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Ishikawa H, Smith KM, Wheelwright JC, Christensen GV, Henninger HB, Tashjian RZ, Chalmers PN. Rotator cuff muscle imbalance associates with shoulder instability direction. J Shoulder Elbow Surg 2023; 32:33-40. [PMID: 35961497 DOI: 10.1016/j.jse.2022.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/07/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although muscle weakness and/or imbalance of the rotator cuff are thought to contribute to the development of shoulder instability, the association between muscular dysfunction and shoulder instability is not completely understood. The purpose of this study was to evaluate rotator cuff and deltoid muscle cross-sectional areas in different types of shoulder instability (anterior, posterior, and multidirectional instability [MDI]) and to determine the associations between muscular imbalance and shoulder instability direction. METHODS Preoperative magnetic resonance images of patients with shoulder instability who subsequently underwent arthroscopic glenohumeral labral repair or capsular plication were evaluated. Shoulder instability was classified into 3 categories by direction: (1) anterior, (2) posterior, and (3) MDI. The rotator cuff (supraspinatus, subscapularis, and infraspinatus + teres minor) and deltoid (anterior and posterior portions, and total) muscle areas were measured on T1 sagittal and axial slices, respectively. The ratios of the subscapularis to infraspinatus + teres minor area and the anterior deltoid to posterior deltoid area were calculated to quantify the transverse force couple imbalance. RESULTS A total of 189 patients were included, where each group consisted of 63 patients. The infraspinatus + teres minor muscle area was smaller than the subscapularis muscle area in the anterior instability group (P = .007). The subscapularis muscle area was smaller than the infraspinatus + teres minor muscle area in the posterior instability and MDI groups (P ≤ .003). The anterior deltoid muscle area was smaller than the posterior deltoid muscle area in all groups (P ≤ .001). The subscapularis-to-infraspinatus + teres minor area ratio in the anterior instability group (1.18 ± 0.40) was higher than that in the posterior instability and MDI groups (0.79 ± 0.31 and 0.93 ± 0.33, respectively; P < .001). There was no difference in the anterior deltoid-to-posterior deltoid area ratio among the 3 groups. CONCLUSION Patients with anterior instability have smaller muscle area of the posterior rotator cuff as compared with the anterior rotator cuff. In contrast, patients with posterior instability and MDI have smaller muscle area of the anterior rotator cuff as compared with the posterior rotator cuff. Thus, the direction of shoulder instability is associated with rotator cuff muscle area.
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Affiliation(s)
- Hiroaki Ishikawa
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA.
| | - Karch M Smith
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - J Cade Wheelwright
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Garrett V Christensen
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Heath B Henninger
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA; Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Robert Z Tashjian
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Peter N Chalmers
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
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Itoigawa Y, Uehara H, Koga A, Morikawa D, Kawasaki T, Shiota Y, Maruyama Y, Ishijima M. Arthroscopic Bankart repair with additional footprint fixation using the double-row technique at the 4 o'clock position anatomically restored the capsulolabral complex and showed good clinical results. Knee Surg Sports Traumatol Arthrosc 2022; 30:3827-3834. [PMID: 35428941 DOI: 10.1007/s00167-022-06974-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 03/29/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE To investigate the clinical outcome and magnetic resonance imaging (MRI) findings after arthroscopic Bankart repair with additional double anchor footprint fixation (DAFF) at the 4 o'clock position, where the native footprint is widest anatomically, for recurrent anterior shoulder instability. METHODS Forty-two patients (mean age 27.0 years) with recurrent anterior shoulder instability and without severe glenoid bone defects underwent arthroscopic Bankart repair with additional DAFF at the 4 o'clock position. Using three standard portals, single-row repair was performed at the 2, 3, and 5 o'clock positions, and DAFF with the suture bridging technique was conducted at the 4 o'clock position. MRI was performed preoperatively and at 6 months postoperatively. Patients with follow-up periods of ≥1 year were included in the present study and clinically evaluated at the final follow-up. The morphology at the 2 and 4 o'clock positions on radial MRI slices was compared between the preoperative and 6-month postoperative scans, and the footprint of the repaired capsulolabral complex at 6 months postoperatively was compared between the 2 and 4 o'clock positions. RESULTS The average follow-up period was 19.5 ± 6.2 months. The rates of dislocation recurrence and positive apprehension test results were 2.4 and 4.8%, respectively. External rotation was restricted by 3.5°. The University of California at Los Angeles and Rowe scores at the final follow-up were 34.5 ± 1.0 points and 97.2 ± 5.7 points, respectively, representing significant improvements over the preoperative scores (p < 0.01). Although the capsulolabral complex at 6 months postoperatively was firmly repaired at both the 2 and 4 o'clock positions compared to its preoperative state, the footprint of the restored capsulolabral complex was wider at the 4 o'clock position than at the 2 o'clock position (p < 0.01). CONCLUSIONS Additional DAFF at the 4 o'clock position improved the glenohumeral stability and function of the shoulder joint. This study suggests that this technique is a reliable and useful treatment for shoulder instability. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Yoshiaki Itoigawa
- Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan.
| | - Hirohisa Uehara
- Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Akihisa Koga
- Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Daichi Morikawa
- Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Takayuki Kawasaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Yuki Shiota
- Department of Orthopaedic Surgery, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Yuichiro Maruyama
- Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Muneaki Ishijima
- Department of Orthopaedic Surgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
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Lacheta L, Dekker TJ, Anderson N, Goldenberg B, Millett PJ. Arthroscopic Knotless, Tensionable All-Suture Anchor Bankart Repair. Arthrosc Tech 2019; 8:e647-e653. [PMID: 31334024 PMCID: PMC6624186 DOI: 10.1016/j.eats.2019.02.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/20/2019] [Indexed: 02/03/2023] Open
Abstract
Surgical management for glenohumeral instability has advanced to provide stronger fixation and to be less invasive. Arthroscopic suture anchor repair has been the gold standard for isolated capsulolabral tears over the years. Despite the ability of the solid suture anchors to handle physiologic load, they can present challenges such as chondral damage due to anchor size and imperfect angulation, osteolysis, anchor breakage, revision drilling, difficulty of revision surgery with accompanied bone loss, and compromised postoperative magnetic resonance imaging quality. Recently, knotless all-suture anchors have been introduced as a technique to overcome these challenges. These anchors lack a rigid component and can be placed in a tunnel of smaller diameter, thereby allowing for maintenance of glenoid bone stock. The purpose of this Technical Note is to describe our preferred surgical technique with a minimally invasive approach for the fixation of capsulolabral tears using a knotless all-suture anchor construct.
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Affiliation(s)
- Lucca Lacheta
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Travis J. Dekker
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,Steadman Clinic, Vail, Colorado, U.S.A
| | - Nicole Anderson
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Peter J. Millett
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,Steadman Clinic, Vail, Colorado, U.S.A.,Address correspondence to Peter J. Millett, M.D., M.Sc., Steadman Philippon Research Institute, The Steadman Clinic, 181 W Meadow Dr, Ste 400, Vail, CO 81657, U.S.A.
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Latarjet procedure using subscapularis split approach offers better rotational endurance than partial tenotomy for anterior shoulder instability. Knee Surg Sports Traumatol Arthrosc 2018; 26:88-93. [PMID: 28258327 DOI: 10.1007/s00167-017-4480-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 02/13/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Latarjet, which is a coracoid bone block procedure, is an effective treatment for anterior shoulder instability with glenoid bone loss. During this reconstructive procedure the subscapularis may be tenotomized or be split to expose the glenoid neck. The aim of this study was to assess the effect of subscapularis management on functional outcomes and internal and external rotation durability and strength. Hypothesis is that the subscapularis split approach will result in better functional results and superior internal rotation strength and endurance. METHODS The study included 48 patients [median age 30 (range 16-69); 42 males, 6 females], who underwent a modified Latarjet procedure for anterior shoulder instability. There were 20 patients in the subscapularis tenotomy group and 28 patients in the subscapularis split group. The groups were compared isokinetically using a computerized dynamometer for internal and external rotation durability and strength. At the latest follow-up, the patients were evaluated with the American Shoulder and Elbow Surgeons (ASES) and ROWE scores for functional outcomes. RESULTS At a median follow-up period of 25 (range 12-73) months after the Latarjet procedure, the internal rotation durability was significantly higher in the split group (p = 0.045). However, a statistically significant difference could not be found for internal and external rotational strengths (n.s.). There was also no significant difference between the final ASES and ROWE scores (n.s.). CONCLUSION Although both approaches offer promising results, the subscapularis split approach appears to provide better internal rotation durability compared to subscapularis tenotomy. Therefore, the subscapularis split approach may be more preferable for the management of the subscapularis muscle during Latarjet procedure. LEVEL OF EVIDENCE Retrospective cohort study, Level III.
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Hill-Sachs Off-track Lesions as Risk Factor for Recurrence of Instability After Arthroscopic Bankart Repair. Arthroscopy 2016; 32:1993-1999. [PMID: 27161511 DOI: 10.1016/j.arthro.2016.03.005] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 02/25/2016] [Accepted: 03/04/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the effect of "off-track" Hill-Sachs lesions, according to the glenoid track concept, as a risk factor for recurrent instability and need for revision surgery after arthroscopic Bankart repair. METHODS We retrospectively reviewed 254 patients with anteroinferior glenohumeral instability who were managed with an arthroscopic stabilization procedure between 2006 and 2013. Preoperative magnetic resonance imaging and/or computed tomography scans were available for 100 of these patients to calculate the glenoid track and the presence of "on-track" or off-track Hill-Sachs lesions. Recurrence of instability was evaluated at a mean follow-up of 22.4 months. RESULTS Of 100 patients whose magnetic resonance imaging and/or computed tomography scans were available, 88 had an on-track Hill-Sachs lesion and 12 had an off-track Hill-Sachs lesion. Revision surgery for recurrent instability was performed in 5 patients (6%) with an on-track Hill-Sachs lesion and in 4 patients (33%) with an off-track Hill-Sachs lesion (odds ratio, 8.3; 95% confidence interval, 1.85-37.26; P = .006). CONCLUSIONS An off-track Hill-Sachs lesion is a significant and important risk factor for recurrence of instability and need for revision surgery after arthroscopic Bankart repair when compared with an on-track Hill-Sachs lesion. LEVEL OF EVIDENCE Level IV, prognostic case series.
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A multicenter study to evaluate subscapularis muscle function using 5:30 o'clock portal for antero-inferior shoulder stabilization. Arch Orthop Trauma Surg 2016; 136:1143-52. [PMID: 27154578 DOI: 10.1007/s00402-016-2467-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The purpose of this study was to compare the outcome after arthroscopic antero-inferior shoulder stabilization with and without using a 5:30 o'clock portal. MATERIALS AND METHODS Sixty-two patients [age (mean ± SD), 28.05 ± 8.25 years] with a mean follow-up of 15.23 ± 5.02 months were included in this study. Thirty-one patients underwent arthroscopic antero-inferior shoulder stabilization using the 5:30 o'clock portal in center A (group I) and were compared to 31 matched patients managed with the 3 o'clock portal in center B (group II). Physical examination, standard shoulder scores, ultrasound assessment and subscapularis strength measurement were used to evaluate postoperative shoulder function. RESULTS Good to excellent results were seen in both groups. No significant differences were seen when comparing ASES, Constant and Rowe Score of both groups. Patients of group II achieved a significant higher score in the SST than patients of group I. (p < 0.05) Patients of group I had a significantly lesser loss of passive external rotation in 0° and 90° of abduction. (p = 0.04; p = 0.056) Ultrasound evaluation and strength measurement showed no significant differences in subscapularis muscle integrity or function neither between the involved and uninvolved shoulder nor between both groups. CONCLUSION Arthroscopic anterior-inferior shoulder stabilization results in excellent clinical results. When considering portal placement, the deep trans-subscapularis portal allows a more precise suture anchor placement at the inferior glenoid rim and capsular shift with a significant improved external rotation but does not negatively affect the subscapularis function in terms of internal rotation strength or structural integrity. LEVEL OF EVIDENCE III.
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