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The treatment of massive, retracted rotator cuff tears remains a significant challenge to orthopaedic surgeons. While debridement and partial repair has been described as a viable option, surgeons seeking to perform a complete repair often must employ advanced mobilization techniques to lateralize retracted immobile rotator cuff tissue. Tears that appear irreparable often may be effectively mobilized with elements of capsular release, anterior interval slide, or posterior interval slide. When rotator cuff tissue is mobilized to the medial aspect of the anatomic footprint, a low-tension repair can be performed with good clinical outcomes.

Proper patient positioning is a key consideration when performing elbow arthroscopy. The lateral decubitus position for arthroscopic management of a variety of elbow disorders has recently gained popularity among elbow surgeons. There are several advantages of the lateral decubitus position. However, the elbow rests in 90° of flexion with the hand hanging free, and an assistant is required to maintain any adjustment to the elbow’s flexion angle. This article describes how a commercially available low-profile multi-articulated mechanical upper-limb holder may be used as a mechanical forearm holder in conjunction with a classic static arm support to provide stable positioning of the elbow in space during elbow arthroscopy. This technique simply and reproducibly provides an effective means to temporarily or permanently maintain the elbow joint in any desired degree of extension or flexion during elbow arthroscopy without the need for an assistant.

Attempts to restore the anatomical footprint during rotator cuff repair for retracted, relatively immobile tears can be difficult. In some cases, it can lead to excessive tension of the repair. Previous studies have noted improved clinical outcomes when repair tension is not excessive, and medialization of the anatomical footprint has been suggested as a technique that can help surgeons repair large, retracted tears without excessive tension and achieve improved clinical outcomes. Of note, excessive tension when restoring the rotator cuff tendon to the anatomical footprint is not limited to large, retracted tears. In some cases, restoring small- and medium-sized tears to the anatomical footprint also can lead to excessive tension. Therefore, it is not uncommon for the authors to employ some degree of footprint medialization even for repair of small- or medium-sized tears if repair to the anatomical footprint will lead to excess tension. The purpose of this article and video demonstration is to provide instruction for a reproducible rotator cuff technique using a medialized single-row rip-stop construct combined with convergence.

Adequate arthroscopic visualization in the subacromial space is a necessity to appropriately characterize rotator cuff tears and to subsequently develop a suture construct that best reduces the cuff tear with the least tissue tension possible for optimal healing. The purpose of this article and corresponding video is to demonstrate a technique for carrying out a limited deltoid fasciectomy, resulting in enhanced visualization of the rotator cuff through the lateral viewing portal.

Glenoid articular cartilage lesions are a source of shoulder pain and can occur in the setting of glenohumeral instability and degenerative shoulder disease. Glenolabral articular disruption lesions have been reported to be associated with worse outcomes after arthroscopic repair of labral tears. There are relatively few published studies evaluating outcomes after surgical treatment of glenoid articular lesions; however, it is generally accepted that management should consist of restoring the glenoid articular surface, minimizing exposed articular defect, and re-establishing capsulolabral integrity to achieve stability. We present arthroscopic strategies to manage these glenoid articular defects through debridement, abrasion, microfracture, capsulolabral advancement and labral interposition.

The hourglass biceps is a condition in which the intra-articular portion of the biceps tendon becomes inflamed and hypertrophies relative to the remaining tendon. This condition can be seen in association with rotator cuff and labral pathology and may lead to anterior shoulder pain. Diagnosis requires careful visualization and inspection of the biceps tendon during shoulder arthroscopy, as the presentation may be subtle. Surgical treatment includes tenotomy or tenodesis, depending on patient factors and surgeon preference.

Os acromiale is a relatively common anatomic variant that can occasionally be associated with shoulder pain. Several surgical options to address a symptomatic os acromiale that has failed nonoperative treatment have been described. Published techniques, however, are often very invasive, technically challenging, and carry the risk of potential complications that can be difficult to manage. The technique presented here describes a relatively simple arthroscopic alternative, coined by the authors as the “Wallow technique” due to the fact that the arthroscopic shaver is used to rotate within and resect the os site, that results in complete resection of the os acromiale pseudoarthrosis and avoids the need for an open approach or the use of implants.

Displaced greater tuberosity fractures of the humerus require anatomic reduction with stable fixation to optimize rotator cuff function and prevent subacromial impingement. A wide variety of surgical approaches and fixation constructs have been reported, largely with favorable results. Arthroscopic management of these fractures allows excellent visualization with strong suture anchor fixation while minimizing soft tissue disruption, blood loss, and radiation exposure. The purpose of this article is to describe an arthroscopic technique for reduction and suture-anchor fixation of displaced greater tuberosity fractures.

Purpose: To determine the significance of initial and residual rotator cuff tear defect size on the need for revision surgery or additional nonsurgical therapy, in a consecutive group of patients undergoing partial repair of massive rotator cuff tears. Methods: A retrospective chart review was carried out for all arthroscopic rotator cuff repairs performed by a single surgeon between January of 2013 and December of 2016. All patients with massive rotator cuff tears (>30 cm2) who underwent partial repair were included in the study. Outcomes for the surgical procedure were measured based on the necessity for revision surgery or adjunct therapy, including steroid injections or additional physical therapy after initial release from care. Results: In total, 1954 patients who underwent arthroscopic rotator cuff repair were identified. Thirty-eight of these met the inclusion criteria. Those patients undergoing revision surgery represented 5.2% (2/38) of the series and had an average initial/residual tear defect area of 45.0/7.0 cm2. Patients requiring adjunct therapy represented 7.9% (3/38) of the series and possessed an average initial/residual tear defect size of 40.0/16.0 cm2. The remaining 33 (86.9%) patients did not require revision surgery or adjunct therapy at a minimum follow-up of 2 years. There was no significance between initial and/or residual rotator cuff tear defect size and the need for revision surgery. However, there was a significant difference in the mean residual defect size in the patients requiring additional nonoperative treatment after initial release from care (P = .012). Conclusions: There was no relationship between residual defect size after partial repair and the need for revision surgery. Patients who returned for additional nonoperative treatment after being released from care were noted to have a statistically larger residual defect size at the time of index surgical intervention. Only 5% of patients underwent subsequent surgery at an average of more than 4 years’ follow-up, suggesting that partial repair of massive rotator cuff tears can provide a durable, joint-preserving intervention. Level of Evidence: Level IV, Therapeutic Case Series

Identifying and repairing subscapularis tears can be challenging for the arthroscopic surgeon and is commonly related to the difficulty in accurately recognizing the distorted anatomy that may be encountered. Defining and differentiating this anterior glenohumeral joint anatomy are often made even more challenging in clinical situations in which large, retracted subscapularis and anterosuperior tears are present. Identifying the “comma tissue” during the initial arthroscopic assessment is very helpful because it provides an important anatomic landmark that not only serves to orient the surgeon but also facilitates reduction and repair of these tears. Identification of the comma tissue is sometimes a critical surgical step in subscapularis repair, and we provide tips and techniques that can aid the surgeon in reliably and reproducibly recognizing and incorporating the comma tissue.

Reconstruction of the superior capsule is a valuable intervention for some patients in whom massive, irreparable posterosuperior rotator cuff tears are identified. Superior capsular reconstruction techniques most commonly use either tensor fascia lata autograft or dermal allograft. As an alternative to more traditional superior capsular reconstruction, we commonly transpose and incorporate the biceps tendon into the rotator cuff repair construct in such patients instead. This biological superior capsular reconstruction biceps transposition technique (”bio-SCR”), described herein, provides increased structural integrity and supplemental tendon graft using viable cells while potentially serving the role of the superior capsule. As such, transposition of the biceps tendon may offer unique and significant advantages over other techniques and can be an effective and valuable alternative in appropriate cases.

As a result of the continued improvement in arthroscopic equipment and techniques, subscapularis tears are now more reliably identified and are being repaired at higher rates than previously reported. Whereas small upper-border subscapularis tears can usually be effectively managed using an intra-articular view, larger tears often cannot be fully visualized with a standard 30° arthroscope when viewed from the posterior portal. These tears may require either using a 70° arthroscope or viewing through the standard 30° arthroscope from a subacromial portal-site location to completely visualize the tear. This article illustrates and discusses the advantages of using a subacromial-space portal site to view and arthroscopically manage large subscapularis tears.

Osteochondritis dissecans of the capitellum is an overuse injury that occurs primarily in adolescent athletes that causes pain and motion loss and can lead to chronic dysfunction. When diagnosed in its early stages, most lesions can be treated conservatively and without long-term consequences. Many osteochondritis dissecans lesions, however, continue to cause progressive symptoms despite nonoperative measures or are too advanced at the time of initial clinical presentation to be effectively treated without surgical intervention. The authors describe a safe and reproducible technique for the arthroscopic treatment of unstable, contained capitellar lesions.

Arthroscopic elbow surgery can be difficult due to the highly congruent nature of the joint and the surrounding neurovascular and ligamentous structures at risk. In a patient with valgus extension overload, posterior medial olecranon osteophytes must be removed safely to restore range of motion and alleviate pain. Arthroscopic burrs and shavers create significant debris, therefore limiting visualization, and their use has inherent risks to the surrounding structures that need to be preserved. Small, handheld osteotomes can facilitate the safe and efficient removal of these posterior medial osteophytes while preserving normal bone and articular cartilage.

The indications and best technique for plication of the rotator interval capsule, performed as a supplemental procedure at the time of arthroscopic shoulder stabilization, remain a controversial topic. There are currently no well-accepted surgical indication guidelines that have been established. Several biomechanical studies, however, have demonstrated the important contribution of the rotator interval capsule to stability of the glenohumeral joint, and the utilization of rotator interval plication in patients with glenohumeral instability has been supported in several publications. The indications for and surgical steps to accomplish the arthroscopic “seamster” technique for rotator interval plication, used by the authors for >20 years, is described.

Identifying and mobilizing rotator cuff tissue during arthroscopic revision rotator cuff repair can be challenging. A particularly complex situation is encountered when rotator cuff tendons become adhered to surrounding bony structures. Tendon adherence to the undersurface of the acromion may occur after rotator cuff repair, especially when concurrent acromioplasty was carried out during the index procedure. This adhered and retracted rotator cuff tissue may be difficult to both recognize and mobilize, once identified, arthroscopically. The authors present a technique that can aid in both identifying and lateralizing this adhered rotator cuff tissue within the subacromial space.

Partial-thickness rotator cuff tears are among the most common challenges faced by orthopaedic surgeons today. The ability to adequately manage these injuries depends on identifying their full extent during arthroscopic evaluation. There are many ways to fully visualize these tears, including arm positioning and gentle debridement. The purpose of this article is to highlight several tips and techniques to enable full visualization of partial-thickness rotator cuff tears to determine appropriate treatment.

The formation of heterotopic ossification around the shoulder is a rare but potentially debilitating condition. It is found most commonly around the hip and is usually associated with an inciting event such as trauma, burn, previous surgery, or traumatic brain/spinal cord injury. The formation of shoulder heterotopic ossification following arthroscopic surgery is very uncommon, with few data pertaining to it in the current literature. Formation of heterotopic ossification in the shoulder after arthroscopic surgery typically occurs around the acromioclavicular joint and in the subacromial space. This location may lead to chronic pain and decreased mobility. The purpose of this article is to describe an arthroscopic technique for excision of heterotopic ossification.

Management of rotator cuff defects that are created in the process of excising calcific deposits for patients undergoing surgical intervention for symptomatic calcific tendinitis is not well defined. Such defects can vary considerably in depth, size, and location, and surgical treatment of these rotator cuff lesions depends on a number of factors. Accurately identifying the location and extent of these calcific deposits is important in ensuring their complete removal, and techniques designed to consistently localize these calcific deposits are also described.

Paralabral cysts are an increasingly recognized cause of suprascapular nerve (SSN) impingement, often causing insidious weakness in the rotator cuff. Compression at the suprascapular notch is often due to the presence of a SLAP tear and leads to pain, weakness, and atrophy of both the supraspinatus and infraspinatus muscles. Compression of the SSN at the spinoglenoid notch leads to weakness and atrophy of the infraspinatus only. Arthroscopic decompression of cysts with repair of labral pathology is typically performed in a sublabral fashion, which may make visualization of the extent of the cyst difficult and places the SSN at increased risk. With any approach, an intimate knowledge of the anatomy of the SSN is vital to safe decompression. We present a surgical technique for decompression of paralabral cysts using an intra-articular transcapsular approach. This approach maximizes visualization and efficiency and reduces possible damage to the SSN.

Elbow stiffness occurs as a consequence of multifactorial etiologies and can be broadly classified into either extra-articular or intra-articular contracture. Although nonoperative treatment regimens may prove successful, recalcitrant cases may require operative management. Both open and arthroscopic procedures to address these contractures have been described. Open techniques have historically been the mainstay of surgical management prior to the advent and advancement of arthroscopy. Although often successful, open elbow contracture release introduces added iatrogenic insult to the soft tissue envelope and has the potential to compromise the intraoperatively obtained gains in motion. Arthroscopic contracture release, although not without its own inherent risks, has been shown to be an effective intervention for the release of elbow capsular contractures. Arthroscopic release of the elbow capsule can be challenging, however, because of its thickness and proximity to vital neurovascular structures. The authors describe an adjunctive technique for effectively and efficiently releasing the anterior and posterior capsule under arthroscopic visualization using a 4.5-mm large metal trocar.

Arthroscopic elbow surgery is a challenging procedure in part because of the limited intra-articular volume of the joint, the congruence of the elbow articulation, and the close proximity of the neurovascular structures. Arthritic conditions that result in the development of bony prominences and osteophytes are usually amenable to arthroscopic management and include diagnoses such as osteoarthritis, rheumatoid arthritis, and valgus extension overload syndrome. Safe and efficient removal of these osteophytes can be problematic, however, because of technical difficulties often encountered while using arthroscopic burrs and shavers as well as the risks of inadvertent, iatrogenic injury to adjacent articular cartilage and other structures. A valuable and effective technique using small handheld osteotomes to facilitate the arthroscopic removal of intra-articular osteophytes and other bony prominences is described and shown.

Combined lesions of the glenoid labrum are a relatively common finding in shoulder instability patients. Even so, relatively few studies have been published evaluating outcomes after repair of these complex labral detachments. To achieve a successful outcome, accurate identification of all pathologic lesions in the shoulder combined with an organized, stepwise approach to sometimes circumferential labral fixation is required. Repair of 360° labral tears can be effectively and efficiently achieved by implementing the reproducible steps and sequence described to reconstruct these circumferential labral tears.

Locked posterior shoulder dislocations occur relatively uncommonly but pose aunique array of challenges for the treating surgeon. Posterior labral detachments and capsular damage along with reverse Hill-Sachs lesions are commonly present in these patients and must often be addressed at the time of surgical intervention. Multiple open and arthroscopic procedures that address these pathologic lesions have been described. Arthroscopic shoulder stabilization for patients with locked posterior shoulder dislocations for whom significant posterior instability and subluxation persist following closed reduction is described. A specific patient who underwent both arthroscopic posterior stabilization and supplemental advancement of the subscapularis into the reverse Hill-Sachs defect serves as a case example of this technique.

Rotator cuff tears are extremely common in the adult population, and medial transtendinous rotator cuff tears, although rare, have recently been reported in the literature. These tears are almost always traumatic, which is a common indication for surgical management. It is necessary to consider these tears as a distinct subset when planning for rotator cuff repair because traditional repair techniques would overtension the tendon, increasing the risk for failure of the repair. The objective of this Technical Note is to describe an arthroscopic repair technique for these tears that avoids overtensioning the rotator cuff while still using repair techniques that are familiar to the arthroscopic shoulder surgeon.

The “floating” posterior inferior glenohumeral ligament (floating PIGHL) is an uncommon cause of posterior shoulder instability. This pathologic lesion, defined as detachment of both the origin of the PIGHL (posterior Bankart lesion) and insertion of the of the PIGHL from its humeral head insertion site, often results in significant and persistent shoulder instability symptoms. An effective surgical technique for arthroscopic repair of a floating PIGHL lesion is described and demonstrated.

Posterior shoulder instability occurs less often than anterior shoulder instability but is increasingly recognized as a relatively common condition. The reverse Hill-Sachs lesion is present in some patients with posterior instability and is best described as an impaction fracture of the anterior humeral head. These reverse Hill-Sachs lesions can predispose the patient to recurrent instability events and may need to be addressed directly at the time of surgery. Multiple open and arthroscopic procedures have been described to transfer bone or soft tissue structures into this reverse Hill-Sachs defect. An arthroscopic technique for the transfer of the subscapularis tendon into the defect using a standard 30° arthroscope, standard portals, and suture anchors is described.

Pathologic changes to the biceps tendon including subluxation are frequently encountered in patients with subscapularis tears. Operatively managing these combined lesions can be difficult depending on the status of the subscapularis tendon and the degree of biceps medialization. The presented technique is an effective and relatively simple method that simultaneously and efficiently provides for secure tenodesis of the biceps and fixation of subscapularis tendon detachment.

Rotator cuff repair depends on both the fixation strength of the chosen repair construct and the local healing response of the repaired tissue. Among a growing discussion surrounding the superiority of one surgical technique over another, the surgeon's ability to complete a rotator cuff repair with technical acuity in a timely manner remains paramount. Double-row repairs as well as rip-stop configurations have been proposed to limit failures found after arthroscopic rotator cuff repairs. Implementation of both techniques during arthroscopic shoulder surgery may represent a technical challenge for the average orthopaedist. The purpose of this article is to give simple instructions for reproduction of an arthroscopic double-row rip-stop repair for rotator cuff fixation.

Proximal biceps tendon pathology is a common source of shoulder symptoms. Thus, visualization of the entire extent of the biceps tendon is often required for both diagnostic and therapeutic purposes. Accurately recognizing the presence and extent of biceps pathology intraoperatively is made more difficult, however, due to the extra-articular location of a significant portion of the biceps tendon as it courses within the bicipital groove. Unfortunately, identification of the biceps groove in the subacromial space is often challenging due to the lack of visual and tactile landmarks. A technique that facilitates efficient and reliable bicipital groove identification and biceps tendon visualization along its entire course within the groove is presented.

Patients with rotator cuff tears may present with or subsequently develop concomitant shoulder stiffness. The treatment of rotator cuff tears in the face of passive glenohumeral motion loss is controversial. Preoperative shoulder stiffness has been considered by some a contraindication to rotator cuff repair. Some surgeons recommend staging surgical procedures and delaying rotator cuff repair until shoulder stiffness has resolved. However, this can lead to prolonged recovery times and patient dissatisfaction. We describe a surgical technique that allows for the single-stage arthroscopic management of rotator cuff tears with associated adhesive capsulitis. Arthroscopic capsular release and shoulder manipulation are performed in the same operative setting as arthroscopic rotator cuff repair. We have found that this combined, single-stage arthroscopic approach can effectively treat patients with rotator cuff tears and concomitant shoulder stiffness.

Most patients diagnosed with lateral epicondylitis respond well to conservative management. For patients who do not respond to nonoperative modalities, surgical treatment represents a viable option for long-term symptomatic relief. The arthroscopic surgical technique described in this article has been consistently used by the senior author for the treatment of recalcitrant lateral epicondylitis for more than 5 years (198 patients) without the occurrence of any major complications and appears to be a safe, reliable, and efficacious surgical intervention for the management of lateral epicondylitis.