Operative Techniques in Sports Medicine最新文献

The best treatment approach for massive, irreparable rotator cuff tears is a complex and unsolved clinical problem. There are a variety of surgical options described in the literature and debate on the ideal treatment approach depending on the patient's shoulder pathology, preoperative function, postoperative goals, and medical co-morbidities. The subacromial balloon spacer is an innovative device, recently approved by the US Food and Drug Administration (FDA), that can provide pain relief, reduced operative and postoperative recovery time, and has biomechanical as well as early clinical support for its use. This review will uncover the subacromial balloon spacer technology in a comprehensive fashion. We will evaluate the biomechanical data and mechanism of function, current surgical indications, intraoperative techniques, early patient outcomes, and potential avenues for future utilization.

LHBT tendinopathy is frequently encountered during the treatment of rotator cuff tears. Persistently symptomatic, or structurally abnormal/unstable LHBT may necessitate surgical treatment. Biceps tenotomy remains a viable option. Biceps tenodesis, when appropriate, may be performed through an arthroscopic intra-articular, high-in-the-groove approach, suprapectoral approach, or an open subpectoral approach with data supporting each technique. Biological augmentation of the rotator cuff using the LHBT or anterior cable reconstruction of the LHBT are promising alternative uses for the LHBT to decrease the incidence of large rotator cuff re-tears.

Technical considerations of the rotator cuff repair remain of great importance as retear rates remain high. The double-row (DR) rotator cuff repair was designed to better restore the native enthesis footprint to maximize healing. The DR repair features a medial and lateral row of suture anchors. Anatomical and cadaveric studies have demonstrated improved footprint restoration with DR repair. Biomechanically, the DR repair has a superior load to failure, decreased gap formation under cyclic loading, and greater contact areas and pressures. It is unclear whether the number of sutures per anchor may be more important than the number of rows and the row configuration. Medial row knots and suture tape constructs may improve the biomechanics of the repair, but the impact on clinical outcomes is unknown. High-quality clinical studies have shown that the DR repair in small to medium tears does not yield better clinical outcomes than the single-row (SR) and is not cost-effective. Healing rates seem to improve with the DR repair, and retear rates may be slightly reduced. However, in larger tears, the DR repair demonstrates favorable clinical outcomes with significant increases in functional scores, healing rates, and retear rates compared to SR repair. Although the DR repair has biomechanical advantages to SR constructs, clinical evidence suggests that the double-row repair should be reserved for large to massive tear patterns.

Rotator cuff disease is extremely common, affecting between 6.8% and 22.4% of the population over age 40. Tear prevalence, size, likelihood of progression, and retear rates after surgical repair are all related to increasing age. These data suggest that asymptomatic rotator cuff tears are a process related to aging, and the description of this as a “tear” may be inaccurate. In addition to age, other nonmodifiable variables related to the presence and progression of rotator cuff tears include male sex, family history, and hand dominance. Smoking and certain disease states (diabetes, hypertension, serum lipid disorders) are potentially modifiable influences on rotator cuff disease. The relationship between symptoms and the presence of a rotator cuff tear and the progression of a rotator cuff tear are not robust. As fewer than 95% of people with rotator cuff tears come to surgery, the majority of rotator cuff tears are either asymptomatic or mildly symptomatic. Approximately half of existing rotator cuff tears progress over time. Those that progress more rapidly are more likely to have symptoms as the ability to compensate through teres minor hypertrophy and other adaptive mechanisms are exceeded. Both surgery and nonoperative treatments are effective at treating symptoms in patients with rotator cuff disease, but at this time it is not known which treatment is better for which patients. While some authors recommend repair for younger patients with smaller tears, the data on whether this approach can modify the natural history of rotator cuff disease is lacking.

Repair of the rotator cuff is a common procedure with a relatively high success rate. Failures do occur for a variety of issues, most related to healing and trauma. Neuropathy may also be a cause of failure of repair, more often related to cervical myelopathy or nerve root compression, but also due to compression, traction, or scarring of the suprascapular nerve at either the suprascapular notch or the spinoglenoid notch. In primary cases, the patient presents with weakness out of proportion to the history and physical examination. In revision cases one may observe progressive atrophy with eventual failure of the repair. Early imaging may show edema in the muscle and inflammation around the suprascapular or spinoglenoid notch, with later imaging showing significant atrophy of the muscle of the supraspinatus and/or infrapinatus. Electromyography should demonstrate evidence of nerve compression or inflammation with changes in the muscle consistent with compromise of the nerve. Operative indications include proper diagnosis, and the suprascapular nerve may be decompressed at both the suprascapular notch and spinoglenoid notch.

The optimal approach to the treatment of massive irreparable rotator cuff tears (MIRCTs) continues to be debated among shoulder surgeons. While nonsurgical treatment is a reasonable option for some, many of these patients continue to experience pain, weakness, and overall limited function of the shoulder. Superior capsular reconstruction has become a widely accepted approach to the treatment of MIRCT, however, there exists several technical and biological challenges to this technique. Overcoming many of these difficulties, a recently described technique involves the placement of a biological interpositional graft over the greater tuberosity which acts as a permanent spacer between the humerus and acromion. With the primary goal of providing pain relief, this technique may function to improve the benefit of rehab following MIRCT. In this article, we describe the indications, technique, and early outcomes of this so-called “tuberoplasty” approach to MIRCT.

Rotator cuff tears are a common injury in adults, and many patients will subsequently require surgical repair. While advancements in surgical technique have allowed for excellent time-zero mechanical repair of rotator cuff tears, retears remain a significant issue for patients and surgeons. Biologic adjuvants have been under investigation with the hope of reducing retears by enhancing the healing milieu following mechanical repair. Some of these adjuvants, which include platelet-rich plasma (PRP) products and pluripotent cell populations derived from bone marrow and subacromial bursa tissue can be harvested from the patient and administered intraoperatively. Our aim is to highlight the features of these adjuvants and review how they are implemented, including clinical outcomes when possible. Despite a significant amount of randomized controlled trials, inconsistent characterization of PRP products and lack of standardization regarding the production and implementation of PRP have led to heterogenous studies. Bone marrow aspirate concentrate and subacromial bursa tissue have shown the potential to enhance cellular regeneration but currently lack substantial clinical evidence. While standardization of methods may be impractical due to the numerous options for implementation, more consistent characterization of biologics may expedite progress toward consensus. Newer adjuvants in the setting of rotator cuff repair include exogenous pluripotent cells from human amnion, as well as bio-inductive scaffolds, and conditioned medium. As research on these burgeoning adjuvants grows, efforts to increase transparency through improved reporting and detailed methods may help to push this field forwards.

The subscapularis muscle plays an essential role in full, pain-free shoulder function. Injuries to the subscapularis tendon exist on a spectrum of severity. In the evaluation of the injured and/or painful shoulder, careful scrutiny of the subscapularis tendon on advanced shoulder imaging in all planes facilitates detection of subscapularis pathology. Specific surgical techniques of subscapularis tendon repair, including arthroscopic and open approaches, are tailored to tear size, pattern, retraction, tissue quality and concomitant pathologies. Smaller, upper border tears of the subscapularis tendon may be treated with a single-row repair construct while tears greater than 2cm are typically treated with a double-row repair. Surgical pearls include adequate debridement of the rotator interval, identification of the comma tissue in retracted tears, use of a lateral viewing portal during arthroscopic repair, and gentle decortication of the lesser tuberosity footprint. While unrecognized subscapularis tendon tears is associated with worse clinical outcomes in the setting of multi-tendon tears, further study is needed to identify additional strategies to improve rotator cuff tendon healing following surgical repair.

Massive irreparable rotator cuff tears (MIRCT) is a difficult clinical problem to treat in young, active individuals with minimal arthritis. Tendon transfers allow for donation of muscle units that can power the shoulder and restore kinematics. Posterosuperior rotator cuff deficiency can be treated with either a latissimus dorsi tendon or lower trapezius tendon transfer. The authors preferred method for treating irreparable supraspinatus and infraspinatus tears is with an arthroscopic assisted lower trapezius tendon transfer. The advantage of the lower trapezius tendon is that its vector is directly in line with the infraspinatus tendon allowing for better external rotation and abduction moment arms. The tendon is harvested from the spine of the scapula and augmented with an Achilles tendon allograft for length which is then secured at the footprint of the rotator cuff. Anterosuperior rotator cuff deficiency can be treated with a pectoralis major tendon or anterior latissimus tendon transfer. For subscapularis deficiency, our preferred method is an open versus arthroscopic latissimus tendon transfer. The tendon is harvested in the posterior axilla and augmented with an Achilles tendon allograft at the tendon interface to provide bulk. The tendon is passed arthroscopically to the anterior humerus and secured at the lesser tuberosity. Tendon transfers are a safe, reliable and reproducible technique when treating MIRCTs.