Jae-Chul Yoo

Arthroscopic Posterior Labral Repair and Capsular Shift for Traumatic Unidirectional Recurrent Posterior Subluxation of the Shoulder

BACKGROUND The purpose of this study was to evaluate the results of arthroscopic treatment of traumatic unidirectional recurrent posterior subluxation of the shoulder. METHODS We treated twenty-seven patients who had traumatic unidirectional recurrent posterior subluxation of the shoulder with arthroscopic labral repair and posterior capsular shift, and we evaluated them at a mean of thirty-nine months postoperatively. Patients who had posteroinferior instability, multidirectional instability, or an atraumatic onset or who were undergoing revision were excluded. There were twenty-five male and two female patients with a mean age of twenty-one years (range, fourteen to thirty-three years). All patients were involved in sports activity, and all had had a substantial injury prior to the onset of the instability. Results were assessed on the basis of stability, motion, and UCLA (University of California at Los Angeles), ASES (American Shoulder and Elbow Surgeons), and Rowe scores. Pain and function were also evaluated with visual analog scales. RESULTS All patients had one or more lesions in the posteroinferior aspect of the labrum and capsule. The most common finding was incomplete stripping of the posteroinferior aspect of the labrum (eighteen patients). At the arthroscopy, the posteroinferior aspect of the capsule appeared to be stretched in twenty-two patients. At the time of follow-up, all patients had improved shoulder function and scores (p < 0.01). All patients also had a stable shoulder according to subjective and objective measurements, except for one patient who had recurrent subluxation. Except for that patient, all patients were able to return to their prior sports activity with little or no limitation. Shoulder function was graded as >90% of the preinjury level in twenty-four patients. There were twenty-one excellent UCLA scores, five good scores, and one fair score. The average pain score improved from 4.5 points preoperatively to 0.2 point at the time of follow-up (p < 0.0001). The mean loss of internal rotation was one vertebral level. There were no operative complications. CONCLUSIONS Arthroscopic posterior labral repair and capsular shift to treat traumatic unidirectional recurrent posterior subluxation is a reliable procedure with respect to providing stability, pain relief, and functional restoration.

Clinical Results of Single-Tunnel Coracoclavicular Ligament Reconstruction Using Autogenous Semitendinosus Tendon

Background Over 60 repair/reconstruction techniques have been described for the treatment of coracoclavicular (CC) ligament injuries. Purpose To report the functional and radiological outcomes of single-tunnel CC ligament reconstruction using autogenous semitendinosus tendon. Study Design Case series; Level of evidence, 4. Methods Between August 2005 and January 2008, a total of 21 patients, 16 patients (14 men, 2 women) with a Rockwood type IV, type V, or a chronic type III acromioclavicular (AC) dislocation and 5 patients (4 men, 1 woman) with a painful nonunited distal clavicle fracture with CC separation, underwent CC reconstructive surgery using a semitendinosus autograft. All 21 patients were followed up clinically and radiographically. The mean follow-up was 33 months (range, 18-47), and the mean patient age was 39.8 years (range, 18-70). Chronic type III AC dislocations and nonunited distal clavicle fractures with CC separation were scored using preoperative AC scoring (AC Joint Separation Questionnaire). Constant, University of California—Los Angeles (UCLA), and AC scores were evaluated for all patients at final follow-up. Results At the final follow-up, 10 patients achieved an “excellent” result and 11 a “good” result according to the AC scoring scheme. Mean final Constant and UCLA scores were 84.7 (range, 67-94) and 30.0 (range, 23-35), respectively. In the anteroposterior (AP) plane, 17 (81%) of the 21 patients maintained complete reduction, and 1 of the remaining 4, a manual laborer, had complete reduction loss. Of the 17 patients with an axillary view at final follow-up, 1 patient (5.9%) showed partial subluxation, although no subluxation was observed in the AP radiograph. The other 16 patients (94.1%) had a complete reduction state in axillary view. Conclusion Single-tunnel CC reconstruction with an autogenous hamstring tendon graft after a mean follow-up of 33 months (range, 18-47) appears to be a satisfactory means of treating acute Rockwood type IV, V, chronic type III, and painful nonunited distal clavicle fractures with CC separation.

Three-dimensional Isotropic Shoulder MR Arthrography: Comparison with Two-dimensional MR Arthrography for the Diagnosis of Labral Lesions at 3.0 T

PURPOSE To compare the diagnostic accuracy of three-dimensional (3D) isotropic magnetic resonance (MR) arthrography with two-dimensional (2D) MR arthrography for the diagnosis of labral lesions of the shoulder performed by using a 3.0-T imager. MATERIALS AND METHODS Institutional review board approval was given for this retrospective study and informed consent was waived. From March 2006 to January 2007, 100 patients underwent 3D isotropic and 2D MR shoulder arthrographic imaging by using a 3.0-T imager and subsequent arthroscopic surgery. The 3D isotropic sequences were performed by using fast gradient-echo imaging with fat suppression (voxel size, 0.6 x 0.6 x 0.6 mm; imaging time, 5 minutes 32 seconds) and were evaluated for the presence of superior, anterior, and posterior labral lesions by using 3D isotropic and 2D MR arthrography. The statistical differences between the sensitivity and specificity for both methods were analyzed by using the McNemar test, with arthroscopic findings regarded as reference standard. RESULTS Surgical findings confirmed 53 superior labral anterior posterior (SLAP) lesions, 17 anterior labral lesions, and five posterior labral lesions. Respective sensitivity and specificity were 85% and 96% for SLAP lesions, 100% and 98% for anterior labral lesions, and 80% and 99% for posterior labral lesions by using 2D MR arthrography and 83% and 96% for SLAP lesions, 100% and 96% for anterior labral lesions, and 80% and 99% for posterior labral lesions by using 3D isotropic MR arthrography. There was no significant difference in sensitivities and specificities of both methods; however, the power of this study was limited and larger comparison is needed. CONCLUSION Isotropic 3D shoulder MR arthrography combined with a multiplanar reconstruction technique can help in the diagnosis of shoulder labral lesions as does 2D MR arthrography, but with shorter imaging times.

Comparison of indirect isotropic MR arthrography and conventional MR arthrography of labral lesions and rotator cuff tears: a prospective study.

OBJECTIVE The purpose of our study was to prospectively compare the diagnostic accuracy of 3D isotropic indirect MR arthrography with conventional sequences of indirect MR arthrography for the diagnosis of labral and rotator cuff lesions on a 3-T MR unit. SUBJECTS AND METHODS Thirty-six consecutive patients who were scheduled for shoulder arthroscopic surgery at our institution underwent indirect MR arthrography. Both conventional sequences and an additional 3D isotropic sequence were obtained 1 day before arthroscopic surgery. Two musculoskeletal radiologists prospectively evaluated the images in consensus for the presence of superior and anterior labral lesions and subscapularis and supraspinatus-infraspinatus tendon tears using the conventional sequences and the 3D isotropic sequence. We analyzed the statistical difference between the sensitivities and specificities of both methods using arthroscopic findings as the reference standard. RESULTS Surgical findings confirmed the presence of 23 superior labral lesions, eight anterior labral lesions, 21 subscapularis tears, and 24 supraspinatus-infraspinatus tears. The sensitivity and specificity of the conventional sequences were 74% and 54% for superior labral lesions, 88% and 96% for anterior labral lesions, 67% and 85% for subscapularis tendon tears, and 96% and 75% for supraspinatus-infraspinatus tendon tears. The sensitivity and specificity of the 3D isotropic sequence were 70% and 85% for superior labral lesions, 100% and 100% for anterior labral lesions, 67% and 85% for subscapularis tendon tears, and 96% and 67% for supraspinatus-infraspinatus tendon tears. No statistically significant difference was seen in sensitivities and specificities for both methods. CONCLUSION Three-dimensional isotropic MR arthrography sequences with multiplanar reconstruction can provide a similar capability for the diagnosis of labral and rotator cuff lesions as conventional MR arthrography sequences but in a shorter imaging time.

Arthroscopic Knot Tying

Arthroscopy has evolved from a merely diagnostic procedure to a therapeutic procedure, with most reconstructive procedures being done by arthroscopy. Suturing has been the cornerstone of all reconstructive surgeries to hold the tissues together and without excessive tension to facilitate healing and knot tying has been practiced for centuries. Arthroscopic shoulder reconstructive procedures also employ sutures and knots, and every shoulder surgeon must understand the principle and learn the technique of arthroscopic knots. Though the principles of repair are the same, arthroscopic reconstruction is different from open techniques in that suturing is much more difficult in arthroscopic procedures. The surgeon has to suture tissues at a distance, under the constraint of cannula and in a wet field. This necessitates the use of knot pusher and placement of knot with asymmetric tensioning of suture limbs. Surgeon does not have the benefit of tactile feedback as in tying open knots. Furthermore, the knot is often tightened at an acute angle to suture and not perpendicular to defect, an ideal situation described in open knotting.

The "bridging sign": a MR finding for combined full-thickness tears of the subscapularis tendon and the supraspinatus tendon

Background In daily practice, we discovered one of the secondary magnetic resonance (MR) findings of the subscapularis (SSC) tendon tear, the “bridging sign”, which has not been previously described. Purpose To describe the “bridging sign” on shoulder MR imaging and its radiological and clinical significance in patients with SSC tendon tear. Material and Methods Twenty-nine patients who had undergone shoulder arthroscopy and had full-thickness tear of the subscapularis tendon were enrolled. The medical records of the 29 patients were retrospectively reviewed for the duration of shoulder pain, rotator cuff tears, and associated arthroscopic findings: biceps tendon abnormality and superior glenoid labral tear. Then, preoperative shoulder MR images were retrospectively reviewed for the presence or absence of the “bridging sign” and associated MR findings: periarticular fluid and fatty atrophy of the supraspinatus and subscapularis muscles. The type of rotator cuff tear associated with the “bridging sign” was assessed and the sensitivity, specificity, and accuracy of the “bridging sign” for the diagnosis of a certain type of rotator cuff tear were calculated. Associated arthroscopic and MR findings and mean duration of the shoulder pain between the patients with and without the “bridging sign” were compared. Results The “bridging sign” was seen in 17 of 29 patients and corresponded to a complex of the torn and superomedially retracted subscapularis tendon, coracohumeral ligament, and superior glenohumeral ligament, adhered to the anterior margin of the torn supraspinatus (SSP) tendon on arthroscopy. All patients with the “bridging sign” had combined full-thickness tear (FTT) of the cranial 1/2 portion of the subscapularis tendon and anterior 1/2 portion of the SSP tendon. The sensitivity, specificity, and accuracy of the “bridging sign” for the diagnosis of combined FTTs of the SSC tendon and anterior portion of the SSP tendon were 81.0%, 100%, and 86.2%, respectively. The patients with the “bridging sign” had longer duration of shoulder pain and more frequent associated arthroscopic and MR findings than the patients without the “bridging sign”. Conclusion The “bridging sign” is a highly specific finding for combined full-thickness tears of the subscapularis tendon and anterior portion of the supraspinatus tendon, associated with more chronic shoulder pain and more sever rotator cuff tear.

Epinephrine in irrigation fluid for visual clarity in arthroscopic shoulder surgery: a systematic review and meta-analysis

PurposeTo investigate whether epinephrine in irrigation fluid improves visual clarity in arthroscopic shoulder surgery.MethodsWe performed a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared the surgical outcomes of patients who did and did not receive epinephrine during arthroscopic shoulder surgery. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for relevant RCTs. We used the Cochrane Collaboration’s tool to assess the risk of bias and adopted random-effects model meta-analysis to combine data. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to evaluate the overall quality of the body of the retrieved evidence. The primary outcome was visual clarity. The secondary outcomes were operative time, amount of irrigation fluid, the need for increased pump pressure, and adverse cardiovascular events.ResultsThis study included three RCTs with a total of 238 participants (124 in the epinephrine group and 114 in the non-epinephrine group). The use of epinephrine in irrigation fluid for shoulder arthroscopy achieved better visual clarity (standardized mean difference, 1.01; 95% confidence interval [CI] 0.63 to 1.39; p < 0.0001) and less need for increased pump pressure (risk ratio, 0.40; 95% CI 0.25 to 0.64; p = 0.0001) compared to the non-epinephrine group. No significant differences were noted in operative time (mean difference − 5.08; 95% CI − 14.46 to 4.31; p = 0.29) and amount of irrigation fluid (mean difference − 1.04; 95% CI − 2.38 to 0.39; p = 0.12) between the two groups. No adverse events were recorded in any of the included trials.ConclusionsThe current evidence shows that the use of epinephrine in arthroscopic shoulder surgery may improve visualization and does not appear to have any major disadvantages.Level of evidenceLevel I