Erik M. Fritz

Anterior Capsular Reconstruction for Irreparable Subscapularis Tears

Chronic anterior shoulder instability due to structural failure of the subscapularis muscle and the anterior capsule is a rare and challenging diagnosis for surgeons to manage because poor-quality capsular, labral, and rotator cuff tissue often limits effective treatment options. If primary repair is not possible because of retraction and poor tissue quality, reconstruction with an allograft or autograft may be the only joint-preserving option. The purpose of this article is to describe a surgical technique for anterior capsular reconstruction using a human acellular dermal allograft for the treatment of irreparable subscapularis tears.

Intramedullary Fixation of Midshaft Clavicle Fractures.

Summary: Clavicle fractures are among the most common fractures occurring in the general population, and the vast majority are localized in the midshaft portion of the bone. Management of midshaft clavicle fractures remains controversial. Although many can be managed nonoperatively, certain patient populations and fracture patterns, such as completely displaced and shortened fractures, are at risk of less optimal outcomes with nonoperative management; surgical intervention should be considered in such cases. The purpose of this article is to demonstrate our technique of midshaft clavicle fixation using minimally invasive intramedullary fixation.

Arthroscopic Treatment of Greater Tuberosity Avulsion Fractures

Isolated fractures of the greater tuberosity of the humerus are an uncommon and frequently missed diagnosis. Mistreated and unrecognized, these fractures can cause chronic pain and diminished shoulder range of motion and function. Operative treatment options include open reduction and internal fixation, as well as arthroscopic-assisted reduction and internal fixation. The purpose of this Technical Note is to describe a bridging arthroscopic technique for the treatment of bony avulsions of the supraspinatus tendon.

15 – Treatment Options: Distal Clavicle Fractures

The authors of this chapter review the anatomy, classification, indications, imaging, surgical techniques, complications and post-operative rehabilitation of distal clavicle fractures. Advanced arthroscopic techniques and open reduction internal fixation (ORIF) are discussed for high-risk young athletes.

Minimum Five-Year Outcomes and Clinical Survivorship Following Arthroscopic Double-Row Repair for Full-thickness Supraspinatus Tears

Objectives: Rotator cuff tears lead to significant morbidity due to pain and decreased function. Despite the prevalence of cuff repairs, mid-term outcomes have been scarcely reported. The purpose of this study is to report minimum 5-year outcomes and clinical survivorship after double-row rotator cuff repair for full-thickness supraspinatus tendon tears. Methods: Patients at least five years out from arthroscopic double-row repair for a full-thickness cuff tear involving the supraspinatus tendon were included. Pre- and postoperative ASES, SF-12 PCS, QuickDASH, SANE, and satisfaction scores were collected. The relationship between outcomes and (1) tear chronicity, (2) number of tendons involved, (3) type of repair, and (4) primary versus revision procedure, was also evaluated. Kaplan-Meier survivorship analysis was conducted defining failures as progression to revision rotator cuff surgery. Results: From November 2005 to February 2012, a total of 189 shoulders were eligible for inclusion. Fifteen shoulders (7.9%) underwent revision rotator cuff repair and were considered failures. Outcomes data were reported at a mean follow-up of 6.6 (range, 5.0-11.0) years. All outcome scores significantly improved from pre- to postoperative time point, including mean ASES (57.9 to 92.9, P < 0.001), SF-12 PCS (43.4 to 52.0, P < 0.001), QuickDASH (35.2 to 10.5, P < 0.001), and SANE scores (61.5 to 86.5, P < 0.001). Acute tears demonstrated significantly better ASES and SANE scores than chronic tears (ASES 95.1 ± 8.9 versus 91.7 ± 11.2, P = 0.025; SANE 89.6 ± 19.9 versus 85.7 ± 21.3, P = 0.042). No other analyzed variable had a significant association with outcomes scores (P > 0.05). Survivorship analysis demonstrated a postoperative clinical survivorship of the repair of 96.5% at two years and 93.8% at five years (Figure 1). Conclusion: Patients can expect excellent clinical outcomes and a low failure rate following arthroscopic double-row repair of full-thickness supraspinatus tears at mid-term follow-up. The repair of acute tears and primary repairs were associated with better postoperative outcomes.

Suprascapular Nerve Release with Rotator Cuff Tears

Suprascapular neuropathy is an increasingly recognized pathology associated with retracted large or massive rotator cuff tears; however, there is currently a paucity of data in the literature to guide optimal management. The cases presented emphasize the diagnostic workup, particularly electrodiagnostic studies, followed by a discussion of surgical technique for arthroscopic suprascapular nerve release for compression in the context of rotator cuff tears and after rotator cuff repair. Clinical studies have shown that most cases of suprascapular neuropathy associated with rotator cuff tears resolve following rotator cuff repair alone. In certain cases of irreparable tears or massive tears requiring extensive mobilization, release of the suprascapular nerve may be indicated. In addition, suprascapular neuropathy should be considered as a possible etiology in the differential in patients who experience weakness and pain following rotator cuff repair.

Failure following arthroscopic Bankart repair for traumatic anteroinferior instability of the shoulder: is a glenoid labral articular disruption (GLAD) lesion a risk factor for recurrent instability?

BACKGROUND Recurrent instability is a frequent complication following arthroscopic Bankart repair. The purpose of this study was to investigate risk factors for poor patient-reported clinical outcome scores and failure rates. METHODS Patients who underwent arthroscopic Bankart repair at least 2 years earlier were included. Preoperative and postoperative Single Assessment Numeric Evaluation; Quick Disabilities of the Arm, Shoulder and Hand; American Shoulder and Elbow Surgeons; and satisfaction scores were collected. The relationship of the following factors with outcomes and failure rates was assessed: (1) previous arthroscopic stabilization, (2) 3 or more dislocations prior to surgery, (3) glenoid labral articular disruption (GLAD) lesion, (4) concurrent superior labral anterior-to-posterior tear repair, and (5) concurrent biceps tenodesis. RESULTS The study included 72 patients with a median age of 23 years (range, 14-49 years). Subsequent revision was required in 9 (12.5%); 1 additional patient (1.4%) had recurrent dislocation. Outcome data were available at a median follow-up of 3 years (range, 2-9 years). All scores significantly improved from preoperatively to postoperatively (P <.05); the mean patient satisfaction score was 9, with a median of 10 (range, 1-10). None of the analyzed factors were associated with worse postoperative outcome scores. GLAD lesions were significantly associated with a higher rate of failure (P = .007). No other analyzed factors had a significant association with failure rates (P > .05). CONCLUSIONS Patients with arthroscopic Bankart repair for traumatic anteroinferior shoulder instability had excellent outcomes, even in the context of previous arthroscopic stabilization surgery, 3 or more dislocations prior to surgery, concurrent superior labral anterior-to-posterior tear repair, or concurrent biceps tenodesis. However, GLAD lesions were associated with higher rates of failure, and the presence of a GLAD lesion may herald the presence of changes in the articular version or other as-yet-undetermined factors that could predispose patients to failure.

Technique for Type IV SLAP Lesion Repair

Type IV SLAP tears involve bucket-handle tears of the superior labrum with the tears extending into the biceps tendon. Surgical treatment options involve either primary repair or biceps tenodesis. Recent literature has shown good clinical outcomes after subpectoral biceps tenodesis for the treatment of type II and IV SLAP lesions. The purpose of this article is to present our technique for arthroscopic superior labrum repair with suture anchors and open subpectoral biceps tenodesis with an interference screw.

Septic Arthritis After Anterior Cruciate Ligament Reconstruction: How Important Is Graft Salvage?:

Background: Septic arthritis (SA) of the knee after anterior cruciate ligament reconstruction (ACLR) is a rare but potentially devastating condition. In certain cases, graft removal becomes necessary. Purpose: To evaluate clinical, subjective, and radiologic outcomes of patients with SA after ACLR and assess whether graft retention has superior clinical results as compared with graft removal. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who were at least 12 months out from arthroscopic treatment of SA after isolated ACLR at our institution were eligible for inclusion. Patients were categorized into 2 groups: group 1, patients with initial graft retention; group 2, patients with initial graft removal. Group 2 was subdivided into 2 groups: group 2a, patients with graft reimplantation; group 2b, patients without graft reimplantation. Objective and subjective assessments were obtained at follow-up, including the International Knee Documentation Committee (IKDC) knee examination form, KT-1000 arthrometer measurements, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score, Lysholm score, and IKDC subjective evaluation. Radiologic assessment was performed with pre- and postoperative magnetic resonance imaging. Results: Of the 41 patients included, 33 (81%) were available for follow-up at a mean ± SD 54.7 ± 24.4 months at an age of 28.4 ± 9.3 years. When compared with patients from group 2 (n = 12), patients from group 1 (n = 21) obtained significantly better results on the objective IKDC score (normal or nearly normal: group 1, 66.6%; group 2, 36.4%; P = .047) and KT-1000 measurements (group 1, 1.3 ± 1.0 mm; group 2, 2.9 ± 1.5 mm; P = .005). Group 1 also scored better than group 2 on the Lysholm (P = .007), IKDC subjective (P = .011), and WOMAC (P = .069) measures. Between groups 2a (n = 4) and 2b (n = 8), no significant differences in outcomes could be detected (P values, .307-.705), although patients with anterior cruciate ligament graft reimplantation showed a clear tendency toward better results in objective and not subjective parameters. Magnetic resonance imaging evaluation showed higher rates of cartilage damage and meniscal tears among patients with graft resection versus graft retention. Conclusion: Patients with graft retention showed superior postoperative results when compared with patients who underwent initial graft resection, although subanalysis showed comparable outcomes between graft retention and reimplantation. Thus, while graft-retaining protocols should have the highest priority in the treatment of SA after ACLR, graft reimplantation should be performed in cases where graft resection becomes necessary, to avoid future cartilage and meniscal lesions. Finally, further studies with larger numbers of patients are needed to gain a better understanding of the outcomes of patients with SA after ACLR.

Open Subpectoral Biceps Tenodesis for Isolated Biceps Reflection Pulley Lesions: Minimum 2-year Outcomes in a Young Patient Population

Objectives: Biceps Reflection Pulley (BRP) lesion is a common generator of anterior shoulder pain and cause of biceps tendon instability. The purposes of this study were (1) to investigate if patients younger than 50 years had improved functional outcomes following open subpectoral biceps tenodesis (BT) for treatment of an isolated BRP lesion with a minimum follow-up of 2-years, and (2) to determine whether a correlation exists between patient age and outcomes scores. It was hypothesized that subpectoral BT would result in reduced pain, improved functional outcomes, and a high return-to-activity rate and that there would be no association between patient age and outcomes scores. Methods: This was an IRB-approved study with retrospective review of prospectively-collected data. All patients who had arthroscopically confirmed isolated BRP lesion treated with open subpectoral biceps tenodesis were at least 2 years out from surgery were included in the study. Patients with additional surgery on the index shoulder were excluded from the study. ASES (pain and function), QuickDASH, and SF-12 scores were collected pre- and postoperatively. Postoperative satisfaction (10-point scale) was also collected. The pre- and postoperative scores of each patient were compared with a Wilcoxon-test, and association between patient age and outcomes scores were investigated with a Spearman correlation test. Further, patient return-to-activity was evaluated by questionnaire. Failure was defined as revision surgery of the biceps tenodesis. Results: 14 shoulders in 14 patients (6 male, 8 female) with a mean age of 37 ± 8.9 years met the inclusion criteria. Minimum 2-year outcomes data were available for 13 (93%) shoulders. The mean follow-up time was 3.6 ± 1.3 years. There were significant improvements postoperatively for all outcome scores (p<0.05, see table 1) and no patients underwent revision surgery of the biceps tenodesis. There was no correlation between age and outcomes scores (p>0.05). Overall, median patient satisfaction was 9 out of 10 (range 3-10). Of 14 patients who answered the “return-to-activity” questions, 5 patients () reported return to activity with no modification; 9 patients reported return to activity with modifications. The 5 patients who returned to activity with no modification had significantly less time from initial injury/onset of symptoms until surgery in comparison to the 9 patients who modified their activity (p <0.05, see table 1). Conclusion: At minimum 2-year follow-up, patients with symptomatic isolated BRP lesions can expect excellent clinical outcomes, high satisfaction, and a high return-to-activity rate with little postoperative pain if treated with an open subpectoral BT close to the time of their initial injury/onset of symptoms. No differences in outcomes were observed upon patient age. Table 1: Pre- and postoperative outcomes scores and p-values. Values are expressed as median (range) unless otherwise indicated. Test Preoperative Postoperative p-value ASES Total 62 (33-80) 97 (28-100) 0.017 ASES Func 29 (13-38) 45 (18-50) 0.005 ASES pain 35 (15-50) 50 (10-50) 0.034 QuickDash 39(11-70) 7(0-54) 0.002 SF-12 PCS 43 (22-58) 56 (39-59) 0.003 Satisfaction - 9 (3-10) - Return to activity – Patients (Percent) Time until surgery (days) - 5 (36%) no modifications 215 (49-414)9 (64%) w/ modications 1375 (79-7472) P = 0.028