Posterior Portal Research Articles

Anterior capsulectomy through humeral fenestration in arthroscopic arthrolysis for elbow stiffness is safe and effective

PurposeTo evaluate arc of motion and complications following transhumeral anterior capsulectomy through a purely posterior approach with the Outerbridge-Kashiwagi procedure in the treatment of elbow stiffness. MethodsPatients who were treated for elbow stiffness between April 2003 and February 2023 were retrospectively identified. The inclusion criteria were an extension/flexion arc deficit of at least 30° and treatment with arthroscopic arthrolysis through posterior and posterolateral portals with humeral fenestration. Elbow joint range of motion and the Mayo Elbow Performance Score (MEPS) was assessed preoperatively, intraoperatively, at 6 weeks and at final follow-up. The follow-up ended when the elbow became asymptomatic again or when the recovery was considered stable. Postoperative complications were recorded. ResultsA total of 30 patients (23 males/7 females; 31 elbows; 1 bilateral/29 unilateral) were included. Mean follow-up was 11.1 months (1 – 64). Mean joint amplitudes intraoperatively increased in all areas of mobility; extension/flexion: from 86° to 132.6° ( p=0,001); pronation/supination: from 163.9° to 179.7° (p=0,025). At the longest follow-up, mean joint amplitude was increased from 86° to 118.9° ( p=0.002) in extension/flexion and from 136.9° to 173.9° (p=0.022) in pronation/supination. The mean deficit was reduced from 54° to 21.1° ( p = 0.001) in extension/flexion and from 16.1° to 6.1° ( p=0.006) in pronation/supination. The mean gain in the extension/flexion arc was 31.5° and 10° for the pronation/supination arc. Loss in flexion/extension was limited (mean: 14.2°, extreme: 50°). The study showed no neurological complications ConclusionArthroscopic arthrolysis of a stiff elbow using a purely posterior approach with anterior capsulectomy via the Outerbridge-Kashiwagi procedure was safe and effective. Clinical results showed improvement in joint range of motion in flexion/extension and pronation/supination, both intraoperatively and postoperatively, with no postoperative neurological complications.

Proximally positioned femoral grafts decrease passive anterior tibial subluxation in anterior cruciate ligament reconstruction using a posterior trans-septal portal.

To compare the anterior and posterior trans-septal (TS) portal approaches in anterior cruciate ligament reconstruction (ACLR) by evaluating femoral tunnel positioning and passive anterior tibial subluxation (PATS). A total of 205 patients who underwent primary ACLR using the outside-in technique between March 2018 and December 2021 were retrospectively enrolled. Patients were classified into two groups based on the viewing techniques: the anterior group was treated using anteromedial or anterolateral portals (n = 155), and the TS group was treated using posterior TS portal (n = 55). The relative locations of the femoral tunnel were evaluated using the deep-shallow planes (X-axis) and superior-inferior planes (Y-axis) with the quadrant method in the lateral femoral condyle on a 3-dimensional computed tomography image. Anterior tibial subluxation for the lateral and medial compartments relative to the femoral condyles was evaluated as measured on magnetic resonance imaging. Knee laxity was assessed using the pivot-shift test and stress radiography. In the posterior TS group, the femoral tunnel was usually located deeper on the X-axis and more superior on the Y-axis, which corresponds to a more proximal position, than in the anterior group (deeper on the X-axis and superior on the Y-axis). Moreover, the femoral tunnel locations in this group were more compactly distributed than those in the anterior group. The TS group showed significantly better reduction of postoperative PATS in the lateral compartments than the anterior group (anterior group vs. TS group: lateral compartment, 3.2 ± 3.1 vs. 4.5 ± 3.2mm; p = .016). Significantly better results were found in the TS group for knee stability as assessed by the pivot-shift grade (p = .044); however, there were no significant differences between the two groups with respect to patient-reported outcome measures (p > .05) and other complications (p = .090). Our results suggest that positioning the femoral tunnel using the posterior TS portal approach may lead to better outcomes in terms of PATS and rotational stability compared to the anterior portal approach in ACLR.

Migration of patella tension band metal wires to popliteal fossa: Retrieval by posterior knee arthroscopy – A case report and literature review

Breakage of metal wires after fixation of patella fractures are common. However, migration of the broken wires to intraarticular location, popliteal fossa and distant sites can be least expected and a difficult scenario for retrieval. We describe in a 58-year male who presented with recurrent locking and migration of broken wires in popliteal fossa. he had fixation of patella fracture nine years ago. The metal wire was retrieved safely from the posterior lateral aspect of knee popliteal fossa by posterior knee arthroscopy using two posterior lateral portals. Through this case, we review the presentation of migrated wires, methods of retrieval and role of arthroscopy. Retrieval of migrated wires by knee arthroscopy can be successful in intraarticular location and in select cases at popliteal fossa, however with significant challenges. To avoid concerns with migration of wires, patients treated with wires for patella fractures should be adequately followed with radiography and sensitized for removal before breakage or at the time of breakage.

Basketball Anterior and Posterior Portal Veins Doppler Imaging of Sports Medicine Technique Exploration

INTRODUCTION: Basketball, as a high-intensity sport, has attracted much attention for its effects on the cardiovascular system of athletes. The anterior and posterior portal veins are some of the vital blood vessels in the human circulatory system, and their blood flow is closely related to the athletes' physical status. Doppler ultrasound technology is widely used in sports medicine and provides a powerful tool for an in-depth understanding of the effects of basketball on portal vein blood flow. This study aimed to explore the potential of sports medicine technology in assessing cardiovascular adaptations in athletes through portal Doppler imaging before and after basketball exercise.OBJECTIVES: The primary objective of this study was to analyze the effects of basketball exercise on portal vein blood flow in athletes before and after basketball exercise through the use of Doppler ultrasound technology. Specifically, this study aimed to explore the dynamics of pre- and post-exercise Doppler imaging of the posterior and posterior veins in order to assess the cardiovascular adaptations of athletes during exercise more comprehensively and objectively.METHODS: A group of healthy professional basketball players were selected as the study subjects, and Doppler ultrasound instruments were utilized to obtain portal Doppler images before, during, and after exercise. The functional status of the vasculature was assessed by analyzing parameters such as portal blood flow velocity and resistance index. At the same time, the physiological parameters of the athletes, such as heart rate and blood pressure, were combined to gain a comprehensive understanding of the effects of basketball on portal blood flow.RESULTS: The results of the study showed that the anterior and posterior portal blood flow velocities of the athletes changed significantly during basketball exercise. Before the exercise, the blood flow velocity was relatively low, while it rapidly increased and reached the peak state during the exercise. After exercise, blood flow velocity gradually dropped back to the baseline level. In addition, the change in resistance index also indicated that portal blood vessels experienced a particular stress and adaptation process during exercise.CONCLUSION: This study revealed the effects of exercise on the cardiovascular system of athletes by analyzing the Doppler images of the portal vein before and after basketball exercise. Basketball exercise leads to significant changes in portal hemodynamics, which provides a new perspective for sports medicine. These findings are of guiding significance for the development of training programs for athletes and the prevention of exercise-related cardiovascular problems and provide a valuable reference for further research in the field of sports medicine.

Arthroscopic Remplissage Using a Double-Pulley Technique

Background: Anterior shoulder instability is associated with Hill-Sachs lesions (HSLs) in 40% to 90% of cases. When addressing anterior shoulder instability, unaddressed engaging or “off-track” HSL have a recurrence rate of 75%. Remplissage is a known technique to address recurrent instability in the setting of an engaging HSL. In this video, we demonstrate that a double-anchor-pulley technique may be used to address recurrent instability in the setting of engaging HSL. Indications: Patients with recurrent anterior shoulder instability with off-track HSL in patients with glenoid bone loss <20% are candidates for arthroscopic Remplissage. Technique Description: Patients are placed in the lateral decubitus position. Examination under anesthesia is performed to assess for degree of instability and engagement of HSL. Posterior, anterosuperior, and anteroinferior portals are established. Routine diagnostic arthroscopy is performed with identification of the HSL. While viewing from an anterosuperior portal and working through the posterior portal, the HSL bed is prepared with curettage and a bur. A 5.5-mm accessory Cannula is used through an accessory posterior portal. Two knotless all-suture self-tensioning anchors are placed in the anterior and inferior aspect of the defect, passed through the cannula, and tagged for later identification. Bankart stabilization is performed. The knotless anchors are linked to each other to perform a knotless repair with a broad area of compression. Results: Results are excellent with only a 5.6% failure rate, significant patient improvement, low complication rate, and 95.5% return to play. Discussion: We demonstrate the technical aspects of an all-arthroscopic Remplissage technique using all-suture knotless anchors to provide a simple and reproducible method of performing a Remplissage. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic-Assisted Core Decompression of Humeral Head Osteonecrosis With Bone Marrow Aspirate Concentrate Augmentation

Background: The proximal humerus is the second-most common anatomic site for osteonecrosis, a condition of disrupted blood supply leading to death of bone tissue, with resultant shoulder pain and dysfunction. Core decompression is a viable joint-preserving surgical intervention that aims to improve local blood supply and restore bone health prior to bony collapse. Indications: Humeral head osteonecrosis has numerous underlying causes, most commonly the sequelae of prior trauma, chronic use of systemic corticosteroids, sickle cell disease, and alcohol abuse. Core decompression may be indicated in the early, pre-collapse stages of osteonecrosis, whereas more advanced stages of disease are commonly indicated for joint reconstruction procedures, such as bone grafting or arthroplasty. Technique Description: With the patient in the beach chair position, bone marrow aspirate concentrate (BMAC) is harvested through a percutaneous incision along the anterolateral proximal humerus. While viewing through a standard posterior portal, a transtibial anterior cruciate ligament (ACL) guide is placed through an anterior portal at a site on the humeral head surface, centered at the area of greatest humeral head bone edema as identified on preoperative magnetic resonance imaging. A guide pin is placed through a lateral portal within the ACL guide, to the subchondral bone. A 7.0-mm reamer is applied over the guidewire, followed by administration of demineralized bone matrix soaked in BMAC into the reamed channel within the proximal humerus. Results: In patients with early stages of humeral head osteonecrosis, core decompression confers superior clinical outcomes with reduced rates of subsequent surgical procedures compared with nonoperative treatment. Core decompression has shown to reduce the radiographic progression of osteonecrosis. Further research is necessary to determine the additional clinical benefits of augmentation with orthobiologic agents, such as BMAC. Conclusion: Arthroscopic-assisted core decompression is a valuable, minimally invasive surgical treatment for early-stage proximal humerus osteonecrosis. Adjunctive treatment with BMAC and demineralized bone matrix may enhance clinical outcomes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Single Working Portal Technique with 70-Degree Arthroscope for Arthroscopic Bankart Repair

The Bankart lesion is a common injury to the labrum in the shoulder joint, usually resulting from anterior shoulder dislocation. Arthroscopic Bankart repair is a surgical technique used to treat recurrent dislocations by reattaching the labrum to the glenoid rim using suture anchors. Typically, 3 portals are created: 1 for visualization and 2 for instrumentation. However, this Technical Note proposes a single working portal approach using a 70° arthroscope from the posterior portal. This technique enhances visualization and prevents portal jamming, particularly in cases with a small rotator interval.

Arthroscopic Trans-septal Portal of the Knee With Direct Visualization and No Need for Posterolateral Portal Creation

Arthroscopic visualization and access of the posterior knee are limited when using standard anterior and posterior portals. The creation of a trans-septal portal allows for complete access to the posterior compartment as arthroscopic instruments are able to be passed back and forth between the posteromedial and posterolateral compartments. Due to the close proximity of the popliteal artery and its branches, precise portal placement and safe orientation of arthroscopic instruments are critical to avoid iatrogenic injury. The conventional technique of trans-septal portal creation, involving a posterolateral portal, can be difficult in some cases. To overcome these obstacles, a posteromedial technique of trans-septal portal creation is presented. By using the medial parapatellar portal as the viewing portal, our technique allows for direct visualization of the posterior septum on each step of creation of the trans-septal portal, eliminating the need for “blind” maneuvers. What is more, no posterolateral portal is needed, decreasing the risk of potential complications. Using the posterior cruciate ligament fibers as a main landmark for trans-septal portal placement, preservation of the posterior part of the septum is achieved. This ensures optimal safe-margin distance away from the popliteal neurovascular bundle and making the technique safe and reproducible.

Avoidance of Direct Posterior Portal During Elbow Arthroscopic Surgery in Posterior Compartment

Arthroscopic surgery for the posterior compartment in elbow has been used in the treatment of many pathologies. The direct posterior portal has been commonly used for this compartment. However, this portal involves penetrating the triceps brachii tendon responsible for extensor mechanism. This can possibly lead to poor performance during recovery and portal wound sensation with scar formation. An accessory posterolateral portal can be used as a substitute with adequate viewing and working space in all areas of the posterior compartment. This report describes in detail on how to manage pathologies in the posterior compartment without using direct posterior portal and instead using accessory posterolateral, posterolateral, and direct lateral portals.

DIRECT POSTERIOR KNEE PORTALS USING NEEDLE ARTHROSCOPY: A TECHNICAL FEASIBILITY STUDY

Knee arthroscopy is typically approached from the anterior, posteromedial and posterolateral portals. Access to the posterior compartments through these portals can cause iatrogenic cartilage damage and create difficulties in viewing the structures of the posterior compartments. The purpose of this study was to assess the feasibility of needle arthroscopy using direct posterior portals as both working and visualising portals.For workability, the needle scope was inserted advanced from anterior between the cruciate ligament bundle and the lateral wall of the medial femoral condyle until the posterior compartments were visualised. For visualisation, direct postero-lateral and -medial portals were established. The technique was performed in 9 knees by two experienced researchers.Workability and instrumentation of the posteromedial compartment and meniscus was achieved in 56%. The posterior horns could not be visualised in four specimens as the straight lens could not provide a more medial field of view. Visualisation from the direct medial posterior portal allowed a clear view of the medial meniscus, femoral condyle and posterior cruciate ligament in all specimens. Workability and instrumentation of the posterolateral compartment was not possible with the needle scope.Direct posterior approaches for the posteromedial compartment access are challenging with the current needle scope options and could only be achieved in over 50%. The postero-lateral compartment was not accessible. An angled lens or a flexible Needle scope would be better suited for developing this technique further.

DETERMINING THE SAFETY AND ACCESSIBILITY OF DIRECT POSTERIOR PORTALS INTO THE KNEE WITH RESPECT TO THE NEUROVASCULAR STRUCTURES: A CADAVERIC STUDY

The posterior compartments of the knee are currently accessed arthroscopically through anterior, posteromedial or posterolateral portals. A direct posterior portal to access the posterior compartments has been overlooked due to a perceived high-risk of injury to the popliteal neurovascular structures. Therefore, this study aimed to investigate the safety and accessibility of a direct posterior portal into the knee.This cross-sectional study comprised a sample of 95 formalin-embalmed cadaveric knees and 9 fresh-frozen knees. Cannulas were inserted into the knees, 16mm from the vertical plane between the medial epicondyle of the femur and medial condyle of the tibia and 8 and 14mm (females and males respectively) from the vertical plane connecting the lateral femoral epicondyle and lateral tibial condyle. Landmarks were identified in full extension and cannula insertion was completed with the formalin-embalmed knees in full extension and the fresh-frozen in 90-degree flexion. Posterior aspects of the knees were dissected from superficial to deep, to assess potential damage caused by cannula insertion. Incidence of neurovascular damage was 9.6% (n=10); 0.96% medial cannula and 8.7% lateral cannula. The medial cannula damaged one small saphenous vein (SSV) in a male specimen. The lateral cannula damaged one SSV, 7 common fibular nerves (CFN) and both CFN and lateral cutaneous sural nerve in one specimen. All incidences of damage occurred in formalin-embalmed knees. The posterior horns of the menisci were accessible in all specimens.A medial-lying direct posterior portal into the knee is safe in 99% of occurrences. The lateral-lying direct posterior portal is of high risk to the CFN.

Safe Ultrasonography-Assisted Knee Posterior Transseptal Portal Creation Technique

Knee arthroscopy is a minimally invasive surgical technique that allows surgeons to diagnose and treat various knee conditions using much smaller incisions than open surgery. However, it is difficult to fully visualize the posterior compartment of the knee joint using the usual anterior portal approach because of blind spots. The transseptal portal technique enables surgeons to visualize the surgical field and access instruments in the posterior compartment of the knee during arthroscopic surgery. However, creation of the posterior transseptal portal increases the risk of neurovascular injury. Particular attention should be paid to avoid damaging the saphenous nerve, common peroneal nerve, popliteal artery, and tibial nerve. Here, we describe an ultrasonography-guided surgical method for creating the posterior transseptal portal by confirming the surrounding anatomy.

Endoscopic Calcaneoplasty in Haglund's Disease: Surgical Technique, Clinical and Subjective Outcomes

Category: Arthroscopy; Ankle Introduction/Purpose: During the last decade, arthroscopic procedures have been replacing open techniques in Haglund's disease treatment due to their considerable advantages. Endoscopic calcaneoplasty is a technique that allows resection of posterosuperior calcaneal exostosis and retrocalcaneal bursitis. The objective of this article is to describe this technique and report its clinical and subjective outcome. Methods: A retrospective cohort study was carried out in patients who underwent endoscopic surgery between July 2014 and March 2020. The patients were clinically and radiologically evaluated. All cases included were studied prior to the intervention and postoperative. All patients who did not show any clinical improvement after 6 months of conservative treatment were surgically treated with endoscopic treatment in the prone position through two posterior arthroscopic portals. Results: In this study, 14 endoscopic calcaneoplasties were performed in 14 patients, with an average follow-up of 40 months. The visual analog scale improved from a preoperative average value of 9.07 to 1.79 after surgery (p> 0.0001). The AOFAS scale rose from 38.71 before surgery to 94.57 postoperative (p> 0.0001). Good subjective results were observed in twelve patients ( 85.71%) and all of them would have surgery again. There were no wound complications or infections. No patient required reoperation. Conclusion: Endoscopic treatment is a useful technique, with good clinical and subjective results and few complications, being a good alternative to open techniques.

CT scan versus Saline Load Test for Detection of Traumatic Shoulder Arthrotomy: A Cadaveric Study.

Traumatic shoulder arthrotomy (TSA) is a rare injury that is commonly detected through saline load test (SLT). There are no studies that have studied the ability of CT scan to detect a TSA. The purpose of this study is to determine the ability of CT scan to detect a TSA and compare it to the SLT. Twelve cadaveric shoulders were included in the study. Before intervention, a CT scan was conducted to determine presence of intra-articular air. After confirmation that no air was present, an arthrotomy was made at the anterior or posterior portal site. A CT was obtained post-arthrotomy to evaluate for intra-articular air. Each shoulder then underwent a SLT to assess the sensitivity of SLT and the volume needed for extravasation. Twelve shoulders were included after pre-intervention CT scan. Six shoulders received an arthrotomy through the anterior portal and six shoulders received an arthrotomy through the posterior portal. After the arthrotomy, air was visualized on CT scan in eleven of the twelve shoulders (92%). All twelve shoulders demonstrated extravasation during SLT. The mean volume of saline needed for extravasation was 29 ml with a standard deviation of 10 and range of 18 to 50ml. CT scan is a sensitive modality (sensitivity of 92%) for detection of TSA. In comparison, SLT is more sensitive (sensitivity of 100%) and outperforms CT scan for the diagnosis of TSA in a cadaveric model. Further research is needed to solidify the role that CT imaging has in the diagnosis of TSAs.

A biomechanical study to optimize superior capsular reconstruction operative technique

The goals of this study were to optimize superior capsular reconstruction by assessing the relative fixation strength of 4 suture anchors; evaluating 3 glenoid neck locations for fixation strength and bone mineral density (BMD); determining if there is a correlation between BMD and fixation strength; and determining which portal sites have optimal access to the posterosuperior and anterosuperior glenoid neck for anchor placement. Twenty cadaveric specimens were randomized into 4 groups: all-suture anchor (FiberTak), conventional 3.0-mm knotless suture anchor (SutureTak), 3.9-mm knotless PEEK (polyetheretherketone) Corkscrew anchor, and 4.5-mm Bio-Corkscrew anchor. Each specimen was prepared with 3 anchors into the glenoid: an anterosuperior anchor, superior anchor, and posterosuperior anchor. All anchors were inserted into the superior glenoid neck 5 mm from the glenoid rim. A materials testing system performed cyclic testing (250 cycles) followed by load-to-failure testing at 12.5 mm/s. Cyclic elongation, first cycle excursion, maximum load, and stiffness were recorded. Using custom software, BMD was calculated at each anchor location. This software was also used to assess access to the posterosuperior and anterosuperior glenoid neck from standard arthroscopic portal positions. There was no significant difference in cyclic elongation (P=.546), first cycle excursion (P=.476), maximum load (P=.817), or stiffness (P=.309) among glenoid anchor positions. Cyclic elongation was significantly longer in the PEEK Corkscrew group relative to the other implants (P≤.002). First cycle excursion was significantly greater in the FiberTak group relative to all other implants (P≤.008). For load-to-failure testing, the Bio-Corkscrew group achieved the highest maximum load (P≤.001). No other differences in cyclic or failure testing were observed between the groups. No differences in stiffness testing were observed (P=.133). The superior glenoid rim had the greatest BMD (P=.003), but there was no correlation between BMD and cyclic/load outcomes. The posterior portal (80% of specimens) and the anterior portal (60% of specimens) demonstrated the best access to the posterosuperior and anterosuperior glenoid neck, respectively. The 4.5-mm Bio-Corkscrew anchor provided the most robust fixation to the glenoid during superior capsular reconstruction as it demonstrated the strongest maximum load, had minimal elongation, had minimal first cycle excursion, and did not fail during cyclic testing. The superior glenoid neck had the highest BMD; however, there was no correlation between BMD or glenoid anchor location and biomechanical outcomes. The posterior portal and anterior portal provided optimal access to the posterosuperior glenoid neck and anterosuperior glenoid neck, respectively.

Revision Posterior Cruciate Ligament Reconstruction Technique

Background: Revision posterior cruciate ligament reconstruction (PCLR) is challenging, especially in existing semi-anatomic tunnels, whereas there is an increased risk of overlapping with a new positioned anatomic tunnel. Few cases were published with no consensus regarding the optimal operative technique. Indications: A 22-year-old male patient, with failed PCLR with hamstring autograft in 2020 due to improper tunnels placement, presented for pain and instability of his right knee. Physical examination revealed a positive posterior drawer and reverse Pivot-Shift test, with no varus-valgus or rotational laxity. Radiograph showed no signs of arthritis, normal tibial slope, and normal long-leg standing axis. Magnetic resonance imaging showed rupture of the PCL graft with no meniscal, chondral, or concomitant ligament injuries. Technique Description: We described a single-bundle transtibial technique with a posterior transeptal portal approach to reconstruct the PCL. We started by preparing the allograft with an internal brace augmentation and an adjustable button (Arthrex) placed on the femoral side for cortical fixation. The old semi-anatomical femoral tunnel was drilled and grafted using an allograft bone dowel (Biobank), and a new anatomic femoral tunnel was drilled inside-out. Under direct visualization via posterior transeptal portals, a new anatomic tibial tunnel was drilled posterior to the existing nonanatomic tunnel. Using a shuttle suture, the transplant was passed and fixed by an adjustable button at the femur and by two interference screws and a backup fixation using a Swive-lock anchor at the tibia (Arthrex). Results: Favorable functional and clinical outcomes with improvement of anteroposterior stability. Significant improved side-to-side differences on posterior stress radiography and improved subjective and objective clinical scores. Satisfactory outcomes with 75% of patients returned to preinjury Tegner activity scale level of function. Discussion/Conclusion: The use of the posterior transeptal portals approach protects the vital neurovascular structures and ensures proper PCL tibial tunnel placement by providing direct visualization of the tibial attachment. Allograft bone dowels facilitate PCL revision in a one-stage procedure by filling the existing semi-anatomic tunnels and allowing to drill the new anatomic tunnels without tunnel overlap. The use of the internal brace augmentation strengthens the construct to protect the graft during the revascularization and remodeling process by facilitating tissue ingrowth and incorporation. In revision surgery, backup fixation is encouraged and often essential due to the compromised bone stock. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic Posterior Labral Repair for Posterior Shoulder Instability

Background: Posterior shoulder instability occurs in 2% to 10% of shoulder instability cases and is more commonly due to repetitive microtrauma as opposed to the more traumatic onset seen in anterior shoulder instability. In posterior instability, the posterior capsulolabral complex becomes attenuated or torn. Thus, surgical treatment aims to restore the posterior soft-tissue stabilizers typically with an arthroscopic, suture-anchor-based labral repair. Indications: Surgical indications include posterior instability with traumatic cause and associated soft-tissue and/or osseous pathology and for those patients with repetitive microtrauma who have failed nonsurgical management. Technique Description: Following diagnostic arthroscopy, the glenoid is prepared using an arthroscopic elevator, rasp, and chisel first viewing from the posterior portal, then from the anterior portal using a 70° arthroscope. An all-suture anchor is placed at the 7 o’clock position using a curved guide which obviates the need for an accessory 7 o’clock portal. The repair suture is then shuttled through the labrum using a suture lasso and monofilament. This repair suture is then shuttled through the suture anchor using the inbuilt shuttling fiberlink. The repair suture is then tightened to secure the labrum. The remainder of the repair uses knotless 2.9-mm biocomposite suture anchors and free suture tape as the all-suture anchor and associated curved guide are typically only necessary for the angle of the most inferior portal. Following a 3 to 5 anchor repair, the posterior portal capsular rent is closed to avoid leaving a stress riser. Posterior capsular closure is achieved using monofilament suture passed with a birdbeak and tied blindly in the subacromial space. Results: In a study of 200 shoulders at 36 months, patients undergoing posterior stabilization had improvements in their American Shoulder and Elbow Surgeons (ASES) scores and improvements in stability, pain and function. Ninety percent of patients were able to return to sport and 64% of patients returned to the same level. Failure rate was low at 6%. Discussion/Conclusion: Posterior labral repair is a technically nuanced but reliable procedure for the management of posterior instability. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Eighth Cervical Nerve Root Block During Interscalene Brachial Plexus Block Decreases Pain Caused by Posterior Portal Placement but Increases Horner Syndrome in Patients Undergoing Arthroscopic Shoulder Surgery: A Randomized Controlled Trial

To compare the intensity of pain on posterior portal placement between a C5-C7 root block (conventional interscalene brachial plexus block [ISBPB]) and a C5-C8 root block in patients undergoing arthroscopic shoulder surgery. In this prospective, single-blinded, parallel-group randomized controlled trial, patients were randomized to receive either a C5-C7 root block (C5-C7 group, n= 37) or a C5-C8 root block (C5-C8 group, n= 36) with 25 mL of 0.75% ropivacaine. The primary outcome was the pain intensity on posterior portal placement, which was graded as 0 (no pain), 1 (mild pain), or 2 (severe pain). The secondary outcomes were the bilateral pupil diameters measured 30 minutes after ISBPB placement; the incidence of Horner syndrome, defined as a difference in pupil diameter (ipsilateral - contralateral) of less than -0.5 mm; the onset of postoperative pain; and the postoperative numerical rating pain score, where 0 and 10 represent no pain and the worst pain imaginable, respectively. Fewer patients reported mild or severe pain on posterior portal placement in the C5-C8 group than in the C5-C7 group (9 of 36 [25.0%] vs 24 of 37 [64.9%], P= .003). Less pain on posterior portal placement was reported in the C5-C8 group than in the C5-C7 group (median [interquartile range], 0 [0-0.75] vs 1 [0-1]; median difference [95% confidence interval], 1 [0-1]; P=.001). The incidence of Horner syndrome was higher in the C5-C8 group than in the C5-C7 group (33 of 36 [91.7%] vs 22 of 37 [59.5%], P= .001). No significant differences in postoperative numerical rating pain scores and onset of postoperative pain were found between the 2 groups. A C5-C8 root block during an ISBPBreduces the pain intensity on posterior portal placement. However, it increases the incidence of Horner syndrome with no improvement in postoperative pain compared with the conventional ISBPB (C5-C7 root block). Level I, randomized controlled trial.

Outcome of Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction Using the Posterior Trans-Septal Approach.

Posterior Cruciate Ligament (PCL) reconstruction is a complex surgical procedure and often challenging. The newer posterior trans-septal portal technique is thought to make tibial tunnel preparation easier with better visualization of the tibial attachment site. It is also thought to lower the risk of neurovascular injuries. The aim of this study was to evaluate the functional and clinical outcomes of patients who underwent arthroscopic all-inside PCL reconstruction using the posterior trans-septal portal at our institute. This was a retrospective study with prospectively collected data between 2016 and 2020. Data collected were age, gender, types of graft used, range of movement, posterior drawer test grade, KOOS score, Lysholm knee scoring scale, and post-operative complications. All patients underwent pre- and post-operative PCL rehabilitation. A total of 36 patients (26 males and 10 females) were identified from our database. The mean age was 35.2years. Mean time from injury to surgery was 20months. Mean follow-up was 41.2months (range, 13-72months). Twenty cases involved multi-ligament injuries and another 16 patients had isolated PCL injury. Post-operative mean posterior drawer test grade improved from 2.7 to 0.7 (p < 0.001). Knee range of movement was 116.3 degrees pre-operatively and 115.6 degrees postoperatively (p = 0.814). Lysholm knee scoring scale improved from 50.9 to 91.0 (p < 0.001). KOOS score improved from 65.1 to 77.2 (p = 0.196). One patient required manipulation under anesthesia for stiffness. No patients needed any additional surgical procedures. All PCLs were clinically intact at the final follow-up. Greater visualization of the PCL tibial attachment minimizes the 'killer turn' giving a huge advantage to this technique. Arthroscopic all-inside PCL reconstruction using the posterior trans-septal portal technique is a safe, reliable and reproducible procedure. From our study, it shows that post-operative clinical and functional outcomes improved significantly.

Arthroscopic Repair of a 360° Labrum and Full-Thickness Rotator Cuff Tear After Shoulder Dislocation

Background: Rotator cuff tears after anterior shoulder instability are more common in patients &gt;40 years of age and rare in younger patients where shoulder instability is most common. Although infrequent, little data exist on the evaluation of combined labral and rotator cuff tears in athletes. Indications: Combined rotator cuff and labral tears in the young patient population have a high risk of recurrent instability and require unique intraoperative and postoperative considerations. This patient is a Division 1 collegiate wrestler who sustained a 360° labral and full-thickness rotator cuff tear after an acute traumatic anterior shoulder dislocation. Technique Description: The lateral decubitus position is utilized and a posterior viewing portal is established along with anterior and accessory lateral portals. The 360° labral tear is first addressed by appropriately preparing the glenoid creating a quality healing surface. Tape sutures are then utilized to perform a knotless anterior labral repair. The superior labrum, anterior to posterior (SLAP) and then posterior labral repair are sequentially performed. The posterior portal is closed with a polydioxanone (PDS) suture to prevent a stress riser in the capsule. The rotator cuff tear is then repaired in a knotless double row configuration after appropriate greater tuberosity preparation. Results: Recent studies evaluating athletes with combined rotator cuff and labral pathology who underwent arthroscopic repair reported 90% good to excellent satisfaction with 77% returning to pre-injury level of athletics. Although few studies have evaluated combined labral and rotator cuff repair and concerns with stiffness exist, the current literature and the authors own experience have found good outcomes following single-stage repair. Discussion/Conclusion: Combined labral and rotator cuff tears after anterior shoulder dislocation in the young athletic population are rare and can be challenging to treat. Although there is limited data on these combined injuries in young athletic populations, the current literature and authors’ experience support single stage surgical treatment of combined labral and rotator cuff tears which typically result in improved patient reported outcomes and return to sport. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.