Background:Rotator cuff tears are common, and rotator cuff repair represents a major health care expense. While patients often benefit from rotator cuff repair, anatomic failure of the repair is not unusual.Purpose:To identify the published evidence on the factors associated with retears and with suboptimal clinical outcomes of rotator cuff repairs.Study Design:Systematic review and meta-analysis of articles with evidence levels 1-4.Methods:A total of 2383 articles on rotator cuff repairs published between 1980 and 2012 were identified. Only 108 of these articles, reporting on over 8011 shoulders, met the inclusion criteria of reporting quantitative data on both imaging and clinical outcomes after rotator cuff repair. Factors related to the patients, their shoulders, the procedures, and the results were systematically categorized and submitted for meta-analysis.Results:While the number of relevant articles published per year increased dramatically over the period of the study, the clinical and anatomic re...

Rotator Cuff Repair: Published Evidence on Factors Associated With Repair Integrity and Clinical Outcome

Background:Reconstruction of the disrupted acromioclavicular (AC) joint has historically resulted in high complication rates. As a result, there has been a move toward anatomic coracoclavicular (CC) ligament fixation and reconstruction, owing to its numerous biomechanical advantages and perceived clinical advantages.Purpose:To report and analyze the unique complications associated with these anatomic CC ligament procedures using either cortical fixation buttons (CFBs) or tendon grafts (TGs) and to evaluate the effect that these complications have on patient outcomes.Study Design:Case series; Level of evidence, 4.Methods:From January 2006 until May 2011, a total of 59 primary anatomic CC ligament procedures were performed using either CFBs or TGs. Demographic, surgical, subjective (including the American Shoulder and Elbow Surgeons [ASES], quick Disabilities of the Arm, Shoulder and Hand [QuickDASH], Short Form–12 [SF-12], and Single Assessment Numeric Evaluation [SANE] scores), and radiographic data along...

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Complications After Anatomic Fixation and Reconstruction of the Coracoclavicular Ligaments

Injuries to the acromioclavicular joint are common but underdiagnosed. Sprains and minor subluxations are best managed conservatively, but there is debate concerning the treatment of complete dislocations and the more complex combined injuries in which other elements of the shoulder girdle are damaged. Confusion has been caused by existing systems for classification of these injuries, the plethora of available operative techniques and the lack of well-designed clinical trials comparing alternative methods of management. Recent advances in arthroscopic surgery have produced an even greater variety of surgical options for which, as yet, there are no objective data on outcome of high quality. We review the current concepts of the treatment of these injuries.

Injuries to the acromioclavicular joint

Acromioclavicular joint (ACJ) injuries represent a common injury to the shoulder girdle. In the management algorithm of acute ACJ injuries complete radiological evaluation represents the key to a successful therapy. According to the classification of Rockwood the presence of a horizontal component in addition to vertical instability has to be detected. Using axillary functional views or Alexander views dynamic horizontal ACJ instability can be diagnosed in a simple, efficient and cost-effective manner reducing the number of mis-/underdiagnosed ACJ injuries. MRI should not be the imaging modality of first choice. The treatment of ACJ dislocations must consider two aspects. In addition to the correct type of injury therapy strategies should be adapted to patient’s demands and compliance. Low grade AC injuries types I and II are treated non-operatively in terms of “skilful-neglect”. High-grade injuries types IV–VI should be treated operatively within a time frame of 2–3 weeks after injury. A certain debate is still ongoing regarding type III injuries. Out from the literature, non-operative treatment of type III injuries results to provide at least equal functional outcomes as compared to surgical treatment associated with less complications and earlier return to professional and sports activities. If surgical treatment is indicated, open surgical procedures using pins, PDS-slings or hook plates are still widely used concurring with recently raising minimally invasive, arthroscopic techniques using new implants designed to remain in situ. Combined coracoclavicular and acromioclavicular repair are gaining in importance to restore horizontal as well as vertical ACJ stability.

Management of acute acromioclavicular joint dislocations: current concepts.

Background:Acromioclavicular (AC) instability is a frequent injury affecting young and athletic populations. Symptomatic, high-grade dislocations may be managed by a myriad of operative techniques ...

Current Concepts in the Operative Management of Acromioclavicular Dislocations: A Systematic Review and Meta-analysis of Operative Techniques:

The ideal treatment for acute acromioclavicular joint dislocation is still controversial, both in terms of indications and surgical technique. The clinical and radiographic outcomes of 16 patients affected by acute AC joint dislocation (type III-V) and arthroscopically treated with a coracoclavicular double flip button are presented. Despite the excellent clinical results both in terms of Constant score (mean 97 points) and patient satisfaction, at a mean follow-up of 31 months the radiographs showed partial loss of reduction due to distal migration of the flip button within the upper third of the clavicle in one-fourth of the cases. The technique presented here proved to be safe and minimally invasive while delivering good aesthetic results and allowing for the treatment of associated lesions. Furthermore, the technique could benefit from more advanced retention devices, which ought to reduce or avoid migration of the flip buttons.

Arthroscopic treatment of acute acromioclavicular joint dislocation with double flip button.

A safe and easy-to-tie sliding knot is necessary for arthroscopic repair of rotator cuff tears and glenoid labrum lesions. We describe the double-twist knot (DTK) technique, having tested the knot's tensile strength and compared it with other commonly used arthroscopic knots. The DTK is a modified Lark's head knot that can be tied only on a double suture. A No. 2 braided polyester suture was used to test the DKT against the Tennessee slider knot and Snyder's knot by means of a material testing system. Results showed a statistically significant (P <.001) higher tensile strength with the DTK than with the other 2 knots. The rationale for using a stitch with a double suture is to double the tensile strength while using the same number of surgical steps and operating time as with single-suture stitches.

The double-twist knot *: A new arthroscopic sliding knot

The literature reports good functional results obtained with arthroscopic repair of the rotator cuff, but the incidence of anatomical healing has not been sufficiently studied. Ultrasound examination makes it possible to accurately document the healing process of the tendon at the bone, gathering information that may be useful in a comparison with clinical data. A total of 43 consecutive arthroscopic repairs of rotator cuff injuries were considered, that had made use of anchors and non-resorbable suturing. A total of 42 patients were willing to undergo clinical monitoring with an associated ultrasound examination after 3, 6 and 12 months. When ultrasound examination after 6 and 12 months was carried out, 36 patients presented with anatomical healing of the rotator cuff. The total percentage of repair failures was 14.3% and increased to 23% if we take into consideration the subscapular tendon alone. Constant score went from a preoperative mean of 51.25 to a mean of 78.21 after 12 months (p<0.001). Arthroscopic repair of the rotator cuff leads to anatomical healing of the tendons in a high percentage of cases, obtaining good functional results. The absence of healing is associated with lower values for recovery of strength at clinical follow-up. The advanced age of the patients (p<0.001) and the extensive injuries that involve several tendons (p=0.002) are negative prognostic factors.

Clinical and ultrasound results after arthroscopic repair of the rotator cuff.

An original technique for the arthroscopic diagnosis and treatment of the fractures of the radial head is proposed and described. The elbow arthroscopy is started with a 4.5-mm 30° arthroscope from the proximal anteromedial portal and the anterior elbow is examined; then a proximal anterolateral portal is created and a full-radius blade inserted to take out the hematoma and to allow visualization of the radial head that is explored through the whole range of motion to visualize the fracture fragment. The fragment is manipulated by means of arthroscopic tools to reduce the anteromedial surface of the radial head. The arthroscope is now switched to the posterolateral portal and the posterior aspect of the humeral radial joint is visualized. The soft spot portal is used to insert a periosteal elevator to complete the reduction and firmly hold the fragment in the reduced position. An anterolateral portal is now created to allow the safe insertion of a guidewire, angled 45° to the longitudinal axis of the radius, to pierce the fragment with. A 14-mm long cannulated screw is inserted along the guide after specific drilling. Finally, the reduction and the stability of the fixation are checked with during full rotation of the elbow. The described procedure has been performed in 6 patients. Short-term preliminary results show a satisfactory functional outcome. Among the advantages of the technique are the minimally invasive approach, the direct visualization of the fracture, and the benefits derived from the radiation-free procedure.

Arthroscopic Treatment of Fractures of the Radial Head

An original technique for the treatment of acute acromioclavicular (AC) joint dislocations is proposed. It consists of a closed reduction and stabilization of the AC joint, positioning a cannulated screw between the clavicle and the coracoid under arthroscopic control, without any exposure to x-rays. The conoid and trapezoid ligaments are not sutured or reconstructed. The screw is finally removed under local anesthesia 12 weeks after surgery. The described procedure has been performed in 9 patients. Short-term preliminary results show an excellent functional outcome without any residual pain. Among the advantages of the technique are that it does not require specific instrumentation, is a minimally invasive approach, has the possibility of searching the glenohumeral joint for associated lesions and eventually treating them, and has the benefits of not exposing the patient or surgical team to ionizing radiation.

Arthroscopic treatment of acute acromioclavicular joint dislocation.

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