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Purpose: To describe an all-endoscopic technique for infra- and supraclavicular brachial plexus (BP) neurolysis and to assess its functional outcomes for patients suffering from nonspecific neurogenic thoracic outlet syndrome (NTOS)., Methods: Between January 2010 and January 2013, 36 patients presenting an idiopathic nonspecific NTOS benefited from an endoscopic decompression in our institution. The inclusion criteria were a typical clinical NTOS and failure of a 6-month well-conducted nonsurgical treatment. Preoperative findings about other shoulder conditions and complementary procedures were exclusion criteria. Interscalene, costoclavicular, and retropectoralis minor spaces were released endoscopically. The primary endpoint was the Disability of the Arm, Shoulder and Hand (DASH) score improvement 6 months after the surgery. Postoperative criteria such as pain relief, paresthesia, upper limb weakness, and provocative tests were also assessed., Results: Of 36 patients, 10 were excluded and 5 were lost during follow-up. The data of the 21 remaining patients were analyzed after 6 months. Pre- and postoperative mean DASH scores were, respectively, 70 (range 36-98) and 34 (range 2-91). The average improvement was 36 (range -20 to 80), with P = .0002. Pain and paresthesia were relieved in 80% to 90% of the cases. No complication was reported., Conclusions: Although requiring arthroscopic skills and expert knowledge of the anatomy, our technique seems to be safe and reproducible, and it provides significant functional improvements in the selected patients with nonspecific NTOS, with an average postoperative DASH score improvement of 36%., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Neurogenic thoracic outlet syndrome is caused by a neurologic compression of the brachial plexus before it reaches the arm. Three anatomic areas are common locations for such an entrapment because of their congenital and/or acquired tightness: the interscalene triangle, the costoclavicular space, and the retropectoralis minor space. Because the compression level usually remains unknown, the treatment is still controversial and most teams focus on only one potential site. We propose an all-endoscopic technique of complete brachial plexus neurolysis that can be divided into three parts, one for each entrapment area. First, with a subacromial approach, the suprascapular nerve is released distally from the transverse ligament and then followed up to the upper trunk. Once the upper trunk is located, the middle and lower trunks are dissected in the interscalene triangle. Then, by use of an infraclavicular approach, the brachial plexus is released from the costoclavicular space by detaching the subclavian muscle from the clavicle. Finally, the pectoralis minor is released from the coracoid so that the brachial plexus is distally freed. This technique seems to be safe and reproducible, but expert knowledge of the neurovascular anatomy and advanced endoscopic skills are required.

The subscapularis is the largest and strongest muscle of the rotator cuff, and it plays an essential role in global shoulder function. Beyond its primary function as an internal rotator, the subscapularis also acts to pull the humeral head posteriorly on the glenoid and is an important dynamic and static anterior stabilizer of the glenohumeral joint. In comparison with tears of the tendons of the rest of the rotator cuff, isolated tears of the subscapularis have a tendency for both early retraction and fatty infiltration. Consequently, full-thickness tears of the subscapularis tendon generally require surgical management. Arthroscopic suture-anchor repair allows anatomic reconstruction of the anterior aspect of the rotator cuff, with all of the benefits of arthroscopic surgery. The principal steps of this procedure include (1) verifying the subscapularis tear and identifying any concomitant lesions during diagnostic arthroscopy, (2) exposing the subscapularis tendon, (3) releasing tendon adhesions and so enabling anatomic reduction, (4) placing suture anchors at the anatomic subscapularis footprint on the lesser tuberosity and anatomically repairing the subscapularis tendon to its anatomic insertion, and (5) performing biceps tenodesis or tenotomy, if indicated. Postoperatively, patients with an isolated subscapularis tear are managed with immobilization in a sling for 6 weeks, while those with combined anterosuperior rotator cuff tears are managed with an abduction pillow. Arthroscopic subscapularis reconstruction provides a good structural repair, substantially restores shoulder mobility and strength, reduces pain, and results in high levels of patient satisfaction and return of shoulder function as measured by functional outcome scores.

Arthroscopic Latarjet procedure is an efficient and reliable approach for the treatment of shoulder instability. Nevertheless, the screws fixing the bone block may sometimes be responsible for pain and uncomfortable snapping in the shoulder that is triggered during active external rotation. We propose an all-arthroscopic technique for screw removal in cases of complications involving the screws from a Latarjet procedure. The all-arthroscopic screw removal is reliable and efficient. This procedure is indicated in more cases than thought because of the bone block resorption. It permits a revision of the glenohumeral joint in case of persisting pain.

Purpose: To macroscopically, histologically, and radiologically describe a time-dependent remodeling process of a neo-tendon or -ligament in the shoulder after the arthroscopic Latarjet procedure., Methods: During follow-up surgery after the arthroscopic Latarjet procedure, 17 shoulders in 16 patients were evaluated for a remodeled tendon-like structure. The mean overall follow-up period was 27.4 months. The mean time between the arthroscopic Latarjet procedure and revision was 11.6 months. All shoulders were evaluated with magnetic resonance imaging, and seven histologic specimens were obtained during revision surgery., Results: A distinct, oriented strand of tissue was found in 16 of 17 shoulders on revision surgery. Postoperative magnetic resonance imaging analyses showed a signal-free, longitudinal tendon-like structure originating at the tip of the acromion, traversing the space of the former subcoracoid bursa to attach in the course of the transposed conjoint tendon or the proximal short head of the biceps. Histologic analysis of seven specimens showed a characteristic timeline of remodeling., Conclusions: A tendon- or ligament-like structure is remodeled between the anterior bottom tip of the acromion and the transposed coracoid process in a time-dependent manner after the arthroscopic Latarjet procedure., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background and Hypothesis: The Latarjet procedure has been shown to be a reliable method to prevent recurrent anterior shoulder instability. Coracoid bone graft osteolysis is a potential catastrophic complication and can lead to recurrent instability. The purpose of our study is to present a novel quantitative method to measure the amount of coracoid bone osteolysis using 3-dimensional (3D) computed tomography (CT) scan imaging., Materials and Methods: This is a prospective study with 15 patients (16 shoulders) who underwent an arthroscopic Latarjet procedure. Three-dimensional CT scans were obtained at 6 weeks and 6 months. Using volumetric analysis, we quantified the amount of bone loss using our described method. Interobserver reliability and intraobserver reliability were calculated., Results: On the basis of our new volumetric analysis of the arthroscopic Latarjet procedure using 3D CT scans, we found that the superior half of the coracoid bone graft undergoes a significant amount of osteolysis at 6 months postoperatively. The interobserver reliability and intraobserver reliability were excellent., Discussion: This study presents a reproducible method to quantify and compare coracoid bone graft osteolysis after an arthroscopic Latarjet procedure. We also developed a description system that may be used for comparison studies. To our knowledge, this is the first method that quantifies the amount of coracoid bone graft osteolysis using more accurate 3D CT scanning., Conclusion: The 3D analysis we propose is a valid method to measure the amount of coracoid bone graft osteolysis after an arthroscopic Latarjet procedure. Our description system may guide the surgeon regarding possible revision surgery when faced with significant osteolysis of the coracoid bone graft., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Arthroscopic Bankart repair has become the most common treatment option for patients who have anterior shoulder instability. Although arthroscopic Bankart repair is generally an effective treatment method, it may be insufficient for the treatment of many patients who have anterior shoulder instability. Risk factors for failure of arthroscopic Bankart repair include younger age, level and type of sport, and shoulder specific risks, such as ligamentous laxity and the presence of bone loss. Recently, researchers have defined the limits of arthroscopic Bankart repair and more clearly defined treatment options for patients who have a high risk for failure after arthroscopic Bankart repair. Surgeons must recognize patients with anterior shoulder instability in whom a more aggressive surgical approach should be considered as well as patients who have a high risk for failure after arthroscopic Bankart repair to optimize outcomes in this patient population.

Purpose: To describe the technique of an all-arthroscopic Eden-Hybinette procedure in the revision setting for treatment of a failed instability procedure, particularly after failed Latarjet, as well as to present preliminary results of this technique., Methods: Between 2007 and 2011, 18 shoulders with persistent instability after failed instability surgery were treated with an arthroscopic Eden-Hybinette technique using an autologous bicortical iliac crest bone graft. Of 18 patients, 12 (9 men, 3 women) were available for follow-up. The average follow-up was 28.8 months (range, 15 to 60 months). A Latarjet procedure was performed as an index surgery in 10 patients (83%). Two patients (17%) had a prior arthroscopic Bankart repair., Results: Eight patients (67%) obtained a good or excellent result, whereas 4 patients (33%) reported a fair or poor result. Seven patients (58%) returned to sport activities. A positive apprehension test persisted in 5 patients (42%), including 2 patients (17%) with recurrent subluxations. The Rowe score increased from 30.00 to 78.33 points (P < .0001). The Walch-Duplay score increased from 11.67 to 76.67 points (P < .0001). The Western Ontario Shoulder Instability Index score showed a good result of 28.71% (603 points). The average anterior flexion was 176° (range, 150° to 180°), and the average external rotation was 66° (range, 0° to 90°). Two patients (16.67%) showed a progression of glenohumeral osteoarthritic changes, with each patient increasing by one stage in the Samilson-Prieto classification. All 4 patients (33%) with a fair or poor result had a nonunion identified on postoperative computed tomography scan., Conclusions: An all-arthroscopic Eden-Hybinette procedure in the revision setting for failed instability surgery, although technically demanding, is a safe, effective, and reproducible technique. Although the learning curve is considerable, this procedure offers all the advantages of arthroscopic surgery and allows reconstruction of glenoid defects and restoration of shoulder stability in this challenging patient population. In our hands, this procedure yields good or excellent results in 67% of patients. Successful outcome is correlated with bony healing of the iliac crest graft to the glenoid., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: Subscapularis tendon ruptures, which are small in size, can be missed on CT or MRI imaging and are also difficult to diagnose by arthroscopy. Here we discuss a new sign of biceps tendon, which may point towards rupture of the subscapularis tendon. The biceps tendon may have scuffing, abrasion or partial tear of its anterior portion. We have named this as sentinel sign as it signals the presence of a coexisting subscapularis rupture., Materials and Methods: This study was a retrospective analysis of available arthroscopic rotator cuff repair surgery videos of 2009-2010. The videos were studied, and data recorded for number of cases showing the presence of sentinel sign and coexisting subscapularis rupture. Sensitivity, positive predictive value of the sign, was calculated., Results: Out of 330 available videos, 79 showed the presence of subscapularis rupture. Ten patients had a positive sentinel sign, but an intact biceps pulley that obscured the visualisation of the subscapularis tendon tear. This tear became apparent after removal of anterior part of biceps sling., Conclusion: The presence of sentinel sign of the biceps tendon indicates the presence of a coexistent subscapularis rupture. If the rupture is not apparent, obscuring parts of the biceps sling should be removed to see the upper fibres of subscapularis tendon., Level of Evidence: Study of diagnostic test, Level III.

Shoulder dislocation and subsequent anterior instability is a common problem in young athletes. The arthroscopic Bankart repair was originally described by Morgan et al. in 1987. The procedure has benefited from many technical advancements over the past 25 years and currently remains the most commonly utilized procedure in the treatment of anterior glenohumeral instability without glenoid bone loss. Capsulolabral repair alone may not be sufficient for treatment of patients with poor capsular tissue quality and significant bony defects. In the presence of chronic anterior glenoid bony defects, a bony reconstruction should be considered. The treatment of anterior shoulder instability with transfer of the coracoid and attached conjoint tendon such as the Latarjet procedure has provided reliable results. The arthroscopic Latarjet procedure was described in 2007 by the senior author, who has now performed the procedure over 450 times. The initial surgical technique has evolved considerably since its introduction, and this article presents a comprehensive update on this demanding but well-defined procedure. This article reviews technical tips to help the surgeon perform the surgery more smoothly, navigate through challenging situations, and avoid potential complications. Level of evidence V.

The Latarjet procedure is an established and effective option for the treatment of recurrent anterior shoulder instability. Symptomatic compression of the vasculature around the shoulder and adjacent brachial plexus is uncommon and may be difficult to diagnose and treat. The purpose of this report is to describe a patient with neurovascular compression of the axillary artery and brachial plexus after an open Latarjet procedure. This is the first known report of documented combined vascular and neurologic thoracic outlet syndrome after a Latarjet procedure. Evaluation of this suspected problem requires a detailed clinical examination and a dynamic angiogram to verify which neurovascular structures are compressed. Treatment includes decompression of the brachial plexus and axillary vasculature by releasing tethering scar tissue or the remaining pectoralis minor that is creating a constricting sling effect. An arthroscopic approach provides for a careful and specific decompression. Additionally, the authors provide a review of the literature for neurologic complications and management for these complications., (Copyright 2015, SLACK Incorporated.)

The Latarjet procedure is an operation performed either arthroscopically or open for recurrent anterior shoulder instability, in the setting of glenoid bone loss; with good to excellent functional results. Despite excellent clinical results, the complication rates are reported between 15 and 30 %. Intraoperative complications such as graft malpositioning, neurovascular injury, and graft fracture can all be mitigated with meticulous surgical technique and understanding of the local anatomy. Nonunion and screw breakage are intermediate-term complications that occur in less than 5 % of patients. The long-term complications such as graft osteolysis are still an unsolved problem, and future research is required to understand the etiology and best treatment option. Recurrent instability after the Latarjet procedure can be managed with iliac crest bone graft reconstruction of the anterior glenoid. Shoulder arthritis is another complication reported after the Latarjet procedure, which poses additional challenges to both the surgeon and patient.

Background: The arthroscopic Latarjet procedure combines the benefits of arthroscopic surgery with the low rate of recurrent instability associated with the Latarjet procedure. Only short-term outcomes after arthroscopic Latarjet procedure have been reported., Purpose: To evaluate the rate of recurrent instability and patient outcomes a minimum of 5 years after stabilization performed with the arthroscopic Latarjet procedure., Study Design: Case series; Level of evidence, 4., Methods: Patients who underwent the arthroscopic Latarjet procedure before June 2008 completed a questionnaire to determine whether they had experienced a dislocation, subluxation, or further surgery. The patients also completed the Western Ontario Shoulder Instability Index (WOSI)., Results: A total of 62 of 87 patients (64/89 shoulders) were contacted for follow-up. Mean follow-up time was 76.4 months (range, 61.2-100.7 months). No patients had reported a dislocation since their surgery. One patient reported having subluxations since the surgery. Thus, 1 patient (1.59%) had recurrent instability after the procedure. The mean ± standard deviation aggregate WOSI score was 90.6% ± 9.4%. Mean WOSI domain scores were as follows: Physical Symptoms, 90.1% ± 8.7%; Sports/Recreation/Work, 90.3% ± 12.9%; Lifestyle, 93.7% ± 9.8%; and Emotions, 88.7% ± 17.3%., Conclusion: The rate of recurrent instability after arthroscopic Latarjet procedure is low in this series of patients with a minimum 5-year follow-up. Patient outcomes as measured by the WOSI are good., (© 2014 The Author(s).)

Rotator cuff repairs have a high failure rate proportional to the tear size. Various techniques have been described to improve the repair strength and failure rate. The described surgical technique uses a biodegradable subacromial balloon-shaped spacer (InSpace; OrthoSpace, Caesarea, Israel) that is implanted arthroscopically to protect our tendon repair. We describe the introduction technique and suggest some hints and tricks. The spacer is placed under direct vision in the subacromial space after the rotator cuff repair is finished. Correct placement is verified by moving the arm freely. The subacromial spacer may help to protect the rotator cuff repair by centering the humeral head and reducing friction between suture knots and the acromion. It may also help to flatten dog-ear formations.

Purpose: The purpose of this study was to evaluate outcome and structural integrity after arthroscopic repair of large subscapularis tendon (SSC) tears at 2 to 4 years' follow-up., Methods: Between January 2006 and October 2008, 52 consecutive patients underwent arthroscopic repair of Lafosse type III and IV SSC ruptures. A total of 46 patients (38 men and 8 women) with a mean age of 62 years (range, 45 to 81 years) were available for final follow-up. Clinical findings were assessed for all patients preoperatively and postoperatively, including range of motion, the lift-off test, the belly-press test, the Constant score, and the modified University of California, Los Angeles score. Subscapularis muscle strength by use of the bear-hug test and external rotation were compared in both shoulders postoperatively. Patients were evaluated with plain radiographs and magnetic resonance imaging or computed tomographic arthrography before surgery. Postoperatively, radiographic examination was completed by use of magnetic resonance imaging or computed tomographic arthrography in 39 patients (85%). Patients completed the subjective shoulder value and rated their satisfaction at final follow-up., Results: The mean follow-up period was 35.3 ± 9.6 months (range, 23 to 57 months). An isolated lesion was detected in 13% of patients; a lesion of the SSC and supraspinatus tendon was found in 37%; and a lesion of the SSC, supraspinatus tendon, and infraspinatus tendon was detected in 50%. At latest follow-up, the mean Constant score significantly improved from 46.4 points to 79.9 points and the modified University of California, Los Angeles score improved from 15.1 points to 31.5 points (P < .001). Subscapularis strength was 92% and external rotation was 96% of the nonoperative shoulder. All outcome scores were similar between Lafosse type III and IV SSC ruptures. Radiographic evaluation showed a rerupture rate of 11%. The coracohumeral distance increased from 9.7 mm to 10.1 mm postoperatively (P = .086). The subjective shoulder value improved from 51% to 88% (P < .001), and 98% of patients were satisfied or very satisfied., Conclusions: Arthroscopic treatment of large to massive SSC ruptures results in significant clinical improvements, excellent maintenance of muscle strength, and durable tendon integrity at 2 to 4 years' follow-up., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Posterior instability is a relatively rare and challenging condition to treat. Soft-tissue procedures do not always provide satisfactory results. We present the results after arthroscopic posterior bone block augmentation with an iliac crest bone graft and a minimum of 12 months' follow-up., Materials and Methods: Between 2008 and 2009, we performed 19 arthroscopic posterior bone blocks on 18 patients with posterior instability (bilaterally in 1 patient). The mean age was 29.85 years at the time of surgery. The mean follow-up was 20.5 months. All patients had a painful, unstable shoulder. Preoperative etiology included trauma, glenoid dysplasia, Ehlers-Danlos syndrome, and arthrosis with posterior glenoid erosion., Results: The Rowe score improved from 18.4 points to 82.1 points, and the Walch-Duplay score improved from 37.4 points to 82.9 points, both statistically significant (P < .01). Radiologic bone healing was achieved in all cases. Nine cases had an excellent result with return to the previous level of sports, six were satisfied, and three had a persistently painful shoulder. Subsequent removal of screws improved symptoms in two of these patients, and in one patient, a cause for the pain and persistent instability was not found., Conclusion: Arthroscopic posterior bone block augmentation presents a reliable technique for the treatment of symptomatic posterior instability with varying origin. Although this is a technically demanding procedure, in our experience, the potential benefits and minimally invasive nature outweigh the risks and benefits of more invasive procedures., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Posterior glenohumeral instability remains a difficult problem. There are still many controversies regarding surgical treatment, due to a lack of understanding the pathomechanical issues leading to posterior instability. This article presents a new arthroscopic technique of posterior bone block augmentation, which we found to be effective, repeatable and successful. This technique can be used for combined soft tissue and bony defects as well as for revisions after previous soft tissue reconstructions.

Purpose: The purpose of this study was to evaluate a new all-arthroscopic technique in the management of recalcitrant globally stiff frozen shoulders. This adopts an initial extra-articular approach followed by intra-articular entry to perform a 360° capsular release., Methods: Ten patients with global adhesive capsulitis were prospectively evaluated. All patients had not improved after undergoing a minimum of 6 months of physiotherapy, and 5 received intra-articular injections of steroids. The mean age was 47 years (range, 33 to 56 years). Patients were examined preoperatively and postoperatively for range of motion. A Constant score and visual analog scale score for pain were recorded. We described an all-arthroscopic technique by entering the subacromial space laterally and opening the rotator interval from the outside in, followed by a complete 360° capsular release and biceps tenotomy., Results: The mean follow-up was 42 months (range, 18 to 90 months), and the mean Constant score improved from 21 to 72 (P < .01). Preoperative abduction improved from a mean of 40° to 165°, elevation improved from 55° to 175°, and external rotation improved from 6° to 58°. The visual analog scale pain score improved from 7 to 1.6, and all patients reported an excellent outcome after surgery. There were no complications particularly regarding axillary nerve injury, fracture, or infection., Conclusions: This study shows a combined extra-articular and intra-articular approach that is controlled and anatomic and achieves excellent results that were maintained at the midterm. The technique permits anatomic debridement of the rotator interval, enabling excellent intra-articular access, a circumferential capsular release, and biceps tenotomy. There were no complications, and no manipulations were required, which pose a risk of creating soft-tissue lesions, fractures, or dislocations. We recommend this 360° capsular release technique for releasing globally stiff shoulders where the surgeon is experienced in arthroscopy., (Copyright © 2012 Arthroscopy Association of North America. All rights reserved.)

Background. We introduce a novel description system of shoulder pathoanatomy. Its goal is to provide a comprehensive three-dimensional picture, with an additional component of time; thus, we call it the 4D code. Methods. Each line of the code starts with right versus left and a time designation. The pillar components are recorded regardless of pathology; they include subscapularis, long head of biceps tendon, supraspinatus, infraspinatus, and teres minor. Secondary elements can be added if there is observed pathology, including acromioclavicular joint, glenohumeral joint, labrum, tear configuration, location and extent of partial cuff tear, calcific tendonitis, fatty infiltration, and neuropathy. Results. We provide two illustrative examples of patients which show the ease and effectiveness of the 4D code. With a few simple lines, significant amount of information about patients' pathology, surgery, and recovery can be easily conveyed. Discussion. We utilize existing validated classification systems for parts of the shoulder and provide a frame work to build a comprehensive picture. The alphanumeric code provides a simple language that is universally understood. The 4D code is concise yet complete. It seeks to improve efficiency and accuracy of the communication, documentation, and visualization of shoulder pathology within individual practices and between providers.

Background: The tissue-suture interface remains the most common site of failure in rotator cuff repairs. Improving stitch strengths may lead to lower failure rates., Purpose: To compare biomechanical properties of 3 self-cinching stitches to the simple, mattress, modified Mason-Allen, and massive cuff stitches., Study Design: Controlled laboratory study., Methods: In sum, 336 sheep infraspinatus tendon grafts were randomized among 7 stitches. Each graft was cyclically loaded on a mechanical testing system from 5 to 30 N for 20 cycles and then loaded to failure. A mixed-effect multivariate regression model was used to test significance of suture type on cyclic elongation, peak-to-peak displacement, and ultimate load. Estimated means and standard deviations are reported from the regression model., Results: Ultimate load for the simple stitch was significantly lower than for the other stitches. The lasso-loop and mattress stitch demonstrated similar ultimate loads. The double-cinch had a higher ultimate load than the lasso-loop or mattress stitch, although it was significantly weaker than the modified Mason-Allen, lasso-mattress, and massive cuff. The lasso-mattress had a superior ultimate load to the modified Mason-Allen and a similar ultimate load to the massive cuff stitch. One significant difference was found in cyclic elongation (1.42 mm for the simple to 1.80 mm for the double-cinch), and the cinching mechanism accounted for 0.2-mm higher elongation., Conclusion: Self-cinching stitches lead to superior tissue-holding strength at the tissue-suture interface when compared with equivalent non-self-cinching stitches. Self-cinching stitches have greater elongation values. How these differences in cyclic elongation clinically influence gap formation at the repair site is unknown. The greater displacement seen in the self-cinching stitches is a potential concern because minimal gap formation is desired for a strong repair., Clinical Relevance: The lasso-loop stitch is a stronger alternative to a simple stitch, and the double-cinch and lasso-mattress stitches are stronger alternatives to a mattress stitch.

Although soft tissue stabilization procedures in the shoulder yield good results, arthroscopy and radiological investigations have identified more complex soft tissue and bony lesions that can be successfully treated using a Latarjet procedure. The authors have advanced this technique to make it possible arthroscopically, thereby conferring all the benefits that arthroscopic surgery offers. This article describes how and why the arthroscopic Latarjet procedure is a valuable tool in the treatment of complex shoulder instability and how the procedure can be introduced into practice. This technique has shown excellent results at short- to mid-term follow-up, with minimal complications. As such, this procedure is recommended to surgeons with good anatomic knowledge, advanced arthroscopic skills, and familiarity with the instrumentation., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Total shoulder replacement (TSR) is an effective treatment of shoulder arthritis. However, subscapularis insufficiency after TSR remains a significant cause of poor outcomes after shoulder arthroplasty. We describe a novel technique for performing a TSR entirely through the rotator interval (RI) without tenotomy of the subscapularis or supraspinatus tendons and without dislocating the shoulder using the superior approach., Material and Methods: We prospectively followed up 22 patients who underwent this procedure. Subjective patient satisfaction, Constant, Simple Shoulder Test (SST) scores, and range of motion (ROM) were evaluated preoperatively and postoperatively at a mean follow-up of 29 months. Radiographic findings are also presented., Results: Subjective patient satisfaction results were good in 5 of 17 patients and excellent in 12. Patients also had significant increases in Constant, visual analog scale, SST, and ROM scores. One patient was excluded due to a traumatic periprosthetic fracture (fall), 3 patients refused to return for follow-up, and 1 patient was lost to follow-up. Postoperative results included nonanatomic humeral head osteotomies in 6, residual inferior humeral neck osteophytes in 8, and the humeral head prosthesis was undersized in 5., Conclusions: The patients had favorable clinical outcomes. This technique for TSR demonstrates that in the postoperative period, patients can immediately partake in unrestricted physical therapy. This study reports the clinical outcomes of this technique for TSR with a minimum of 2 years of follow-up., Level of Evidence: Level 4; Case series, treatment study.

Lateral reattachment of the rotator cuff and the more recent introduction of the double-row rotator cuff repair technique require adequate visualization to define the rotator cuff footprint and the greater tuberosity. In many cases extensive debridement in this area is required to remove the overlying subdeltoid bursa, which can impair visualization laterally on the proximal humerus. Inadequate visualization laterally may lead to improper placement of the lateral row of fixation, compromising the reduction and fixation of the repaired rotator cuff tendon. We describe a surgical technique used to improve lateral visualization of the proximal humerus for placement of lateral anchors during arthroscopic rotator cuff repair using a Foley catheter. The end of a 14F-diameter Foley catheter is cut just proximal to the balloon end. One to three catheters are introduced in the subacromial space through small anterolateral or posterolateral portals and inflated with 15 mL of air. Adequate distension of the subacromial space allows better visualization, triangulation of the arthroscopic instruments, and anatomic repair of the rotator cuff tendon.

The double-row rotator cuff repair has proved to be biomechanically superior to the single-row technique. However, this has not been shown clinically. At the moment, all the methods proposed for medial-row suturing in the suture-bridge technique recommend a mattress suture or a simple stitch. The lasso-loop stitch has been proposed as a technique to improve tissue grip and has been used in open rotator cuff repairs, in biceps tenodesis, and in the Bankart procedure. We propose a method in which a modified version of this stitch can be used to repair the medial row of a double-row repair. In the "modified lasso-loop stitch," a circumferential stitch is constructed over the posteromedial and anteromedial anchor. This stitch exerts an appropriate amount of radial compression on the encased tendon as the tails of the posteromedial and anteromedial suture are fixed to the anterolateral anchor. Through this technique, the reduction force is augmented and a compression force is created, thus allowing restoration of the rotator cuff footprint. This technique provides a strong cuff-suture interface while appropriate tensioning of the modified lasso-loop stitch allows minimal strangulation of the tendon. This technique has been shown to work with and without a knot.

Background: The reported rate of failure after arthroscopic rotator cuff repair has varied widely. The influence of the repair technique on the failure rates and functional outcomes after open or arthroscopic rotator cuff repair remains controversial. The purpose of the present study was to evaluate the functional and anatomic results of arthroscopic rotator cuff repairs performed with the double-row suture anchor technique on the basis of computed tomography or magnetic resonance imaging arthrography in order to determine the postoperative integrity of the repairs., Methods: A prospective series of 105 consecutive shoulders undergoing arthroscopic double-row rotator cuff repair of the supraspinatus or a combination of the supraspinatus and infraspinatus were evaluated at a minimum of two years after surgery. The evaluation included a routine history and physical examination as well as determination of the preoperative and postoperative strength, pain, range of motion, and Constant scores. All shoulders had a preoperative and postoperative computed tomography arthrogram (103 shoulders) or magnetic resonance imaging arthrogram (two shoulders)., Results: There were thirty-six small rotator cuff tears, forty-seven large isolated supraspinatus or combined supraspinatus and infraspinatus tendon tears, and twenty-two massive rotator cuff tears. The mean Constant score (and standard deviation) was 43.2 +/- 15.1 points (range, 8 to 83 points) preoperatively and 80.1 +/- 11.1 points (range, 46 to 100 points) postoperatively. Twelve of the 105 repairs failed. Intact rotator cuff repairs were associated with significantly increased strength and active range of motion., Conclusions: Arthroscopic repair of a rotator cuff tear with use of the double-row suture anchor technique results in a much lower rate of failure than has previously been reported in association with either open or arthroscopic repair methods. Patients with an intact rotator cuff repair have better pain relief than those with a failed repair. After repair, large and massive rotator cuff tears result in more postoperative weakness than small tears do.

Anterior instability is a difficult clinical problem that is treated by a variety of open and arthroscopic methods with good results. Bankart repair remains a popular option. However, in those situations involving irreparable ligamentous damage or bony deficiency, this technique may be insufficient to stabilize the shoulder. One of the principal methods of open treatment for this problem is the Latarjet procedure, as described in his article in 1954. It has proven to be a durable and reliable method of treatment for anteroinferior instability of the glenohumeral joint. Several authors have reported on the long-term outcomes of this procedure with satisfactory results. There has been no previous description of the Latarjet procedure being performed arthroscopically. We present the first report of a new surgical technique, the arthroscopic Latarjet procedure. This procedure is fully arthroscopic and combines the advantages of the open procedure with those of arthroscopic stabilization. This is a significant step forward in the development of arthroscopic shoulder reconstruction and enables shoulder surgeons to treat all cases of instability arthroscopically.

Background: Isolated tears of the subscapularis occur less commonly than those involving the superior and posterior components of the rotator cuff. The purpose of the present study was to evaluate the structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears., Methods: A prospective study of seventeen consecutive patients who were managed with an all-arthroscopic repair of the subscapularis tendon was performed. The study group included thirteen men and four women who had an average age of forty-seven years at the time of surgery. The average interval from the onset of symptoms to the time of surgery was twenty-four months. Thirteen tears were traumatic, and four were degenerative. Seven patients had a tear involving the superior third of the tendon, six had a tear involving the superior two-thirds of the tendon, and four had complete separation of the subscapularis from its insertion on the lesser tuberosity. Clinical findings were assessed for all patients preoperatively and postoperatively with use of the Constant and University of California at Los Angeles scoring systems, and all patients had postoperative computed tomographic arthrography studies to evaluate the structural integrity of the repair., Results: The average duration of follow-up was twenty-nine months. When the preoperative findings were compared with the most recent findings, the average relative Constant score had improved from 58% to 96% (p < 0.05), the average University of California at Los Angeles score had improved from 16 to 32 points (p < 0.05), the average pain score had improved from 5.9 to 13.5 points (p < 0.05), the average forward flexion had improved from 146 degrees to 175 degrees (p < 0.05), the average external rotation had improved from 50 degrees to 60.3 degrees (p < 0.05), the average internal rotation had improved from the level of the sacrum to L1-L2 (p < 0.05), and the average abduction strength had improved from 7.4 to 15.6 points (p < 0.05). The structural integrity of the repair was completely intact in fifteen patients and was partially reruptured in two patients on the basis of computed tomographic arthrography. Progression of fatty infiltration of the subscapularis was not observed in any patient. Subjectively, twelve patients were very satisfied with the result, four were satisfied, and one was not satisfied., Conclusions: Arthroscopic repair of an isolated subscapularis tear can yield marked improvements in shoulder function, can significantly reduce pain, and can result in a durable structural repair., Level of Evidence: Therapeutic Level IV.

Purpose: We describe a novel all-arthroscopic technique for suprascapular nerve (SSN) decompression and present our preliminary results for this procedure., Methods: A prospective series of 10 patients with preoperative electromyographic findings consistent with chronic SSN compression, posterior shoulder pain, and subjective weakness were treated with arthroscopic SSN decompression. There were 8 men and 2 women, with a mean age of 50 years. The mean follow-up was 15 months (range, 6 to 27 months). In 8 of 10 patients, we performed an electromyographic examination postoperatively to evaluate nerve recovery after decompression. The clinical outcomes measures used to assess preoperative and postoperative function were the visual analog scale for pain, the Constant score, strength testing of the supraspinatus and infraspinatus, and a subjective satisfaction questionnaire. In all patients preoperative and postoperative computed tomography arthrograms were obtained to document the absence of a rotator cuff tear., Results: There were no complications resulting from SSN decompression. Of 10 patients, 8 had postoperative electromyography at a mean of 6 months after SSN release and 2 refused to undergo this study after surgery. Of the 8 postoperative electromyograms, 7 had complete normalization of the latency in the motor fibers of the SSN and normalization of the voluntary motor action potential for the supraspinatus and infraspinatus muscles. Two of the electromyograms showed evidence of partial recovery. The preoperative and postoperative Constant scores for these patients were 60.3 and 83.4, respectively (P < .001). All patients returned to their normal work and sports activity at a mean of 3 weeks (range, 2 days to 3 months). The abduction and external rotation strength also significantly improved. At the time of last follow-up, 9 patients graded their clinical outcome as excellent and responded that they had complete relief of pain. One of the study subjects reported a satisfactory result with moderate relief of pain., Conclusions: Arthroscopic release of the SSN can be performed safely and effectively. All of the patients in this preliminary study had improvement in their postoperative electromyographic findings and had marked improvement in pain relief and function., Level of Evidence: Level IV, therapeutic case series.

Purpose: The purpose of this study was to evaluate arthroscopically the frequency and type of instability of the long head of the biceps (LHB) tendon in patients undergoing rotator cuff repair., Methods: In 200 consecutive patients undergoing arthroscopic rotator cuff repair, LHB instability was assessed statically and dynamically in the anteroposterior direction. In addition, macroscopic lesions of the LHB, as well as lesions of the adjacent rotator cuff tendons, were documented., Results: LHB instability (subluxation or dislocation) was found in 45% of patients, with isolated anterior instability in 16%, isolated posterior instability in 19%, and combined anteroposterior instability in 10%. Whereas LHB subluxations were observed in both directions, dislocations were only seen in anterior LHB instability. Anterior instability was more associated with a subscapularis lesion, whereas posterior instability was more associated with a supraspinatus tear. Lesions of the LHB tendon were strongly associated with LHB instability and the size of the rotator cuff tear., Conclusions: In 200 patients with rotator cuff tears LHB instability could be observed arthroscopically in 45%, with 16% being anterior, 19% being posterior, and 10% being anteroposterior. LHB instability was associated with LHB lesions, with 15% of the LHB tendons showing a normal appearance when unstable versus 70% when stable. Preoperative O'Brien and Speed tests did not correlate with intraoperative observed LHB pathology. The size of the rotator cuff tear could be correlated with the grade of LHB lesion, becoming more significant with augmenting tear size. On the basis of these observations, we created a new arthroscopic classification of LHB instability with respect to the direction and extent of LHB instability, lesions of the LHB, and status of the adjacent rotator cuff tendons., Level of Evidence: Level IV, diagnostic study with poor reference standard.

In the chain of reattachment of the rotator cuff, links extend from the tendon to the anchor within the bone. Passage of the suture through the tendon is noted at the start of the chain, but as shown before, this is most vulnerable, depending on the quality of the tendon. We present a new technique of suture placement designed to improve tissue grip: "The lasso-loop stitch." One side of the wire is passed through the edge of the tendon, which is ruptured by the wire in the middle-not at the end. The wire is not pulled through completely. Through this process, a loop is created at the upper side of the tendon. The end of the wire, at the same side used to make the loop, is passed through the loop with a grasp. The wire is passed through the loop, and the end of the wire is brought extra-articularly. Through this technique, the reduction force of a suture is augmented, and a constricting factor is added. We have not changed the location of the anchors. So far, we have used the technique in rotator cuff repair, biceps tenodesis, and the Bankart procedure.

Footprint fixation with a double-row technique is a new concept for arthroscopic capsulolabral reconstruction in anterior shoulder instability. The described double-row fixation technique with 2 suture anchors on the glenoid neck and 3 on the glenoid rim allows healing of the capsulolabral complex to a broader bony surface and not only to the thin glenoid rim as achieved with current techniques. Because the anchor insertion W-shaped form resembles the star constellation of Cassiopeia, this technique is called the Cassiopeia double-row technique. The restoration of the original capsulolabral footprint with the Cassiopeia double-row technique by a stronger fixation should decrease recurrence rates of instability after arthroscopic stabilization but we need longer follow-up and larger numbers of patients to confirm.

Purpose of the Study: Totally arthroscopic repair of rotator cuff tears is now common practice. The techniques used were evaluated by a retrospective multicentric analysis conducted by the French Society of Arthroscopy., Material and Methods: The series was limited to arthroscopic repair of full thickness tears of the supraspinatus or infraspinatus evaluated using the Constant score and arthro-MRI or arthroscan performed with at least one year follow-up. Data were processed with SPSS 10. The series included 576 patients who underwent surgery between January 2001 and June 2003. Mean patient age was 57.7 years; 52% were men and 60% were manual laborers. The mean preoperative Constant score was 46.4 +/- 13.4/100. The tear was limited to the supraspinatus in 69% of shoulders, with extension to the upper third of the infraspinatus in 23.5% and the entire infraspinatus in 7.5%. The supraspinatus tear was distal in 41.7% of shoulders, intermediary in 44% and retracted in 14.3%. Fatty degeneration of the supraspinatus was noted grade 0 in 60%, 1 in 27%, 2 in 11% and 3 in 2%. Arthroscopic repair was performed in all cases, with locoregional anesthesia in 60.9%. Bioresorbable implants were used in 33% and metallic implants in 62.1%. Acromioplasty was performed in 92.7% and capsulotomy in 14.9%., Results: On average, the subjective outcome was scored 8.89/10. The Constant score improved from 46.3 +/- 13.4 to 82.7 +/- 10.3 with 62% having a strictly pain free shoulder. Muscle force improved from 5.8 +/- 3.7 to 13.6 +/- 5.4. Outcome was excellent in 94% of shoulders at 18.5 months mean follow-up. The complication rate in this series was 6.2% with 3.1% prolonged stiffness, 2.7% reflex dystrophy, 0.2% infection, and 0.2% anchor migration. The cuff was considered normal in 55.7% of shoulders with an intratendon addition image in 19%, i.e. 74.7% of non-ruptured cuffs. Minimal loss of integrity was noted in 9.5% and was marked in 15.7%, i.e. 25.2% iterative tears.ANATOMOCLINICAL CORRELATIONS: The Constant score was strongly correlated with rotator cuff integrity (p<0001). This correlation was also found for force (p<0001), motion (0.01) and activity (0.04), but not for pain. The clinical outcome was correlated with extension, retraction, intrasubstance tear, and fatty degeneration of the lesion preoperatively. Anatomic results were statistically less favorable for tears which were older, extensive, retracted or associated with fatty degeneration. Age was correlated with extent of the initial tear and also with less favorable anatomic and clinical outcome. Occupational accidents were correlated with less favorable clinical outcome., Conclusion: Functional improvement after healing is a strong argument for repair. Arthroscopy has the advantage of combining a low complication rate with good clinical and anatomic results. Age is correlated with functional outcome and healing, but is not a contraindication.

This article presents an all-arthroscopic technique for coracoclavicular ligament reconstruction by ligamentoplasty after acute or chronic acromioclavicular joint dislocation. A coracoacromial ligament transfer is done to reconstruct the torn coracoclavicular ligaments, similar to open surgery. The coracoacromial ligament is dissected from the undersurface of the acromion and is reinserted on the inferior clavicle by transosseous suture fixation. Additional wire or screw stabilization may be used. With this method, we achieve a very satisfactory reduction of the dislocated acromioclavicular joint.

Purpose of the Study: The aim of this study was to evaluate the anatomical and technical limits of endoscopic rotator cuff repair. Anatomical results were also compared with functional assessment of the shoulder., Material and Methods: A multicentric serie of 87 patients presenting a full thickness rotator cuff tear repaired endoscopically was retrospectively reviewed at 25.4 months (mean) post surgery. Limits of the surgical technique were studied in correlation with functional results and anatomic radiographic evaluation (arthroscans in 93 p. 100)., Results: Anatomical repair (normal thickness and no contrast in the subacromial space on arthroscan) was achieved in 83 p. 100 of the rotator cuffs with limited damage to the frontal part of the supra spinatus tendon. This percentage fell to 57.8 p. 100 in case of posterior extension of the tear to the supra spinatus tendon and further dropped to 40.8 p. 100 in case of retraction to the apex of the humeral head. Functional outcome evaluated with the Constant score was strongly related to the radiographic cuff condition (p <0.05). For distal and anterior tears of the supra spinatus tendon, the Constant score at revision was 89.8 points in cases with anatomic repair at revision. This score fell to 75 when the rotator cuff tear was evidenced radiographically (p <0.0001). For tears involving the entire supra spinatus tendon repaired by arthroscopy, the functional difference at revision was 8 points on the Constant scale. Objective and subjective analysis of the surgical procedure identified significant peroperative elements predictive of clinical and anatomical outcome (difficult reduction, p <0.05; subjective degree of solidity, p <0.0001; anatomical aspect of the repaired cuff, p <0.05)., Discussion: A comparison of our findings with data on equivalent lesions reported in the literature suggests that endoscopic surgery for rotator cuff tears offers both functional and anatomic results equivalent to those achieved with conventional open surgery. This assumes that the surgical procedure is carried out by surgeons experienced in shoulder arthroscopy who can precisely gauge the posterior/anterior extension of the tears and the limits of the surgical technique.

Summary: To evaluate the reliability of the arthroscopic assessment of full-thickness rotator cuff tears, 117 cases were prospectively investigated by imaging, arthroscopy, and open surgery. The confidence of the surgeon, his accuracy, and the surgeon-dependent character of arthroscopic assessment were evaluated in terms of the description of the main anatomic parameters. The surgeons were confident and accurate in diagnosing a full-thickness tear of the supraspinatus, but they underestimated its coronal and sagittal extent and its reducibility to the greater tuberosity. Conversely, the technique appeared very accurate in describing the rotator interval. Endoscopic assessment was particularly operator-dependent in the anteroposterior analysis of the tear. This study shows the limits of endoscopic assessment of full-thickness rotator cuff tears. It illustrates the need for an adequate arthroscopic technique with a thorough knowledge of normal and pathological anatomy of the rotator cuff.