The new subclavian portal and modified Neviaser portal for arthroscopic rotator cuff repair

Treatment of suprascapular nerve entrapment syndrome

Suprascapular nerve entrapment syndrome (SNES) is an often-overlooked etiology of shoulder pain and weakness. Treatment varies depending on the location and etiology of entrapment, which can be described as compressive or traction lesions. In some cases, treating the primary cause of impingement (ie. rotator cuff tear, ganglion cyst, etc.) is sufficient to relieve pressure on the nerve. In other cases where impingement is caused by dynamic microtrauma (as seen in overhead athletes and laborers), treatment is often more conservative. Conservative first-line therapy includes rehabilitation programs, nonsteroidal anti-inflammatory drugs, and lifestyle modification. Physical therapy is targeted at strengthening the rotator cuff muscles, trapezius, levator scapulae, rhomboids, serratus anterior, and deltoid muscle(s). If non-operative treatment fails to relieve suprascapular neuropathy, minimally invasive treatment options exist, such as suprascapular nerve injection, neurostimulation, cryoneurolysis, and pulsed radiofrequency. Multiple treatment modalities are often used synergistically due to variations in shoulder anatomy, physiology, pain response, and pathology as a sole therapeutic option does not seem successful for all cases. Often patients can be treated with non-invasive measures alone; however, injuries refractory to conservative treatment may require either arthroscopic or open surgery, particularly if the patient has an identifiable and reversible cause of nerve compression. Indications for invasive treatment include, but are not limited to, refractory to non-operative treatment, have a space-occupying lesion, or show severe signs and symptoms of muscle atrophy. Open decompression has fallen out of favor due to the advantages inherent in the less invasive arthroscopic approach.

Circumferential rotator cuff repair with the n+4 portal, subclavian portal, and high posteromedial portal

Passing suture during a rotator cuff repair requires proper orientation and purchase of the rotator cuff tendon. Our technique uses a new portal to improve access to the supraspinatus and infraspinatus and uses additional portals for a circumferential repair of the tear, thereby restoring the footprint. Using a penetrating suture passer through the anterior, posterior, and superomedial portals allows 270° of coverage. The lateral anchors complete the circumferential repair. Sutures from the medial anchors are passed in a retrograde fashion using 3 small incisions with no cannula. A spinal needle is used to localize the orientation of each portal. The N+4 portal is the workhorse portal, allowing access to the supraspinatus and infraspinatus. The suture retriever enters the trapezius 5 cm from the medial border of the acromion and 1 cm anterior to the spine of the scapula. It enters the subacromial space on top of the supraspinatus. This provides protection to the suprascapular nerve in the supraspinatus fossa. The cuff is lifted with a grasper to allow perpendicular passage of suture. The suture is retrieved for tying. The tissue purchase and location of suture placement help restore the footprint of the supraspinatus and infraspinatus. Additional sutures are passed anteriorly through the subclavian portal and posteriorly through the high posteromedial portal. The repair is completed with lateral-row anchors as needed.

The global percutaneous shuttling technique tip for arthroscopic rotator cuff repair

Most arthroscopic rotator cuff repairs utilize suture passing devices placed through arthroscopic cannulas. These devices are limited by the size of the passing device where the suture is passed through the tendon. An alternative technique has been used in the senior author’s practice for the past ten years, where sutures are placed through the rotator cuff tendon using percutaneous passing devices. This technique, dubbed the global percutaneous shuttling technique of rotator cuff repair, affords the placement of sutures from nearly any angle and location in the shoulder, and has the potential advantage of larger suture bites through the tendon edge. These advantages may increase the area of tendon available to compress to the rotator cuff footprint and improve tendon healing and outcomes. The aim of this study is to describe the global percutaneous shuttling (GPS) technique and report our results using this method. The GPS technique can be used for any full thickness rotator cuff tear and is particularly useful for massive cuff tears with poor tissue quality. We recently followed up 22 patients with an average follow up of 32 months to validate its usefulness. American Shoulder and Elbow Surgeons scores improved significantly from 37 preoperatively to 90 postoperatively (P<0.0001). This data supports the use of the GPS technique for arthroscopic rotator cuff repair. Further biomechanical studies are currently being performed to assess the improvements in tendon footprint area with this technique.

The low-anterolateral portal for arthroscopic biceps tenodesis: description of technique and cadaveric study

PURPOSE

Arthroscopic biceps tenodesis surgery is an important procedure for the correction of biceps tendonitis or in conjunction with rotator cuff repair with biceps symptoms. Recent trends have developed in placing the biceps tendon lower in the bicipital groove for a tenodesis. However, a more distal biceps tenodesis location is technically challenging when carried out arthroscopically with standard posterior and lateral portals. We aimed to establish the safety of a low-anterolateral portal location for direct access to the lowest aspect of the bicipital groove.

METHODS

An anatomical study design was used to examine portal to neurovascular structural measurements in 23 cadaveric shoulders. These shoulders had undergone low-anterolateral portal placement over the inferior most aspect of the bicipital groove as determined by palpation and direct arthroscopic visualization. No arthroscopic irrigation was performed. Following this, the shoulders underwent open dissection with the cannula in place to evaluate for any potential damage to any portion of the axillary nerve.

RESULTS

All of the resultant portals in this study provided direct access to the inferior most aspect of the bicipital groove, and the dissection revealed that the portal was touching a small distal axillary nerve branch on the undersurface of the anterior deltoid in nearly half of the shoulders.

CONCLUSIONS

The placement of a low-anterolateral portal for arthroscopic biceps tenodesis at the distal bicipital groove does not produce significant neurovascular damage; the portal trajectory comes close to distal anterior branches of the axillary nerve. Given these findings, this portal should be placed bluntly to best protect these underlying neurovascular structures.

Suprascapular nerve block as a method of preemptive pain control in shoulder surgery

The purpose of the study was to evaluate the effect of suprascapular nerve block (SSNB) in shoulder surgery. The study group consisted of 260 patients, which were subjected to shoulder operations. The patients were divided into two equal groups: group I with nerve block compared to a control group II without a nerve block. The mean age of the patients in group I was 56.2 +/- 6.86 years and that in group II was 54.5 +/- 7.06 years. The female to male ratio was 71:59 in group I and was 69:61 in group II. Surgical procedures were arthroscopic rotator cuff repair, arthroscopic subacromial decompression, arthroscopic acromioclavicular resection, arthroscopic removal of calcific tendonitis, arthroscopic reconstruction of instability, arthroscopic capsular release and shoulder replacement. In all cases the pain was documented by the visual analogue scale (VAS) preoperative, at the first, the second as well as at the third day after surgery. In order to evaluate the amount of fluid, which is needed for infiltration of the area of the supraspinatus fossa, we injected different amount of local anesthetic in combination with contrast dye in five patients. In this study to document the fluid distribution, after injecting with different milliliters, 10 ml is proved to be more than enough to have sufficient local anesthetic to block the SSN. Pre-operatively the mean VAS was comparable between both groups. We documented a significant difference in favour of SSNB from day 1 to day 3 after surgery. No specific complications due to this nerve block procedure were found in any patient post-operatively.

Arthroscopic biceps tenodesis incorporated into rotator cuff repair using suture anchors

A simple and effective technique is described for incorporating arthroscopic biceps tenodesis into arthroscopic suture anchor rotator cuff repair.

Arthroscopic rotator cuff repair with double-row fixation

BACKGROUND

The treatment of rotator cuff tears has evolved from open surgical repairs to complete arthroscopic repairs over the past two decades. In this study, we reviewed the results of arthroscopic rotator cuff repairs with the so-called double-row, or footprint, reconstruction technique.

METHODS

Between 1998 and 2002, 264 patients underwent an arthroscopic rotator cuff repair with double-row fixation. The average age at the time of the operation was fifty-nine years. Two hundred and thirty-eight patients (242 shoulders) were available for follow-up; 210 were evaluated with a full clinical examination and thirty-two, with a questionnaire only. Preoperative and postoperative examinations consisted of determination of a Constant score and a visual analogue score for pain as well as a full physical examination of the shoulder. Ultrasonography was done at a minimum of twelve months postoperatively to assess the integrity of the cuff.

RESULTS

The average score for pain improved from 7.4 points (range, 3 to 10 points) preoperatively to 0.7 point (range, 0 to 3 points) postoperatively. The subjective outcome was excellent or good in 220 (90.9%) of the 242 shoulders. The average increase in the Constant score after the operation was 25.4 points (range, 0 to 57 points). Ultrasonography demonstrated an intact rotator cuff in 83% (174) of the shoulders overall, 47% (fifteen) of the thirty-two with a repair of a massive tear, 78% (thirty-two) of the forty-one with a repair of a large tear, 93% (113) of the 121 with a repair of a medium tear, and 88% (fourteen) of the sixteen with a repair of a small tear. Strength and active elevation increased significantly more in the group with an intact repair at the time of follow-up than in the group with a failed repair; however, there was no difference in the pain scores.

CONCLUSIONS

Arthroscopic rotator cuff repair with double-row fixation can achieve a high percentage of excellent subjective and objective results. Integrity of the repair can be expected in the majority of shoulders treated for a large, medium, or small tear, and the strength and range of motion provided by an intact repair are significantly better than those following a failed repair.

LEVEL OF EVIDENCE

Therapeutic Level IV.

The superior-medial shoulder arthroscopy portal is safe

PURPOSE

The superior-medial (SM) shoulder arthroscopic portal (Neviaser portal) is the portal anatomically closest to the suprascapular nerve, and any potential benefits of this portal would be mitigated if risk of suprascapular nerve injury were significant. The purpose of this study is to determine the safety of the SM arthroscopic shoulder portal. We hypothesize that the SM shoulder arthroscopic portal is safe.

METHODS

Twelve fresh cadaveric shoulders were securely positioned to simulate shoulder arthroscopy in the beach-chair position with the arm at the patient's side in neutral rotation. An SM portal was established 1 cm medial to the acromion and 1 cm posterior to the clavicle, and a 5.5-mm burr sheath was oriented toward the acromioclavicular joint. The skin and trapezius were resected, the supraspinatus was retracted, and the suprascapular nerve was identified. The distance between the sheath and the nerve was measured by 2 independent observers with calipers. A safe distance was defined as 10 mm.

RESULTS

The measured distances between the nerve and burr ranged from 18.5 to 35.7 mm, with a mean of 24.2 +/- 5 mm. The distance is significantly greater than the safe distance of 10 mm (P < .0001).

CONCLUSIONS

This study shows that the SM portal is safe. The distance between an instrument oriented toward the acromioclavicular joint via the SM portal and the suprascapular nerve was 18.5 mm or greater in all specimens.

CLINICAL RELEVANCE

Our study has clinical relevance because the SM portal is useful for arthroscopic rotator cuff repair, arthroscopic superior labrum repair, and arthroscopic distal clavicle excision.

Single-portal SLAP lesion repair

SLAP lesions are increasingly being recognized as a common cause of shoulder pain. Because an intact superior labral complex is required for peak performance of the shoulder, it is critical that all arthroscopic surgeons are able to recognize and repair these injuries. The most common method of repair involves at least 2 additional portals. The area of repair can become quite crowded, and the method can be challenging at times. A simple and highly reproducible technique is described. This technique requires only an anterior portal for suture management and no special instrumentation. A 5-mm anterior portal is established along with a standard posterior portal. A spinal needle is inserted from the anterior-lateral aspect of the acromion to identify the most desirable location for the suture anchor. After placement of the suture anchor, a second spinal needle is placed in the area of the subclavian portal. This needle is passed through the base of the biceps origin. PDS suture (Ethicon, Somerville, NJ) is placed through the needle and captured with a standard grasper. Before the needle is removed, a loop grasper or crochet hook is used to locate the needle. This prevents the suture from getting caught in hypertrophic tissue. A standard switching technique is then performed, and both sutures are brought out of the anterior portal and tied. This technique is simple and reproducible and requires no special instrumentation.

The accessory posteromedial portal revisited: utility for arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair is a technically challenging procedure. Accessory arthroscopic portals have been described that allow for optimal suture anchor placement, suture management, and knot tying. We describe here the usefulness of an accessory posteromedial portal that facilitates direct suture retrieval through the posterior aspect of a rotator cuff tear. This portal is created approximately 4 to 5 cm medial to the posterolateral corner of the acromion and 2 cm inferior to the scapular spine. The accessory posteromedial portal is especially useful when a retracted tear of the infraspinatus or teres minor is encountered. Because these tendons retract in a posterior and medial direction, the accessory posteromedial portal places the tendon-penetrating device in an ideal position for suture passage through the posterior portion of the rotator cuff tear. This portal also allows placement of margin convergence sutures for large U-shaped or L-shaped tears by permitting a direct "hand-off" of the suture to or from a second penetrating device that is placed through a standard anterior portal. If multiple suture anchors are required (as in the case of large or massive cuff tears, or when double-row fixation is employed), sutures can be pulled out through the accessory posteromedial portal to facilitate suture management.

Arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair is being performed by an increasing number of orthopaedic surgeons. The principles, techniques, and instrumentation have evolved to the extent that all patterns and sizes of rotator cuff tear, including massive tears, can now be repaired arthroscopically. Achieving a biomechanically stable construct is critical to biologic healing. The ideal repair construct must optimize suture-to-bone fixation, suture-to-tendon fixation, abrasion resistance of suture, suture strength, knot security, loop security, and restoration of the anatomic rotator cuff footprint (the surface area of bone to which the cuff tendons attach). By achieving optimized repair constructs, experienced arthroscopic surgeons are reporting results equal to those of open rotator cuff repair. As surgeons' arthroscopic skill levels increase through attendance at surgical skills courses and greater experience gained in the operating room, there will be an increasing trend toward arthroscopic repair of most rotator cuff pathology.

Suprascapular nerve block for shoulder arthroscopy

The suprascapular nerve (SSN) originates from the C5 and C6 nerve roots and provides sensation for the posterior shoulder capsule, acromioclavicular joint, subacromial bursa, and coracoclavicular ligament. Blocking it provides pre-emptive anesthesia, decreased intraoperative pain, and postoperative pain relief in shoulder arthroscopy. Under general anesthesia, 25 mL of 0.5% bupivacaine is injected by a spinal needle placed 1 cm medial to the convergence of the spine and clavicle, angling toward the coracoid. At a depth of 3 to 4 cm, the needle strikes the scapula body. The surgeon probes with the needle anteriorly until the scapula is no longer felt, then moves the needle back posteriorly until the bone is felt again. This places the needle at the coracoid base in the supraspinatus fossa where the SSN curves around the coracoid and heads to the glenohumeral joint. At this point, the anesthetic is injected, "flooding" the SSN location. In addition to the SSN block, other pain-control procedures should be performed, including bupivacaine injection of all portals and an intra-articular injection of morphine sulfate at the end of the procedure. The SSN block is an effective technique and can reduce postoperative medication needs and allow earlier patient discharge from the surgery center.

Arthroscopic biceps tenodesis using suture anchors through the subclavian portal

Biceps tenodesis is typically performed through an open anterior incision. Even when an arthroscopic rotator cuff repair is performed, an open procedure is typically performed to address the biceps rupture or subluxation. Recently, there has been great interest in performing this procedure arthroscopically. Techniques have included using an interference screw or 2 suture anchors through an anterior cannula. If the biceps is partially ruptured or subluxated and the proximal end is still visible in the joint, a biceps tenodesis can be performed using standard arthroscopic techniques and suture anchors. The senior author (K.D.N.) developed the subclavian portal in 1997 for arthroscopic repair of rotator cuff tears using a pointed suture grasper. This portal is located 1 to 2 cm medial to the acromioclavicular joint line, directly above and slightly medial to the coracoid. It provides an optimal angle for suture anchor placement directly through the anterior supraspinatus or coracohumeral ligament and into the humeral head at the edge of the articular cartilage. Anchors inserted through the subclavian portal reproduce the 45 degrees Deadman's angle, which was described for placing anchors during rotator cuff repair. Using a burr or shaver through the lateral portal, the articular and bony surface under the biceps tendon and just proximal to the bicipital groove are abraded. Suture anchors are inserted through the subclavian portal, then through the biceps tendon, and into the bone. Sutures are retrieved and tied through the lateral cannula if there is a tear of the supraspinatus. If the supraspinatus is intact, the sutures can be tied intra-articularly through the anterior cannula. Release of the biceps is not performed until the repair is accomplished, which prevents the tendon from retracting down the bicipital groove. The anatomy of the subclavian portal is reviewed and the technique of the arthroscopic biceps tenodesis is presented. Preliminary results of 11 cases with average follow-up of 24 months are presented. Ninety-one percent of the cases had good/excellent results. Adhesive capsulitis occurred in 1 Workers' Compensation patient, which resulted in a fair outcome.