Sumant G. Krishnan

Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?

BACKGROUND Good functional results have been reported for arthroscopic repair of rotator cuff tears, but the rate of tendon-to-bone healing is still unknown. Our hypothesis was that arthroscopic repair of full-thickness supraspinatus tears achieves a rate of complete tendon healing equivalent to those reported in the literature with open or mini-open techniques. METHODS Sixty-five consecutive shoulders with a chronic full-thickness supraspinatus tear were repaired arthroscopically in sixty-five patients with use of a tension-band suture technique. Patients ranged in age from twenty-nine to seventy-nine years. The average duration of follow-up was twenty-nine months. Fifty-one patients (fifty-one shoulders) had a computed tomographic arthrogram, and fourteen had a magnetic resonance imaging scan, performed between six months and three years after surgery. All patients were assessed with regard to function and the strength of the shoulder elevation. RESULTS The rotator cuff was completely healed and watertight in forty-six (71%) of the sixty-five patients and was partially healed in three. Although the supraspinatus tendon did not heal to the tuberosity in sixteen shoulders, the size of the persistent defect was smaller than the initial tear in fifteen. Sixty-two of the sixty-five patients were satisfied with the result. The Constant score improved from an average (and standard deviation) of 51.6 +/- 10.6 points preoperatively to 83.8 +/- 10.3 points at the time of the last follow-up evaluation (p < 0.001), and the average University of California at Los Angeles score improved from 11.5 +/- 1.1 to 32.3 +/- 1.3 (p < 0.001). The average strength of the shoulder elevation was significantly better (p = 0.001) when the tendon had healed (7.3 +/- 2.9 kg) than when it had not (4.7 +/- 1.9 kg). Factors that were negatively associated with tendon healing were increasing age and associated delamination of the subscapularis or infraspinatus tendon. Only ten (43%) of twenty-three patients over the age of sixty-five years had completely healed tendons (p < 0.001). CONCLUSIONS Arthroscopic repair of an isolated supraspinatus detachment commonly leads to complete tendon healing. The absence of healing of the repaired rotator cuff is associated with inferior strength. Patients over the age of sixty-five years (p = 0.001) and patients with associated delamination of the subscapularis and/or the infraspinatus (p = 0.02) have significantly lower rates of healing.

Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis. Two to fifteen-year outcomes.

BACKGROUND Biologic glenoid resurfacing was developed in 1988 as an alternative to total shoulder arthroplasty in selected (usually younger) patients with primary, posttraumatic, or postreconstructive glenohumeral arthritis. A variety of biologic surfaces, including anterior capsule, autogenous fascia lata, and Achilles tendon allograft, have been combined with a humeral hemiarthroplasty. METHODS From November 1988 to November 2003, thirty-four patients (thirty-six shoulders) who were managed with biologic glenoid resurfacing and humeral head replacement either with cement (ten shoulders) or without cement (twenty-six shoulders) were followed prospectively. The study group included thirty men and four women with an average age of fifty-one years. The diagnoses included primary glenohumeral osteoarthritis (eighteen shoulders), postreconstructive arthritis (twelve), posttraumatic arthritis (five), and osteonecrosis (one). Anterior capsule was used for seven shoulders, autogenous fascia lata for eleven, and Achilles tendon allograft for eighteen. All shoulders were assessed clinically and with serial radiographs. RESULTS The mean American Shoulder and Elbow Surgeons score was 39 points preoperatively and 91 points at the time of the most recent follow-up. According to Neers criteria, the result was excellent for eighteen shoulders, satisfactory for thirteen, and unsatisfactory for five. Glenoid erosion averaged 7.2 mm and appeared to stabilize at five years. There were no revisions for humeral component loosening. Complications included infection (two patients), instability (three patients), brachial plexitis (one patient), and deep-vein thrombosis (one patient). Factors that appeared to be associated with unsatisfactory results were the use of capsular tissue as the resurfacing material and infection. CONCLUSIONS Biologic resurfacing of the glenoid can provide pain relief similar to total shoulder arthroplasty. It allows selected younger patients to maintain an active lifestyle, including weight-lifting and manual work, without the risk of polyethylene wear. On the basis of this and previous reviews, we currently recommend Achilles tendon allograft as the preferred resurfacing material when this option is chosen. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Subscapularis repair after shoulder arthroplasty: Biomechanical and clinical validation of a novel technique

HYPOTHESIS We hypothesized that releasing the subscapularis with lesser tuberosity bone may improve strength of fixation of the subscapularis during total shoulder atthroplasty (TSA). MATERIALS AND METHODS In 15 cadaveric humeri, all musculature was removed except the subscapularis. A standard humeral head osteotomy was performed for TSA. The subscapularis was released with a fleck of lesser tuberosity bone in 10 specimens from five matched pairs, and a tenotomy was performed in five. Five osteotomies were repaired with single-row heavy non-absorbable sutures and five with an additional double-row. Repairs were subjected to cyclical loading at 180 newtons for 400 cycles, increasing by 180 newtons to failure. A retrospective review of 100 consecutive patients who underwent dual-row repair of the subscapularis fleck osteotomy following TSA was also performed with minimal follow-up of 24 months (24-48). RESULTS Both single (430 N) and double-row (466 N) fixation of the fleck osteotomy were significantly stronger than tenotomy suture repair (252 N) (p < .04). There was no significant difference between single and double-row ultimate strengths. Qualitatively, double-row fixation fixed the fleck osteotomy more securely to the donor site with respect to gross rotational motion. At final clinical review, the lift-off test was rated as normal in 79%. The belly press was rated as normal in 86%. Eighty-two percent were able to tuck in their shirts. CONCLUSION Subscapularis release with fleck osteotomy provides superior biomechanical ultimate strength compared to standard tenotomy. There was no visible motion during biomechanical testing with dual-row osteotomy fixation compared to single-row fixation. Clinical results of this dual-row technique document showed good restoration of subscapularis integrity for activities of daily living. LEVEL OF EVIDENCE Basic science study and level 4; retrospective review, case series, no control group.

Shoulder Arthroplasty for Fracture: Restoration of the ???Gothic Arch???

Shoulder arthroplasty for fracture remains a technically challenging procedure, often with unpredictable clinical outcomes in the reported literature. Consequently, the appropriate management of certain 3- and 4-part fractures and fracture-dislocations of the proximal humerus remains controversial. However, recent advances in our understanding of the intraoperative technical pitfalls with shoulder fracture arthroplasty have created the potential for more reproducible functional results. Restoration of the “gothic arch” of the shoulder girdle combined with anatomic tuberosity reconstruction can make this operative procedure reproducible.

Arthroscopic Biceps Tenodesis: A New Technique Using Bioabsorbable Interference Screw Fixation

Interference screw fixation has been used with success for hamstring anterior cruciate ligament reconstruction of the knee. We propose the same fixation principle for arthroscopic tenodesis of a pathologic long head of the biceps (LHB) using bioabsorbable interference screws. Forty-three patients underwent tenodesis of the LHB for a pathologic tendon (tenosynovitis, pre-rupture, subluxation, or dislocation) encountered in three clinical situations: 1) with arthroscopic or mini-open rotator cuff repair (n = 3); 2) with intact cuffs (n = 6); or 3) with massive, irreparable cuff tears (n = 34). Mean age was 63 years. Minimum clinical and radiographic follow-up was 2 years. Six steps were required: 1) glenohumeral exploration and tenotomy of LHB; 2) anterior bursectomy and opening of bicipital groove; 3) LHB exteriorization and preparation; 4) humeral socket preparation; 5) trans-humeral Beath pin “pull-through” technique; and 6) bioabsorbable interference screw fixation. Constant score averaged 43 points before surgery and 79 points at review (p < 0.05). No deficit in elbow flexion-extension was observed. Spring-balance strength of the tenodesed biceps averaged 90% of the contralateral side (range, 80%–100%). Two early patients demonstrated distal biceps retraction and failure of the tenodesis within 3 months. Magnetic resonance imaging at final review revealed tight fixation of the LHB in the humeral socket and no adverse tissue reaction to the screw. These short-term results compare favorably with both open and previously described arthroscopic tenodeses using sutures. This technique is advantageous for pathologic LHB with intact cuffs, associated arthroscopic cuff repairs, and irreparable cuff tears instead of simple tenotomy.

Arthroscopic transosseous (anchorless) rotator cuff repair

The traditional open transosseous rotator cuff repair gives excellent results for the fixation of tendon to bone and has represented the gold standard for rotator cuff surgery with excellent long-term results. In the last few years, different arthroscopic techniques using suture anchors have been developed to increase the tendon–bone contact area in an attempt to reconstitute a more anatomic configuration of the rotator cuff footprint while providing a better environment for tendon healing. However, the anchor-based techniques have still not replicated the traditional open transosseous repair. A surgical technique that allows surgeons to perform a standardized arthroscopic transosseous (anchor free) repair of rotator cuff tears using a new disposable device is described. With this system, it is possible to perform a transosseous technique in a reproducible fashion. This novel technique combines the clinical advantages of minimally invasive arthroscopic surgery and the biomechanical advantages of open transosseous procedures. Level of evidence V.

Complications of shoulder arthroscopy.

Over the past 20 to 30 years, arthroscopic shoulder techniques have become increasingly popular. Although these techniques have several advantages over open surgery, surgical complications are no less prevalent or devastating than those associated with open techniques. Some of the complications associated with arthroscopic shoulder surgery include recurrent instability, soft-tissue injury, and neurapraxia. These complications can be minimized with thoughtful consideration of the surgical indications, careful patient selection and positioning, and a thorough knowledge of the shoulder anatomy. Deep infection following arthroscopic shoulder surgery is rare; however, the shoulder is particularly susceptible to Propionibacterium acnes infection, which is mildly virulent and has a benign presentation. The surgeon must maintain a high index of suspicion for this infection. Thromboemoblic complications associated with arthroscopic shoulder techniques are also rare, and studies have shown that pharmacologic prophylaxis has minimal efficacy in preventing these complications. Because high-quality studies on the subject are lacking, minimal evidence is available to suggest strategies for prevention.

Humeral Hemiarthroplasty With Biologic Resurfacing of the Glenoid and Acromion for Rotator Cuff Tear Arthropathy

Symptomatic rotator cuff tear arthropathy remains one of the most challenging entities in shoulder reconstruction. The appropriate surgical treatment of this patient population is highly controversial. However, it is clear that the primary goal in treating these patients remains durable and reproducible pain relief. We present here our rationale, indications, technique, and results for anatomic humeral hemiarthroplasty combined with biologic resurfacing of both the glenoid and acromion in patients with cuff tear arthropathy.

Arthroscopic Biceps Tenodesis

Owing to the multiple possibilities of pathology of the tendon itself and its pulley system, the long head of the biceps is often a cause of shoulder pain. Surgical treatment for disorders of the long head of the biceps is limited to removal of the intra-articular portion of the tendon, with either tenotomy or tenodesis. Biceps tenodesis with or without rotator cuff repair, is a common and well-accepted open surgical procedure. Previous authors have described biceps tenodesis under arthroscopic control, either using isolated sutures (Habermeyer) or sutures with anchors (Snyder, Gartsman). Because of familiarity and success with the technique of interference screw fixation for hamstring anterior cruciate ligament (ACL) reconstruction grafts in a bone tunnel, a similar technique was developed for use in both open and arthroscopic tenodeses of the biceps.

Long stem reverse shoulder arthroplasty and cerclage for treatment of complex long segment proximal humeral fractures with diaphyseal extension in patients more than 65 years old.

INTRODUCTION Treatment of long segment proximal humeral fractures with extension below the surgical neck into the diaphysis remains a significant challenge for orthopaedic surgeons. The purpose of this paper was to evaluate the clinical and radiological outcomes following primary long-stem RSA with cerclage fixation for complex long segment proximal humeral fractures with diaphyseal extension in patients more than 65 years old. MATERIAL AND METHODS Between February 2010 and March 2013, 22 patients who suffered a complex proximal humerus fracture with extended diaphyseal involvement underwent surgery with long-stem RSA and cerclages fixation. There were 17 female and 5 male patients, and the mean age was 77.2 years at time of surgery (range 65-84 years). All patients had a 3 or 4-part proximal humerus fracture or a two part fracture with a split of humeral head, with extension to the proximal diaphysis. Clinical and radiographic follow-up was performed on all 22 patients at 6 weeks, at 3, 6, and 12 months postoperatively, and then at 2 years. Clinical evaluation consisted of the shoulder rating Constant scale. X ray evaluation was done to evaluate fracture healing and eventually humeral and glenoid component loosening or other complications. RESULTS No infections were reported, neither other serious complications. Two patients developed a seroma and one patient developed chronic pain at that was treated with referral to pain management. No patients were lost at follow-up. At final follow-up, average active elevation was 132.5° (range 100°-140°), external rotation 30° (range 55°-10°). Average abduction was 120° (range 90°-135°). The mean adjusted Constant score was 72/100 (range 64-82). All fractures were healed within 3 months after surgery. No loosening of the humeral or glenoid components and no episodes of dislocation/instability were observed in this series. We did not observe scapular notching in any patient on the x-ray at most recent follow-up. CONCLUSION Long-stem RSA with cerclages wire fixation represents a viable treatment option for complex long-segment displaced proximal humerus fractures with diaphyseal extension in patients older than 65 years. Our results suggest clinical outcomes at two years of follow up are satisfactory with an acceptable complication rate.