Michael Q. Freehill

Nonoperative Management for In-Season Athletes With Anterior Shoulder Instability

Background Acute or recurrent anterior shoulder instability is a frequent injury for in-season athletes. Treatment options for this injury include shoulder immobilization, rehabilitation, and shoulder stabilization surgery. Purpose To determine if in-season athletes can be returned to their sports quickly and effectively after nonoperative treatment for an anterior instability episode. Methods Over a 2-year period, 30 athletes matched the inclusion criteria for this study. Nineteen athletes had experienced anterior dislocations, and 11 had experienced subluxations. All were treated with physical therapy and fitted, if appropriate, with a brace. These athletes were followed for the number of recurrent instability episodes, additional injuries, subjective ability to compete, and ability to complete their season or seasons of choice. Results Twenty-six of 30 athletes were able to return to their sports for the complete season at an average time missed of 10.2 days (range, 0-30 years). Ten athletes suffered sport-related recurrent instability episodes (range, 0-8 years). An average of 1.4 recurrent instability episodes per season per athlete occurred. There were no further injuries attributable to the shoulder instability. Sixteen athletes underwent surgical stabilization for their shoulders during the subsequent off-season. Conclusions Most of the athletes were able to return to their sport and complete their seasons after an episode of anterior shoulder instability, although 37% experienced at least 1 additional episode of instability during the season.

Complications Observed Following Labral or Rotator Cuff Repair with Use of Poly-L-Lactic Acid Implants

BACKGROUND A variety of complications associated with the use of poly-L-lactic acid (PLLA) implants, including anchor failure, osteolysis, glenohumeral synovitis, and chondrolysis, have been reported in patients in whom these implants were utilized for labral applications. We report on a large series of patients with complications observed following utilization of PLLA implants to treat either labral or rotator cuff pathology. METHODS Patients who had undergone arthroscopic debridement to address pain and loss of shoulder motion following index labral or rotator cuff repair with PLLA implants were identified retrospectively with use of our research database. A total of forty-four patients in whom macroscopic anchor debris had been observed and/or biopsy samples had been obtained during the debridement were included in the study. Synovial biopsy samples taken at the time of the arthroscopic debridement were available for thirty-eight of the forty-four patients and were analyzed by a board-certified pathologist. Magnetic resonance imaging (MRI) scans acquired after the index procedure and data from the arthroscopic debridement were available for all patients. RESULTS Macroscopic intra-articular anchor debris was observed in >50% of the cases. Giant cell reaction was observed in 84%; the presence of polarizing crystalline material, in 100%; papillary synovitis, in 79%; and arthroscopically documented Outerbridge grade-III or IV chondral damage, in 70%. A significant correlation (rho = 0.36, p = 0.018) was observed between the time elapsed since the index procedure and the degree of chondral damage. A recurrent rotator cuff tear that was larger than the tear documented at the index procedure was observed in all patients whose index procedure included a rotator cuff repair. CONCLUSIONS Clinically important gross, histologic, and MRI-visualized pathology was observed in a large cohort of patients in whom PLLA implants had been utilized to repair lesions of the labrum or rotator cuff.

Clinical and Radiographic Outcomes of the Simpliciti Canal-Sparing Shoulder Arthroplasty System: A Prospective Two-Year Multicenter Study.

BACKGROUND Stemmed humeral components have been used since the 1950s; canal-sparing (also known as stemless) humeral components became commercially available in Europe in 2004. The Simpliciti total shoulder system (Wright Medical, formerly Tornier) is a press-fit, porous-coated, canal-sparing humeral implant that relies on metaphyseal fixation only. This prospective, single-arm, multicenter study was performed to evaluate the two-year clinical and radiographic results of the Simpliciti prosthesis in the U.S. METHODS One hundred and fifty-seven patients with glenohumeral arthritis were enrolled at fourteen U.S. sites between July 2011 and November 2012 in a U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE)-approved protocol. Their range of motion, strength, pain level, Constant score, Simple Shoulder Test (SST) score, and American Shoulder and Elbow Surgeons (ASES) score were compared between the preoperative and two-year postoperative evaluations. Statistical analyses were performed with the Student t test with 95% confidence intervals. Radiographic evaluation was performed at two weeks and one and two years postoperatively. RESULTS One hundred and forty-nine of the 157 patients were followed for a minimum of two years. The mean age and sex-adjusted Constant, SST, and ASES scores improved from 56% preoperatively to 104% at two years (p < 0.0001), from 4 points preoperatively to 11 points at two years (p < 0.0001), and from 38 points preoperatively to 92 points at two years (p < 0.0001), respectively. The mean forward elevation improved from 103° ± 27° to 147° ± 24° (p < 0.0001) and the mean external rotation, from 31° ± 20° to 56° ± 15° (p < 0.0001). The mean strength in elevation, as recorded with a dynamometer, improved from 12.5 to 15.7 lb (5.7 to 7.1 kg) (p < 0.0001), and the mean pain level, as measured with a visual analog scale, decreased from 5.9 to 0.5 (p < 0.0001). There were three postoperative complications that resulted in revision surgery: infection, glenoid component loosening, and failure of a subscapularis repair. There was no evidence of migration, subsidence, osteolysis, or loosening of the humeral components or surviving glenoid components. CONCLUSIONS The study demonstrated good results at a minimum of two years following use of the Simpliciti canal-sparing humeral component. Clinical results including the range of motion and the Constant, SST, and ASES scores improved significantly, and radiographic analysis showed no signs of loosening, osteolysis, or subsidence of the humeral components or surviving glenoid components. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Anteromedial Capsular Redundancy and Labral Deficiency in Shoulder Instability

Background: Redundancy of the anteromedial capsule of the shoulder may persist despite proper tensioning of the capsule and repair of a Bankart lesion during an anteroinferior capsular shift procedure. Hypothesis: A barrel-stitch suture technique incorporated into a capsular shift procedure is effective in achieving satisfactory shoulder stability. Study Design: Uncontrolled retrospective review. Methods: A barrel-stitch technique was used for patients identified as having anteromedial capsular redundancy during a capsular shift procedure for anteroinferior instability. Results: The incidence of anteromedial capsular redundancy and labral deficiency was 49% (38 of 78). Patients with anteromedial capsular redundancy had a significantly greater number of dislocations before surgery (16.1 ± 21.3 versus 7.4 ± 7.4) and a greater duration of symptoms (79.8 ± 84.2 versus 31.6 ± 32.2 months). The mean postoperative Rowe score of patients with anteromedial capsular redundancy was 88.7 ± 14.8, with 92% having excellent or good results, compared with 88.9 ± 14.8 in the remaining patients and 93% excellent or good results. Conclusions: Anteromedial capsular redundancy is associated with longer preoperative duration of symptoms and more dislocations, but effective treatment can be achieved with a capsular shift procedure augmented with medial capsular imbrication with a barrel stitch.

Diagnosis and Treatment of Ganglion Cysts about the Shoulder

With the advent of magnetic resonance imaging, supraglenoid cyst identification has become more common. A high incidence of type II SLAP lesions has been described in association with these cysts, which are frequently located in the region of the suprascapular notch. Clinical evaluation frequently reveals posterolateral shoulder pain and infraspinatus weakness and atrophy. We have successfully treated patients with symptomatic cysts using diagnostic arthroscopy followed by arthroscopic cyst decompression. All patients in our study were identified with a superior labral pathology and subsequently went on to have arthroscopic superior labral stabilization. Open decompression is reserved for patients when an adequate arthroscopic decompression cannot be confirmed, or a large cyst is associated with significant neurologic involvement of the infraspinatus or supraspinatus muscle, or both.

Arthroscopic Treatment of the Unstable Mesoacromion

Unstable symptomatic os acromiale is an unusual cause of impingement syndrome and rotator cuff pathology. Failure of nonoperative measures may require surgical intervention. Arthroscopic excision of the unstable bone fragment and treatment of any associated minor rotator cuff pathology have produced acceptable results.

Split Pectoralis Major Tendon Transfer for the Treatment of Serratus Anterior Palsy

Scapular winging secondary to serratus anterior palsy was first described nearly three centuries ago. Since that time numerous procedures, dynamic and static in design, have been developed for the treatment of this clinical entity. Recent clinical studies demonstrate excellent results with the use of a split pectoralis major transfer to the inferior angle of the scapula. Autologous tendon grafts such as fascia lata or semitendinosus/gracilis may be used to augment the transfer. Successful direct transfer of the pectoralis major tendon, which may lower donor site morbidity associated with graft harvest, has been recently described. Overall, the literature reports satisfactory outcomes in 81% to 100% of patients treated with the pectoralis major transfer.