Jason Old

Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review

Department of Orthopaedic Surgery and Sports Traumatology, Hopital de L’Archet II, University of Nice Sophia-Antipolis, Nice, France Department of Orthopaedic Surgery and Traumatology, University of Bern, Inselspital, Bern, Switzerland Shoulder and Elbow Service, Section of Orthopaedic Surgery, University of Manitoba, Pan Am Clinic, Winnipeg, MB, Canada Department of Orthopaedic Surgery, Clinica Las Condes, Santiago, Chile

Arthroscopic Bankart-Bristow-Latarjet (2B3) Procedure: How to Do It and Tricks To Make it Easier and Safe

The all-arthroscopic technique that the authors propose combines a Bristow-Latarjet procedure with a Bankart repair. This combined procedure provides a triple blocking of the shoulder (the so-called 2B3 procedure): (1) the labral repair recreates the anterior bumper and protects the humeral head from direct contact with the coracoid bone graft (Bumper effect); (2) the transferred coracoid bone block compensates for anterior glenoid bone loss (Bony effect); and (3) the transferred conjoined tendon creates a dynamic sling that reinforces the weak anteroinferior capsule by lowering the inferior part of the subscapularis when the arm is abducted and externally rotated (Belt or sling effect). The procedure combines the theoretic advantages of the Bristow-Latarjet procedure and the arthroscopic Bankart repair, eliminating the potential disadvantages of each. The extra-articular positioning of the bone block together with the labral repair and capsule retensioning allows the surgeon to perform a nearly anatomic shoulder repair. This novel procedure allows the surgeon to extend the indications of arthroscopic shoulder reconstruction to the subset of patients with recurrent anteroinferior shoulder instability with glenoid bone loss and capsular deficiency. It is an attractive surgical option to treat patients with a previous failed capsulolabral repair for which the surgical solutions are limited.

Ipsilateral Versus Contralateral Hamstring Grafts in Anterior Cruciate Ligament Reconstruction A Prospective Randomized Trial

Background: Benefits of graft harvest from the side contralateral to the anterior cruciate ligament (ACL)–deficient leg have been identified when using bone–patellar tendon–bone autografts in ACL reconstruction (ACLR). As hamstring tendon autografts are becoming more commonly used, a study examining the effect of contralateral graft harvest of semitendinosus gracilis (STG) tendons on patient quality of life was conducted. Purpose: To evaluate if ACLR using a hamstring tendon autograft results in better patient quality of life if the graft is harvested from the leg contralateral to the ACL rupture compared with the ipsilateral leg. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 100 participants between 16 and 50 years of age with a complete ACL tear were randomly assigned to undergo ACLR using either the ipsilateral or contralateral leg as the STG graft donor. Primary outcome measures were the ACL Quality of Life questionnaire (ACL-QOL), concentric knee flexion and extension strength at 60 and 240 deg/s, International Knee Documentation Committee (IKDC) knee assessment form, early postoperative pain and diary of analgesic use, and rate of reruptures. Outcome measures were evaluated before surgery and at 3, 6, 12, and 24 months after surgery. Results: The ACL-QOL score improved over time for both groups (P < .001), and there were no significant differences between groups at any time point (P = .528). Significant differences in knee flexion and extension strength were found at 3 months after surgery. There were no differences between groups in IKDC knee assessment scores or rerupture rates. Conclusion: There does not appear to be any measurable benefit or drawback in quality of life to the use of an STG graft from the unaffected limb. In light of this finding, further research to examine other possible effects on agility and balance as well as time and ability to return to sport should be conducted. Longer term follow-up beyond 2 years would allow for a more thorough evaluation of the risk of reruptures or contralateral reruptures using this novel approach.

Shoulder Arthroscopy Does Not Adequately Visualize Pathology of the Long Head of Biceps Tendon

Background: Pulling the long head of the biceps tendon into the joint at arthroscopy is a common method for evaluation of tendinopathic lesions. However, the rate of missed diagnoses when using this technique is reported to be as high as 30% to 50%. Hypothesis: Tendon excursion achieved using a standard arthroscopic probe does not allow adequate visualization of extra-articular sites of predilection of tendinopathy. Study Design: Descriptive laboratory study. Methods: Seven forequarter amputation cadaveric specimens were evaluated. The biceps tendon was tagged to mark the intra-articular length and the maximum excursions achieved using a probe and a grasper in both beach-chair and lateral positions. Statistical analyses were performed using analysis of variance to compare means. Results: The mean intra-articular and extra-articular lengths of the tendons were 23.9 and 82.3 mm, respectively. The length of tendon that could be visualized by pulling it into the joint with a probe through the anterior midglenoid portal was not significantly different when using either lateral decubitus (mean ± SD, 29.9 ± 3.89 mm; 95% CI, 25.7-34 mm) or beach-chair positions (32.7 ± 4.23 mm; 95% CI, 28.6-36.8 mm). The maximum length of the overall tendon visualized in any specimen using a standard technique was 37 mm. Although there was a trend to greater excursion using a grasper through the same portal, this was not statistically significant. However, using a grasper through the anterosuperior portal gave a significantly greater mean excursion than any other technique (46.7 ± 4.31 mm; 95% CI, 42.6-50.8 mm), but this still failed to allow evaluation of Denard zone C. Conclusion: Pulling the tendon into the joint with a probe via an anterior portal does not allow visualization of distal sites of predilection of pathology. Surgeons should be aware that this technique is inadequate and can result in missed diagnoses. Clinical Relevance: This study demonstrates that glenohumeral arthroscopy does not allow visualization of common areas of pathology of the long head of the biceps tendon.

Does External Rotation Bracing for Anterior Shoulder Dislocation Actually Result in Reduction of the Labrum? A Systematic Review

Background: External rotation (ER) bracing has been shown to improve labral reduction in cadaveric studies, but this has not translated to universal improvement in re-dislocation rates in clinical series. Purpose: To systematically review and critically appraise the literature that investigates how well the labrum is actually reduced by ER in patients who have had an anterior shoulder dislocation. Study Design: Systematic review. Methods: We conducted a systematic review of the literature using the online databases Medline, EMBASE, and the Cochrane Controlled Trial Register. Studies were included if they reported on the difference in labral reduction after ER and internal rotation bracing in patients who had a traumatic anterior shoulder dislocation. Results: Of the 6 studies included, 5 assessed labral reduction on magnetic resonance imaging and 1 arthroscopically. Each study reported an overall improvement in labral reduction with ER, but anatomic reduction was not commonly achieved. This was despite the use of extreme positions that are unlikely to be well tolerated. Conclusion: External rotation results in anatomic reduction of the labrum in only 35% of cases. We postulate that failure to reduce the labrum may be a contraindication to ER bracing and propose further study to determine whether acute MRI could be used to help identify patients in whom ER achieves labral reduction in a comfortable position. This approach also has the advantage of avoiding the significant inconvenience of ER bracing in those in whom the labrum does not reduce and are therefore theoretically less likely to benefit. However, it is a novel strategy with significant resource implications and therefore warrants further study.

Postoperative deep shoulder infections following rotator cuff repair

Rotator cuff repair (RCR) is one of the most commonly performed surgical procedures in orthopaedic surgery. The reported incidence of deep soft-tissue infections after RCR ranges between 0.3% and 1.9%. Deep shoulder infection after RCR appears uncommon, but the actual incidence may be higher as many cases may go unreported. Clinical presentation may include increasing shoulder pain and stiffness, high temperature, local erythema, swelling, warmth, and fibrinous exudate. Generalized fatigue and signs of sepsis may be present in severe cases. Varying clinical presentation coupled with a low index of suspicion may result in delayed diagnosis. Laboratory findings include high erythrocyte sedimentation rate and C-reactive protein level, and, rarely, abnormal peripheral blood leucocyte count. Aspiration of glenohumeral joint synovial fluid with analysis of cell count, gram staining and culture should be performed in all patients suspected with deep shoulder infection after RCR. The most commonly isolated pathogens are Propionibacterium acnes, Staphylococcus epidermidis, and Staphylococcus aureus. Management of a deep soft-tissue infection of the shoulder after RCR involves surgical debridement with lavage and long-term intravenous antibiotic treatment based on the pathogen identified. Although deep shoulder infection after RCR is usually successfully treated, complications of this condition can be devastating. Prolonged course of intravenous antibiotic treatment, extensive soft-tissue destruction and adhesions may result in substantially diminished functional outcomes.

Biceps Tenoscopy: Arthroscopic Evaluation of the Extra-articular Portion of the Long Head of Biceps Tendon

The recent literature shows that imaging modalities, physical examination tests, and glenohumeral arthroscopy all have low sensitivities and specificities with respect to the diagnosis of the long head of biceps tendon pathology. Biceps tenoscopy is a strategy that aims to reduce the rate of missed diagnoses by improving visualization of the extra-articular part of the tendon. This is an area of predilection of pathology that is not adequately visualized with conventional arthroscopic techniques. This technical note presents the surgical technique for biceps tenoscopy.

Outcomes for intra-substance free coracoid graft in patients with antero-inferior instability and glenoid bone loss in a population of high-risk athletes at a minimum follow-up of 2 years

Background The aim of this retrospective case series study was to assess the outcomes of patients with recurrent anterior shoulder instability with antero-inferior glenoid bone loss treated with a specific open stabilization technique using intra-substance coracoid bone-grafting and Bankart repair. Methods Over a 4-year period, 34 shoulders in all male patients of mean age 21 years were stabilized with this technique. Pre- and postoperative function, motion and stability were assessed as part of Rowe stability scoring, and American Shoulder and Elbow Surgeons (ASES) and Oxford Instability were recorded, with at least 2 years of follow-up in all patients. Union of the graft was determined by post-operative computed tomography (CT) of the affected shoulder. Results For all cases, two redislocations (5.9%) and two subluxations occurred when continuing high-risk sport after 2 years. Post-operative scores [median, mean (SD): Rowe 77.5, 77.2 (19.5); ASES 94.2, 92 (7.7); Oxford 43, 41.2 (6)]. CT scans on 28 shoulders at a mean of 4.5 months after surgery showed non-union in three cases (10%). Conclusions These results demonstrate a high rate of success in cases of glenoid bone loss in the young contact athlete with recurrent instability treated with open stabilization and bone grafting.

Massive Acromioclavicular Joint Cyst with Intramuscular Extension: Case Report and Review

Acromioclavicular cysts are an uncommon manifestation secondary to a massive rotator cuff tear and/or a degenerative osteoarthritic AC joint. We present a case of an 80-year-old female with a symptomatic acromioclavicular cyst that extended intramuscularly into the trapezius. She did not complain of symptoms associated with a massive rotator cuff tear; however, the cyst has been increasing in size and she was interested in having it removed. Intraoperatively, the mass extended into the trapezius muscle and was removed en bloc after dissecting it down to the stalk. A distal clavicle excision was then performed using an oscillating saw. After the cyst was excised, it was incised revealing thick mucoid content. The patient did well postoperatively at the three-month follow-up without signs of recurrence. To our knowledge, this is the first case of AC joint cyst with intramuscular extension that was managed operatively.

First-time anterior shoulder dislocation natural history and epidemiology: immobilization versus early surgical repair

Traumatic anterior shoulder dislocations are a common problem. There is a high rate of recurrent instability, especially in patients <30 years of age that are involved in high level sports. The purpose of this review is to discuss the natural history after a first-time shoulder dislocation and provide a brief overview of management options. Initial nonoperative management consists of immobilization in internal rotation for 1–3 weeks. The current evidence does not support immobilization in external rotation or for longer periods of time. For those patients who are at a high risk of recurrent instability, the evidence suggests that early surgical repair to address the pathology can be undertaken. This has shown to be clinically and fiscally effective while improving patient outcomes.