Stephen J. Snyder

An analysis of 140 injuries to the superior glenoid labrum.

Between 1985 and 1993 140 injuries of the superior glenoid labrum were identified on arthroscopic evaluation and were recalled from a data bank of 2375 shoulder procedures performed during that time. The average patient age was 38 years, and 91% of the patients were men. The most common problem was pain, with 49% of all patients noting mechanical catching or grinding in their shoulders. No preoperative imaging modality consistently defined disease in the superior labral area. Fifty-five percent of all lesions were type II, 21% were type I, 10% were type IV, 9% were type III, and 5% were complex. Twenty-nine percent of lesions were associated with a partial-thickness tear of the rotator cuff, 11% with a full-thickness tear, and 22% with an anterior Bankart lesion. Twenty-eight percent of the superior labral lesions seen were isolated and did not have any associated rotator cuff or anterior labral disease. Type I lesions were debrided. Fifty-six percent of type II lesions were debrided in conjunction with an abrasion of the underlying glenoid rim. More recently suture anchors have been used to stabilize type II lesions. Treatment of type III and IV lesions depended on the extent of labral tissue disruption and involved either debridement or suture repair. Repeat arthroscopies were performed on 18 shoulders. Three of five type lesions treated with debridement and glenoid abrasion were healed. Four of five type II lesions treated with an absorbable anchor were healed. Three type III and one type IV lesion treated with debridement had normal superior labrums. Two type IV injuries treated with suture repair had completely healed. Two complex type II and III injuries treated with debridement and anchor fixation were healed.

Partial thickness rotator cuff tears: Results of arthroscopic treatment

Thirty-one patients with arthroscopically documented partial thickness rotator cuff tears treated by arthroscopic debridement of the lesion were retrospectively reviewed. The patients had had symptoms for an average of 20.5 months prior to surgery. Twenty-two of these 31 shoulders also had bursoscopy, with 18 having arthroscopic subacromial decompression. The results were graded by both the UCLA Shoulder Rating Scale and Neers criteria. Twenty-six (84%) of the patients had satisfactory results with the remaining 5 (16%) patients having unsatisfactory results. A classification system for the size and location of partial thickness rotator cuff tears is presented. The lesion size did not affect the result. Repeat arthroscopy in three patients demonstrated no further deterioration of their rotator cuff. The results with and without subacromial decompression were similar. The need for subacromial decompression is best determined by the arthroscopic finding of a bursal side tear.

Arthroscopic Replacement of Massive, Irreparable Rotator Cuff Tears Using a GraftJacket Allograft: Technique and Preliminary Results

PURPOSE Our purpose was to assess the short-term results and describe the technique of arthroscopic repair of irreparable rotator cuff tears by use of a GraftJacket allograft (Wright Medical Technology, Arlington, TN). METHODS Between March 2003 and February 2004, 16 patients with massive, contracted, immobile rotator cuff tears were treated with arthroscopic placement of a GraftJacket allograft by a single surgeon. Patients were followed up for 1 to 2 years. All were evaluated preoperatively and postoperatively by use of the modified University of California, Los Angeles scoring system, Constant score, and Simple Shoulder Test. Magnetic resonance imaging was performed postoperatively at 3 months and 1 year. RESULTS At a mean follow-up of 26.8 months (range, 12 to 38 months), 15 of 16 patients were satisfied with the procedure. The mean University of California, Los Angeles score increased from 18.4 preoperatively to 30.4 postoperatively (P = .0001). The Constant score increased from 53.8 to 84.0 (P = .0001). Statistically significant improvements were seen in pain, forward flexion, and external rotation strength. Thirteen patients had full incorporation of the graft into the native tissue as documented on magnetic resonance imaging. There were no complications in this cohort of patients. CONCLUSIONS Our study supports GraftJacket allograft as a viable solution for surgical salvage in select cases of massive, irreparable rotator cuff pathology. This treatment option may provide patients with decreased pain and increased function despite a previously irreparable rotator cuff tear. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Arthroscopic GraftJacket repair of rotator cuff tears

HYPOTHESIS Management of massive, degenerative, and irreparable rotator cuff tears is challenging. Excessive re-tear rates and poor clinical outcome after standard repair have led to alternative methods of treatment. Tendon transfers and shoulder arthroplasty have had mixed results; both are invasive procedures with high potential morbidity. We began performing rotator cuff augmentation and replacement using GraftJacket allograft acellular human dermal matrix as a biologic minimally invasive alternative in this difficult population almost 6 years ago. This article highlights our preferred arthroscopic technique and early results. MATERIALS AND METHODS From January 2004 to June 2007, 45 patients (36 men, 9 women) with massive rotator cuff tears were treated arthroscopically with the GraftJacket allograft. All patients completed a preoperative University of California, Los Angeles (UCLA) score. Follow-up was a minimum of 2 years (range, 24-68 months) and patients completed UCLA, Western Ontario Rotator Cuff (WORC), and American Shoulder and Elbow Surgeons (ASES) scores. RESULTS Analysis was performed using the 3 validated outcomes measurement scores. The mean UCLA score increased from 18.4 preoperatively to 27.5 postoperatively (P < .000). The average WORC score was 75.2, and the ASES score was 84.1 at the final follow-up. DISCUSSION Evidence-based data to outline an algorithm for management of irreparable rotator cuff tears is being developed. We documented significant clinical improvement with arthroscopic rotator cuff reconstruction using the GraftJacket allograft acellular human dermal matrix. The procedure is safe and associated with high patient satisfaction, without the morbidity of tendon transfer or arthroplasty. For those few cases where further surgery is required, no bridges are burned. The early success of this procedure warrants further study with more patients, longer follow-up, and higher levels of evidence-based investigation.

Rotator cuff repair healing influenced by platelet-rich plasma construct augmentation.

PURPOSE To assess the effect of platelet-rich plasma fibrin matrix (PRPFM) construct augmentation on postoperative tendon healing as determined by magnetic resonance imaging (MRI) and clinical outcome of arthroscopic rotator cuff repair. METHODS A comparative series of patients undergoing arthroscopic rotator cuff repair was studied. Two matched groups of patients (20 each) were included: rotator cuff repairs without PRPFM augmentation (group 1) and rotator cuff repairs augmented with 2 sutured platelet-rich plasma (PRP) constructs (group 2). A single-row cuff repair to the normal footprint without tension or marrow vents was performed by a single surgeon. Postoperative rehabilitation was held constant. Postoperative MRI scans were used to evaluate rotator cuff healing. Outcome measures included American Shoulder and Elbow Surgeons, Rowe, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Constant scores. RESULTS We followed up 40 patients (2 matched groups with 20 patients each) with a mean age of 57 years (range, 44 to 69 years) for a mean of 31 months (range, 24 to 44 months). Postoperative MRI studies showed persistent full-thickness tendon defects in 60% of controls (12 of 20) and 30% of PRPFM-augmented repairs (6 of 20) (P = .03). Of the control group tears measuring less than 3 cm in anteroposterior length, 50% (7 of 14) healed fully, whereas 86% of the PRPFM group tears measuring less than 3 cm in anteroposterior length (12 of 14) healed fully (P < .05). There was no significant difference between groups 1 and 2 in terms of American Shoulder and Elbow Surgeons (94.7 and 95.7, respectively; P = .35), Single Assessment Numeric Evaluation (93.7 and 94.5, respectively; P = .37), Simple Shoulder Test (11.4 and 11.3, respectively; P = .41), and Constant (84.7 and 88.1, respectively; P = .19) scores. The Rowe scores (84.8 and 94.9, respectively; P = .03) were statistically different. CONCLUSIONS The addition of 2 PRPFM constructs sutured into a primary rotator cuff tendon repair resulted in lower retear rates identified on MRI than repairs without the constructs. Other than the Rowe scores, there was no postoperative clinical difference by use of standard outcome measures. LEVEL OF EVIDENCE Level III, case-control study.

The arthroscopic mumford procedure: An analysis of results

A total of 50 arthroscopic distal clavicle resections were performed for acromioclavicular joint pathology at our institution between 1990 and 1993. Follow-up on 50 shoulders (100%) was obtained at an average postoperative time of 2 years. Data were collected via physical examination, radiograph review, University of California at Los Angeles (UCLA) shoulder score, and questionnaire. Average patient age was 42 years. Preoperatively all patients showed acromioclavicular joint tenderness, whereas 80% had a positive adduction test. The diagnosis of acromioclavicular degeneration was made by a combination of physical examination and radiographs (100%), acromioclavicular joint injection (4%), bone scan (44%), and magnetic resonance imaging (30%). Intraoperatively, a Claviculizer (Smith-Nephew Dyonics, Andover, MA) burr was used through standard portals in a subacromial approach to the acromioclavicular joint. There were no intraoperative complications. Forty-one patients (82%) had their general anesthetic augmented with an intrascalene block, and all procedures were done on an outpatient basis. The average distal clavicle resection was 14.8 mm. Calcifications within the resected clavicle zone were noted in the shoulders of four of the patients (16%) who returned for radiographic follow-up. The UCLA shoulder score ranked 47 shoulders (94%) good to excellent and 3 fair (6%). Subjective patient satisfaction recorded 47 (94%) good to excellent results, with an average pain relief grade of 87%. Forty-five patients (98%) would recommend the procedure. The arthroscopic Mumford procedure effectively treats acromioclavicular joint pathology. The amount of bone removed can be precisely determined with the Claviculizer burr and reliably reproduced. The procedure has low associated morbidity and high patient satisfaction regarding functional outcome.

Arthroscopic total rotator cuff replacement with an acellular human dermal allograft matrix

Purpose: To describe the technique and short-term results of arthroscopic repair of irreparable rotator cuff tears using a GraftJacket® allograft. Although current rotator cuff repair techniques offer excellent results in most cases, there are still many instances where tendon repair is not possible. Allograft substitutes offer the advantages of saving bone stock, while maintaining anatomic integrity within the shoulder. Materials and Methods: Between March 2003 and February 2004, 16 patients with massive, contracted immobile rotator cuff tears were treated with arthroscopic placement of a GraftJacket® allograft by a single surgeon. Patients were followed for 1-2 years. All were evaluated preoperatively and postoperatively using the modified University of California Los Angeles (UCLA) scoring system, Constant score and Simple Shoulder Test. MRI was performed postoperatively at 3 months and 1 year. Results: At mean follow-up time of 26.8 months (range, 12-38 months), 15 of 16 patients were satisfied with the procedure. The mean UCLA score increased from 18.4 preoperatively to 30.4 postoperatively ( P = 0.0001). The Constant score increased from 53.8 to 84.0 ( P = 0.0001). Statistically significant improvements were seen in pain, forward flexion and external rotation strength. Thirteen displayed full incorporation of the graft into the native tissue, as documented on magnetic resonance imaging. There were no complications in this cohort of patients. Conclusions: Our study supports GraftJacket® allograft as a viable solution for surgical salvage in select cases of massive irreparable rotator cuff pathology.

Arthroscopic bankart reconstruction with a bioabsorbable anchor

This study evaluated the clinical effectiveness of a poly-l-lactic acid biodegradable suture anchor for arthroscopic Bankart reconstruction with a prospective multicenter study. Inclusion criteria were one or more episodes of traumatic dislocation or multiple posttraumatic subluxations as a manifestation of unidirectional anterior instability. Exclusion criteria were significant glenoid bone deficiency, large Hill-Sachs lesions, rotator cuff tears, multidirectional instability, posterior labrum tears, or biceps ruptures. Fifty-seven patients were followed up for a mean of 24 months. Postoperative apprehension tests were negative in all but two. Motion improved from 155 degrees preoperatively to a mean of 175 degrees postoperatively. Four patients had postoperative instability symptoms (two dislocators and two with subluxations). Postoperative radiographs demonstrated no lytic or resorptive bone changes from the suture anchors. The mean postoperative Rowe score was 93. The biodegradable suture anchor achieved good clinical results when used for arthroscopic Bankart reconstruction with no material-related adverse events.

Results of Arthroscopic Revision Anterior Shoulder Reconstruction

Background Recurrent instability after surgical stabilization of the shoulder is uncommon. Although results of open revision stabilization procedures have been reported, only 3 studies have evaluated the outcome of arthroscopic revision surgery. Purpose To analyze results of arthroscopic revision anterior shoulder reconstruction at the authors’ institution. Study Design Case series; Level of evidence, 4. Methods Chart review identified 18 shoulders that had arthroscopic revision anterior shoulder reconstruction at the Southern California Orthopedic Institute between November 4, 1997, and May 14, 2002. Anterior reconstruction of the shoulder was performed using suture anchors and nonabsorbable sutures. In most patients, posterior capsular plication was also performed; in 1 patient, closure of the rotator interval was performed. Sixteen shoulders in 15 patients were examined and 1 patient who required revision surgery was interviewed at a mean of 38 months (range, 24-67 months) after arthroscopic revision anterior shoulder reconstruction. The patient population consisted of 13 men and 3 women whose age at surgery was between 17 and 55 years (mean, 30 years; SD, 11.9 years). Patient satisfaction, the Simple Shoulder Test, and the Rowe scale were used to measure outcome. Results Prior surgeries included 10 arthroscopic procedures in 9 shoulders and 10 open procedures in 8 shoulders. In this study group, 1 patient dislocated his shoulder 4 months after arthroscopic revision anterior shoulder reconstruction during an altercation and subsequently underwent a Bristow procedure. Of the remaining cases, none of the 16 shoulders had recurrence of dislocation or subluxation; all 15 patients were satisfied with their revision surgeries. Among this group, the Simple Shoulder Test responses improved from 8.3 yes responses to 11.3 after arthroscopic revision anterior shoulder reconstruction (P < .05). Using the Rowe scale, there were 9 excellent, 4 good, and 3 fair results. Mean Rowe score at follow-up was 83.8 (range, 55-100; SD, 14.7) for these 16 shoulders. Conclusion In this series, 94% of shoulders were stable after arthroscopic revision anterior shoulder reconstruction, and there were a high number of good and excellent outcomes. Results suggest arthroscopic revision anterior shoulder reconstruction using suture anchors is a viable treatment alternative for patients with failed anterior shoulder reconstructions.

Sonographic evaluation of the rotator cuff: Correlation with arthroscopy

High-resolution real-time sonography has been reported as a non-invasive means of evaluating the integrity of the rotator cuff. Fifty-two patients underwent both sonographic and arthroscopic evaluation of the rotator cuff. There were 42 men and 10 women with an average age of 47 years (range 28-71 years). The duration of shoulder pain averaged 24 months (range 3 months to 9 years). Thirty-five rotator cuff tears were noted arthroscopically. Twenty-seven of the tears were diagnosed by sonography for a sensitivity rate of 77%. Eleven of the 17 intact rotator cuffs were normal by sonography for a specificity rate 65%. The overall accuracy of sonography was 73% and the predictive value of a positive sonogram was 82%. Sonography appears to be a good initial screening examination in evaluating the integrity of the rotator cuff. It is noninvasive and relatively inexpensive. Technical limitations of this technique as well as the experience of the radiologist in performing and interpreting the examination play a major role in the accuracy of this test. As instrumentation improves and as experience in using this technique increases, we expect the accuracy of sonography in detecting tears of the rotator cuff to continue to improve.