Larry D. Field

REPAIR OF THE ROTATOR CUFF: Mini-open and Arthroscopic Repairs

The repair of rotator cuff tears by traditional open subacromial decompression and rotator cuff tendon reapproximation has proved successful in restoring function and decreasing pain, but open rotator cuff repair has some inherent disadvantages. Postoperative detachment of the deltoid repair has been reported and results in significant morbidity. The open technique may also require a longer period of limited motion resulting in greater stiffness. Arthroscopically assisted mini-open repairs and, more recently, completely arthroscopic repairs of the rotator cuff have been developed and increasingly are being applied. Both techniques avoid detachment of the deltoid. The mini-open and arthroscopic approaches to rotator cuff repair have the added benefit of arthroscopic evaluation of the glenohumeral joint. The mini-open technique has the advantage of allowing the direct visualization of the cuff repair and allows surgeons to place the stitches in an open fashion, which is familiar to all surgeons. The mini-open technique also allows the placement of tension-absorbing stitches in the rare cases that they are needed. Mini-open techniques also allow the choice of bone anchors or osseous tunnels for fixation. The completely arthroscopic cuff repair has several potential advantages over the open and mini-open cuff repair techniques; first is the decreased disruption of the soft tissues, which may result in less scarring and adhesions. The procedure is the most cosmetically appealing of the techniques. Reduced postoperative pain is also cited as an advantage but has been demonstrated only in a single, nonrandomized study. Finally, if technical difficulties arise, the conversion to a mini-open repair can be done easily. In a few studies, arthroscopic cuff repair techniques have shown promise as an alternative to mini-open or open repair, but these results have been at the hands of a few surgeons who have extensive experience in arthroscopy of the shoulder. In contrast, the mini-open procedure requires modest arthroscopic skills and has a documented history of success. Nevertheless, arthroscopic rotator cuff repair is a viable and effective technique in the hands of surgeons with adequate skills, and this procedure is likely to become more commonly performed in the future as shoulder arthroscopic skills and instrumentation improve.

Biomechanical evaluation of the medial collateral ligament of the elbow

Anatomical dissection and biomechanical testing were used to study twenty-eight cadaveric elbows in order to determine the role of the medial collateral ligament under valgus loading. The medial collateral ligament was composed of anterior, posterior, and occasionally transverse bundles. The anterior bundle was, in turn, composed of anterior and posterior bands that tightened in reciprocal fashion as the elbow was flexed and extended. Sequential cutting of the ligament was performed while rotation caused by valgus torque was measured. The anterior band of the anterior bundle was the primary restraint to valgus rotation at 30, 60, and 90 degrees of flexion and was a co-primary restraint at 120 degrees of flexion. The posterior band of the anterior bundle was a co-primary restraint at 120 degrees of flexion and a secondary restraint at 30 and 90 degrees of flexion. The posterior bundle was a secondary restraint at 30 degrees only. The reciprocal anterior and posterior bands have distinct biomechanical roles and theoretically may be injured separately. The anterior band was more vulnerable to valgus overload when the elbow was extended, whereas the posterior band was more vulnerable when the elbow was flexed. The posterior bundle was not vulnerable to valgus overload unless the anterior bundle was completely disrupted. The intact elbows rotated a mean of 3.6 degrees between the neutral position and the two-newton-meter valgus torque position. Cutting of the entire anterior bundle caused an additional 3.2 degrees of rotation at 90 degrees of flexion, where the effect was greatest. CLINICAL RELEVANCE: Physical findings in a patient who has an injury of the anterior bundle may be subtle, and an examination should be performed with the elbow in 90 degrees of flexion for greatest sensitivity. As the anterior bundle is the major restraint to valgus rotation, reconstructive procedures should focus on anatomical reproduction of that structure. Parallel limbs of tendon graft placed from the inferior aspect of the medial epicondyle to the area of the sublimis tubercle will simulate the reciprocal bands of the anterior bundle. Temporary immobilization with the elbow in flexion may relax the critically important anterior band of the reconstruction during healing.

Isolated Closure of Rotator Interval Defects for Shoulder Instability

Fifteen patients noted at surgery to have an isolated defect in the rotator interval and no other pathologic abnormality underwent closure of the defect as an iso lated procedure for recurrent instability symptoms. In traoperative assessment of each of these shoulders after the closure demonstrated adequate stability, and no other stabilization procedures were performed. The average age of the patients was 24 years, and 10 of the 15 patients were women. Examination under anesthe sia revealed increased inferior translation in all patients, as illustrated by at least a 1 + sulcus sign. The rotator interval defect averaged 2.75 cm in width and 2.3 cm in height. The rotator interval defect edges were fresh ened and approximated (nine patients) or imbricated (six patients), depending on the anterior capsular laxity and the degree of glenohumeral joint translation pos sible. Followup averaged 3.3 years (range, 2.2 to 5.3), and all patients achieved either a good or excellent re sult using the American Shoulder and Elbow Surgeons evaluation scale and the Rowe rating scale. Although most patients with a defect in the rotator interval require a standard stabilization procedure as a supplement to closure of the defect, approximation or imbrication of the defect as an initial step at surgery may confer adequate stability in selected patients and obviate the need for formal capsular advancement.

Hemiarthroplasty of the shoulder for rotator cuff arthropathy.

Sixteen patients underwent hemiarthroplasty for rotator cuff arthropathy between June 1989 and March 1992, and evaluations obtained before and after surgery in all patients were compared. A modular head large enough to articulate with the coracoacromial arch but not so large as to prevent approximately 50% of humeral head translation on the glenoid was used in these cases. Each patient was evaluated with Neers limited goals rating scale after an average follow-up of 33 months (24 to 55 months). Ten patients were rated as successful and six as unsuccessful. Four of the six unsuccessful patients had undergone at least one attempt at rotator cuff repair with acromioplasty before the index procedure, and two of these four patients had deficient deltoid function after this rotator cuff surgery as a result of postoperative deltoid detachment. Also, three of these four patients who had previously undergone acromioplasty subsequently had anterosuperior subluxation after hemiarthroplasty. Hemiarthroplasty did not provide for a successful outcome in all patients with rotator cuff arthropathy. However, 10 of the 12 patients in this series with good deltoid function and an adequate coracoacromial arch were rated as successful by Neers limited goals criteria. In addition, this study illustrates that formal acromioplasty carried out during attempts at rotator cuff repair in such patients may jeopardize the subsequent success of hemiarthroplasty.

Arthroscopic suture repair of superior labral detachment lesions of the shoulder

Twenty consecutive patients with superior labral ante rior and posterior lesions of the shoulder involving the biceps attachment to the labrum (Snyder types II and IV) were repaired arthroscopically and reviewed post operatively to evaluate the efficacy of the technique in the management of this recently described injury pat tern. Follow-up time averaged 21 months (range, 12 to 42). All patients were managed by an arthroscopic repair technique that included debridement of the frayed labrum and abrasion of the superior glenoid neck, fol lowed by the placement of multiple sutures into the torn labrum-biceps tendon complex using a Caspari suture punch. Patients were reexamined, and the results were quantitated with the shoulder evaluation form of the American Shoulder and Elbow Surgeons and with the Rowe rating scale. On evaluation, all patients obtained good or excellent results. This suture technique is recommended in the management of unstable superior labral detachment lesions of the shoulder.

The pain control infusion pump for postoperative pain control in shoulder surgery

PURPOSE This study was initiated to evaluate the effect of a pain control infusion catheter in managing postoperative pain. TYPE OF STUDY In a prospective, randomized trial, 62 consecutive patients undergoing arthroscopic subacromial decompression had an indwelling pain control infusion catheter placed at the operative site. MATERIALS AND METHODS Thirty-one patients received 0.25% bupivacaine and 31 patients received saline infusions, each at a constant rate of 2 mL per hour. Patients evaluated their pain by visual analog scale, and also tabulated the amount of narcotic and nonnarcotic medication used each day in the first week of surgery. RESULTS There was a statistically significant difference in pain in all parameters tested in the bupivacaine group as compared with the saline control group (P <.05). CONCLUSIONS The bupivacaine pain control infusion pump is an effective means of decreasing postoperative pain.

MASSIVE ROTATOR CUFF TEARS: DEBRIDEMENT VERSUS REPAIR

In many studies, short-term and midterm results of debridement seem to show satisfactory results. However, the three long-term studies currently available all report that these initial results deteriorate significantly with time and are not acceptable. If debridement is considered, careful preoperative and intraoperative evaluation as discussed by Burkhart should be followed. We believe an adequate understanding of the anatomic subtleties, pathologic changes, biomechanical forces, and advanced reconstructive techniques allows repair to be performed in most, if not all, rotator cuff tears of the shoulder. The findings of the study described herein indicate that repair of these tears is the treatment of choice.

Arthroscopic anatomy of the lateral elbow: A comparison of three portals

Ten fresh cadaveric elbows were used to evaluate the proximity of the radial nerve and its branches to three anterolateral portals. A proximal anterolateral portal used routinely at our institution and located 2 cm proximal and 1 cm anterior to the lateral epicondyle was compared with the distal anterolateral portal described by Andrews and with a mid-anterolateral portal. The three portals were initially established without joint distention while the elbows were flexed 90 degrees. Measurements were then obtained with and without joint distention at flexion angles of 0 degrees and 90 degrees. The radial nerve was found to be an average distance of 3.8 mm at extension and 7.2 mm at 90 degrees of flexion from the distal anterolateral portal, located 3 cm distal and 1 cm anterior to the lateral epicondyle. Conversely, the distance between the proximal anterolateral portal cannula and the nerve was statistically greater (p < 0.05), averaging 7.9 mm in extension and 13.7 mm in flexion. The remaining anterolateral portal, located 1 cm directly anterior to the lateral epicondyle, was found to be at a statistically greater average distance from the nerve than was the distal anterolateral portal but statistically closer than was the more proximal portal. The ability to visualize the joint arthroscopically was assessed using the three portals, and although the ulnohumeral joint could be adequately seen using all portals, radiohumeral joint visualization was most complete and technically easiest using the most proximal portal.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Evaluation of the Arthroscopic Valgus Instability Test of the Elbow

Seven fresh-frozen cadaveric elbows were used to evaluate the extent to which the medial collateral liga ment must be injured before arthroscopic evidence of valgus instability is seen, the amount of ulnohumeral joint opening that does occur after such an injury, and the elbow position that maximizes visualization of this opening. While visualizing the most medial aspect of the ulnohumeral joint arthroscopically through the an terolateral portal, we sequentially sectioned the medial collateral ligament complex until all of the medial liga mentous restraints were cut. A valgus load was applied after each incision, and the extent to which the ulno humeral joint opened was measured. Ulnohumeral joint opening was not visualized in any specimen until complete sectioning of the anterior bundle was per formed. After the anterior bundle was released, 1 or 2 mm of joint opening was present in all specimens. Complete release of the medial collateral ligament led to dramatic increases in medial joint opening in all seven specimens (4 to 10 mm). Varying the angle of elbow flexion from 15° to 120° revealed that visualiza tion of the medial joint opening was best at 60° to 75°. Finally, forearm pronation increased ulnohumeral joint opening and supination decreased joint opening in all specimens. We found that the entire anterior bundle must be sectioned before measurable and reproduc ible medial joint opening can occur.