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To investigate and compare the pathologies and clinical outcomes of patients with traumatic anterior shoulder instability who underwent arthroscopic stabilization at 40 years or older between shoulders with initial dislocation before age 40 years and at 40 years or after. Shoulders that underwent arthroscopic stabilization for recurrent traumatic anterior shoulder instability at 40 years or older with a minimum of 2-year follow-up were included. The subjects were divided into 2 groups according to age at initial dislocation after propensity score matching to reduce potential bias: younger than 40 years (group 1) and 40 years or older (group 2). Radiographic findings, pathologies, clinical outcomes, and complications were compared between the groups. Group 1 included 56 shoulders in 56 patients (26 men and 30 women) with a mean age of 51 years (range, 40-77 years). Group 2 included 28 shoulders in 28 patients (13 men and 15 women) with a mean age of 51 years (range, 40-77 years). Glenoid bone loss was greater in group 1 than in group 2 (P =.004). Rotator cuff tears were more frequently observed in group 2 than in group 1 (P <.001). Both groups showed significant improvement in the West Ontario Shoulder Instability Index score (P <.001 for each) and flexion (P <.001 for each). The recurrence rate was 4% in group 1 and 7% in group 2. Rotator cuff tears are significantly more frequent in recurrent shoulder instability patients with initial dislocation at age 40 or older. Arthroscopic stabilization yielded a low recurrence rate and favorable outcomes with a good return-to-sport rate in patients 40 years or older. Level III, retrospective comparative prognostic trial. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate the clinical and radiographic outcomes of arthroscopic iliac bone grafting with capsulolabral reconstruction for severe glenoid bone loss with a minimum of 5 years' follow-up.Methods: The inclusion criterion was shoulders that underwent arthroscopic iliac bone grafting for >20%-25% glenoid defect between January 2007 and April 2014, and the exclusion criterion was <5 years' follow-up. Iliac crest bone grafts of approximately 2.0 cm length and 0.8 cm height were arthroscopically fixed to the anterior glenoid using 2 cannulated screws followed by capsulolabral repair. Rowe score, Western Ontario Shoulder Instability Index (WOSI), and passive range of motion were evaluated. Radiographic findings including the Kellgren and Lawrence osteoarthritis grade and graft integration on 3-dimensional computed tomography at the final follow-up were also evaluated.Results: Forty-eight shoulders met the inclusion criteria, and 24 shoulders with ≥5 years' follow-up were included (1 died; 23 were lost follow-up): 22 males, 2 females; a mean age at surgery, 30 years (range, 18-52 years); a mean follow-up of 8 years (range, 5-11 years). The mean preoperative glenoid bone defect was 22% (range, 20%-28%). All shoulders had a Hill-Sachs lesion including 4 on-track lesions. One shoulder experienced traumatic redislocation at 5 years after surgery. The scores significantly improved: Rowe score, 19 ± 8 to 94 ± 8 (P < .001); WOSI, 1547 ± 241 to 439 ± 318 (P < .001). Postoperative flexion showed significant improvement from 158 ± 18 to 169 ± 11 (P = .008), whereas internal rotation deteriorated from T8 ± 3 to T10 ± 3 (P = .005). Graft integration showed remodeling in 54% and excessive absorption in 13%. Osteoarthritis grades progressed significantly (P < .001), but only grade 1 osteoarthritic changes were seen, except for 4 shoulders with grade 2 osteoarthritis.Conclusions: Arthroscopic iliac bone grafting for traumatic anterior shoulder instability with severe glenoid bone loss yielded satisfactory outcomes with mid-term follow-up. Arthritic changes progressed in half of the shoulders; however, most shoulders only demonstrated grade 1 osteoarthritis.Level Of Evidence: Level IV, therapeutic case series. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the incidence of axillary nerve palsy after arthroscopic shoulder stabilization and to measure the distance between the nerve and capsule in shoulders with a capsular lesion.Methods: This retrospective study included 2,027 shoulders (1,909 patients; 1,433 male and 476 female patients; mean age, 32 years [age range, 13-81 years]) subjected to arthroscopic soft-tissue stabilization for recurrent shoulder instability from 2005 to 2017. The exclusion criteria were bone grafting or transfer and preoperative axillary nerve symptoms. We retrospectively reviewed patient records and investigated the incidence and clinical features of axillary nerve palsy. We measured the closest distance between the axillary nerve and capsule on preoperative magnetic resonance images.Results: Postoperative axillary nerve palsy occurred in 4 shoulders (0.2% of all arthroscopic stabilizations). Capsular repair was performed in 2 shoulders (1.2% of 160 capsular repairs); humeral avulsion of the glenohumeral ligament (HAGL) repair, 1 shoulder (2% of 47 HAGL repairs); and isolated Bankart repair, 1 shoulder (0.05% of 1,941 Bankart repairs). The closest distance between the nerve and capsule was 3.4 ± 3.2 mm in shoulders with capsular or HAGL lesions and less than 1 mm in the 3 shoulders with palsy. The common symptoms in axillary nerve palsy cases were shoulder discomfort, delayed recovery of range of motion, and deltoid weakness and atrophy. A definitive diagnosis was made with electromyography in all cases. Nerve injury by a suture was confirmed during revision surgery in 3 shoulders subjected to capsular or HAGL repair during the initial operation. The palsy was transient and fully recovered in 1 shoulder with isolated Bankart repair.Conclusions: The incidence of axillary nerve palsy after arthroscopic soft-tissue shoulder stabilization was low but higher in shoulders subjected to capsular or HAGL repair. We should always consider the possibility of axillary nerve palsy in shoulders that require capsular or HAGL repair.Level Of Evidence: Level IV, therapeutic case series. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate osteoconductivity of a poly-L-lactide co-glycolide (PLG)-calcium sulfate (CS)-β-tricalcium phosphate (β-TCP) biocomposite suture anchor after arthroscopic shoulder labral repair.Methods: The subjects of this study were patients who participated in a clinical trial for acquisition of marketing approval of a PLG-CS-β-TCP biocomposite anchor in Japan. They underwent arthroscopic labral repair using the anchor, and computed tomographic (CT) images of the glenoid were obtained 2 years after surgery. Osteoconductivity at the anchor sites was evaluated with the CT images using the established ossification quality score. Shoulder function scores including the Rowe score and Japanese Shoulder Society shoulder instability score were also assessed 2 years after surgery.Results: CT images and functional scores were obtained from 37 patients, comprising 29 men and 8 women with a mean age of 29 years (range, 25-33 years) at surgery. A total of 148 anchors were implanted in the 37 shoulders. Osteoconductivity was seen in 133 of 148 anchor sites (90.0%) 2 years after implantation. No significant differences in osteoconductivity were found by anchor diameter or position. The Rowe score significantly improved from 39.9 points (95% confidence interval [CI], 33.8-45.9 points) preoperatively to 96.6 points (95% CI, 95.1-98.1 points) at 2 years postoperatively (P < .001). The Japanese Shoulder Society shoulder instability score also significantly improved, from 63.1 points (95% CI, 58.4-67.7 points) preoperatively to 96.3 points (95% CI, 94.7-97.8 points) at 2 years postoperatively (P < .001).Conclusions: Biocomposite suture anchors made of PLG, CS, and β-TCP exhibited some osteoconductivity 2 years after arthroscopic labral repair, as well as good clinical outcomes.Level Of Evidence: Level IV, therapeutic case series. [ABSTRACT FROM AUTHOR]

Purpose: This retrospective study aimed to report repair integrity and clinical outcomes after arthroscopic suture bridge subscapularis (SSC) tendon repair.Methods: The subjects included 101 shoulders subjected to arthroscopic suture bridge repair for full-thickness SSC tear with a minimum of a 2-year follow-up. There were 57 men and 44 women with a mean age of 66 years (range, 32-85 years). The mean follow-up was 30 months (range, 24-71 months). Tenotomy or tenodesis was performed for the long head of the biceps in all cases. All patients were assessed for active range of motion; belly-press and bear-hug tests; University of California, Los Angeles score; and American Shoulder and Elbow Surgeons score preoperatively and at the final follow-up. Repair integrity and fatty degeneration of the SSC muscle were evaluated with magnetic resonance imaging at a mean 14 months (range, 12-58 months) after surgery.Results: Flexion, internal rotation, and both functional scores significantly improved after surgery. Retears were found in 5 shoulders (5%). The shoulders with a retear showed significantly inferior functional scores compared with the intact shoulders. Fatty degeneration was significantly improved in the intact group, whereas there was no significant improvement in the retear group. Both belly-press and bear-hug test scores significantly improved after surgery; however, weakness persisted in shoulders with higher grade preoperative fatty degeneration even after successful repair.Conclusions: Arthroscopic suture bridge repair for SSC tears yielded good clinical outcomes and a very low retear rate, even for larger tears or shoulders with higher grade fatty degeneration. Fatty degeneration of the SSC muscle improved after successful repair, although internal rotation weakness persisted in shoulders with higher grade preoperative fatty degeneration. Arthroscopic suture bridge repair is a promising procedure for treating SSC tears.Level Of Evidence: Level IV, case series study. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract: 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. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to clarify the effectiveness of an arthroscopic procedure for restoration of anterior transverse sliding (RATS) mechanism of the subscapularis tendon in patients with loss of external rotation after surgical stabilization of anterior glenohumeral instability. Methods: Seven patients who underwent an arthroscopic RATS procedure for loss of external rotation after surgical stabilization of anterior glenohumeral instability were retrospectively reviewed. There were 4 male and 3 female patients with a mean age of 30.7 years. The original procedure was arthroscopic Bankart repair and rotator interval closure in 5 patients, open Bankart repair in 1, and an open Bristow procedure in 1. The arthroscopic RATS procedure was performed as follows: (1) removal of the fibrous tissue in the rotator interval; (2) release of the subscapularis tendon from the glenoid neck; and (3) incision of the superior part of the inferior glenohumeral ligament until a sufficient external rotation angle was obtained without causing anterior instability. We evaluated the mean forward flexion and external and internal rotation angles, Constant score, and University of California, Los Angeles score before the arthroscopic RATS procedure and at final follow-up (mean, 24 months). Results: The mean forward flexion and external and internal rotation angles improved from 162.1° ± 9.5° to 171.4° ± 3.8° (P < .05), from 2.9° ± 4.9° to 47.9° ± 9.1° (P < .005), and from T10 to T8 (P < .05), respectively. The mean Constant and University of California, Los Angeles scores improved from 81.0 ± 13.6 points to 95.1 ± 4.0 points and from 24.0 ± 3.7 points to 33.9 ± 2.0 points, respectively (P < .005). Conclusions: The arthroscopic RATS mechanism procedure is a useful treatment option with minimum morbidity in patients with loss of external rotation after surgical stabilization of traumatic anterior glenohumeral instability. Level of Evidence: Level IV, therapeutic case series. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to clarify anatomically and clinically how the subscapularis tendon supports the superior portion of the biceps tendon to the intertubercular groove. Methods: Thirty-three embalmed shoulder girdles were examined to investigate the subscapularis tendon and the pathway of the biceps tendon. In addition, operation records of 435 consecutive arthroscopic rotator cuff repairs were retrospectively reviewed. Results: Anatomically, the superior-most insertion of the subscapularis tendon was located on the upper margin of the lesser tuberosity. In addition, a thin tendinous slip extended from the insertion and attached to the fovea capitis of the humerus. The insertion, the tendinous slip, and the lateral portion of the cranial part of intramuscular tendons were in direct contact with the inferior side of the biceps tendon at its corner portion. The clinical study showed that 27.4% of rotator cuff tears (119/435) had subscapularis tendon tears. In cases with an unstable biceps tendon there was no intact subscapularis tendon. The superior-most insertion of the subscapularis tendon was involved in all transverse tears. Of 29 full-thickness transverse tears, 13 (44.8%) showed intra-articular dislocation. Conclusions: The trochlea-like structure was composed of the superior-most insertion, the tendinous slip, and the lateral portion of the cranial part of intramuscular tendons supporting the biceps tendon. The transverse tear of the subscapularis tendon, which included this trochlea-like structure, often leads to intra-articular dislocation of the biceps tendon. Clinical Relevance: Instability of the biceps tendon should be carefully assessed because it is associated with subscapularis tendon tears at a very high incidence. When we repair a transverse tear of the subscapularis tendon, we should widely fix sufficiently strong tissue to support the biceps tendon on the uppermost margin, not on the anteromedial portion, of the lesser tuberosity. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to compare the functional as well as the structural outcomes of single-row and dual-row fixation after arthroscopic full-thickness rotator cuff repair. Type Of Study: Retrospective cohort study. Methods: A consecutive series of 80 shoulders in 78 patients with full-thickness rotator cuff tears was evaluated using the rating scale of the University of California Los Angeles (UCLA) and the shoulder index of the American Shoulder and Elbow Surgeons (ASES) at an average of 35 months (range, 24 to 60 months) after arthroscopic rotator cuff repair. Thirty-nine shoulders were repaired using the single-row technique and 41 shoulders using the dual-row technique. Postoperative cuff integrity was determined through magnetic resonance imaging and was classified into 5 categories: type I, sufficient thickness with homogenously low intensity; type II, sufficient thickness with partial high intensity; type III, insufficient thickness without discontinuity; type IV, presence of a minor discontinuity; type V, presence of a major discontinuity. Results: The average UCLA score improved significantly to 32.4 in the single-row and to 33.1 in the dual-row group. The ASES shoulder index improved significantly to 93.0 in the single-row group and to 94.6 in the dual-row group. However, there was no statistical difference between the groups in the postoperative scores. Postoperative MRI revealed 11 type I, 6 type II, 12 type III, 4 type IV, and 6 type V in the single-row group, and 22 type I, 8 type II, 7 type III, 4 type IV, and no type V in the dual-row group. A statistical difference was observed between the groups (P < .01). Conclusions: Arthroscopic rotator cuff repair yielded successful functional outcomes without significant difference between single and dual-row fixation techniques. However, dual-row repairs excelled in structural outcome over the single-row technique. Level Of Evidence: Level III. [ABSTRACT FROM AUTHOR]

Abstract: We describe 3 cases of an all-arthroscopic technique for repair of a humeral avulsion of the glenohumeral ligament (HAGL) lesion and the postoperative clinical outcomes. From a technical perspective, the most critical part of the surgeries was the anchor insertion at an optimal position on the humerus in order to achieve proper tension of the glenohumeral ligament. The arm-free beach-chair position, which facilitates maximum internal rotation, use of a 70° angled arthroscope, and an anterior-inferior trans-subscapularis tendon portal were considered key factors to accomplish this procedure. [Copyright &y& Elsevier]

Abstract: Anterior glenoid fractures associated with glenohumeral instability are normally treated with open fixation of the fragment. However, recent technical development enables this procedure to be performed under arthroscopic control using screws or even suture anchors if the fragment is small enough. We developed a unique method of stabilizing a larger fragment with suture anchors and the use of a clear imaging method of three-dimensional computed tomography (3D-CT) with the humeral head eliminated, preoperatively and postoperatively. In the present article, we report a detailed method of arthroscopic stabilization for a consecutive series of 8 patients, with an average of 27% bone loss (fragment size) against the lower part of the circular glenoid portion, using suture anchors. [Copyright &y& Elsevier]