Paul C. Brady

The Value of Arthroscopy Before an Open Modified Latarjet Reconstruction

PURPOSE The purpose of this study was to identify the presence of intra-articular pathology in patients undergoing shoulder arthroscopy immediately before modified Latarjet reconstruction for recurrent anterior instability with bone deficiency. METHODS The records of 33 consecutive patients who underwent shoulder arthroscopy immediately before the modified Latarjet reconstruction were analyzed. Arthroscopy was performed just before the open procedure to identify and treat intra-articular pathology that would otherwise have been missed or not well treated during the routine open anterior approach to the shoulder. RESULTS In 24 of 33 cases (73%) associated pathologic lesions were identified and addressed arthroscopically (lesions not likely to have been discovered and treated optimally during the open deltopectoral approach). We identified and addressed 21 type 2 SLAP lesions (64%) as well as 1 posterior Bankart lesion, 2 loose bodies, 2 rotator cuff tears, and 2 localized areas of grade 4 chondromalacia. CONCLUSIONS Arthroscopic examination before modified Latarjet reconstruction is recommended because it allows the surgeon to identify and arthroscopically address associated pathologic entities that are present in over two thirds of the cases. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Associated Lesions Requiring Additional Surgical Treatment in Grade 3 Acromioclavicular Joint Dislocations

PURPOSE To evaluate the incidence of associated pathologic shoulder lesions that were addressed surgically in grade 3 acromioclavicular joint (ACJ) dislocations, as well as to compare this incidence between younger and older patients and between acute and chronic cases. METHODS In this multicenter nonrandomized retrospective study, 98 patients operated on for grade 3 ACJ dislocation underwent concomitant arthroscopic evaluation for the identification and treatment of any associated lesions. The type and treatment of associated lesions were collected in a central database and analyzed. We classified patients according to age (<45 years and ≥ 45 years) and according to the length of time between trauma and surgical treatment (≤ 30 days and ≥ 120 days), obtaining the following stratification: younger acute, older acute, younger chronic, and older chronic. RESULTS Of the patients, 42 (42.8%) were diagnosed with at least 1 additional pathologic lesion, and 29 (29.5%) required a dedicated additional treatment. Rates of treatment on associated lesions were analyzed: younger versus older groups presented a significant difference, as did younger acute versus older acute groups; SLAP and posterior rotator cuff tear treatments represented 24 of the 35 additional surgeries (68.5%). CONCLUSIONS The overall rate of associated pathologic lesions requiring additional surgical treatment in patients with ACJ dislocation was 29.5%. Patients aged 45 years or older had a greater risk of presenting with associated lesions that needed to be surgically addressed (odds ratio, 3.01). The overall rates of associated surgical lesions in acute versus chronic cases were not shown to be significantly different. LEVEL OF EVIDENCE Level IV, prognostic case series.

A systematic approach for diagnosing subscapularis tendon tears with preoperative magnetic resonance imaging scans.

PURPOSE To determine and propose a systematic approach to evaluating magnetic resonance imaging (MRI) scans for subscapularis tears and compares preoperative MRI interpretations with findings of the same shoulders at arthroscopy. METHODS The study was composed of 202 patients who underwent shoulder arthroscopy by 1 of 5 orthopaedic surgeons during a 3-month period. All patients had MRI scans performed within 6 months before arthroscopy. RESULTS Of the 202 patients, 82 had subscapularis tendon tears confirmed at the time of arthroscopy. The orthopaedic surgeons correctly diagnosed 60 of 82 patients (73%) with subscapularis tendon tears on preoperative MRI that were subsequently identified by arthroscopy. The orthopaedic surgeons correctly diagnosed 113 of 120 patients (94%) as not having subscapularis tendon tears. This resulted in an overall sensitivity of 73%, specificity of 94%, positive predictive value of 90%, negative predictive value of 84%, and accuracy of 86%. The frequency of subscapularis tears was highest when the long head of the biceps was displaced from the groove (88%), a combined supraspinatus/infraspinatus tear existed (71%), or the long head of the biceps tendon was torn (69%). CONCLUSIONS Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with the described systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies. A consistent finding is that larger subscapularis tendon tears are more easily detected using MRI scans whereas smaller tears are more frequently missed. LEVEL OF EVIDENCE Level III, development of diagnostic criteria with universally applied reference (nonconsecutive patients).

Pseudoparalysis From a Massive Rotator Cuff Tear Is Reliably Reversed With an Arthroscopic Rotator Cuff Repair in Patients Without Preoperative Glenohumeral Arthritis

Background: Pseudoparalysis is defined as active forward flexion less than 90° with full passive motion. There is controversy about the ideal surgical management of a massive rotator cuff tear with pseudoparalysis. Purpose/Hypothesis: The purpose of this study was to prospectively analyze the ability to reverse pseudoparalysis with an arthroscopic rotator cuff repair (ARCR). The hypothesis was that in the absence of substantial glenohumeral arthritis, preoperative fatty infiltration of grade 3 or higher and an acromiohumeral interval (AHI) of less than 7 mm would not prevent reversal of pseudoparalysis with an ARCR. Study Design: Case series; Level of evidence, 4. Methods: A prospective multicenter study of ARCR performed for preoperative pseudoparalysis was conducted. The minimum follow-up was 1 year. The mean patient age was 63 years, and pseudoparalysis was present for a mean of 4.2 months preoperatively. Preoperative radiographic evaluation included plain film evaluation of the AHI and Hamada classification and MRI evaluation of fatty degeneration and rotator cuff retraction. Functional outcome was determined by the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, visual analog scale (VAS), and subjective shoulder value (SSV). Results: Of the 58 patients enrolled, 56 had at least 1 year of follow-up. Mean active forward flexion improved from 47° preoperatively to 159° postoperatively (P < .001). Statistically significant improvements were seen in the SST (from 2.8 preoperatively to 10.1 postoperatively), SSV (from 28 to 83), ASES Shoulder Score (from 37 to 88), and VAS (from 5.7 to 1.1) (P < .001). Pseudoparalysis was reversed in 53 of 56 patients (95%). There was no difference in the rate of reversal of pseudoparalysis between those patients with an AHI of less than 7 mm (88.2%) and those with an AHI of 7 mm or more (96.9%) (P =.289). Pseudoparalysis was reversed in all 8 of the patients with fatty degeneration of grade 3 or higher in 1 or more of the rotator cuff muscles. Conclusion: ARCR can lead to reversal of preoperative pseudoparalysis in patients with minimal preoperative glenohumeral arthritis. ARCR is a viable first line of treatment for patients with pseudoparalysis in the absence of advanced glenohumeral arthritis.

Arthroscopic Rotator Cuff Repair: Establishing the Footprint

Arthroscopic rotator cuff repair has gained much momentum and acceptance over the past decade due to the excellent patient outcomes and diminished patient morbidity. The optimal technique and repair construct continues to be a subject of much interest and debate. This article will explore the subject of footprint restoration and describe our technique for maximizing the footprint coverage in rotator cuff repairs.

Editorial Commentary: The Larger Holes or Larger Number of Holes We Drill in the Coracoid, the Weaker the Coracoid Becomes

The larger holes or larger number of holes we drill in the coracoid, the weaker the coracoid becomes. Thus, minimizing bone holes (both size and number) is required to lower risk of coracoid process fracture, in patients in whom transosseous shoulder acromioclavicular joint reconstruction is indicated. A single 2.4-mm-diameter tunnel drilled through both the clavicle and the coracoid lowers the risk of fracture, but the risk cannot be entirely eliminated.

Capsulolabral Advancement for the Treatment of Glenoid Chondromalacia

The capsulolabral advancement procedure performed for glenoid articular defects resulted in a significant decrease in pain and improved UCLA scores, and postoperative range of motion was not significantly diminished.