Joe F. de Beer

Arthroscopic rotator cuff repair with double-row fixation.

BACKGROUND The treatment of rotator cuff tears has evolved from open surgical repairs to complete arthroscopic repairs over the past two decades. In this study, we reviewed the results of arthroscopic rotator cuff repairs with the so-called double-row, or footprint, reconstruction technique. METHODS Between 1998 and 2002, 264 patients underwent an arthroscopic rotator cuff repair with double-row fixation. The average age at the time of the operation was fifty-nine years. Two hundred and thirty-eight patients (242 shoulders) were available for follow-up; 210 were evaluated with a full clinical examination and thirty-two, with a questionnaire only. Preoperative and postoperative examinations consisted of determination of a Constant score and a visual analogue score for pain as well as a full physical examination of the shoulder. Ultrasonography was done at a minimum of twelve months postoperatively to assess the integrity of the cuff. RESULTS The average score for pain improved from 7.4 points (range, 3 to 10 points) preoperatively to 0.7 point (range, 0 to 3 points) postoperatively. The subjective outcome was excellent or good in 220 (90.9%) of the 242 shoulders. The average increase in the Constant score after the operation was 25.4 points (range, 0 to 57 points). Ultrasonography demonstrated an intact rotator cuff in 83% (174) of the shoulders overall, 47% (fifteen) of the thirty-two with a repair of a massive tear, 78% (thirty-two) of the forty-one with a repair of a large tear, 93% (113) of the 121 with a repair of a medium tear, and 88% (fourteen) of the sixteen with a repair of a small tear. Strength and active elevation increased significantly more in the group with an intact repair at the time of follow-up than in the group with a failed repair; however, there was no difference in the pain scores. CONCLUSIONS Arthroscopic rotator cuff repair with double-row fixation can achieve a high percentage of excellent subjective and objective results. Integrity of the repair can be expected in the majority of shoulders treated for a large, medium, or small tear, and the strength and range of motion provided by an intact repair are significantly better than those following a failed repair. LEVEL OF EVIDENCE Therapeutic Level IV.

A new technique of continuous interscalene nerve block

PurposeTo describes a technique of indwelling interscalene catheter placement and to evaluate its complications.MethodsOne hundred and twenty patients undergoing major shoulder surgery received interscalene nerve block (ISNB) and were studied in three groups. Group IISNB using Winnie’s technique; group 2 by Winnie’s technique with nerve stimulator and group 3 by epidural needle and catheter technique with nerve stimulator. All patients received 20 mL bupivacaine 0.5% and group 3 patients received an additional bupivacaine 0.25% infusion. Diaphragmatic movements were measured sonographically on emergence from anesthesia. Complications were noted. A visual analogue scale (0–10) was used to assess pain four hours postoperatively.ResultsMean ipsilateral diaphragmatic movements were 4 ± 8, 14 ± 11 and 18 ± 8 mm (mean ± SD) in groups 1,2 and 3 respectively. This was less than contralateral movements in all three groups (P < 0.05). None of the patients in groups 2 and 3 reported postoperative pain. The block failed in 10% of group I patients. Complete ipsilateral phrenic nerve block occurred in 85% of the patients in group 1, 35% of group 2 and 20% of group 3 (P < 0.05). Ipsilateral recurrent laryngeal nerve paralysis occurred in 20% of the patients in group I, 5% of group 2 and in none of the patients in group 3 (P < 0.05). Homer’s syndrome was noted in group I (30%), group 2 (12%) but not in group 3. None of the catheters in group 3 patients dislodged after an average use of 2.8 ± 2.1 days.ConclusionsIndwelling catheter placement into the brachial plexus sheath as described in this communication was effective and associated with few complications.RésuméObjectifDécrire une technique de mise en place d’une sonde interscalène à demeure et évaluer ses inconvénients.MéthodeCent vingt patients admis pour une chirurgie majeure de l’épaule ont reçu un blocage nerveux interscalène (BNIS) et ont été répartis en trois groupes d’étude. Dans le Ier groupe, on a utilisé la technique de Winnie; dans le 2e, la technique et un neurostimulateur; dans le 3e, une aiguille péridurale et la technique avec stimulateur. Tous ont reçu 20 ml de bupivacaïne 0,5 % et ceux du groupe 3, une perfusion supplémentaire de bupivacaïne 0,25 %. Au réveil, on a mesuré par échographie les mouvements diaphragmatiques et, quatre heures après l’intervention, on a noté les complications et évalué la douleur à l’aide de l’échelle visuelle analogue (0–10).RésultatsLes mouvements homolatéraux du diaphragme ont été de 4 ± 8, 14 ± 11 et de 18 ± 8 mm (moyenne ± écart-type) dans les groupes 1,2 et 3 respectivement et plus faibles que les mouvements controlatéraux dans les trois groupes (P < 0,05). Aucun patient des groupes 2 et 3 n’ont eu de douleur postopératoire. Le bloc a échoué chez 10 % des patients du groupe I. Le bloc complet du nerf phrénique homolatéral est survenu chez 85 % des patients du groupe I, 35 % du groupe 2 et 20 % du groupe 3 (P < 0,05); la paralysie récurrente du nerf laryngé homolatéral, chez 20 % des patients du groupe I, 5 % du groupe 2, mais chez aucun patient du groupe 3 (P < 0,05). On a noté le syndrome de Horner dans les groupes I (30 %) et 2 (12 %), mais non dans le groupe 3. Aucune sonde du groupe 3 ne s’est déplacée après un usage moyen de 2,8 ± 2,1 jours.ConclusionLa mise en place d’une sonde à demeure dans la gaine du plexus brachial, telle qu’on la décrite ici, a été efficace et a présenté peu de complications.

Early experience with continuous cervical paravertebral block using a stimulating catheter.

Background and Objectives: This study reports our early experience with continuous cervical paravertebral block (CCPVB) using a stimulating catheter for the management of acute pain after shoulder surgery. Methods: This prospective observational study presents 256 CCPVB for pain relief after 14 different shoulder operations. Surgery was performed under general anesthesia and blocks were placed prior to induction of general anesthesia (n = 81 [32%]), after induction of general anesthesia (n = 116 [45%]), or postoperatively in the recovery room (n = 59 [23%]). A bolus dose of 30 mL of 0.5% ropivacaine was followed by an infusion of 0.1 mL/kg/h of 0.2% ropivacaine. Patient- or nurse-initiated bolus doses of 10 mL of the same drug were used for breakthrough pain and rescue analgesics were available. Postoperative pain, patient satisfaction, and motor function in different parts of the upper limb were evaluated immediately after surgery (time 0), and then 6, 12, 24, 48, 60 hours, and 14 days postoperatively. Results: An average of 2 (range 1-7) attempts were needed to advance the catheter while still stimulating the nerve. Average postoperative pain ranged from 0.27 ± 1.04 cm to 0.78 ± 1.56 cm (mean ± SD) on a visual analog scale (VAS) (0-10 cm) for the first 48 hours and 3.8 ± 2.1 cm and 3.5 ± 2.4 cm at 60 hours and 14 days, respectively. Patient satisfaction on a VAS of 0 to 5 was 4.19 ± 1.1, 4.28 ± 1.01, and 4.69 ± 1.05 at times 0, 6 hours, and 14 days, respectively. Motor function returned to normal in the fingers within 24 hours and in the shoulder within 60 hours. Complications included Horners syndrome (40%), dyspnea (8%), superficial skin infection (5%), posterior neck pain (22%), subclavian artery puncture (1%), contralateral epidural spread (4%), and 8% of the patients complained of an unpleasant “dead feeling” of the arm. Ninety-one percent of patients would request CCPVB again for future shoulder surgery. There was no evidence of nerve damage.

The sensory branch distribution of the suprascapular nerve: an anatomic study.

The suprascapular nerve is responsible for most of the sensory innervation to the shoulder joint and is potentially at risk during surgery. In this study, 31 shoulders in 22 cadavers were dissected to investigate the sensory innervation of the shoulder joint by the suprascapular nerve, with special reference to its sensory branches. In 27 shoulders (87.1%), a small sensory branch was observed that splits off from the main stem of the suprascapular nerve proximal (48.2%), inferior (40.7%), or distal (11.1%) to the transverse scapular ligament. This percentage is considerably higher than has been previously found. In 74.2% of the shoulders, an acromial branch was also found, originating just proximal to the scapular neck, running to the infraspinatus tendon. These cadaveric results indicate that sensory branches to the shoulder joint are more common and numerous than previously described and therefore should be considered in shoulder surgery and nerve blocks to this area.

The “bench-presser’s shoulder”: an overuse insertional tendinopathy of the pectoralis minor muscle

Background: Tendinopathies of the rotator cuff muscles, biceps tendon and pectoralis major muscle are common causes of shoulder pain in athletes. Overuse insertional tendinopathy of pectoralis minor is a previously undescribed cause of shoulder pain in weightlifters/sportsmen. Objectives: To describe the clinical features, diagnostic tests and results of an overuse insertional tendinopathy of the pectoralis minor muscle. To also present a new technique of ultrasonographic evaluation and injection of the pectoralis minor muscle/tendon based on use of standard anatomical landmarks (subscapularis, coracoid process and axillary artery) as stepwise reference points for ultrasonographic orientation. Methods: Between 2005 and 2006, seven sportsmen presenting with this condition were diagnosed and treated at the Cape Shoulder Institute, Cape Town, South Africa. Results: In five patients, the initiating and aggravating factor was performance of the bench-press exercise (hence the term “bench-presser’s shoulder”). Medial juxta-coracoid tenderness, a painful active-contraction test and bench-press manoeuvre, and decrease in pain after ultrasound-guided injection of a local anaesthetic agent into the enthesis, in the absence of any other clinically/radiologically apparent pathology, were diagnostic of pectoralis minor insertional tendinopathy. All seven patients were successfully treated with a single ultrasound-guided injection of a corticosteroid into the enthesis of pectoralis minor followed by a period of rest and stretching exercises. Conclusions: This study describes the clinical features and management of pectoralis minor insertional tendinopathy, secondary to the bench-press type of weightlifting. A new pain site-based classification of shoulder pathology in weightlifters is suggested.

An Anatomic Study of Inferior Glenohumeral Recess Portals: Comparative Anatomy at Risk

PURPOSE The purpose of this study was to describe the musculotendinous relations and neurologic structures at risk during establishment of posterior portals for access to the inferior glenohumeral recess (IGHR). METHODS Three 18-gauge spinal needles were used to establish 2 posteroinferior portals and 1 axillary pouch portal in 14 embalmed cadaveric shoulders, without joint distention and arthroscopic visualization. At dissection, musculotendinous structures traversed by the needles were recorded, and distances from the (1) axillary nerve (at the deltoid undersurface, quadrangular space, and capsule), (2) nerve to teres minor (at the inferior border of the teres minor muscle and at the capsule), and (3) suprascapular nerve were measured. Additional parameters studied included the vertical distances between the acromion and IGHR and between the acromion and axillary nerve. Statistical analysis (multiple comparisons procedure) was performed to compare relative portal safety. RESULTS The mean distance of the axillary pouch portal to the 3 nerves, at each level, was greater than that of the posteroinferior portals. In 1 specimen (7.1%), the posteroinferior portal tracts were in close proximity (within 2 mm) to the axillary nerve and its branch to the teres minor. The distance of the axillary pouch portal to the nerves was significantly greater (P < .05) at every level, except at the deltoid undersurface. CONCLUSIONS Our study suggests that posterior portal techniques described for access to the IGHR are safe; the risk of axillary nerve injury with posteroinferior portals is low, though possible. The axillary pouch portal is relatively farther away from the neurologic structures and provides safer access to the same region. CLINICAL RELEVANCE Arthroscopic procedures that require access to the IGHR can be safely performed with posteroinferior and axillary pouch portals. The axillary pouch portal may be used preferentially for this access because it is placed farthest from the neurologic structures.

Suprascapular nerve block: an alternative method of placing a catheter for continuous nerve block.

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Shoulder injuries in rugby players

Glenohumeral joint The shoulder joint itself may be injured during a direct fall onto the shoulder or when the horizontally abducted arm is forced posteriorly (‘straight-arm tackle’). After an analysis of patients’ descriptions of their falls and close examination of video clips of rugby games, we have come to the conclusion that this specific mechanism may be one of the causes for the high frequency of bony lesions in shoulder instability of rugby players. Another frequent cause of anterior dislocation is when a player falls forward with the elbow flexed, and the elbow contacts the ground first; as the body falls forwards, the arm is forced posteriorly and this results in an anterior dislocation. Anterior dislocations with bone loss, resulting in engaging Hill-Sachs lesions with anteroinferior loss of the glenoid bone (‘inverted-pair glenoid’), are often seen in rugby. Simple Bankart lesions do not seem to be a frequent occurrence in rugby. HAGL (humeral avulsion of the glenohumeral ligaments) lesions are not uncommon in rugby. The mechanism is not entirely clear, but some players report that with the arm in forward elevation, an inferiorly directed force caused the onset of the pain and disability. It seems that in these players the mechanism causing the tearing of the inferior glenohumeral ligament may be an inferiorly directed force rather than the mechanism of abduction and external rotation. GLAD (glenolabral articular disruption) lesions occur commonly in rugby. The mechanism may be a direct fall onto the There has been an increase in the frequency and severity of shoulder injuries in rugby players in the recent years. This may be because the game has become more aggressive and intense and, over the years, the game has changed from being largely an amateur sport to one that is played at a professional level. Of equal importance is the fact that younger players are playing more competitively and aggressively, and there are specific injury patterns in these players with immature skeletal structures. Editorial

Evaluation of functional outcomes and complications following modified Latarjet reconstruction in athletes with anterior shoulder instability

Background The optimal management of anterior shoulder instability in athletes continues to be a challenge. The present study aimed to evaluate the functional outcomes of athletes with anterior shoulder instability following modified Latarjet reconstruction through assessing the timing of return to sport and complications. Methods Retrospective assessment was performed of athletes (n = 56) who presented with recurrent anterior shoulder instability and were treated with modified congruent arc Latarjet reconstruction over a 1-year period. Rugby union was the predominant sport performed. Pre-operative instability severity index scores were assessed. Postoperative complications were recorded as was the time taken for the athlete to return to sport. Results Arthroscopic evaluation revealed that 86% of patients had associated bony lesions affecting the glenohumeral joint. The overall complication rate relating to the Latarjet reconstruction was 7%. No episodes of recurrent shoulder instability were noted. Of the patients, 89% returned to competitive sport at the same level as that prior to surgery. The mean time post surgery to returning to full training was 3.2 months. Conclusions The modified congruent arc Latarjet procedure facilitates early rehabilitation and return to sport. These results support our systematic management protocol of performing modified Latarjet surgery in contact sport athletes with recurrent anterior instability.

Glenoid and coracoid morphology are ideally matched for the congruent-arc Latarjet

Background The Congruent-Arc Latarjet is modification of the Latarjet open bony stabilisation for shoulder instability. It involves rotation of the coracoid so the curved under-surface lies congruent with the glenoid. The aim of this study was to define the relationship between the concave under surface of the coracoid and the glenoid. Methods An initial study of 210 cadaveric scapulae was performed followed by a study measuring the same curves using 3D CT reconstruction on 20 scapulae from living patients. Results Cadveric measurement revealed the glenoids surface had a median radius of curvature of 30 mm and the coracoid had a median radius of curvature of 25 mm. The CT measurements revealed similar radii of curvature with the glenoid measuring 23.9 mm and the coracoid measuring 25.4 mm (p = 0.2488). Conclusion The curvature of the glenoid in the cadaveric specimens was slightly larger than the corresponding coracoid curvature. In life this difference may be minimised by articular cartilage, labrum and the attachment of capsule. The CT study revealed similar curves, although in contrast to the cadaveric specimens the coracoid curvature was slightly larger. Overall the curvature of the under surface of the coracoid is similar to the glenoid, which supports this modification of the Latarjet procedure.