Felix H. Savoie

Arthroscopic repair of large and massive rotator cuff tears.

PURPOSE The purpose of this study was to evaluate the outcome of arthroscopically repaired large and massive rotator cuff tears at 1- to 5-year follow-up. TYPE OF STUDY Retrospective chart review. METHODS Sixty consecutive patients who had arthroscopically repairable large or massive tears were identified by retrospective chart review. Large tears are defined as defects in the cuff measuring from 3 to 5 cm and massive tears measuring greater than 5 cm. Ten of these patients were lost to follow-up before 1 year postoperatively and were excluded from the study. The remaining 50 were the focus of this study. RESULTS Thirty-seven patients had large tears and 13 had massive tears. Follow-up averaged 32 months (range, 12 to 63 months). Based on the University of California Los Angeles shoulder rating, 88% of patients had good or excellent outcomes. Although 6 patients were considered failures based on the UCLA score, 98% of patients were satisfied with the result. Only 1 of these failures underwent a second operation for revision repair. There was no significant difference in final scores when comparing the massive tears to the entire group, but all preoperative scores were lower for those with massive tears than the large tears. CONCLUSIONS Arthroscopic management of large and massive tears results in good or excellent outcomes in 88% of patients, which is comparable to reported outcomes following open repairs.

Arthroscopic treatment of multidirectional instability.

Multidirectional instability of the shoulder, described by Neer and Foster, has been treated surgically with the inferior capsular shift procedure. The small number of reports on mid-term outcomes indicate that good to excellent results have been obtained in 75% to 100% of cases. Arthroscopic treatment of multidirectional instability has been previously described. The purpose of this study was to review the results of the arthroscopic capsular shift procedure with a minimum follow-up of 2 years. A retrospective study was performed on 25 patients who underwent an arthroscopic capsular shift performed with the transglenoid technique between January 1990 and December 1993. All patients had earlier not responded to an extensive course of physical therapy. Excluded from the study were patients who had undergone a previous arthroscopic capsular shift or any other procedure, arthroscopic or open, for the shoulder. Average patient age was 26.4 years. There were 20 male and 5 female patients. Sixteen of the affected shoulders involved the dominant extremity. All patients had a history of asymptomatic subluxation that slowly progressed to symptomatic subluxation. Eleven patients had a history of dislocation. Thirteen patients were athletes who were symptomatic in their chosen sport, whereas the other patients were symptomatic in activities of daily living. All patients were examined while they were under anesthesia and had positive results on the sulcus test in abduction with associated anterior instability, posterior instability, or both. Follow-up evaluation was performed with patient interview and examination. All 25 patients were available for follow-up, which occurred an average of 60 months (range 36 to 80 months) after operation. Three patients had episodes of instability after the operation. The average Bankart score was 95 (range of 50 to 100). All but 1 patient had regained full symmetric range of motion by follow-up. Twenty-one (88%) patients had a satisfactory result according to the Neer system. Results of treatment with the arthroscopic capsular shift procedure for multidirectional instability of the shoulder appear to be comparable to those of the open inferior capsular shift.

Common Elbow Injuries in Sport

Athletes of all ages and skill levels are increasingly participating in sports involving overhead arm motions, making elbow injuries more common. Among these injuries is lateral epicondylitis, which occurs in over 50% of athletes using overhead arm motions. Lateral epicondylitis is characterised by pain in the area where the common extensor muscles meet the lateral humeral epicondyle. The onset of this pathological condition begins with the excessive use of the wrist extensor musculature. Repetitive microtraumatic injury can lead to mucinoid degeneration of the extensor origin and subsequent failure of the tendon. Lateral epicondylitis can almost always be treated nonoperatively with activity modification and specific exercises. If the athlete fails to respond to nonoperative treatment after 6 months to 1 year, they are candidates for surgical intervention.Medial epicondylitis is characterised by pain and tenderness at the flexorpronator tendinous origin with pathology commonly being located at the interface between the pronator teres and flexor carpi radialis origin. Golfers and tennis players often develop this condition because of the repetitive valgus stress placed on the medial elbow soft tissues. Careful evaluation is important to differentiate medial epicondylitis from other causes of medial elbow pain. As with lateral epicondylitis, patients with medial epicondylitis not responding to an extensive nonoperative programme are candidates for surgical intervention.A less common cause of medial elbow pain is medial ulnar collateral ligament injury. Repetitive valgus stress placed on the joint can lead to microtraumatic injury and valgus instability. When the medial ulnar collateral ligament is disrupted, abnormal stress is placed on the articular surfaces that can lead to degenerative changes with osteophyte formation. As with other elbow injuries, a strict rehabilitation regimen is first employed; ligament reconstruction is only recommended if the injury fails to improve and only in athletes requiring a high level of performance. Excessive valgus stress can also lead to posteromedial olecranon impingement on the olecranon fossa producing pain, osteophyte and loose body formation. Arthroscopic elbow debridement can often be helpful in improving motion and in reducing pain in such patients.

Osteochondritis dissecans of the elbow

Osteochondritis dissecans of the elbow remains a difficult problem to manage in the young athlete. Though the etiology is unclear, a definite association between overuse with repetitive microtraumatic insult and OCD has been established. Early detection and appropriate treatment can provide the best chance for preventing an unfavorable outcome. In many cases, conservative treatment regimens will provide complete resolution of symptoms, return of function, and full recovery, including return to sports participation. Surgical indications should be recognized, however, and surgical management carried out when warranted. Most authors treat unstable lesions primarily by excision of the fragment, accompanied by drilling or burring of the base of the lesion. Symptoms usually improve significantly, but approximately half of all patients will continue to experience chronic pain or limitation of elbow motion, highlighting the significance and severity of OCD of the elbow.

Operative Treatment of Ulnar Collateral Ligament Insufficiency of the Elbow in Female Athletes

Background As women become more involved in athletic activity, injuries specific to this population also increase. No data exist regarding operative treatment of female patients with elbow instability secondary to ulnar collateral ligament insufficiency. Hypothesis Women with symptomatically unstable elbows who failed nonoperative treatment will improve after surgical intervention. Study Design Case series; Level of evidence, 4. Methods Nineteen women were retrospectively evaluated using the Andrews and Carson Elbow Outcome Score. Patients were included if they underwent repair or reconstruction of the ulnar collateral ligament for symptomatic instability that precluded them from participation in their desired sport or activities, despite nonoperative treatment. Results The mean age was 22.0 years (range, 15.1-37.2 years). The mean follow-up was 38.8 months (range, 12.4-68.6 months). Of the 19 patients, 14 were softball players, gymnasts, and tennis players. Only 1 was a pitcher. Eighteen women underwent repair by one of the following procedures: plication (n = 6), repair to bone using anchors (n = 11), or drill holes (n = 1). One patient underwent a palmaris graft reconstruction. The mean overall preoperative outcome score of 120 improved to 191 postoperatively (P< .0001). Seventeen of 18 athletes were able to return to their sport at a mean of 2.5 months postoperatively. One patient did not participate in athletics. Conclusion This study demonstrated excellent overall results in 16 and good results in 3 female patients after medial elbow repair or reconstruction. Women appear to be able to consistently return to a high level of function after repair or reconstruction for medial elbow instability.

The arthroscopic evaluationand management of elbow trauma and instability

The arthroscope is a useful tool in the evaluation and management of some traumatic elbow injuries and instabilities. Certain elbow fractures and articular injuries are amenable to arthroscopic diagnosis and treatment. Some radial head fractures can be accurately assessed and reduced, and fixation achieved using arthroscopically assisted techniques. Other elbow fractures occasionally can also be treated arthroscopically. The arthroscope also serves an important role not only in the diagnosis and management of elbow instability but also in the treatment of those intra-articular changes that occur as a result of chronic instability. Removal of loose bodies and osteophytes can be effectively accomplished arthroscopically.

Anterosuperior instability and the rotator interval

Abstract An improved understanding of the anatomy of the anterosuperior quadrant of the shoulder and the contributions that these structures make to shoulder stability along with the advances in shoulder arthroscopy have allowed for the recognition and delineation of a number of pathologic conditions. Traumatic avulsion of the superior and/or the middle glenohumeral ligaments can and do occur in the clinical setting, and these capsulolabral disruptions respond very effectively to arthroscopic reconstruction when nonsurgical measures have failed. Another important structure found in the anterosuperior quadrant of the shoulder includes the rotator interval capsule, which has been shown to contribute significantly to stability of the shoulder in both mechanical and clinical studies. Arthroscopic plication of the rotator interval capsule is effective in stabilizing selected cases of shoulder instability and in supplementing other arthroscopic stabilization procedures. This article describes the clinical and arthroscopic findings found with anterosuperior quadrant pathology and provides insights into differentiating pathology from normal variant anatomy. Surgical techniques involved in superior and middle glenohumeral ligament reconstruction as well as arthroscopic rotator interval plication are also described in detail.