamined at 1 week and at 1, 2, 3, 6, and 12 months after surgery. There were no differences between the groups with regard to functional outcome or satisfaction. There was also no difference in terms of estimated blood loss or operative time. However, there was a statistically significant difference in total hospital charges between groups, with the laser group having a 23% higher hospital bill. On the basis of these results, it is concluded that there was no medical benefit to laser-assisted arthroscopic subacromial decompression but there was an increased monetary cost.

Diagnosis and Treatment of Ganglion Cysts about the Shoulder

With the advent of magnetic resonance imaging, supraglenoid cyst identification has become more common. A high incidence of type II SLAP lesions has been described in association with these cysts, which are frequently located in the region of the suprascapular notch. Clinical evaluation frequently reveals posterolateral shoulder pain and infraspinatus weakness and atrophy. We have successfully treated patients with symptomatic cysts using diagnostic arthroscopy followed by arthroscopic cyst decompression. All patients in our study were identified with a superior labral pathology and subsequently went on to have arthroscopic superior labral stabilization. Open decompression is reserved for patients when an adequate arthroscopic decompression cannot be confirmed, or a large cyst is associated with significant neurologic involvement of the infraspinatus or supraspinatus muscle, or both.

Arthroscopic Treatment of the Unstable Mesoacromion

Unstable symptomatic os acromiale is an unusual cause of impingement syndrome and rotator cuff pathology. Failure of nonoperative measures may require surgical intervention. Arthroscopic excision of the unstable bone fragment and treatment of any associated minor rotator cuff pathology have produced acceptable results.