Laurent Lafosse

The Outcome and Structural Integrity of Arthroscopic Rotator Cuff Repair with Use of the Double-Row Suture Anchor Technique

BACKGROUNDnThe reported rate of failure after arthroscopic rotator cuff repair has varied widely. The influence of the repair technique on the failure rates and functional outcomes after open or arthroscopic rotator cuff repair remains controversial. The purpose of the present study was to evaluate the functional and anatomic results of arthroscopic rotator cuff repairs performed with the double-row suture anchor technique on the basis of computed tomography or magnetic resonance imaging arthrography in order to determine the postoperative integrity of the repairs.nnnMETHODSnA prospective series of 105 consecutive shoulders undergoing arthroscopic double-row rotator cuff repair of the supraspinatus or a combination of the supraspinatus and infraspinatus were evaluated at a minimum of two years after surgery. The evaluation included a routine history and physical examination as well as determination of the preoperative and postoperative strength, pain, range of motion, and Constant scores. All shoulders had a preoperative and postoperative computed tomography arthrogram (103 shoulders) or magnetic resonance imaging arthrogram (two shoulders).nnnRESULTSnThere were thirty-six small rotator cuff tears, forty-seven large isolated supraspinatus or combined supraspinatus and infraspinatus tendon tears, and twenty-two massive rotator cuff tears. The mean Constant score (and standard deviation) was 43.2+/-15.1 points (range, 8 to 83 points) preoperatively and 80.1+/-11.1 points (range, 46 to 100 points) postoperatively. Twelve of the 105 repairs failed. Intact rotator cuff repairs were associated with significantly increased strength and active range of motion.nnnCONCLUSIONSnArthroscopic repair of a rotator cuff tear with use of the double-row suture anchor technique results in a much lower rate of failure than has previously been reported in association with either open or arthroscopic repair methods. Patients with an intact rotator cuff repair have better pain relief than those with a failed repair. After repair, large and massive rotator cuff tears result in more postoperative weakness than small tears do.

Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears.

BACKGROUNDnIsolated tears of the subscapularis occur less commonly than those involving the superior and posterior components of the rotator cuff. The purpose of the present study was to evaluate the structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears.nnnMETHODSnA prospective study of seventeen consecutive patients who were managed with an all-arthroscopic repair of the subscapularis tendon was performed. The study group included thirteen men and four women who had an average age of forty-seven years at the time of surgery. The average interval from the onset of symptoms to the time of surgery was twenty-four months. Thirteen tears were traumatic, and four were degenerative. Seven patients had a tear involving the superior third of the tendon, six had a tear involving the superior two-thirds of the tendon, and four had complete separation of the subscapularis from its insertion on the lesser tuberosity. Clinical findings were assessed for all patients preoperatively and postoperatively with use of the Constant and University of California at Los Angeles scoring systems, and all patients had postoperative computed tomographic arthrography studies to evaluate the structural integrity of the repair.nnnRESULTSnThe average duration of follow-up was twenty-nine months. When the preoperative findings were compared with the most recent findings, the average relative Constant score had improved from 58% to 96% (p < 0.05), the average University of California at Los Angeles score had improved from 16 to 32 points (p < 0.05), the average pain score had improved from 5.9 to 13.5 points (p < 0.05), the average forward flexion had improved from 146 degrees to 175 degrees (p < 0.05), the average external rotation had improved from 50 degrees to 60.3 degrees (p < 0.05), the average internal rotation had improved from the level of the sacrum to L1-L2 (p < 0.05), and the average abduction strength had improved from 7.4 to 15.6 points (p < 0.05). The structural integrity of the repair was completely intact in fifteen patients and was partially reruptured in two patients on the basis of computed tomographic arthrography. Progression of fatty infiltration of the subscapularis was not observed in any patient. Subjectively, twelve patients were very satisfied with the result, four were satisfied, and one was not satisfied.nnnCONCLUSIONSnArthroscopic repair of an isolated subscapularis tear can yield marked improvements in shoulder function, can significantly reduce pain, and can result in a durable structural repair.nnnLEVEL OF EVIDENCEnTherapeutic Level IV.

The outcome and structural integrity of arthroscopic rotator cuff repair with use of the double-row suture anchor technique: Surgical technique

BACKGROUNDnThe reported rate of failure after arthroscopic rotator cuff repair has varied widely. The influence of the repair technique on the failure rates and functional outcomes after open or arthroscopic rotator cuff repair remains controversial. The purpose of the present study was to evaluate the functional and anatomic results of arthroscopic rotator cuff repairs performed with the double-row suture anchor technique on the basis of computed tomography or magnetic resonance imaging arthrography in order to determine the postoperative integrity of the repairs.nnnMETHODSnA prospective series of 105 consecutive shoulders undergoing arthroscopic double-row rotator cuff repair of the supraspinatus or a combination of the supraspinatus and infraspinatus were evaluated at a minimum of two years after surgery. The evaluation included a routine history and physical examination as well as determination of the preoperative and postoperative strength, pain, range of motion, and Constant scores. All shoulders had a preoperative and postoperative computed tomography arthrogram (103 shoulders) or magnetic resonance imaging arthrogram (two shoulders).nnnRESULTSnThere were thirty-six small rotator cuff tears, forty-seven large isolated supraspinatus or combined supraspinatus and infraspinatus tendon tears, and twenty-two massive rotator cuff tears. The mean Constant score (and standard deviation) was 43.2 +/- 15.1 points (range, 8 to 83 points) preoperatively and 80.1 +/- 11.1 points (range, 46 to 100 points) postoperatively. Twelve of the 105 repairs failed. Intact rotator cuff repairs were associated with significantly increased strength and active range of motion.nnnCONCLUSIONSnArthroscopic repair of a rotator cuff tear with use of the double-row suture anchor technique results in a much lower rate of failure than has previously been reported in association with either open or arthroscopic repair methods. Patients with an intact rotator cuff repair have better pain relief than those with a failed repair. After repair, large and massive rotator cuff tears result in more postoperative weakness than small tears do.

Arthroscopic assessment of full-thickness rotator cuff tears

SUMMARYnTo evaluate the reliability of the arthroscopic assessment of full-thickness rotator cuff tears, 117 cases were prospectively investigated by imaging, arthroscopy, and open surgery. The confidence of the surgeon, his accuracy, and the surgeon-dependent character of arthroscopic assessment were evaluated in terms of the description of the main anatomic parameters. The surgeons were confident and accurate in diagnosing a full-thickness tear of the supraspinatus, but they underestimated its coronal and sagittal extent and its reducibility to the greater tuberosity. Conversely, the technique appeared very accurate in describing the rotator interval. Endoscopic assessment was particularly operator-dependent in the anteroposterior analysis of the tear. This study shows the limits of endoscopic assessment of full-thickness rotator cuff tears. It illustrates the need for an adequate arthroscopic technique with a thorough knowledge of normal and pathological anatomy of the rotator cuff.

Arthroscopic repair of large subscapularis tendon tears: 2- to 4-year clinical and radiographic outcomes

PURPOSEnThe purpose of this study was to evaluate outcome and structural integrity after arthroscopic repair of large subscapularis tendon (SSC) tears at 2 to 4 years follow-up.nnnMETHODSnBetween January 2006 and October 2008, 52 consecutive patients underwent arthroscopic repair of Lafosse type III and IV SSC ruptures. A total of 46 patients (38 men and 8 women) with a mean age of 62 years (range, 45 to 81 years) were available for final follow-up. Clinical findings were assessed for all patients preoperatively and postoperatively, including range of motion, the lift-off test, the belly-press test, the Constant score, and the modified University of California, Los Angeles score. Subscapularis muscle strength by use of the bear-hug test and external rotation were compared in both shoulders postoperatively. Patients were evaluated with plain radiographs and magnetic resonance imaging or computed tomographic arthrography before surgery. Postoperatively, radiographic examination was completed by use of magnetic resonance imaging or computed tomographic arthrography in 39 patients (85%). Patients completed the subjective shoulder value and rated their satisfaction at final follow-up.nnnRESULTSnThe mean follow-up period was 35.3 ± 9.6 months (range, 23 to 57 months). An isolated lesion was detected in 13% of patients; a lesion of the SSC and supraspinatus tendon was found in 37%; and a lesion of the SSC, supraspinatus tendon, and infraspinatus tendon was detected in 50%. At latest follow-up, the mean Constant score significantly improved from 46.4 points to 79.9 points and the modified University of California, Los Angeles score improved from 15.1 points to 31.5 points (P < .001). Subscapularis strength was 92% and external rotation was 96% of the nonoperative shoulder. All outcome scores were similar between Lafosse type III and IV SSC ruptures. Radiographic evaluation showed a rerupture rate of 11%. The coracohumeral distance increased from 9.7 mm to 10.1 mm postoperatively (Pxa0= .086). The subjective shoulder value improved from 51% to 88% (P < .001), and 98% of patients were satisfied or very satisfied.nnnCONCLUSIONSnArthroscopic treatment of large to massive SSC ruptures results in significant clinical improvements, excellent maintenance of muscle strength, and durable tendon integrity at 2 to 4 years follow-up.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

Subacromial Internal Spacer for Rotator Cuff Tendon Repair: The Balloon Technique

Lateral reattachment of the rotator cuff and the more recent introduction of the double-row rotator cuff repair technique require adequate visualization to define the rotator cuff footprint and the greater tuberosity. In many cases extensive debridement in this area is required to remove the overlying subdeltoid bursa, which can impair visualization laterally on the proximal humerus. Inadequate visualization laterally may lead to improper placement of the lateral row of fixation, compromising the reduction and fixation of the repaired rotator cuff tendon. We describe a surgical technique used to improve lateral visualization of the proximal humerus for placement of lateral anchors during arthroscopic rotator cuff repair using a Foley catheter. The end of a 14F-diameter Foley catheter is cut just proximal to the balloon end. One to three catheters are introduced in the subacromial space through small anterolateral or posterolateral portals and inflated with 15 mL of air. Adequate distension of the subacromial space allows better visualization, triangulation of the arthroscopic instruments, and anatomic repair of the rotator cuff tendon.

Sentinel sign: a sign of biceps tendon which indicates the presence of subscapularis tendon rupture

AbstractPurposenSubscapularis tendon ruptures, which are small in size, can be missed on CT or MRI imaging and are also difficult to diagnose by arthroscopy. Here we discuss a new sign of biceps tendon, which may point towards rupture of the subscapularis tendon. The biceps tendon may have scuffing, abrasion or partial tear of its anterior portion. We have named this as sentinel sign as it signals the presence of a coexisting subscapularis rupture.Materials and methodsnThis study was a retrospective analysis of available arthroscopic rotator cuff repair surgery videos of 2009–2010. The videos were studied, and data recorded for number of cases showing the presence of sentinel sign and coexisting subscapularis rupture. Sensitivity, positive predictive value of the sign, was calculated.ResultsOut of 330 available videos, 79 showed the presence of subscapularis rupture. Ten patients had a positive sentinel sign, but an intact biceps pulley that obscured the visualisation of the subscapularis tendon tear. This tear became apparent after removal of anterior part of biceps sling.ConclusionThe presence of sentinel sign of the biceps tendon indicates the presence of a coexistent subscapularis rupture. If the rupture is not apparent, obscuring parts of the biceps sling should be removed to see the upper fibres of subscapularis tendon.Level of evidenceStudy of diagnostic test, Level III.

Arthroscopic Treatment of Suprascapular Nerve Neuropathy

Compression of SupraScapular Nerve (SSN) was first described by Thomas in 1936 (Thomas 1936). However, Thompson and Kopell described SupraScapular Nerve (SSN) entrapment occurring at the transverse scapular notch (Thompson and Kopell 1959). Aiello et al differentiated between entrapment of this nerve at the Suprascapular notch and entrapment at the Spinoglenoid notch (Aiello, Serra et al. 1982). The incidence and prevalence of this condition has not been conclusively reported. A metanalysis by Zehetgruber showed there were 88 reports of this condition from 1959 to 2001 (Zehetgruber, Noske et al. 2002). However during the past decade there have been increasing awareness of this condition, leading to a higher reporting of SupraScapular Neuropathy. The senior author (LL) was the first to report the results of Arthroscopic SupraScapular Nerve release in 2006 in a series of 10 patients with mean follow up of 15 months (Lafosse, Tomasi et al. 2007). Reported prevalence of this entity has been reported as 7%-10%. Most of the reported incidence is in overhead athletes like volleyball player, athletic population (12-33%) (Ferretti, Cerullo et al. 1987; Witvrouw, Cools et al. 2000).

Endoscopic Release of Suprascapular Nerve Entrapment at the Suprascapular Notch

Purpose: Suprascapular nerve (SSN) entrapment by compression in its course through the suprascapular notch has been well documented. This usually requires an open incision which must split the trapezius muscle. We have developed a new arthroscopic endoscopic technique of SSN decompression using 3 portals, including a new direct superior access to the suprascapular notch that have never been described, which avoid muscle detachment and allow for outpatient surgery. The purpose of this article is to describe our technique and preliminary results of this procedure in our first 9 consecutive cases. We operated on 18 consecutive patients with electromyographic documentation of chronic SSN compression at the transverse scapular notch that underwent endoscopic decompression using a new portal for specific access. Ten had an isolated suprascapularis nerve entrapment, and 8 had an associated cuff tear. In all cases, the landmarks of the coracoclavicular ligaments were identified, and the transverse scapular ligament, artery, and nerve were clearly visualized before sectioning of the transverse scapular ligament. Results: All patients who underwent surgery for isolated nerve compression were discharged from the hospital on the day of surgery, and there were no complications from the procedure. All except one patient described their shoulders as completely relieved of pain and graded their result as excellent. One patient had relief of most of his pain and graded his outcome as good. Postoperative electromyogram that documented the recovery of SSN compression. Conclusion: Preliminary results of endoscopic release of refractory and painful SSN compression show an effective benefit to open release.

Caractéristiques tissulaires et cellulaires de la butée après Latarjet

L’instabilite anterieure d’epaule est une pathologie frequente et les luxations d’epaule recidivantes sont responsables de lesions cartilagineuses qui peuvent evoluer vers l’arthrose a long terme. L’objectif de cette etude etait d’analyser la composition histologique et les proprietes cellulaires de la surface articulaire de la butee coracoidienne par rapport a la glene native, apres Latarjet arthroscopique. Des echantillons tissulaires de la glene native et de la surface articulaire de la butee ont ete preleves chez neuf patients consecutifs operes pour ablation de vis apres Latarjet arthroscopique. Les prelevements etaient tous analyses histologiquement. Une analyse des proprietes cellulaires du tissu glenoidien et de la greffe a ete realisee chez deux patients. Le positionnement de la butee etait precise en peroperatoire et par scanner pour chaque patient. Le tissu glenoidien contenait une quantite variable de glycosaminoglycan (GAG) et des chondrocytes ronds principalement organises en grappe. Le tissu recouvrant la greffe contenait moins de GAG et etait plus riche en cellules. Les cellules de ce tissu n’etaient par organisees en grappe et presentaient des morphologies variables. Les cellules glenoidiennes et celles de la greffe presentaient une capacite de proliferation similaire. Il existait une correlation entre la qualite du cartilage glenoidien et celle du tissu «xa0cartilage likexa0» recouvrant la butee. La qualite cartilagineuse n’etait pas dependante du recul par rapport a la chirurgie initiale ni de l’âge du patient. Cette etude est la premiere a fournir une analyse histologique du tissu recouvrant la greffe coracoidienne par rapport au cartilage glenoidien apres intervention de Latarjet. Nous avons demontre que le tissu recouvrant la greffe possede une structure fibro-cartilagineuse meme si la qualite de ce neo-cartilage etait variable chez les differents patients. Nous n’avons pas ete capables de definir s’il existe une correlation entre le positionnement de la greffe et la capacite «xa0chondrogeniquexa0» de la butee ou la qualite du tissu cartilagineux. Certains tissus recouvrant la greffe possedent les capacites cellulaires requises mais n’arrivent pas a amorcer une production de cartilage. D’autres etudes semblent necessaires pour confirmer ces observations. La surface articulaire de la butee est rehabitee par un tissu aux caracteristiques histologiques proches de celles du cartilage glenoidien. Les cellules localisees sur la surface articulaire de la butee ont les capacites susceptibles de creer proliferation chondrale.