Karin S. van Rooyen

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.

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.

The “Subscapularis-Sparing” Approach: A New Mini-Open Technique to Repair a Humeral Avulsion of the Glenohumeral Ligament Lesion

Anterior approaches to the shoulder involve partial or complete detachment of the subscapularis muscle. We have developed a new technique that permits adequate access to the humeral attachment of the inferior glenohumeral ligament (IGHL) without any detachment of the subscapularis, and have used this to successfully repair humeral avulsions of glenohumeral ligament lesions. Preliminary diagnostic arthroscopy using air insufflation of the glenohumeral joint is used to identify and grade the lesion. A 1-inch axillary incision is used to access the subscapularis tendon through the deltopectoral approach. Thereafter, anatomic landmarks are identified to expose the lateral aspect of the inferior border of the subscapularis muscle. Blunt dissection is used to separate the musculocapsular plane, and the subscapularis is retracted in an anterosuperior direction. Adequate exposure for visualization and repair of the avulsed IGHL is possible in a majority of cases where this approach is attempted. The use of arthroscopic instruments and suture anchors facilitates suture passage through the mid and posterior regions of the IGHL. If exposure is inadequate, the approach can be easily converted to a conventional L-shaped tenotomy approach through the lower or upper region of the subscapularis.

The "paraglider-wing" sign: an arthroscopic indicator of partial-thickness bursal-surface tears of the supraspinatus tendon.

Partial-thickness bursal-surface tears of supraspinatus tendon may be missed on preoperative investigations and can be overlooked at surgery if not specifically sought. The authors describe an arthroscopic sign to detect these tears, when they involve more than half the tendon fibres, from the articular-side of the joint. The “paraglider-wing” sign, visualized during diagnostic glenohumeral arthroscopy, is demonstrated as an upward bulge of the capsulo-tendinous layer through the bursal-surface tear, under pressure of the inflow fluid. A positive sign indicates (1) presence of a partial-thickness bursal-side tear of the supraspinatus tendon, (2) significant depth (stage II or III) of the tear, and (3) the medial extent of the tear along the length of the tendon. A meticulous subacromial bursoscopy and excision of the bursa is then performed to visualize the tear from the subacromial space. Repair of the tear is performed with a double-row suture anchor fixation technique; the medial row of sutures is passed through the intact region of the tendon using the “paraglider-wing” sign as a guide.

Displaced scapular neck fracture: a case report

We report on a displaced surgical scapular neck fracture with an ipsilateral undisplaced distal clavicle fracture of the dominant shoulder in a professional athlete. Although directives for determining the treatment of choice, whether conservative or operative, can be found in the literature, confusion still exists.1,6,14-16 Our management adds a treatment alternative, which has not yet been reported to our knowledge.

Paper #19 Dimensions of the transferred coracoid process in the latarjet procedure

The proximity of neural structures to the coracoclavicular ligaments limits the amount of coracoid process that can be harvested. The purpose of this study of 100 dry human scapulae was to define the anatomic limitations. We found the mean measurement of the horizontal arm of the coracoid process anterior to the conoid tubercle was 21.5 mm (SD 0.9 mm). In 10% of the scapulae, it was larger than 30 mm. In 66%, the posterior aspect of the conoid fused with the vertical ramus and the lateral lip of the suprascapular notch. This amount of coracoid appears to be large enough to expand the glenoid vault, and to hold two AO small fragment screws. It can be safely harvested if the conoid ligament is respected. Partial sacrifice of the trapezoid ligament is unavoidable, but does not compromise coracoclavicular stability. If the coracoid osteotomy is extended medial to the conoid tubercle it encroaches on the vertical ramus of the coracoid and can damage the suprascapular nerve. Posterior advancement of the osteotomy can extend onto the anterosuperior glenoid.