Markus Scheibel

Arthroscopically Assisted Stabilization of Acute High-Grade Acromioclavicular Joint Separations

Background: The purpose of this study was to evaluate the clinical and radiological results after arthroscopically assisted and image intensifier–controlled stabilization of high-grade acromioclavicular (AC) joint separations using the double TightRope technique with the first-generation implant. Hypothesis: The double TightRope technique using the first-generation implant leads to good clinical and radiological results by re-creating the anatomy of the AC joint. Study Design: Case series; Level of evidence, 4. Methods: Thirty-seven consecutive patients (4 women and 33 men; mean age, 38.6 years) who sustained an acute AC joint dislocation grade V according to Rockwood were included in this prospective study. The Subjective Shoulder Value (SSV), the Constant Score (CS), the Taft Score (TS), and a newly developed Acromioclavicular Joint Instability Score (ACJI) were used for final follow-up. Bilateral stress views and bilateral Alexander views were taken to evaluate radiographic signs of recurrent vertical and horizontal AC joint instability. Results: Twenty-eight patients (2 women and 26 men; mean age, 38.8 years [range, 18-66 years]) could be evaluated after a mean follow-up of 26.5 months (range, 20.1-32.8 months). The interval from trauma to surgery averaged 7.3 days (range, 0-18 days). The mean SSV reached 95.1% (range, 85%-100%), the mean CS was 91.5 points (range, 84-100) (contralateral side: mean, 92.6 points), the mean TS was 10.5 points (range, 7-12), and the ACJI averaged 79.9 points (range, 45-100). The final coracoclavicular distance was 13.6 mm (range, 5-27 mm) on the operated versus 9.4 mm (range, 4-15 mm) on the contralateral side (P < .05). Radiographic signs of posterior instability were noted in 42.9% of cases. Patients with evidence of posterior instability had significantly inferior results in the TS and the ACJI (P < .05). Neither coracoid fractures nor early (within 6 weeks postoperatively) loss of reduction due to tunnel malpositioning or implant loosening was observed. Conclusion: The combined arthroscopically assisted and image intensifier–controlled double TightRope technique using implants of the first-generation represents a safe technique and yields good to excellent early clinical results despite the presence of partial recurrent vertical and horizontal AC joint instability.

Postoperative Subscapularis Muscle Insufficiency After Primary and Revision Open Shoulder Stabilization

Background Postoperative subscapularis muscle insufficiency after open shoulder stabilization procedures represents an unrecognized condition. Hypothesis Primary and revision open shoulder stabilization using the inverted L-shaped tenotomy approach impairs subscapularis muscle recovery and affects final clinical outcome. Study Design Cohort study; Level of evidence, 3. Methods Twenty-five patients who underwent primary (group 1: n = 13; mean age, 36.5 years; follow-up, 48 months) or revision (group 2: n = 12; mean age, 34.2 years; follow-up, 52 months) open shoulder stabilization procedures were followed up clinically (clinical subscapularis tests and signs, Constant score, and Rowe score) and by magnetic resonance imaging (tendon integrity, defined muscle diameters, and signal intensity analysis [ratio infraspinatus/upper subscapularis muscle and infraspinatus/lower subscapularis muscle]). A third group (group 0) of 12 healthy volunteers served as a control. Results Clinical signs for subscapularis muscle insufficiency were present in 53.8% of cases in group 1 and 91.6% of cases in group 2. There were no significant differences between groups with regard to Constant and Rowe scores (P >. 05). On magnetic resonance imaging, no complete tendon ruptures were found. The mean vertical diameter of the subscapularis muscle and the mean transverse diameter of the upper subscapularis muscle portion were significantly greater in group 0 than in group 1 and greater in group 1 than in group 2 (P <. 05). The mean transverse diameter of the lower subscapularis muscle was comparable in all groups (P >. 05). The signal intensity analysis revealed the infraspinatus/upper subscapularis muscle ratio was greater in group 0 than in group 1 and greater in group 1 than in group 2 (P <. 05). The infraspinatus/lower subscapularis muscle ratio was lower in group 0 than in groups 1 and 2 (P <. 05). Conclusion Open shoulder stabilization using an inverted L-shaped tenotomy approach may lead to atrophy and fatty infiltration, particularly of the upper part of the subscapularis muscle, resulting in postoperative subscapularis muscle insufficiency. Revision procedures using the same approach may further compromise clinical subscapularis muscle function and structure. The lower portion of the subscapularis muscle seems to have a compensating effect that may, in addition to a meticulous capsulolabral reconstruction, account for the uncompromised overall clinical outcome.

Arthroscopic Soft Tissue Tenodesis Versus Bony Fixation Anchor Tenodesis of the Long Head of the Biceps Tendon

Background: Currently there are no prospective data available that compare the different tenodesis techniques of the long head of the biceps tendon with regard to their clinical and structural results. Hypothesis: Soft tissue tenodesis provides clinical and structural results equivalent to those of bony fixation anchor tenodesis. Study Design: Cohort study; Level of evidence, 3. Methods: Fifty-seven patients with arthroscopically proven lesions of the long head of the biceps tendon (LHB) were prospectively included in this study. Thirty patients (7 women, 23 men; mean age, 57.9 years) were treated with an arthroscopic soft tissue tenodesis (STT) and 27 patients (8 women, 19 men; mean age, 61 years) with an arthroscopic bony fixation anchor tenodesis (BFAT). The clinical evaluation included the Constant score as well as a newly developed LHB score (maximum 100 points) that includes evaluation of pain and cramps (maximum 50 points), the patient- and examiner-dependent grading of the cosmetic result (maximum 30 points), and the measurement of elbow flexion strength (maximum 20 points). The integrity of the tenodesis construct was evaluated indirectly by detecting the position of the LHB using magnetic resonance imaging. A proximal intertubercular location of the tendon was judged as an intact tenodesis construct (3 points), a distal intertubercular location as a failure of tenodesis followed by autotenodesis in the sulcus (2 points), and an extratubercular location as a complete failure (1 point). Results: Twenty-four patients (5 women, 19 men; mean age, 58.6 years; mean follow-up, 19.6 months) in the STT group and 20 patients (5 women, 15 men; mean age, 59.1 years; mean follow-up, 22.4 months) in the BFAT group could be evaluated. The overall Constant score did not reveal any significant difference in the STT group (mean, 75.0 points) compared with the BFAT group (mean, 78.3 points) (P > .05). However, the BFAT group showed significantly better results in the LHB score (BFAT mean, 91.8 points vs STT mean, 80.9 points), the examiner-dependent evaluation of the cosmetic result (BFAT mean, 11.3 points vs STT mean, 8.0 points), as well as in the evaluation of the structural integrity of the tenodesis construct (BFAT mean, 2.7 points vs STT mean, 2.2 points) (P < .05). Conclusion: When arthroscopic tenodesis of the LHB is indicated, the authors recommend a bony fixation over soft tissue fixation because anchor fixation provides significant advantages concerning the clinical and structural outcome.

Structural Integrity and Clinical Function of the Subscapularis Musculotendinous Unit After Arthroscopic and Open Shoulder Stabilization

Background Postoperative subscapularis dysfunction after open shoulder stabilization has recently received increasing attention. The potential advantage of arthroscopic stabilization procedures is that they do not violate the subscapularis musculotendinous unit, which might preserve its structural integrity and clinical function, which would lead to superior clinical results. Hypothesis Arthroscopic shoulder stabilization does not lead to clinical and radiological signs of subscapularis insufficiency. Study Design Cohort study; Level of evidence, 3. Methods Twenty-two patients who underwent arthroscopic (group I, n = 12; average age, 30.9 years; mean follow-up, 37 months) or open (group II, n = 10; average age, 28.8 years; mean follow-up, 35.9 months) shoulder stabilization procedure were followed up clinically (clinical subscapularis tests and signs, Constant Score, Rowe Score, Walch-Duplay Score, Western Ontario Shoulder Instability Index and Melbourne Instability Shoulder Score) and by magnetic resonance imaging (subscapularis tendon integrity, cross-sectional area, defined muscle diameters, and signal intensity analysis [ratio infraspinatus/upper subscapularis and infraspinatus/lower subscapularis]). A third group (group 0) of 12 healthy volunteers served as a control. Results Clinical signs for subscapularis insufficiency were present in 0% of cases in group I and in 70% of cases in group II. There were no statistically significant differences in either group regarding Constant Score, Rowe Score, Walch-Duplay Score, Western Ontario Shoulder Instability Index, and Melbourne Instability Shoulder Score (P > .05). On magnetic resonance image, no subscapularis tendon ruptures were found. The cross-sectional area, the mean vertical diameter, and the mean transverse diameter of the upper and lower subscapularis muscle portion was significantly less in group II than in group 0 (P < .05). The signal intensity analysis revealed the infraspinatus/upper subscapularis ratio was significantly lower in group II than in group I or group 0. The infraspinatus/lower subscapularis ratio did not significantly differ in all 3 groups (P > .05). Conclusion This study confirms previous observations that open shoulder stabilization using a subscapularis tenotomy may lead to atrophy and fatty infiltration of the subscapularis muscle, resulting in postoperative subscapularis dysfunction. As expected, arthroscopic procedures do not significantly compromise clinical subscapularis function and structural integrity. However, no significant differences were observed in the overall outcome.

Arthroscopically assisted coracoclavicular ligament reconstruction for chronic acromioclavicular joint instability

The treatment of symptomatic chronic acromioclavicular joint dislocations can be challenging. Different surgical procedures have been described in the literature. We present an arthroscopically assisted stabilization using a gracilis tendon transclavicular-transcoracoid loop technique augmented with a Tight-Rope (Arthrex, Naples, FL, USA). In contrast to the classic Weaver–Dunn procedures this technique is designed to stabilize the acromioclavicular joint by recreating the anatomy of the coracoclavicular ligaments via a minimal invasive approach.

Arthroscopic reconstruction of chronic anteroinferior glenoid defect using an autologous tricortical iliac crest bone grafting technique

Only a few reports exist on the management of severe anteroinferior glenoid defects in case of recurrent shoulder instability most of them including open approaches. We describe an all-arthroscopic reconstruction technique of the anteroinferior glenoid that includes an autologous iliac crest bone grafting using bio-compression screws and a capsulolabral repair using suture anchors. This technique recreates the bony and soft-tissue anatomy of the anteroinferior glenoid while preserving the integrity of insertion of the subscapularis (SSC) tendon.

Biomechanical Comparison of 4 Double-Row Suture-Bridging Rotator Cuff Repair Techniques Using Different Medial-Row Configurations

PURPOSE Biomechanical comparison of different suture-bridge configurations of the medial row with respect to initial construct stability (time 0, porcine model). METHODS In 40 porcine fresh-frozen shoulders, the infraspinatus tendons were dissected from their insertions. All specimens were operated on by use of the suture-bridge technique, only differing in terms of the medial-row suture-grasping configuration, and randomized into 4 groups: (1) single-mattress (SM) technique, (2) double-mattress (DM) technique, (3) cross-stitch (CS) technique, and (4) double-pulley (DP) technique. Identical suture anchors were used for all specimens (medial: Bio-Corkscrew FT 5.5 [Arthrex, Naples, FL]; lateral: Bio-PushLock 3.5 [Arthrex]). All repairs were cyclically loaded from 10 to 60 N until 10 to 200 N (20-N stepwise increase after 50 cycles each) with a material testing machine. Forces at 3 and 5 mm of gap formation, mode of failure, and maximum load to failure were recorded. RESULTS The DM technique had the highest ultimate tensile strength (368.6 ± 99.5 N) compared with the DP (248.4 ± 122.7 N), SM (204.3 ± 90 N), and CS (184.9 ± 63.8 N) techniques (P = .004). The DM technique provided maximal force resistance until 3 and 5 mm of gap formation (90.0 ± 18.1 N and 128.0 ± 32.3 N, respectively) compared with the CS (72 ± 8.9 N and 108 ± 20.2 N, respectively), SM (66.0 ± 8.9 N and 90.0 ± 26.9 N, respectively), and DP (62.2 ± 6.2 N and 71 ± 13.2 N, respectively) techniques (P < .05 for each 3 and 5 mm of gap formation). The main failure mode was suture cutting through the tendon. CONCLUSIONS Comparing the 4 different suture-bridge techniques, we found that modified application of suture-bridge repair with double medial mattress stitches significantly enhanced biomechanical construct stability at time 0 in this porcine ex vivo model. CLINICAL RELEVANCE This technique increases initial stability and resistance to suture cutting through the rotator cuff tendon after arthroscopic suture-bridge repair.

Prevalence and pattern of glenohumeral injuries among acute high-grade acromioclavicular joint instabilities.

BACKGROUND With increasing numbers of arthroscopically assisted acromioclavicular (AC) joint stabilization procedures has come an increase in reports of concomitant glenohumeral injuries among AC joint separations. The aim of the present study was to evaluate the prevalence, pattern, and cause of glenohumeral pathologies among a large patient population with acute high-grade AC joint instability. MATERIALS AND METHODS A total of 125 patients (13 women, 112 men) with high-grade AC joint dislocation (6 Rockwood II; 119 Rockwood V) underwent diagnostic glenohumeral arthroscopy before AC joint repair. Pathologic lesions were evaluated for acute or degenerative origin and, if considered relevant, treated all-arthroscopically. RESULTS Concomitant glenohumeral pathologies were found in 38 of 125 patients (30.4%). Analysis of pathogenesis distinguished different patterns of accompanying injuries: acute intra-articular lesions, related to the recent shoulder trauma, were found in 9 patients (7.2%), degenerative lesions, considered to be unrelated to the recent trauma, were found in 18 (14.4%), and 11 (8.8%) had an unclear traumatic correlation (intermediate group). Within the acute and the degenerative group, affected structures were predominantly partial, articular-sided tears of the anterosuperior rotator cuff, including instabilities of the pulley complex, followed by pathologies of the long head of the biceps and superior labrum anteroposterior lesions. The intermediate group presented mainly with articular-sided partial tears of the subscapularis tendon. CONCLUSIONS This prospective study showed a high prevalence (30%) of concomitant glenohumeral pathologies, of which some indicate additional surgical therapy and could be missed by an isolated open AC repair. Hence, the arthroscopic approach for AC joint stabilization allows for the diagnosis and treatment of associated intra-articular pathologies.

Arthroscopic Single-Row Modified Mason-Allen Repair Versus Double-Row Suture Bridge Reconstruction for Supraspinatus Tendon Tears A Matched-Pair Analysis

Background: Arthroscopic double-row fixation of supraspinatus tendon tears compared with single-row techniques is still a matter of debate. Hypothesis: Arthroscopic double-row rotator cuff repair using the suture bridge technique provides better clinical results and lower retear rates than does single-row repair using a modified Mason-Allen stitch technique. Study Design: Cohort study; Level of evidence 3. Methods: Forty patients underwent either an arthroscopic single-row modified Mason-Allen stitch (SR) (n = 20; mean age ± SD, 61.5 ± 7.4 y) or a modified suture bridge double-row repair (DR) (n = 20; age, 61.2 ± 7.5 y). The anteroposterior extension was classified as Bateman I in 10% and Bateman II in 90% of patients in the SR group and as Bateman II in 80% and Bateman III in 20% of patients in the DR group. Patients were matched for sex and age. The subjective shoulder value (SSV), Constant-Murley score (CS), and Western Ontario Rotator Cuff Index (WORC) were used for clinical follow-up. Furthermore, MRI scans were conducted for analysis of tendon integrity, muscle atrophy, and fatty infiltration via semiquantitative signal intensity analysis. In addition, re-defect patterns were evaluated. Results: The mean follow-up time in the SR group was 16.8 ± 4.6 months. The mean SSV was 91.0% ± 8.8%, mean CS was 82.2 ± 8.1 (contralateral side, 88.8 ± 5.3), and mean WORC score was 96.5% ± 3.2%. The mean follow-up time in the DR group was 23.4 ± 2.9 months, with patients achieving scores of 92.9% ± 9.6% for the SSV, 77.0 ± 8.6 for the CS (contralateral side, 76.7 ± 17.1), and 90.7% ± 12.6% for the WORC (P > .05). No significant differences were detected in the clinical outcome between groups. Tendon integrity was as follows. Type 1, none in either group; type 2, 4 SR and 5 DR; type 3, 9 SR and 10 DR; type 4, 3 SR and 3 DR; and type 5, 3 SR and 2 DR. The failure rate was 31.6% (n = 6) in the SR group and 25% (n = 5) in the DR group (P > .05). No significant differences were obtained for muscular atrophy or fatty degeneration (SR group, 0.94 ± 0.16; DR group, 1.15 ± 0.5) (P > .05). Re-defects revealed lateral cuff failure in 83.3% of SR patients in contrast to patients treated with DR techniques. The re-defect pattern was medial cuff failure in 80% of the patients. Conclusion: The clinical results after modified Mason-Allen single-row versus double-mattress suture bridge technique did not demonstrate significant differences in a matched patient cohort. Concerning the failure mode, single- and double-row techniques seem to demonstrate different re-defect patterns.

How long should acute anterior dislocations of the shoulder be immobilized in external rotation

Background Immobilization of the shoulder in external rotation has been shown to reduce the risk of recurrence after traumatic anteroinferior shoulder dislocation. It remains unclear how duration of immobilization affects labral coaptation. Hypothesis Immobilization of the shoulder in 30° of external rotation for 5 weeks allows better coaptation of the anteroinferior labrum than does an immobilization period of 3 weeks. Study Design Cohort study; Level of evidence, 2. Methods Twenty-two patients with traumatic anteroinferior dislocation of the glenohumeral joint were included in this study. Patients were divided into 2 groups. Group 1 consisted of the initial 11 patients (mean age, 37.4 years) immobilized for 3 weeks; group 2 consisted of the subsequent 11 patients (mean age, 29.7 years) immobilized for 5 weeks in 30° of external rotation. With use of magnetic resonance imaging, displacement and separation of the glenoid labrum and anterior joint effusion were assessed in different arm positions (internal rotation, neutral rotation, 30° of external rotation, maximum external rotation) within 3 days, 3 weeks, and 5 weeks after reduction. Results Displacement and separation of the labrum and anterior joint effusion were significantly less, particularly with maximum external rotation compared with neutral and internal rotation, during the acute magnetic resonance imaging evaluation in both groups (P < .05). No statistically significant differences were found in all parameters comparing internal rotation with neutral rotation, 30° of external rotation, and maximum external rotation in both groups after 5 weeks (P > .05). No statistically significant differences were found between both groups comparing the results of the measured variables during the acute, 3-week, and 5-week magnetic resonance imaging examinations (P > .05). Conclusion Immobilization of the shoulder in 30° of external rotation seems to allow a similar coaptation of the glenoid labrum, regardless of duration of immobilization (3 vs 5 weeks). Clinical trials are needed to evaluate the effect of these results on recurrence rates. The optimum position of immobilization in external rotation has yet to be determined.