Gary M. Gartsman

The square knot is the gold standard for open surgical knot tying. One criticism of arthroscopic shoulder surgery is that arthroscopic knots are not as secure as square knots tied during traditional open surgery. In this brief technical note, we describe a simple technique for tying arthroscopic square knots that the senior members of our group have been using in clinical practice for several years with successful results.

The sources for this annual update on shoulder and elbow surgery were presentations and symposia at meetings of the American Orthopaedic Society for Sports Medicine (Specialty Day, Dallas, Texas, February 16, 2002), the Arthroscopy Association of North America (Specialty Day, Dallas, Texas, February 16, 2002; Twenty-first Annual Meeting, Seattle, Washington, April 19–22, 2002; and Twentieth Fall Course, San Antonio, Texas, November 29–December 2, 2002), the American Academy of Orthopaedic Surgeons (Sixty-ninth Annual Meeting, Dallas, Texas, February 13–17, 2002), and the American Shoulder and Elbow Surgeons (Specialty Day, Dallas, Texas, February 16, 2002, and Eighteenth Annual Meeting, Napa, California, September 2001). Several studies have employed sophisticated animal models to investigate rotator cuff repair and healing. Coleman reported on a chronic rotator cuff injury and repair model involving sheep. Infraspinatus contractile forces and histological findings were evaluated at various times following either immediate or delayed tendon repair. Longer delays to repair led to greater decreases in force and more modest recovery following repair. Muscle biopsies confirmed progressive fatty infiltration that was partially reversed after tendon repair in the group with a six-week delay before repair but not in the group with an eighteen-week delay before repair. This model has important implications regarding the recovery of strength following the repair of chronic rotator cuff tears. Rodeo presented a study on growth factor-enhanced rotator cuff tendon-bone healing in a sheep model. Histological analysis demonstrated greater new-bone and fibrovascular tissue formation in the treated animals. A substantial increase in attachment strength was noted in the treated animals at twelve weeks. The study demonstrates the ability of a growth factor to influence changes at the tendon-bone interface. MacGilivray evaluated the augmentation of rotator cuff repairs with a bioabsorbable scaffold in a goat model. Biomechanical testing showed no significant improvement in load to failure when a tendon defect was covered with a polylactic acid patch. The inability of the patch to enhance repair strength was thought to result from shielding of the patch from direct load by the repair. Halder used a cadaveric model to identify the characteristics of rotator cuff tears that were responsible for loss of strength. Detachment of one-third and two-thirds of the supraspinatus tendon affected force transmission by the rotator cuff only slightly, while detachment of the whole tendon resulted in greater reductions in force transmission. Simulated muscle retraction also led to reductions in force transmission. Side-to-side repair of defects involving one third and two thirds of the tendon restored near-normal force transmission. These results echoed the clinical observation that patients with small rotator cuff tears may present without a loss of strength. Furthermore, side-to-side repair of otherwise irreparable defects may help to restore the integrity of the rotator cable. Chronic rotator cuff tears are often accompanied by muscle atrophy, fatty infiltration, and retraction, which may decrease overall muscle volume. Apreleva determined the reliability and validity of magnetic resonance imaging in the assessment of rotator cuff muscle volume in a study of cadaveric shoulders. Magnetic resonance imaging scans were made and the supraspinatus, infraspinatus-teres minor, and subscapularis muscle volumes were then computed with use of three-dimensional image-analysis software. Muscle volumes were confirmed with use of water displacement after dissection. The muscle volumes measured with use of the two methods were found to correlate highly, suggesting that magnetic resonance imaging may hold promise for the preoperative assessment of rotator cuff muscles and the prediction of functional outcome following repair. Bonutti presented research on the use of an allograft bone button for rotator cuff repairs.

Summary: Biceps tenodesis is indicated for partial biceps tendon tears or biceps tendon subluxation. We present our technique for arthroscopic biceps tenodesis.

Background:The indications for resurfacing of the glenoid in patients who have osteoarthritis of the shoulder are not clearly defined; some investigators routinely perform hemiarthroplasty whereas others perform total shoulder arthroplasty.Methods:Forty-seven patients (fifty-one shoulders) w

Summary: We present a case and a description of treatment of an anterior dislocation of the shoulder with a greater tuberosity fracture. Both the Bankart lesion and the tuberosity fracture were repaired using arthroscopic techniques.

Summary: Rotator interval tear is one of the lesions identified in patients with glenohumeral instability. We present our technique for arthroscopic repair that eliminates entry into the subacromial space and allows the surgeon to suture the rotator interval under direct intra‐articular vision.

E followed for at least two years (average, thirty months; range, twenty-four to forty months). The shoulders were evaluated with the rating scale of the University of California at Los Angeles, the shoulder index of the American Shoulder and Elbow Surgeons, and the functional rating scale of Constant and Murley. In addition, the patients completed the Short-Form 36 Health Survey (SF-36) preoperatively and at the yearly follow-up evaluations.Eleven tears were small (less than one centimeter in length), forty-five were medium (one to three centimeters), eleven were large (more than three to five centimeters), and six were massive (more than five centimeters). The average length of the tear was twelve millimeters, and the average width was twenty-seven millimeters. Sixty-nine tendons were repaired anatomically, and four were repaired an average of three millimeters (range, two to eight millimeters) medial to the anatomical insertion of the tendon. An average of 2.3 (range, one to four) suture anchors were used in the repair. Sixty-three glenohumeral joints were normal, and ten had an intra-articular lesion. Seven patients had a concomitant resection of the acromioclavicular joint. The average duration of the operation was fifty-six minutes (range, thirty-five to ninety minutes).The active and passive ranges of motion improved significantly after the procedure (p = 0.0001). The strength of resisted elevation improved from 7.5 to 14.0 pounds (3.4 to 6.3 kilograms) (p = 0.0001). The average total score according to the rating scale of the University of California at Los Angeles improved from 12.4 to 31.1 points; the average total score according to the shoulder index of the American Shoulder and Elbow Surgeons, from 30.7 to 87.6 points; and the average absolute score according to the rating system of Constant and Murley, from 41.7 to 83.6 points (p = 0.0001 for all comparisons). The average score for the pain component of the rating scale of the University of California at Los Angeles improved from 2.4 to 8.6 points; fifty-seven (78 per cent) of the seventy-three patients rated the relief of pain as good or excellent on the visual-analog scale. The average score for satisfaction improved from 0.4 to 4.6 points; sixty-six patients (90 per cent) rated their satisfaction as good or excellent at the time of the most recent examination. None of the shoulders were rated as good or excellent before the operation, whereas sixty-one (84 per cent) were so rated at the most recent follow-up evaluation after the index procedure. In addition, significant improvements (p = 0.0015) were noted in the scales and summary measures of the SF-36.Arthroscopic repair of full-thickness tears of the rotator cuff produced satisfactory results with regard to traditional orthopaedic criteria as well as with regard to patient-assessed criteria such as satisfaction, pain relief, and general health. The arthroscopic method offers several advantages, including smaller incisions, access to the glenohumeral joint for the inspection and treatment of intra-articular lesions, no need for detachment of the deltoid, and less soft-tissue dissection. However, these advantages must be considered against the technical difficulty of the method, which limits its application to surgeons who are skilled in both open and arthroscopic procedures on the shoulder....

Thirty-three consecutive patients in whom an irreparable tear of the rotator cuff had been treated with operative debridement and subacromial decompression were evaluated both preoperatively and postoperatively with regard to pain, ability to perform activities of daily living, range of moti