Search

Background: Shoulder pain following intramuscular administration of vaccine is common. However, a small number of patients experience prolonged pain and dysfunction atypical to normal transient postvaccination shoulder pain. Shoulder Injury Related to Vaccine Administration (SIRVA) remains incompletely understood, whether a robust immune response to vaccine antigen or inappropriate injection technique with needle placement in synovial or bursal tissue, or some combination of the two. Symptoms overlap with those of Cutibacterium acnes ( C. acnes ) infection but the relationship between the two, if any, has not been evaluated., Methods: Clinical case files were reviewed for 3 cases of SIRVA with positive cultures for C. acnes were reviewed. Presentation, treatment, and clinical outcomes were compared., Results: In all cases, patients were thin (body mass index < 23), females, who had high injection placement of a vaccine, all patients had positive magnetic resonance imaging findings of increased signal in the subacromial bursa, and/or greater tuberosity. All patients underwent arthroscopic débridement and culture harvest and cultures were positive for C. acnes . A combination of oral and intravenous antibiotics was used, and all patients demonstrated clinical improvement from the preoperative state., Discussion: This case series presents 3 patients with refractory SIRVA who ultimately underwent arthroscopic irrigation and débridement with culture biopsy. Each case had culture results positive for C. acnes and all responded, at least partially, to arthroscopic débridement and intravenous antibiotic therapy. The purpose of this manuscript is to raise awareness of potential coexistence of SIRVA and C. acnes which may be of assistance to surgeons treating refractory cases of SIRVA., (© 2023 The Authors.)

Treatment of full-thickness rotator cuff repairs vary in surgical technique depending on many factors including tear geometry, delamination of soft tissue, tissue quality, and rotator cuff retraction. The described technique presents a reproducible method of addressing tear patterns where the tear may be larger laterally, but the medial footprint exposure is small. This can be addressed with a single medial anchor combined with a knotless lateral-row technique to provide compression for small tears or two medial row anchors for moderate to large tears. In this modification of the standard knotless double row (SpeedBridge) technique, 2 medial row anchors are used, with 1 augmented with additional fiber tape and an additional lateral row anchor to create a triangular repair construct, increasing the size and stability of the footprint of the lateral row., (© 2022 The Authors.)

Discoid lateral meniscus (DLM) presents with differing pathoanatomy and may exhibit various types of tears. The treatment strategy is based on the presence and location of instability as a result of deficient capsular attachment. Recently, meniscal stabilization after saucerization has been recommended for DLM to preserve the meniscus shape, prevent extrusion, and mitigate against the progression of osteoarthritis. In addition to stabilization, the resection volume is important to prevent osteoarthritic changes. Although there was no tear and no displacement of the lateral meniscus on magnetic resonance imaging, some DLMs were found to have tears and peripheral instability during arthroscopy. Therefore, the assessment of peripheral instability during surgery is very important to achieve a desirable clinical outcome. This Technical Note describes an arthroscopic technique for anterior peripheral stabilization of the DLM, in which we highlight the surgical procedure for repair of the anterior horn, reassess the instability around the popliteal hiatus after the anterior horn is repaired, and the stabilization of the posterior horn, if necessary., (© 2022 The Authors.)

Treatment options for massive irreparable rotator cuff tears continue to evolve. Recently bursal acromial reconstruction (BAR) has been described as an additional option to reduce pain and improve comfort. As originally described, an acellular dermal allograft is secured to the underside of the acromion as an interposition graft. We describe a modified technique that facilitates suture passage, reduces entanglement, and optimizes contact between the bone-graft interface., (© 2021 The Authors.)

Abstract: Preservation of the meniscus has been shown to influence the progression of osteoarthritic changes in the knee. Discoid lateral meniscus (DLM) is classified on the basis of the presence and location of instability resulting from deficient capsular attachments. Recently, meniscal stabilization after saucerization was recommended in cases of DLM to preserve the meniscus shape and avoid the progression of osteoarthritis. However, it is difficult to identify the accurate resection volume and residual meniscal width during surgery, especially when there is an anterocentral shift of the DLM. This Technical Note describes an arthroscopic technique for an anterocentral shift of the DLM in which we highlight the resection point and confirm the methods of retaining an adequate volume of residual meniscus to restore and maintain the shape and function of the meniscus., Level of Evidence: Level 1, Knee; Level 2 , Meniscus., (© 2021 by the Arthroscopy Association of North America. Published by Elsevier.)

Background: Acellular dermal matrix (ADM) allografts are commonly used in the surgical treatment of complex and irreparable rotator cuff tears. Multiple studies report that superior capsule reconstruction (SCR) using ADM has resulted in short-term clinical success as assessed via radiographic and patient-reported outcomes. However, limited information is available regarding the biologic fate of these grafts in human subjects. This case series describes histologic results from 8 patients who had reoperations, during which the previously implanted ADMs were removed. These explanted ADMs were subjected to histologic analysis with the hypothesis that they would have evidence of recellularization, revascularization, and active remodeling., Methods: Eight patients, 38-82 years old, underwent reoperation 6-38 months after undergoing SCR. ADM explants were voluntarily shipped to the manufacturer for histologic analysis. Each graft's structure and composition were qualitatively evaluated by 1 or more of the following histologic stains: hematoxylin and eosin, safranin O, and Russell-Movat pentachrome. Pan-muscle actin staining also assessed the level of neovascularization, potential myoblast or myocyte infiltration, and muscle tissue development in the graft, and was analyzed to determine the proportion of graft that had been recellularized in situ., Results: Grafts showed varying levels of gross and microscopic incorporation with the host. An uneven, but high, overall degree of recellularization, revascularization, and active remodeling was observed. The degree of remodeling correlated with implant duration. These results are consistent with successful biologic reconstruction of the superior shoulder capsule., Conclusions: The present histologic analysis suggests that ADMs used in SCR undergo active recellularization, revascularization, and remodeling as early as 6 months after implantation, and that graft recellularization positively correlates with duration of implantation. These results represent a significant advancement in our knowledge regarding biologic incorporation of ADMs used in SCR., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

The middle glenohumeral ligament (MGHL) is well recognized as a primary stabilizer of the shoulder. Its role in shoulder pathologies such as adhesive capsulitis, subscapularis tendon tear, and glenohumeral arthritis is less understood. Biomechanically, the MGHL plays an important role in range of motion, specifically involving normal and pathologic external rotation in less than 45° of abduction. In this Technical Note, we present a technique for arthroscopic release of the MGHL in the setting of a stable shoulder with preoperative loss of external rotation and a patient at risk for postoperative restriction of external rotation., (© 2021 by the Arthroscopy Association of North America. Published by Elsevier.)

Rotator cuff tears involving the musculotendinous junction with a significant amount of tendon still attached to the footprint laterally represent a challenging scenario for shoulder arthroscopists. Because of these challenges, adjunctive techniques to bridge tissue gaps may be required, and biologic augmentation may be considered to improve the healing environment. The following technique presents a stepwise approach to accomplishing the dual goals of a stable anatomic repair and biologic augmentation of this difficult pattern of rotator cuff pathology., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier.)

Superior capsular reconstruction (SCR) is increasingly being used as a procedure for addressing irreparable rotator cuff tears. The procedure was initially described for failed rotator cuff repairs where the retears are severely retracted and when grade 3-4 fatty infiltration and atrophy exist. The SCR procedure can also be considered for irreparable rotator cuff tears in patients that are either too young or too high demand to be appropriate candidates for arthroplasty. Early short and medium term follow up studies support SCR with favorable outcomes compared with other salvage procedures., (© 2019 by the Arthroscopy Association of North America. Published by Elsevier.)

Arthroscopic rotator cuff repairs (ARCRs) are common procedures that have been increasing in incidence. When performing ARCR, the surgeon often identifies an undesirable flap or fold, referred to as a "dog-ear" deformity, between sutures or knots. The height and/or thickness of a dog-ear deformity may decrease the rotator cuff-to-acromion distance, resulting in possible impingement and repair compromise. Furthermore, the goal of ARCR is to achieve complete restoration of the tendon-to-footprint relation. To restore the entire footprint, this lesion must be reduced and stabilized. We present a technique using looped sutures to augment the rotator cuff repair and prevent dog-ear formation., (© 2019 by the Arthroscopy Association of North America. Published by Elsevier.)

Treatment of full-thickness rotator cuff tears vary in surgical technique dependent on the amount of retraction of the rotator cuff and/or delamination of the soft tissue. The described technique addresses both of those concerns. We present a modification of the SpeedBridge technique used to address retracted or delaminated repairs and effectively expand the indications for use of the double-row knotless technique. In this modification, the reduction is performed by an initial anchor with several stay sutures providing provisional reduction of the tissue in a controlled fashion. This is followed by compression through a standard double-row technique., (© 2019 by the Arthroscopy Association of North America. Published by Elsevier.)

Unlabelled: Shoulder stiffness can be caused by various etiologies such as immobilization, trauma, or surgical interventions. The Upper Extremity Committee of ISAKOS defined the term "frozen shoulder" as idiopathic stiff shoulder, that is, without a known cause. Secondary stiff shoulder is a term that should be used to describe shoulder stiffness with a known cause. The pathophysiology of frozen shoulder is capsular fibrosis and inflammation with chondrogenesis, but the cause is still unknown. Conservative treatment is the primary choice. Pain control by oral medication, intra-articular injections with or without joint distension, and physical therapy are commonly used. In cases with refractory stiffness, manipulation under anesthesia or arthroscopic capsular release may be indicated. Because of various potential risks of complications with manipulations, arthroscopic capsular release is preferred. After the capsular release, stepwise rehabilitation is mandatory to achieve satisfactory outcome., Level of Evidence: Level V, evidence-based review., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Subscapularis tendon tears present a technical challenge because both diagnosis and arthroscopic treatment can be difficult. One difficulty is the limited visualization and working space of the anterior shoulder. Although most tears of the subscapularis are partial- or full-thickness tears of the upper third of the tendon, occasionally, larger or more retracted tears are encountered. Various techniques have been developed to treat a wide variety of tear patterns. We present a simple technique using a looped suture that remains easy to use in the limited working space of the anterior shoulder; can be easily modified to accommodate a broad spectrum of subscapularis pathology, from partial to full and retracted tears; and uses familiar viewing and working portals. This technique creates a single-row, knotless repair. Traction on the superior suture improves visualization and ease of passing more inferior sutures. Risks include unintentional over-tensioning of the repair and medialization of the femoral footprint, which can be avoided with appropriate exposure and arm positioning during repair. Postoperative care includes restriction of external rotation for 3 to 6 weeks and strengthening at 3 months.

Purpose: The purpose of this study was to compare arthroscopic versus open examination of the proximal long head of the biceps tendon (LHB) in patients undergoing open, subpectoral tenodesis., Methods: Eighty consecutive patients were prospectively enrolled, of whom 62 were included in the study. During arthroscopy, the most distal extent of the LHB visualized was marked with a Bovie device. The tendon was pulled into the joint with an arthroscopic grasper, showing additional LHB and was again marked with the device. LHB fraying, flattening, redness, and degeneration were graded as absent, mild, moderate, or severe. During open subpectoral tenodesis, the grossly visualized LHB was graded in the same manner and the locations of both marks plus the total length of the LHB observed during open visualization were measured and recorded. After subpectoral tenodesis, the excised portion of the LHB was histologically graded as normal, fibrosis/tendinosis, or inflamed., Results: On average, during open tenodesis, 95 mm (range, 75 to 130 mm) of LHB was visualized. This was greater than the length visualized during diagnostic arthroscopy of 16 mm (range, 5 to 28 mm), or 17%, and the length visualized while pulling the tendon into the joint with an arthroscopic grasper of 30 mm (range, 15 to 45 mm), or 32%. The difference in LHB length observed during open versus arthroscopic examination with a grasper was statistically significant (P < .0001). In addition, when compared with LHB pathology observed in an open manner, arthroscopic visualization showed only 67% of pathology, underestimated noted pathology in 56% of patients, and overestimated noted pathology in 11% of patients. Histologic evaluation showed fibrosis/tendinosis in 100% of cases but inflammation in only 5%., Conclusions: When compared with open inspection during subpectoral tenodesis, arthroscopic examination of the LHB visualizes only 32% of the tendon and may underestimate pathology., Level of Evidence: Level II, diagnostic study-development of diagnostic criteria based on consecutive patients with universally applied gold standard., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

The goal of this article is to consolidate the International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committee's (UEC's) current knowledge on rotator cuff disease and management, as well as highlight key unresolved issues. The rotator cuff is an anatomically complex structure important for providing glenohumeral function and stability as part of a closed chain system. Current consensus suggests rotator cuff injuries are most accurately diagnosed, at levels similar to diagnosis by magnetic resonance imaging, with a combination of cuff- and impingement-specific clinical tests. Updates in the understanding of acromion morphology, the insertional anatomy of the rotator cuff, and the role of suprascapular nerve release may require changes to current classification systems and surgical strategies. Although initial management focuses on nonoperative protocols, discussion continues on whether surgery for isolated impingement is clinically more beneficial than rehabilitation. However, clear indications have yet to be established for the use of single- versus double-row repair because evidence confirms neither is clinically efficacious than the other. Biceps tenodesis, however, in non-isolated cuff tears has proven more successful in addressing the etiology of shoulder pain and yields improved outcomes over tenotomy. Data reviewing the benefits of tendon transfers, shoulder prostheses, and mechanical scaffolds, as well as new research on the potential benefit of platelet-rich plasma, pluripotential stem cells, and gene therapies, will also be presented., (Published by Elsevier Inc.)

Purpose: The purpose of this investigation was to evaluate the efficacy, complication rate, and cost of a 1-time interscalene block compared with a continuous infusion of a local anesthetic for postoperative pain relief in patients having arthroscopic shoulder surgery., Methods: After prospective power analysis and institutional review board approval, 56 consecutive patients having arthroscopic shoulder surgery under general anesthesia performed by a single surgeon were randomly assigned to 1 of 2 groups to evaluate postoperative pain control. Group 1 patients received a preoperative interscalene block, and group 2 patients received a subacromial continuous infusion of a local anesthetic (0.5% bupivacaine) via a pain pump for 48 hours postoperatively. Pain was evaluated at 12, 24, 36, and 48 hours and then daily on postoperative days 3 through 7 by use of a visual analog scale included in a patient diary. Patients were provided with 2 "rescue" medication options: ibuprofen and Percocet (Endo Pharmaceuticals, Chadds Ford, PA). The total number of tablets ingested was also evaluated over these same intervals. Total hospital outpatient surgical costs for each group were calculated by dividing total hospital charges by the ratio of annual hospital cost to charges., Results: No statistically significant differences were identified between the 2 groups with regard to visual analog scale pain scores, medication intake, or cost. Complications did not occur in either group. One patient inadvertently removed the pain pump catheter., Conclusions: Our results support the null hypothesis. We found no difference between interscalene block versus continuous subacromial infusion of a local anesthetic with regard to efficacy, complication rate, or cost., Level of Evidence: Level I, prospective, randomized controlled trial.

Purpose: The superior-medial (SM) shoulder arthroscopic portal (Neviaser portal) is the portal anatomically closest to the suprascapular nerve, and any potential benefits of this portal would be mitigated if risk of suprascapular nerve injury were significant. The purpose of this study is to determine the safety of the SM arthroscopic shoulder portal. We hypothesize that the SM shoulder arthroscopic portal is safe., Methods: Twelve fresh cadaveric shoulders were securely positioned to simulate shoulder arthroscopy in the beach-chair position with the arm at the patient's side in neutral rotation. An SM portal was established 1 cm medial to the acromion and 1 cm posterior to the clavicle, and a 5.5-mm burr sheath was oriented toward the acromioclavicular joint. The skin and trapezius were resected, the supraspinatus was retracted, and the suprascapular nerve was identified. The distance between the sheath and the nerve was measured by 2 independent observers with calipers. A safe distance was defined as 10 mm., Results: The measured distances between the nerve and burr ranged from 18.5 to 35.7 mm, with a mean of 24.2 +/- 5 mm. The distance is significantly greater than the safe distance of 10 mm (P < .0001)., Conclusions: This study shows that the SM portal is safe. The distance between an instrument oriented toward the acromioclavicular joint via the SM portal and the suprascapular nerve was 18.5 mm or greater in all specimens., Clinical Relevance: Our study has clinical relevance because the SM portal is useful for arthroscopic rotator cuff repair, arthroscopic superior labrum repair, and arthroscopic distal clavicle excision.

Arthroscopic reduction and internal fixation (ARIF) is recommended as state-of-the-art treatment for patients with pure compression fracture of the tibial plateau. We describe a new technique for ARIF of pure compression tibial plateau fractures that uses a cannulated, bioabsorbable interference screw. After a guide pin is placed in the center of the compressed fragment and a tamp is used to elevate the fracture (with bone grafting as desired), the interference screw is advanced over the guide pin, resulting in both elevation and buttressing of the fracture. As compared with previously described techniques in which percutaneous buttress screws were used, ARIF attained with an interference screw via the tibial metaphyseal window allows substantially improved efficiency of surgical steps, improved preservation of the soft tissue envelope, definitive articular reduction under arthroscopic visualization, use of a bioabsorbable implant, and elimination of the need for fluoroscopy.

Complications may result from nonoperative and surgical management of medial or lateral sided knee injuries. Because these injuries are often associated with injury to the medial or lateral meniscus and the anterior or posterior cruciate ligaments (ACL and PCL, respectively), injury to these structures will also be considered. We group these complications in 3 categories: (1) complications associated with either operative or nonoperative management, (2) intraoperative complications, and (3) postoperative complications. Greater understanding of complications of medial and lateral knee ligament injuries may result in improved clinical outcomes.

Purpose: The purpose of this study was to test the hypothesis that video informed consent improves knee arthroscopy patient comprehension and satisfaction compared with traditional verbal informed consent., Type of Study: Prospective, randomized controlled trial., Methods: Consecutive patients having informed consent in preparation for knee arthroscopy by a single surgeon were stratified by educational level < or =12th grade or greater than 12th grade, then randomized to video or traditional verbal informed consent groups. Immediately after the informed consent process, patients completed an outcome questionnaire evaluating comprehension and satisfaction., Results: Patients in the video group showed significantly higher comprehension (78.5%) than patients in the verbal group (65.4%) (P = .00001). In the subgroup with < or = 12th grade education level, the video patients scored 73.1% comprehension and the verbal patients only 54.2% (P = .0011). In the subgroup with greater than 12th grade education level, the video patients scored 82.3% and the verbal patients scored 72.2% (P = .0002). There was no significant difference in subjective self-assessment of satisfaction between groups., Conclusions: Video informed consent improves knee arthroscopy patient comprehension compared with traditional verbal informed consent., Level of Evidence: Level I.

Purpose: The purpose of this study was to answer the question: How many cases are required for a surgeon to become proficient in performing arthroscopic rotator cuff repair? We hypothesize that as surgical experienced is gained, learning can be quantitatively shown by a significant decrease in operative time., Type of Study: Prospective case series., Methods: Rotator cuff repair time (RCRT) in minutes (as well as other time components comprising total surgical time) was recorded for 100 consecutive patients having arthroscopic rotator cuff repair performed by a single surgeon beginning with his first case in private practice. Mean RCRTs for consecutive blocks of 10 cases were compared. Learning is graphically represented by plotting the RCRT by case number and generating a logarithmic trend curve. A best-fit linear equation (y = mx + b) allows comparison of the initial 10 cases with the subsequent 90 cases, where m , the slope, represents the rate of decrease in RCRT (learning)., Results: Mean RCRT decreased significantly (P < .05) from the first block of 10 cases to the second block of 10 cases. There were no significant changes in mean RCRT when comparing other consecutive blocks of 10 cases. The slope of the line fitting the first block of 10 cases is -8.75; the slope (m) of the line fitting the subsequent 90 cases is -0.23. There is no significant difference in mean RCRT when cases are stratified by tear size., Conclusions: Graphic representation of RCRT by case number generates a learning curve whereby learning is quantitatively shown as a significant decrease in operative time as surgical experience is gained., Clinical Relevance: Qualification of the learning curve for arthroscopic rotator cuff repair provides a guide for orthopaedic surgeons contemplating the expected time line for acquiring proficiency in this technique.

Arthroscopic reduction and internal fixation (ARIF) of tibial intercondylar eminence fractures is the emerging state-of-the-art. ARIF is recommended for displaced type III fractures and should be considered for all cases of displaced type II fractures. Fractures without displacement after closed reduction require careful evaluation to rule out meniscal entrapment. Subjective results of ARIF are uniformly excellent, despite reports of objective anteroposterior laxity. Early range-of-motion exercises are essential to prevent loss of extension. Repair using nonabsorbable suture fixation, when of adequate strength to allow early range-of-motion, has the advantages of eliminating the risks of comminution of the fracture fragment, posterior neurovascular injury, and need for hardware removal, compared with ARIF using screws.

Arthroscopy is a valuable tool for the assessment of tibial plateau fractures and is the treatment of choice for associated intra-articular pathology. In addition, (all)-arthroscopic reduction and internal fixation (ARIF) is recommended for type III fractures and is a consideration for types I, II, and IV. Published outcome studies of ARIF of tibial plateau fractures describe results that appear to equal outcomes of open reduction and internal fixation, but these studies suffer from susceptibility bias.

Minimally invasive surgery-total knee arthroplasty (MIS-TKA) requires a skin incision of < or =5 inches (measured with the knee in full extension). A mini midvastus approach limits surgical dissection and resultant soft tissue trauma. The patella is subluxated laterally but not everted . MIS-TKA is technically challenging and instrument dependent. The design of cutting guides, sizers, and retractors must continue to evolve. Prospective, randomized controlled trials are required to test the hypothesis that MIS-TKA results in decreased patient morbidity and outcome equal to or better than traditional TKA. The purpose of this article is to describe the MIS-TKA technique.

Purpose: The purpose of this study is to test the hypothesis that the efficacy of routine arthroscopic evaluation of the posterior compartments of the knee outweighs the morbidity or inefficiency., Type of Study: Prospective cohort analysis., Methods: One hundred consecutive knees underwent posteromedial and posterolateral evaluation according to an algorithm designed to maximize efficiency of technique. Loose bodies were defined as expected when preoperative imaging or arthroscopy of the rest of the knee revealed loose bodies. The number of attempts required for visualization or visualization not accomplished, morbidity (subjective femoral condylar scuffing or complications associated with the technique), and findings were recorded., Results: With regard to posteromedial, directly inserting the camera (as opposed to an obdurator) resulted in instrument breakage. In this study, 82% of posteromedial compartments were visualized on the first attempt, and 3% were not visualized. We found that 66% of femoral condyles had no damage, 28% mild, 3% moderate, and 3% severe. Loose bodies were found in 4 of 11 (36%) when expected and 0 of 86 when not expected, a significant difference. Five other posteromedial positive findings were observed. With regard to posterolateral, 93% of compartments were visualized on the first attempt, directly with the camera via the anterolateral portal. All were visualized. We found that 96% of femoral condyles had no damage, 4% mild, and 0% moderate or severe. Damage occurred significantly less frequently than with posteromedial. No findings were noted., Conclusions: Despite inefficiency, we recommend an obdurator for posteromedial visualization via the anterolateral portal. Posteromedial visualization was associated with morbidity but was efficacious in some cases and is strongly recommended when loose bodies are expected. Posterolateral visualization directly with the camera and via the anterolateral portal is efficient and associated with minimal morbidity but was not efficacious in the cohort evaluated., Level of Evidence: Level II.

Knee injuries in skiers have unique epidemiology and distinct mechanisms. Conversely, evaluation and treatment of the skier's knee is similar to evaluation and treatment of knee injuries in other athletes. A greater understanding of the epidemiology and mechanisms of knee injuries in skiers may aid arthroscopic clinicians and related researchers treating or investigating knee injuries in both skiers and in other athletes.