Superior Glenoid Rim Research Articles

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.

Pyrocarbon hemiprostheses show little glenoid erosion and good clinical function at 5.5 years of follow-up

The success of traditional shoulder hemiarthroplasty with cobalt-chromium (CoCr) heads is limited by a painful glenoid erosion with problematic bone loss. Hemiprostheses with pyrolytic carbon (PyC) heads have shown reduced glenoid erosion in experimental laboratory studies. Few in vivo data are available. Single-center consecutive cohort study of 31 of 34 patients (91%) who underwent PyC hemiarthroplasty between 09.2013 and 06.2018. For eleven of these concentric glenoid reaming was additionally performed. The mean follow-up was 5.5 (range 3.5 - 7) years. Standardized x-rays were taken and clinical function (Constant score) and pain on the visual analogue scale (VAS) were recorded. AP x-rays were analyzed according to an established method by 2 independent observers: A line parallel to the superior and inferior glenoid rim was translated to the most medial point of the glenoid surface. A further parallel line was placed on the spinoglenoid notch (SGN) and the distance between the two lines was measured. Measurements were scaled using the known diameter of the implanted humeral head component. To assess eccentric erosion AP and axial images were classified according to Favard and Walch respectively. The mean medial glenoid erosion was 1.4 mm over 5.5 years. In the first year there was 0.8 mm of erosion, significantly more than the average erosion per year of 0.3 mm (p < 0.001). Mean erosion per year of patients with glenoid reaming was 0.4 mm, without reaming 0.2 mm (p = 0.09). An evolution of glenoid morphology was observed in 6 patients, of which 4 had a progression of the erosion grade. Prosthesis survival rate was 100%. The Constant score improved from 45.0 preoperatively to 78.0 2-3 years postoperatively and 78.8 at latest follow-up 5.5 years postoperatively (p < 0.001). Pain decreased from VAS 6.7 (3 - 9) preoperatively to 2.2 (0 - 8) at latest follow-up (p < 0.001). There was a weak correlation (r = 0.37) between erosion and pain improvement (p = 0.039) and no correlation between erosion and delta Constant score (r = 0.06). PyC HA caused little glenoid erosion and a sustained improvement in clinical function in our cohort at mid-term follow-up. PyC demonstrates a biphasic development of glenoid erosion, with a reduced rate after the first year. PyC hemiarthroplasty should therefore be considered as an alternative to total shoulder arthroplasty or CoCr hemiarthroplasty for patients with a high risk of glenoid component complications.

SLAP Tears: Treatment Algorithm

SLAP lesions can be significant pain generators in the shoulder. These injuries are the most common shoulder injury in overhead athletes, as repetitive overhead motion is the most common etiology of SLAP lesions. These lesions present a diagnostic and treatment challenge to patients and physicians. Factors to consider when discussing treatment options for SLAP lesions include age, type of sports activity, level of sports participation, and degree of symptoms. Nonoperative management is the first-line treatment for most young, active patients without history of trauma, mechanical symptoms, and/or demand for overhead activities. These conservative measures include rest, avoidance of aggravating factors, injections, and physical therapy focusing on correcting scapular dyskinesis, restoring range of motion and strength, and evaluating the biomechanical throwing motion. It has been reported that 40% of professional baseball players can successfully return to play after rehabilitation alone. Alternatively, operative treatment is reserved for failure of nonoperative treatment and those with persistent symptoms that prevent individuals from participating in sports activities or activities of daily living. The two most common operative treatment options include arthroscopic repair versus biceps tenodesis. Arthroscopic repair can be considered in younger athletes (<30 years old) and elite athletes who are involved in overhead sports (baseball, tennis, volleyball) and consists of repairing the labral anchor back to the superior glenoid rim with knotless anchor repair techniques. Alternatively, biceps tenodesis is the first-line treatment option for failed SLAP repairs, and as an index procedure, traditionally has been reserved for middle-aged individuals (>30 years old), patients receiving workers’ compensation, nonoverhead athletes, or in those with concomitant rotator cuff tears. However, due to a relatively high failure rate of SLAP repairs, biceps tenodesis as an index procedure is gaining more popularity, as emerging evidence suggests encouraging functional outcomes and return-to-sport rates even in younger athletes.

Combined Margin Convergence Repair and Subacromial Balloon Spacer for the Treatment of Massive Rotator Cuff Tears

Background: Current joint-sparing treatment options for massive, irreparable rotator cuff tears aim to prevent superior migration of the humeral head and maintain the subacromial space. Although options such as superior capsular reconstruction and posterosuperior tendon transfer may appropriately restore function and reduce pain, these procedures harbor significant comorbidity and intense postoperative rehabilitation. Recently, studies have demonstrated excellent results from a subacromial balloon spacer composed of a biocompatible copolymer that degrades over the 12 months following implantation. This spacer enables a more anatomic position of the humeral head to restore normal shoulder biomechanics. Indications: The subacromial balloon spacer is primarily indicated in patients with massive, irreparable rotator cuff tears who demonstrate proximal humeral migration. Contraindications include subscapularis or teres minor tendon tears, deltoid dysfunction, and pseudoparalysis. Technique Description: Standard arthroscopic portals are established, and a diagnostic arthroscopy is performed to assess the glenohumeral joint space and subscapularis tendon. A subacromial bursectomy is performed without proceeding medial to the superior glenoid rim. The subacromial space is measured utilizing an arthroscopic measurement probe to ensure that the selected spacer will lie slightly medial to the glenoid. The rotator cuff is then reapproximated from the lateral to medial aspect of the tear and repaired via a side-to-side manner with high strength, nonabsorbable tape, and a self-capturing suture device. Following repair, the deployment device is inserted through the lateral portal, placed slightly medial to the glenoid, and inflated with saline. Results: Utilization of the described subacromial balloon augmentation provides significant pain relief by restoring glenohumeral biomechanics, improvements in range of motion, and an enhancement in quality of life. Discussion: This case report and video review of a technique for utilizing a subacromial balloon spacer demonstrates an effective, simple, and safe treatment for massive, irreparable rotator cuff tears. Positive results rely on appropriate inflation and secure fixation. Recent clinical trial data suggest that functional outcomes for the subacromial balloon spacer are noninferior to that of partial rotator cuff repair. These promising results suggest that the subacromial balloon spacer may prove an essential tool for joint-preserving surgery following massive, irreparable rotator cuff tears.

Subacromial Balloon Spacer: Indications, Rationale, and Technique.

First, a diagnostic arthroscopy is performed. In addition to evaluating the rotator cuff, care is taken to evaluate the tendinous insertion of the subscapularis as well as the long head of the biceps tendon, the labrum, and the articular cartilage of the joint. Synovectomy, bursectomy, and biceps tenodesis or tenotomy are performed as appropriate. For cases with an intact or repairable subscapularis, an acromioplasty is performed. The balloon size is determined with use of a probe through the lateral portal, measured from 1 cm medial to the superior glenoid rim to the lateral border of the acromion. The balloon-insertion device is advanced through the lateral portal, and the balloon is inflated with sterile saline solution after appropriate subacromial positioning. The balloon is then sealed and detached from the insertional device. Most treatment algorithms attempt to reduce pain and dysfunction with initial nonoperative treatment options4. For cases in which nonoperative treatment has failed, several surgical techniques have been described. These include partial rotator cuff repair, graft interposition, graft augmentation, superior capsular reconstruction, tendon transfers, and reverse total shoulder arthroplasty5. Ideal candidates for this procedure are patients with irreparable symptomatic rotator cuff tears. These patients should primarily complain of pain and have a preserved range of motion. Alternatively, if they have reduced range of motion because of pain, then their range of motion should improve after a corticosteroid injection. It is also important that the patient has an intact or repairable subscapularis. The balloon is beneficial in patients with medical comorbidities that would limit the use of other techniques dependent on biologic tissue healing or that would limit the use of arthroplasty. Poor candidates would be patients with pseudoparalysis, axillary nerve palsy, irreparable subscapularis tears, or severe glenohumeral arthritis (Hamada grade ≥3). A recent randomized clinical trial demonstrated the 2-year efficacy, safety, and benefits of the InSpace subacromial balloon spacer6. The authors reported significant early clinical benefit that was maintained over 2 years. Additionally, this benefit was equivalent or superior to the partial-repair control group at all included time points. The multiyear clinical efficacy of the subacromial balloon spacer in that study was similar to that reported by Familiari et al. and Senekovic et al. at 3 and 5 years postoperative, respectively1,7. Together, these studies would suggest that the initial benefit of the subacromial balloon spacer lasts beyond its biodegradation at 12 months postoperatively. Proper placement of the lateral portal should be made parallel to the supraglenoid tubercle. Such placement allows easy insertion and orientation of the balloon at the midpoint of the supraglenoid tubercle.Arthroscopic evaluation of the subscapularis must be performed. For cases with a torn subscapularis, partial or complete repair is recommended to maximize anteroposterior coupling forces that are critical to the function of the balloon.Preservation of the medial bursa and coracoacromial ligament will provide structural constraints against medial migration of the balloon into the supraspinatus fossa.Acromioplasty can be performed to create a smooth articulating surface and minimize friction on the implant, but should only be done in cases in which there is an intact or repairable subscapularis to minimize the risk of anterior escape.Adequate debridement, with acromioplasty as needed, will provide full visualization of the subacromial space to allow proper sizing of the spacer. Proper implant sizing will reduce the risk of subsequent balloon displacement postoperatively.If the measurement of the balloon is between 2 sizes, the larger spacer can be selected to limit displacement.Overinflation of the balloon can cause excessive tension on the deltoid. Underinflation increases the risk of escape. To optimize inflation of the balloon, the senior author prefers to fill the balloon to the recommended maximum volume and then remove saline solution until the balloon reaches the recommended final volume.If there is partial tearing of the long head of the biceps, a tenotomy or tenodesis is recommended. ROM = range of motionRCT = randomized clinical trialTSA = total shoulder arthroplastySCR = superior capsular reconstructionRC = rotator cuffISP = infraspinatusSSP = supraspinatusSSC = subscapularisRI = rotator intervalCAL = coracoacromial ligamentCA = coracoacromialC = coracoidMRI = magnetic resonance imagingSAD = subacromial decompressionPRO = patient-reported outcomeFDA = U.S. Food and Drug Administration.

Arthroskopische superiore Kapselrekonstruktion mit einem 6 mm dicken azellulären dermalen Allograft bei irreparablen posterosuperioren Rotatorenmanschettenrupturen

Implantation of an acellular dermal allograft between glenoid and humerus to restore astable glenohumeral center of rotation in cases of irreparable posterosuperior rotator cuff tears. Irreparable posterosuperior rotator cuff tears with low-grade cuff tear arthropathy (Hamada grade1 and2) and isolated pseudoparesis for flexion. Absolute: Infection, nerve lesions (brachial plexus, axillary nerve), concomitant irreparable subscapularis tendon tear, anterosuperior subluxation of the humeral head ("anterosuperior escape"). Relative: Cuff tear arthropathy ≥ Hamada grade3, fatty infiltration of the infraspinatus muscle ≥ Goutallier grade2, deficiency of the deltoid muscle, inability to adhere to the rehabilitation program, poor compliance. Arthroscopic fixation of a6 mm thick acellular dermal allograft with three suture anchors at the superior glenoid rim and adouble-row construct at the greater tuberosity. Dorsal and ventral interval closure with side-to-side sutures. Abduction brace for 6weeks with passive mobilization. Active motion exercises are commenced at 6weeks with progression to strengthening exercises after 12weeks. Between April 2019 and September 2020, 15patients (5women and 10men) underwent arthroscopic superior capsule reconstruction using a6 mm thick acellular dermal allograft for treatment of irreparable posterosuperior rotator cuff tears. After amean follow-up of 15.4 ± 5.5months, there was asignificant improvement in active flexion (102° ± 37°preop vs. 143° ± 24°postop; P = 0.001; 95%CI 19.6-63.7), ASES score (45.5 ± 16.1preop vs. 68.2 ± 17.4postop; P < 0.001; 95% CI; 12.9-33.7) and DASH score (57.2 ± 18.6preop vs. 22.0 ± 17.4postop; P < 0.001; 95% CI; -46.0 to 24.7), along with significant pain reduction (4.5 ± 2.0preop vs. 2.5 ± 2.1postop; P = 0.001; 95% CI; -3.2 to 1.1). There were no complications requiring revision surgery.

Superior Capsular Reconstruction using the Long Head of the Biceps Tendon: The Biceps Loop Technique

Irreparable rotator cuff tears can be treated in several ways. Superior capsular reconstruction has been reported as an excellent option, particularly for the young and active patients. We propose capsule reconstruction using the long head of the biceps tendon in a modified way. After its tenotomy at the musculotendinous junction, the long head is rerouted through a humeral bone tunnel and attached to a suture anchor in the posterior aspect of the superior glenoid rim. Further investigation is required, but this modified technique appears promising.

Normal Glenoid Ossification in Pediatric and Adolescent Shoulders Mimics Bankart Lesions: A Magnetic Resonance Imaging–Based Study

The purpose of this descriptive study was to define patterns of ossification and fusion of growth centers around the pediatric and adolescent glenoid as a function of age using 3-dimensional, frequency-selective, fat-suppressed spoiled gradient recalled echo magnetic resonance (MR) imaging sequences, with a particular focus on the anterior glenoid rim because of its clinical relevance as a potential confounder of glenohumeral instability. Picture Archiving and Communication System records at an urban academic tertiary care orthopaedic facility from October 2005 to December 2018 were queried for shoulder MRI in patients aged 9 to 17years. Patients were excluded if they had any diagnoses that could alter glenoid development. All images were independently evaluated by a musculoskeletal fellowship-trained radiologist. Secondary ossification centers were characterized as cartilage anlage, ossified, or fused at 3 anatomic sites: the anterior glenoid rim, coracoid, and superior glenoid rim. A total of 250MR examinations (143 males, 107 females) were assessed in this study. The glenoid develops in a predictably sequential manner with ossification at the anterior glenoid rim lagging behind the coracoid and superior glenoid rim. The earliest age of anterior glenoid rim ossification was 11years for both males (range 11-17) and females (range 11-12). Anterior glenoid rim ossification peaked at age 16 among males (34.8%, 8/23) and age 11 among females (27.3%, 3/11). Glenoid ossification and fusion progress in a predictable and chronological manner. This pattern should be used as a guideline when interpreting pediatric shoulder MRI examinations. In particular, an anterior glenoid ossification center should not be confused with an anterior glenoid injury (e.g., Bankart lesion), particularly in males 11 to 17years old and females 11 to 12years old. IV (case series).

A comparison of deltopectoral versus Judet approach for glenoid exposure

Open reduction-internal fixation via an anterior or posterior approach is a widely used method for treating displaced glenoid fractures. This study aimed to identify the exposure range of the glenoid rim by these 2 approaches (deltopectoral and Judet approaches)and provide reference data for the choice of surgical approach. Twelve cadaveric shoulders were dissected. Both deltopectoral and Judet approaches were performed on each shoulder to mark the glenoid fracture. In addition, the shoulder was disarticulated to recordthe exposure range of the glenoid rim. For the deltopectoral approach, the range of the exposed glenoid rim was from 5:50 to 11:30, which accounted for about 47.2% of the clock face. For the Judet approach, the range of the exposed glenoid rim was from 1:30 to 6:20, which accounted for about 40.3% of the clock face. Along the inferior glenoid, there was an area of partial overlap for the 2 approaches. The superior glenoid rim located from 11:30 to 1:30 was considered inaccessible, as it could not be exposed by the 2 approaches. Less than 50% of the glenoid rim can be exposed by the deltopectoral or Judet approach. With a single approach, it may be difficult to expose and fix some complex glenoid fractures. The superior part of the glenoid fracture is the non-access area via the deltopectoral or Judet approach.

Superior Capsular Reconstruction for Massive Rotator Cuff Tears

» A massive rotator cuff tear is defined as a tear involving &gt;2 tendons or &gt;5 cm of retraction.» Superior capsular reconstruction is done with either a folded fascia lata autograft (6 to 8 mm in thickness) or acellular dermal allograft (3 to 4 mm in thickness). The graft is secured arthroscopically with anchors on the superior glenoid rim and multiple anchors on the humeral head with use of a transosseous-equivalent repair technique.» Superior capsular reconstruction is indicated for younger patients with massive and irreparable rotator cuff tears involving the supraspinatus and infraspinatus with minimal arthritis, intact subscapularis, and a functional deltoid. Contraindications include bone defects, stiffness, and moderate to severe arthropathy.» Arthroscopic superior capsular reconstruction with fascia lata autograft or humeral dermal allograft is a surgical option, with multiple studies showing statistically significant improvement in short-term outcomes for both pain and function among younger patients with massive irreparable rotator cuff tears. The long-term clinical effectiveness and value have yet to be determined.» Biomechanical data suggest improved restoration of superior glenohumeral stability with decreased subacromial contact pressures in association with the use of the 8-mm fascia lata graft as compared with the 4-mm acellular humeral dermal allograft. In addition, fascia lata graft has shown less elongation and thinning than humeral dermal graft.» Either fascia lata autograft or humeral dermal allograft may be used clinically for arthroscopic superior capsular reconstruction; however, a graft thickness of at least 3 mm is recommended to decrease the risk of radiographic and clinical failure.» No comprehensive quality-of-life or cost-comparison analyses are available to compare superior capsular reconstruction, reverse total shoulder arthroplasty (rTSA), tendon transfer, and partial rotator cuff repair for the treatment of massive irreparable rotator cuff tears. However, the potential higher cost of superior capsular reconstruction and the lack of long-term clinical outcomes or revision data suggest that either an attempt at repair or primary arthroplasty may be more cost-effective than superior capsular reconstruction.» Long-term outcome data are essential to determine the role of superior capsular reconstruction for young patients with massive irreparable rotator cuff tears.» Superior capsular reconstruction using fascia lata autograft may provide a different biomechanical and biological healing environment compared to acellular dermal allograft. Thus, the clinical outcome data between the 2 graft methods should not be generalized.

Joint-preserving treatment options for irreparable rotator cuff tears.

An irreparable cuff tear is defined as the inability to achieve direct repair of native tendon to the great tuberosity despite intra- and extra-articular release of the remaining tissue. Three distinct anatomic patterns are identified: posterosuperior cuff tears which involve the supraspinatus, infraspinatus and teres minor; anterosuperior tears which involve the supraspinatus and subscapularis; and global tears which comprise both. Subacromial debridement and tenotomy or tenodesis of the long head of the biceps are proposed for older patients with afunctional but very painful shoulder. Partial repair-particularly the infraspinatus and the subscapularis-is indicated for young patients if the muscle is still trophic with afatty infiltration less than3. It can be combined with atendon transfer. In irreparable posterosuperior tears, latissimus dorsi or lower trapezius transfer has been reported to improve active elevation and external rotation. In anterosuperior cuff tears, pectoralis major or latissimus transfer has been used. If the lack of external rotation is isolated with good active forward elevation, the L'Episcopo procedure is the procedure of choice. New techniques with ashort follow-up have been proposed recently: implantation of a balloon-shaped, biodegradable spacer in the subacromial space to maintain the position of the humeral head and to facilitate deltoid action; capsular superior reconstruction with afascia lata or an artificial graft implanted between the superior glenoid rim and the great tuberosity to reproduce the natural capsule of the supra- and infraspinatus and to stabilize the humeral head.

Footprint Contact Restoration Between the Biceps-Labrum Complex and the Glenoid Rim in SLAP Repair: A Comparative Cadaveric Study Using Pressure-Sensitive Film

To compare pressurized footprint contact and interface pressure between the biceps-labrum complex and the superior glenoid rim after SLAP repair using 3 different techniques. Twenty-four fresh-frozen human cadaveric shoulders were divided into 3 groups. SLAP lesions were repaired by (1) 2 single-loaded anchors in a simple suture configuration (group T), (2) a double-loaded anchor in a simple suture configuration in a V shape (group V), or (3) a double-loaded anchor by use of a hybrid simple and mattress suture configuration (group H). Pressure-sensitive film quantified pressurized contact areas and interface pressures between the biceps-labrum complex and the glenoid rim after SLAP repair. Groups T and V showed significantly larger contact areas than group H (P < .0001). However, there was no significant difference between groups T and V. Despite a substantial contact area around the biceps-labrum complex in group T, there was a lack of sufficient contact area just below the biceps anchor. Group V showed a uniform contact area around the entire biceps-labrum complex, but in group H the contact area was concentrated only around the posterior superior labrum, where the simple suture was used. The methods using 2 single-loaded suture anchors and using 1 double-loaded suture anchor with a simple suture configuration showed significantly larger pressurized contact areas than the method using 1 double-loaded suture anchor with both a simple and mattress suture configuration. The interface pressure was not significantly different among groups. Although there have been several kinds of repair techniques and biomechanical studies for the type II SLAP lesion, there has been no study about footprint restoration on the superior glenoid rim. This study analyzed and compared the footprint contact restoration after type II SLAP repair among 3 different techniques.

Iatrogenic Suprascapular Nerve Injury After Repair of Type II SLAP Lesion

Suprascapular neuropathy after an arthroscopic repair of a SLAP lesion is theoretically possible, but it has been rarely reported. We present a case of suprascapular nerve injury at the spinoglenoid notch as a complication of an improperly inserted suture anchor after repair of a type II SLAP lesion. The diagnosis was confirmed by the magnetic resonance imaging findings and an electrodiagnostic study, and direct compression of the nerve was visualized under repeat arthroscopy. An anatomic study of the superior glenoid shows that the available bone stock of the superior glenoid rim for the anchor insertion is found to decrease posteriorly. During the repair of a SLAP lesion, surgeons should consider the possibility of an iatrogenic injury to the suprascapular nerve by an improperly inserted suture anchor.

Tendinitis calcificante bilateral del tendón largo del biceps asociado a lesión SLAP

Calcifying tendinitis is a common disorder related to deposition of hidroxyapatite crystals, which is most common around the shoulder joint, involving the supraespinosus tendon. It can however, affect almost any tendon at its insertion. Clinical features are variable and include pain and inflammation that often resolves spontaneously. We present a case of bilateral calcifying tendinitis of the long head of the biceps tendon at its insertion on the superior glenoid rim associated with superior labrum antero-posterior tears (SLAP) confirmed by arthroscopy. Calcium deposits were surgically removed and the SLAP lesions were repaired.

A Cadaveric Analysis of the Arthroscopic Fixation of Anterior and Posterior SLAP Lesions Through a Novel Lateral Transmuscular Portal

To compare the most commonly used portals with a novel, lateral transmuscular portal for the treatment of anterior and posterior SLAP lesions. Six paired cadaveric shoulders underwent arthroscopy to assess 3 different instrumentation portals: the anterior-superior lateral (AL) portal, the Neviaser (N) portal, and the Rothman-lateral (RL) transmuscular portal. After each portal was established, 5-mm cannulas were inserted followed by guidewire-assisted placement of implant fixation instruments. Each shoulder was then dissected to assess the relation of the instruments to the surrounding anatomic structures. When the AL portal was used, instrumentation consistently passed through the rotator interval. When the N and RL portals were used, instrumentation penetrated the rotator cuff muscle belly at a mean distance of 25.75 and 7.67 mm, respectively, from the tendon. The mean angles of entry into the glenoid rim with respect to the glenoid articular surface were 32 degrees, 38 degrees, and -6 degrees for the AL, RL, and N portals, respectively. There was no violation of subchondral bone; however, 2 specimens showed weakened articular surfaces with use of the N portal. The RL portal was the only portal that allowed placement of instrumentation into all 3 zones of the superior glenoid rim (anterior superior, direct superior, and posterior superior) without violation of the subchondral bone and at the recommended 30 degrees to 45 degrees angle of entry. The RL portal provides a safe and efficient method of arthroscopic fixation and knot tying of anterior and posterior SLAP lesions by use of a single instrumentation portal. This novel, lateral transmuscular portal allows optimal angles of implant placement in all areas of the superior glenoid and provides a direct, simplified approach for arthroscopic knot tying.

Shoulder bony landmarks location using the EOS® low-dose stereoradiography system: a reproducibility study

To investigate the reproducibility of shoulder bony landmarks location using the EOS low-dose stereoradiography system, in order to validate this new tool for the study of gleno-humeral pseudo-kinematics. An inter and intraobserver reproducibility study of shoulder bony landmarks location concerning 22 healthy volunteers. This study concerned the neutral position, arm at rest. Humerus and scapula were modeled with simple geometric shapes using specific software. Those shapes were positioned on A-P and lateral x-rays views. Images analysis of the 22 subjects was carried out three times (n(r) = 3), by two observers (n(o) = 2), for a total of n(tot) = 132 analyses. We obtained a very good reproducibility for the humeral head center and the diaphysis axis with 95% confidence interval (IC95%) inferior to 1.09 mm and 0.41 degrees, respectively. The uncertainty was higher for the lateral and medial epicondyles. Regarding the scapular bony landmarks, we observed a good reproducibility for the tip of the coracoid process, the inferior glenoid rim, and the axillar border with a 95% confidence interval lower than 2.13, 2.91 mm, and 3.67 degrees, respectively. The uncertainty was higher for the most postero-lateral point of the acromion and the superior glenoid rim. Our analysis of the x-rays obtained with the EOS low-dose stereoradiography system assessed the location reliability and reproducibility of specific scapular and humeral bony landmarks. This work opens the way to gleno-humeral pseudo-kinematics analysis using EOS imaging system.

Anatomy of the superior glenoid rim. Repair of superior labral anterior to posterior tears.

Successful placement of a fixation device on the superior glenoid rim during superior labrum repairs requires accurate knowledge of the glenoid rim anatomy. To investigate the normal bony anatomy of the superior glenoid rim. Descriptive anatomic study. Twenty cadaveric glenoid specimens were scanned to obtain cross-sectional images with peripheral quantitative computed tomography in three different positions, each perpendicular to the articular surface. Two straight lines were drawn along the interior bony margins of the articular surface and cortex, and image analysis software was used to calculate the angle between these lines. Three bony angles were measured. The bony angles from the 10:30-, 12-, and 1:30-o'clock cross-sections were 55 degrees +/- 5 degrees, 64 degrees +/- 5 degrees, and 62 degrees +/- 8 degrees, respectively. The posterosuperior angle (at the 10:30-o'clock position) was statistically significantly lower than the superior and anterosuperior angles. Intraobserver variation was less than 3%. The most superior point of the glenoid rim (12-o'clock position) seems to provide the most bone stock for anchor insertion. The available bone support was found to decrease posteriorly on the glenoid rim. During superior labral repairs, the anchor or fixation device should be inserted at approximately a 30 degrees angle in relation to the articular surface for maximal bone support.

ＳＬＡＰ ｌｅｓｉｏｎにおけるＭＲＩ Ａｒｔｈｒｏｇｒａｐｈｙの有用性

To determine the accuracy of MR Arthrography (MRA) in the classification of SLAP lesions, we investigated 15 patients (15 men, average 27.5 years) who underwent MRA before arthroscopic operation from 1998 to 2001. Based on the Snyder’s classification, we defined the diagnostic criteria for classification of SLAP lesion on MRA: Type I shows irregularity of the labrum, without evidence of detachment from the superior glenoid rim. Type II shows complete detachment of the bicipital-labral complex. Type III shows detachment and inferior displacement of the superior labrum. Type IV shows Gd-DTPA dissecting into the biceps tendon. MRA findings correlated with arthroscopic findings. In MRA, 4 patients were diagnosed as type I, 10 type II, and 1 type IV. But in surgical findings, 3 out of the 4 patients diagnosed as type I were type II, and 3 out of the 10 patients (type II) were type I. MRA had a sensitivity of 25%, specificity of 73%, accuracy of 60% in type I, and sensitivity of 70%, specificity of 40%, accuracy of 60% in type II. The MRA classification corresponded with those of arthroscopy in 9 out of 15 patients (60%). MRA is a useful technique in the diagnosis of SLAP lesion, but classification is still difficult.

Overlap Endoscopic SLAP Lesion Repair

Summary: The fixation of the superior labrum using the punch-chop needle overlap technique (Aeratec Inc, Uniondale, NY) for reattaching torn labral tissue to bone allows ease of suture placement for type II SLAP lesion repair with fixation overlaping the superior rim of the glenoid and without the use of anchors.The technique presented includes preparation of the superior glenoid rim,drilling of the glenoid tunnels for the punch needles, and peripheral suturing of the labrum. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 7 (October), 1999: pp 796–798

Superior labrum and labral-bicipital complex: MR imaging with pathologic-anatomic and histologic correlation.

The purpose of this study was to analyze the anatomic relationship between the superior labrum, the superior glenoid rim, the superior glenohumeral ligament, and the long head of the biceps tendon. Seventeen cadaveric shoulder specimens underwent axial, oblique coronal, and oblique sagittal MR imaging on a 1.5-T imager. Unenhanced proton density- and T2-weighted spin-echo images with and without fat suppression, and T1-weighted fat-suppressed spin-echo images after intraarticular injection of gadolinium, were obtained of each specimen. The shoulders were then frozen and sectioned into 4-mm-thick slices, either transversely or oblique coronally. After gross anatomic correlation, histologic analysis was performed on 32 sections. A sublabral recess was present in 12 (71%) of 17 shoulders. MR arthrography was significantly better at showing the sublabral recess than was unenhanced MR imaging. Histologically, the synovial recess in all cases was covered by synovial lining cells. Intralabral altered histologic patterns were found in 20 (63%) of 32 labral sections. In addition to signs of degeneration, five sections of two specimens showed proliferating fibroblasts and vessels, as well as fibrosis, suggesting trauma. The presence or absence of altered intralabral histologic patterns was better assessed with T1-weighted fat-suppressed arthrograms than with unenhanced MR images. We found a close association grossly and histologically between the superior labrum and the biceps tendon. The attachment of the superior glenoid labrum to the glenoid rim shows great variability. In MR imaging, an overlap appears to exist between physiologic recesses of the superior labrum and a type 2 superior labrum anterior-posterior lesion. T1-weighted fat-suppressed MR arthrograms provided the best view of the superior labrum and the labral-bicipital complex.