Outcomes of combined arthroscopic rotator cuff and labral repair

Outcomes of Concomitant Glenohumeral Stabilization After Arthroscopic Rotator Cuff Repair in Military Patients Younger Than 40 Years

Background

While concomitant rotator cuff and inferior labral tears are relatively uncommon in young civilians, military populations represent a unique opportunity to study this injury pattern.

Purpose

To (1) evaluate the long-term outcomes after combined arthroscopic rotator cuff and inferior labral repair in military patients <40 years and (2) compare functional outcomes with those after isolated arthroscopic rotator cuff repair.

Study Design

Cohort study; Level of evidence, 3.

Methods

Military patients who underwent arthroscopic rotator cuff repair between January 2011 and December 2016 and had a minimum of 5-year follow-up data were included in this study. The patients were categorized into those who had undergone combined arthroscopic rotator cuff and inferior labral repair (RCIL cohort) and those who had isolated arthroscopic rotator cuff repair (ARCR cohort). Pre- and postoperative outcome measures-visual analog scale for pain, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons shoulder score, Rowe Instability Score, and range of motion-were compared between the groups.

Results

A total of 50 shoulders (27 in the RCIL cohort and 23 in the ARCR cohort) were assessed. The RCIL and ARCR groups were similar in terms of age (mean, 33.19 years [range, 21-39 years] vs 35.39 years [range, 26-39 years], respectively) and sex (% male, 88.46% vs 82.61%, respectively). All patients were active-duty military at the time of surgery. The mean final follow-up was at 106.93 ± 16.66 months for the RCIL group and 105.70 ± 7.52 months for the ARCR group (P = .75). There were no differences in preoperative outcome scores between groups. Postoperatively, both groups experienced statistically significant improvements in all outcome scores (P < .0001 for all), and there were no significant group differences in any final postoperative outcome measures. At the final follow-up, 26 (96.30%) patients in the RCIL cohort and 20 (86.96%) in the ARCR cohort had returned to unrestricted active-duty military service (P = .3223).

Conclusion

The study findings indicate that concomitant glenohumeral stabilization does not prevent worse outcomes after arthroscopic rotator cuff repair in this military cohort. Combined repair produced statistically and clinically significant improvements in outcome scores at the long-term follow-up, indicating that simultaneous repair of combined lesions was an appropriate treatment option in this patient population.

Patient outcomes and return to play after arthroscopic rotator cuff repair in overhead athletes: a systematic review

BACKGROUND

Rotator cuff tear injuries in overhead athletes are common and may lead to chronic pain and joint disability, impairing sport participation and leading to premature retirement. The improvement of the patient reported outcome measures (PROMs) was evaluated, as were the time and level of return to sport and the rate of complication in overhead athletes who had undergone arthroscopic rotator cuff repair.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. In September 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar and Embase. No time constraints were used for the search. All the clinical trials investigating arthroscopic rotator cuff repair in overhead athletes were accessed.

RESULTS

Data from 20 studies were collected. The mean length of the follow-up was 40 months. All PROMs improved at last follow-up: Kerlan-Jobe Orthopaedic Clinic score (P = 0.02), visual analogue scale (P = 0.003), Constant score (P < 0.0001), University of California Los Angeles Shoulder score (P = 0.006) and American Shoulder and Elbow Surgeons' score (P < 0.0001). Elevation also improved (P = 0.004). No difference was found in external and internal rotation (P = 0.2 and P = 0.3, respectively). In total, 75.4% (522 of 692 of patients) were able to return to play within a mean of 6.4  ±  6.0 months. Of 692 patients, 433 (62.5%) were able to return to sport at pre-injury level. Fourteen out of 138 patients (10.1%) underwent a further reoperation. The overall rate of complications was 7.1% (20 of 280).

CONCLUSION

Arthroscopic reconstruction of the rotator cuff is effective in improving function of the shoulder in overhead athletes, with a rate of return to sport in 75.4% of patients within an average of 6.4 months.

LEVEL OF EVIDENCE

III, systematic review.

TRIAL REGISTRATION

Not applicable.

The Arthroscopic Trillat Procedure Is a Valuable and Durable Treatment Option for Recurrent Anterior Instability Associated With Massive Irreparable Cuff Tears

PURPOSE

The purpose of the present study is to report the mid- and long-term clinical and radiologic outcomes of the arthroscopic Trillat for the treatment of recurrent anterior instability in patients with chronic massive irreparable rotator cuff tears (MIRCTs) and maintained active shoulder motion where reverse shoulder arthroplasty (RSA) is not indicated.

METHODS

Twenty-one consecutive patients (mean age 61 years) were identified and retrospectively reviewed. All patients had recurrent anterior dislocations and conserved active forward elevation and active external rotation. The MIRCTs included a retracted (stage 3) supraspinatus tear in 14%, a supra- and infraspinatus tear in 76.5%, and a 3-tendon tear in 14%. A closed-wedge osteotomy of the coracoid was performed, and the coracoid was fixed above the subscapularis with a cannulated screw (10 cases) or suture buttons (11 cases). We followed patients with x-rays and computed tomography scan at 6 months, along with Subjective Shoulder Value, visual analog scale, Walch, Constant, and Rowe scores. The mean clinical and radiographic follow-up was 58 months (24-145 months).

RESULTS

Overall, 96% (20/21) of the patients had a stable and functional shoulder and were satisfied with the procedure; no patient lost active shoulder motion. The Subjective Shoulder Value increased from 44% (10%-75%) to 94% (80%-100%), P < .001. The Constant and Rowe scores improved from 60 (25-81) to 81 (66-96) and from 54 (35 to 65) to 92 (70-100), respectively (P < .001). Among the 13 patients practicing sports before surgery, 10 (77%) went back to sports. At last follow-up, only 1 patient was revised to RSA.

CONCLUSIONS

The arthroscopic Trillat procedure is a valuable and durable option for the treatment of recurrent anterior dislocations in older patients with chronic MIRCTs and conserved active shoulder motion.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Recurrence of glenohumeral instability in patients with isolated rotator cuff repair after a traumatic shoulder dislocation

INTRODUCTION

The primary objective of this study was to assess the incidence of recurrent glenohumeral instability in patients over 40 years with isolated rotator cuff (RC) repair for traumatic shoulder dislocation. The secondary objectives were to identify risk factors for glenohumeral recurrence after RC repair and to describe the causes and incidences of re-intervention.

MATERIALS AND METHODS

In this retrospective cohort study, data of consecutive patients at a single trauma center between January 2014 and July 2019 were reviewed, and 84 patients with a mean age of 57 (range: 40-75) years and follow-up duration of 3.9 (2-6) years were included. The inclusion criteria were as follows: first traumatic anterior shoulder dislocation, reparable RC tear, primary arthroscopic RC repair, no labral or bony Bankart lesion repair, and at least 2 years of follow-up. Patients less than 40 years of age were excluded. Shoulder instability recurrences and surgical reinterventions were reviewed with medical records. Statistical analysis was performed for qualitative variables using the Chi-squared test. Statistical significance was set at P ≤ 0.05.

RESULTS

There was one patient with a redislocation episode (1.2%) at 2.5 years after surgery, who was surgically treated. Age, subscapular tears, bony Bankart injuries, humeral defects, and associated neurological injuries were not risk factors for recurrence in this study. Ten patients (11.9%) required reintervention. Nine patients (10.7%) re-tore their RCs.

CONCLUSIONS

Recurrent glenohumeral instability in active patients over 40 years with isolated RC repair after traumatic shoulder dislocation was infrequent, despite the incidence of significant Hill-Sachs defects, anterior glenoid defects, bipolar bone defects, size of the RC injury, and tendon re-tears. The incidence of re-interventions was 11.9%, with symptomatic RC retear as the main cause.

Concomitant Glenohumeral Instability and Rotator Cuff Injury: An Epidemiologic and Case-Control Analysis in Military Cadets

INTRODUCTION

Concomitant rotator cuff tear and glenohumeral instability in a large cohort of young and active patients has not been examined. The purpose of this study was to investigate the incidence, associated variables, and outcomes in military cadets undergoing shoulder stabilization procedures with these concomitant pathologies.

METHODS

A retrospective cohort study of a consecutive series of collegiate patients who underwent shoulder stabilization from 2014 to 2018 at a single service academy was conducted. Exclusion criteria were noncadets, revision instability cases, multidirectional instability, and prior rotator cuff repair. A nested case-control analysis was done in a matched series of patients with and without MRI evidence of rotator cuff tear. Baseline demographics, VAS pain scale, physical therapy duration, and time to surgery were analyzed. Postoperative metrics included rate of recurrent instability, subjective outcomes, VAS pain scale, and military-specific criteria.

RESULTS

Three hundred twenty-four cadets met the inclusion criteria, including 272 men and 52 women averaging 20.53 ± 1.80 years of age. MRI demonstrated concomitant rotator cuff tears in 5.56% of cases. A matched case-control comparison between patients with (rotator cuff tear group) and without (no rotator cuff tear group) rotator cuff tear showed no differences in preoperative data, recurrent instability rate, or postoperative VAS pain scores (0.24 versus 0.88, P = 0.207) at mean 44-month follow-up. Fifteen of 17 patients (88.2%) in each group returned to full activity (P > 0.999). No patients failed to graduate due to shoulder concerns. No patients in the rotator cuff tear group underwent a medical board for separation from the military compared with 2 (11.8%) in the no rotator cuff tear group (P = 0.163).

CONCLUSIONS

The incidence of concomitant rotator cuff tears in this study of military cadets undergoing shoulder stabilization was 5.56%. In a matched cohort comparison, the presence of a rotator cuff tear on preoperative MRI was not associated with inferior clinical outcomes.

Outcomes of Simultaneous Arthroscopic Rotator Cuff Repair and Inferior Labral Repair Among Active Patients Younger Than 40 Years

Rotator cuff tears as a consequence of shoulder instability, which are uncommon among patients younger than 40 years, have been found to be more prevalent in active duty service members in this age group. As a result, this population provides a unique opportunity to study concurrent arthroscopic treatment of rotator cuff and inferior labrum tears in young, active patients, a topic that has not been studied extensively. The goal of this study was to report clinical outcomes of rotator cuff and inferior labral tears managed concurrently with all-arthroscopic repair for military patients younger than 40 years. Data were collected prospectively from 30 arthroscopic rotator cuff repair procedures with concurrent inferior labral repair performed on 29 individual military patients younger than 40 years (mean, 33.5 years; range, 21-39 years) and retrospectively analyzed. Preand postoperative evaluations conducted during a minimum 2-year follow-up period (mean, 35 months; range, 24-68 months) included visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder and Elbow Surgeons (ASES) shoulder score, and range of motion. Mean VAS score improved from 7.63±1.85 to 1.00±1.44 (P<.0001). Mean SSV improved from 54.83±17.10 to 90.83±9.75 (P<.0001). Mean ASES shoulder score improved from 45.37±12.99 to 90.43±10.67 (P<.0001). No significant improvement was found in range of motion; however, improved mean measurements were consistently noted in all directions. Complications (10%; 3 of 30) included 1 re-tear of the rotator cuff repair and 2 postoperative frozen shoulders. Arthroscopic repair of rotator cuff tears with concurrent repair of inferior labral tear in active patients younger than 40 years produced excellent patient outcomes, with high rates of return to preoperative level of recreational and military job activity and low risk of complications. [Orthopedics. 2021;44(3):e326-e330.].

Rotator Cuff Repair Improves Clinical Function and Stability in Patients Older Than 50 Years With Anterior Shoulder Dislocations and Massive Rotator Cuff Tears

Background:

Older patients with shoulder instability have a higher prevalence of rotator cuff tears and anterior capsular lesions. Simultaneous rotator cuff repair and labral repair are commonly performed to improve shoulder stability and function.

Purpose:

To investigate the clinical outcomes of arthroscopic rotator cuff repair for older patients with shoulder dislocations combined with massive rotator cuff tears and intact labral tissue.

Study Design:

Case series; Level of evidence, 3.

Methods:

A cohort consisting of 11 patients older than 50 years with shoulder dislocations and massive rotator cuff tears undergoing arthroscopic rotator cuff repair was identified between December 2015 and January 2018. Rotator cuff repair was performed after Bankart, superior labral anterior-posterior, and humeral avulsion of the glenohumeral ligament lesions were excluded during arthroscopic surgery. Preoperative and 12-month postoperative outcomes including modified University of California Los Angeles (UCLA), American Shoulder and Elbow Surgeons (ASES), Western Ontario Shoulder Instability Index (WOSI), and visual analog scale for pain scores as well as range of motion (ROM) were recorded.

Results:

The supraspinatus tendon was torn in all patients. Also, 36.4% of the patients had 3 rotator cuff tendons torn. For shoulder function, the preoperative UCLA score (12.1 ± 2.5 [range, 9-16]) and ASES score (35.4 ± 12.7 [range, 24-44]) significantly improved to 29.4 ± 4.3 (range, 24-35; P < .001) and 79.4 ± 16.0 (range, 45-95; P < .001), respectively, at 12 months postoperatively. None of the patients experienced shoulder redislocations at 12 months after surgery. For shoulder stability, the postoperative WOSI score (156.8 ± 121.0 [range, 45-365]) was significantly better than was the preoperative score (713.0 ± 238.6 [range, 395-1090]) (P < .001). For comparisons between preoperative and postoperative ROM, forward flexion, abduction, and external and internal rotation at the side significantly improved.

Conclusion:

For patients older than 50 years with shoulder dislocations combined with massive rotator cuff tears and an intact labrum, arthroscopic rotator cuff repair alone achieved satisfactory functional outcomes and ROM without the recurrence of dislocations.

Comparing clinical outcomes between rotator cuff repairs, SLAP repairs, and combined repairs

BACKGROUND

Superior labrum lesion from anterior to posterior (SLAP) often presents together with other shoulder pathologies such as rotator cuff tear (RCT), but it is uncertain if repairing both SLAP and RCT has superior clinical outcomes over isolated repairs of SLAP and RCT.

MATERIALS AND METHODS

This was a retrospective cohort study with prospectively collected data, reviewing 157 patients who underwent arthroscopic repair of either RCT, SLAP (type II lesion), or both. Before surgery and after 6 weeks, 12 weeks, and 24 weeks, shoulder objective range of motion and strength were measured, patient-reported function and pain was assessed by the modified L'Insalata questionnaire with a Likert scale, and complications after each repair were examined.

RESULTS

At 24 weeks after surgery, the combined group (n = 22) and SLAP group (n = 47) had significantly higher forward flexion (165° ± 4° and 167° ± 4° vs. 154° ± 3°, P = .01 and P = .01), external rotation strength (82 ± 6 N, 81 ± 6 N vs. 61 ± 3 N, P = .01 and P = .01), and abduction strength (94 ± 14 N, 78 ± 8 N vs. 53 ± 3 N, P = .001 and P = .02) compared with the rotator cuff tear repair (RCR) group (n = 88). The combined group also had stronger internal rotation than the RCR group (107 ± 12 N vs. 72 ± 4 N, P = .02). Function and pain improved from "severe-moderate" to "moderate-mild" in all groups after surgery.

CONCLUSION

Repairing RCT and SLAP tears together results in significant clinical benefits compared to repairing just RCT and analogous results against SLAP-only repair.

Functional outcome and tendon integrity of rotator cuff reconstruction after primary traumatic glenohumeral dislocation

INTRODUCTION

Rotator cuff tears (rct) subsequent to glenohumeral dislocation are relevant concomitant injuries, can lead to impaired shoulder function and increase risk of recurrent dislocation.

AIM

The aim of this study was to determine the functional outcome, recurrent dislocation rate and tendon integrity after rotator cuff repair after primary traumatic shoulder dislocation.

MATERIALS AND METHODS

In this retrospective case series, 23 patients (age 56.4 years ± 6.3) who underwent a rotator cuff reconstruction after primary traumatic shoulder dislocation with confirmed combination of full-thickness RCT and Bankart lesion were enrolled after a minimum follow-up of 2 years. Clinical outcome (age and gender adjusted Constant Murley Score (CMS), DASH, Rowe Score) (n = 23) and sonographic tendon integrity (n = 19) were studied.

RESULTS

After a mean follow-up of 58 ± 32 months, a CMS of 85.1% ± 14.7, DASH of 14.2 ± 20.5, and Rowe Score of 82.4 ± 15.2 indicated good functional outcome. In 4 of 19 patients (21.1%) a re-tear was found during sonographic evaluation. In 3 cases (13%), a revision was performed (2 × stiff shoulder, 1 × postoperative infection). One patient had a single traumatic re-dislocation (4.3%).

CONCLUSIONS

Patients undergone reconstruction of the rotator cuff following a primary traumatic shoulder dislocation can achieve good functional results and a low rate of recurrent dislocation. Postoperative tendon integrity is comparable with known data about non traumatic tears.

Return to Sport After Arthroscopic Rotator Cuff Repair: Is There a Difference Between the Recreational and the Competitive Athlete?

BACKGROUND

Return to sport (RTS) remains an important challenge and measure of success for athletes undergoing arthroscopic rotator cuff repair (RCR).

PURPOSE

To determine the rate of RTS after RCR and to analyze predictive factors associated with a lower rate of return.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The electronic databases of PubMed, MEDLINE, Cochrane, and Google Scholar were used for the literature search. Study quality was evaluated according to the Coleman Methodology Score. Studies in English evaluating RTS after arthroscopic repair of partial- or full-thickness rotator cuff tears among athletes of all levels, ages, and sports were included. Random effects meta-analysis and metaregression were performed to investigate RTS activity rate after arthroscopic RCR and to explore study heterogeneity, respectively.

RESULTS

Fifteen studies were reviewed, including 486 patients (499 shoulders) who were treated with arthroscopic RCR and who had a mean follow-up of 40.1 months (range, 18-74.4 months). Eighteen patients were lost to follow-up, leaving 468 patients with outcome data; 347 identified themselves as athletes (81 competitive, 266 recreational). The most commonly included sports were baseball (n = 45), golf (n = 38), football (n = 23), and tennis (n = 18). RTS specific to the type of athlete was reported for 299 of 347 athletes. According to the meta-analysis, the overall rate of RTS at a similar level of play or higher was 70.2%, with 73.3% of recreational athletes and 61.5% of competitive athletes able to return. A subset of 43 baseball and softball players across 4 studies yielded a 79% rate of RTS; however, only 38% returned to the same level of play or higher. Subgroup meta-analysis revealed no significant difference in the rate of RTS between competitive and recreational athletes. Metaregression analysis revealed that the mean follow-up time and mean age at surgery were not significantly associated with RTS rate.

CONCLUSION

Most athletes (70.2%) were able to return to a preinjury level of play after arthroscopic RCR. While recreational sports participation (73.3%) was associated with higher return, competitive sports (61.5%) and overhead sports (38%) were associated with lower return. Exactly why all athletes do not return remains uncertain and likely multifactorial.

Arthroscopic Circumferential Labral Repair for Patients With Multidirectional Instability: A Comparative Outcome Study

Background:

Circumferential tears of the glenohumeral labrum are an uncommon injury, comprising 2.4% of all labral lesions. Currently, the clinical outcomes of arthroscopic circumferential labral repair for patients with instability and combined anterior, posterior, and superior labral tears are not well-known.

Hypothesis:

Patients treated with arthroscopic circumferential shoulder labral repairs will have inferior clinical outcomes and higher failure rates compared with patients who have isolated arthroscopic anterior labral repairs.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective cohort study was performed to identify patients aged 18 years and older who underwent circumferential arthroscopic stabilization for recurrent instability as compared with an age-matched control group of arthroscopic primary anterior labral repairs. Age at surgery, American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score, Simple Shoulder Test (SST) score, 12-Item Short Form Health Survey (SF-12) score (mental and physical), and overall patient satisfaction with surgery were assessed for each group.

Results:

A total of 35 consecutive patients (36 shoulders) who underwent an arthroscopic 360° circumferential labral repair were compared with a matched group of 31 patients who underwent an isolated arthroscopic anterior labral repair. The mean follow-up period was 34.3 and 56.8 months, respectively. No significant difference was found between the 2 groups for overall satisfaction with the surgery or recurrent instability. At the time of the follow-up survey, 22% of the patients experienced pain and 25% of the patients experienced instability in the circumferential repair group, whereas 15% of the patients experienced some level of pain and 30% of patients experienced a subjective sense of subtle instability in the isolated repair group. The ASES scores were 87.3 in the combined labral repair group and 93.3 in the isolated anterior group (P = .35), SST scores were 10.7 and 11.3 (P = .70), SF-12 mental scores were 54.6 and 56.8 (P = .80), SF-12 physical scores were 53.2 and 54.2 (P = .98), and age at time of the surgery was 26.7 and 24.6 years (P = .33), respectively. There was no difference between the 2 groups in pre- and postoperative range of motion (P > .05).

Conclusion:

There was no difference in shoulder stability and function in patients after 360° combined labral repairs versus anterior labral repair alone. With proper patient selection, patients can expect similar outcomes despite the more extensive surgical procedure and complex postoperative rehabilitation protocol for circumferential repairs.

Comparative Study between Multi-slice Computed Tomographic Arthrography and Arthroscopy in the Evaluation of Rotator Cuff Tears

Objective  To compare the imaging findings of anatomical alterations using multi-slice computed tomographic arthrography in the evaluation of rotator cuff tears in the shoulder, correlating them with the arthroscopy (the gold standard diagnostic test) findings. Materials and Methods  A longitudinal, prospective, comparative study of diagnostic accuracy performed in the period between June 2016 and June 2017 in patients of both sexes, aged between 40 and 70 years, with shoulder rotator cuff tendon tears and therapeutic need to undergo shoulder arthroscopy. Patients with contraindication to magnetic resonance imaging were included. After multi-slice computed tomographic arthrography, all patients underwent arthroscopy. Results  To obtain the results, the following parameters were determined: sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and Kappa coefficient, and contrast between the imaging method and arthroscopy. Conclusion  In the impossibility of performing magnetic resonance imaging (the gold standard imaging technique), multi-slice computed tomographic arthrography is an imaging examination capable of evaluating/diagnosing rotator cuff tears.

Comparison of Curved and Straight Anchor Insertion for SLAP Repair: A Cadaveric Study

PURPOSE

To compare a curved drill guide with a straight guide for suture anchor placement into the posterosuperior glenoid from an anterolateral portal with respect to glenoid perforation, drill contact with the suprascapular nerve, and maximum load.

METHODS

Ten bilateral pairs of fresh human cadaveric shoulders were randomized to the curved technique on 1 side and the straight technique on the contralateral side. An anterolateral trans-rotator cuff portal was used for placement of anchors at the posterior (11 o'clock right shoulder) and far posterior (10 o'clock right shoulder) positions on the glenoid with a 24-mm drill stop, and the drill tip was marked with ink. Specimens were dissected for glenoid perforation and drill contact with the suprascapular nerve. The maximum load of each anchor was measured using a material testing system.

RESULTS

Glenoid perforation occurred in 30% in the curved group and 60% in the straight group overall (P = .01). Ink markings demonstrated a direct hit on the suprascapular nerve in most of the penetrations (13 of 18) but was not significantly different between the curved and straight guides (P = .25). Maximum load of the posterior anchor was greater in the curved group than that in the straight group (199.5 vs 146.7 N, respectively; P = .01).

CONCLUSIONS

The curved technique has a lower rate of glenoid perforation and greater maximum load than the straight technique. However, the curved technique can result in glenoid perforation and injury to the suprascapular nerve, and we do not recommend it.

CLINICAL RELEVANCE

Placing suture anchors through an anterolateral portal with a curved guide provides a more optimal trajectory with decreased risk of glenoid perforation and superior biomechanical strength than that with the straight guide, but it is not safe.

Controversies In The Surgical Management Of Shoulder Instability: Associated Soft Tissue Procedures

Background:

The glenohumeral joint is a ball-and-socket joint that is inherently unstable and thus, susceptible to dislocation. The traditional and most common anatomic finding is the Bankart lesion (anterior-inferior capsule labral complex avulsion), but there is a wide variety of anatomic alterations that can cause shoulder instability or may be present as a concomitant injury or in combination, including bone loss (glenoid or humeral head), complex capsule-labral tears, rotator cuff tears, Kim´s lesions (injuries to the posterior-inferior labrum) and rotator interval pathology.

Methods:

A review of articles related to shoulder anatomy and soft tissue procedures that are performed during shoulder instability arthroscopic management was conducted by querying the Pubmed database and conclusions and controversies regarding this injury were exposed.

Results:

Due to the complex anatomy of the shoulder and the large range of movement of this joint, a wide variety of anatomic injuries and conditions can lead to shoulder instability, specially present in young population. Recognizing and treating all of them including Bankart repair, capsule-labral plicatures, SLAP repair, circumferential approach to pan-labral lesions, rotator interval closure, rotator cuff injuries and HAGL lesion repair is crucial to achieve the goal of a stable, full range of movement and not painful joint.

Conclusion:

Physicians must be familiarized with all the lesions involved in shoulder instability, and should be able to recognize and subsequently treat them to achieve the goal of a stable non-painful shoulder. Unrecognized or not treated lesions may result in recurrence of instability episodes and pain while overuse of some of the techniques previously described can lead to stiffness, thus the importance of an accurate diagnosis and treatment when facing a shoulder instability.

Arthroscopic Knot Removal for Failed Superior Labrum Anterior-Posterior Repair Secondary to Knot-Induced Pain

BACKGROUND

Studies on failed superior labrum anterior-posterior (SLAP) repair are increasing. However, the number of reports on treatment options for failed SLAP repair remains quite low, and the clinical results vary between different study groups.

PURPOSE

To describe the clinical presentation of failed SLAP repair due to knot-induced pain and evaluate the efficacy of arthroscopic knot removal.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors retrospectively reviewed records of 11 patients (mean age, 24.6 ± 8.6 years; range, 17-43 years) with stable, healed SLAP lesions with knot-induced pain after arthroscopic fixation of unstable type II SLAP lesions. All patients demonstrated a positive compression-rotation test before knot removal. The mean follow-up duration after knot removal was 48.0 ± 37.4 months (range, 24-156 months). The mean duration between primary fixation and knot removal was 21.2 ± 14.7 months (range, 8-56 months).

RESULTS

Sharp pain (100%) and clicking (64%) were the most common symptoms. The knot was positioned on the glenoid side in 5 patients and the labral side in 6 patients. The knots on the glenoid side had associated humeral head cartilage damage. The mean University of California at Los Angeles score significantly improved from 15.2 points to 31.7 points after knot removal ( P = .003) Additionally, the mean Constant score greatly improved from a mean of 56.5 points to 89.8 points ( P = .003). At a mean of 3 weeks after surgery, we observed dramatic pain relief. Six weeks after surgery, the compression-rotation test was negative in all patients.

CONCLUSION

The most common symptom of knot-induced pain after SLAP repair was persistent sharp pain followed by clicking. The knot appears to be a cause of pain in failed SLAP repairs, and arthroscopic knot removal can provide dramatic pain relief and significant improvement of clinical outcomes.

Variable reporting of functional outcomes and return to play in superior labrum anterior and posterior tear

BACKGROUND

Outcomes assessments after superior labrum anterior and posterior (SLAP) tear/repair are highly varied, making it difficult to draw comparisons across the literature. This study examined the inconsistency in outcomes reporting in the SLAP tear literature. We hypothesize that there is significant variability in outcomes reporting and that although most studies may report return to play, time to return reporting will be highly variable.

METHODS

The PubMed, Medline, Scopus, and Embase databases were systematically reviewed for studies from January 2000 to December 2014 reporting outcomes after SLAP tear/repair. Two reviewers assessed each study, and those meeting inclusion criteria were examined for pertinent data. Outcomes included objective (range of motion, strength, clinical examinations, and imaging) and subjective (patient-reported outcomes, satisfaction, activities of daily living, and return to play) measures.

RESULTS

Of the 56 included studies, 43% documented range of motion, 14% reported strength, and 16% noted postoperative imaging. There was significant variation in use of patient-reported outcomes measures, with the 3 most commonly noted measures reported in 20% to 55% of studies. Return to play was noted in 75% of studies, and 23% reported time to return, with greater rates in elite athletes. Eleven studies (20%) did not report follow-up or noted data with <12 months of follow-up.

CONCLUSIONS

The SLAP literature is characterized by substantial variability in outcomes reporting, with time to return to play noted in few studies. Efforts to standardize outcomes reporting would facilitate comparisons across the literature and improve our understanding of the prognosis of this injury.

Current Practice for the Surgical Treatment of SLAP Lesions: A Systematic Review

PURPOSE

To analyze current literature reporting surgical treatment of SLAP lesions to examine the consistency of reported surgical details (surgical indications, surgical technique, and postoperative rehabilitation) that are deemed important for best treatment outcomes and to try to establish a consensus regarding treatment.

METHODS

A systematic review of papers reporting surgical treatment of a SLAP lesion was performed. Each paper was analyzed for the description of (1) the arthroscopic indications for surgery; (2) surgical aspects including type, location, and number of anchors and sutures; (3) description of criteria for determination of completeness of the repair; and (4) postoperative rehabilitation details. These findings were also analyzed to determine whether a consensus could be developed regarding surgical treatment.

RESULTS

Twenty-six papers were included, with 12 focused on isolated SLAP repair and 14 focused on combined SLAP repair with other lesions; 54% did not report indications for surgery. Reporting of the anchor/suture details was not consistent, with 35% reporting some variation of 12:00 placement but 31% not reporting the position of placement; 89% of papers did not report the criteria for determining completeness of the repair; 85% reported general postoperative rehabilitation guidelines, but only 4% reported in-depth details.

CONCLUSIONS

This review demonstrated a wide variability in the reported surgical aspects and that a relatively high percentage of papers did not report many of the details. This lack of precision and consistency makes analysis of individual papers and comparison between papers and their outcomes difficult and does not allow a consensus regarding current practice to be developed. These findings may be some of the factors responsible for the variability in treatment outcomes and suggest that efforts could be directed toward consistency in documenting and reporting surgical indications, surgical techniques, surgical endpoints, and efficacious rehabilitation programs.

LEVEL OF EVIDENCE

Level IV, systematic review of level III-IV studies.

Management of In-Season Concurrent Rotator Cuff Tear With Shoulder Instability in Professional Contact Football Athletes; Respect the Career Goals!

Introduction

Professional sports injuries are usually all dealt with at one single operation to return the player to the sport after appropriate rehabilitation. We questioned the assumption that rotator cuff tears must be repaired concurrently with instability syndromes, and aimed to allow a professional rugby league player to achieve career goals by NOT correcting all pathology at one surgery.

Case Presentation

A professional rugby league player presented with acute shoulder instability on a setting of a chronic full thickness rotator cuff tear. We performed an “in season” arthroscopic stabilization on an elite rugby league player, leaving a previously diagnosed large full thickness rotator cuff tear untreated. This allowed aggressive rehabilitation and return to contact competition at 12 weeks post-surgery. The player achieved a long held career goal of winning a premiership ring before undertaking rotator cuff repair at the end of the season. Latest follow up at seven years (still at elite level) demonstrated an asymptomatic shoulder.

Conclusions

The assumption that all pathology found at surgical exploration requires correction to play at elite level is not universally correct. We postulate that whilst rotator cuff deficiency has severe long-term sequelae, it is shoulder instability alone that prevents high level contact sports participation. Career goal management is an important part of managing elite level athletes. We have demonstrated that by careful management of the specific pathology preventing participation can allow elite athletes to achieve career goals without compromising long-term health.

Evaluation of functional results from shoulders after arthroscopic repair of complete rotator cuff tears associated with traumatic anterior dislocation

Objective

To evaluate the clinical outcome of arthroscopic rotator cuff fixation and, when present, simultaneous repair of the Bankart lesion caused by traumatic dislocation; and to assess whether the size of the rotator cuff injury caused by traumatic dislocation has any influence on the postoperative clinical outcomes.

Methods

Thirty-three patients with traumatic shoulder dislocation and complete rotator cuff injury, with at least two years of follow up, were retrospectively evaluated. For analysis purposes, the patients were divided into groups: presence of fixed Bankart lesion or absence of this lesion, and rotator cuff lesions smaller than 3.0 cm (group A) or greater than or equal to 3.0 cm (group B). All the patients underwent arthroscopic repair of the lesions and were evaluated postoperatively by means of the UCLA (University of California at Los Angeles) score and strength measurements.

Results

The group with Bankart lesion repair had a postoperative UCLA score of 33.96, while the score of the group without Bankart lesion was 33.7, without statistical significance (p = 0.743). Group A had a postoperative UCLA score of 34.35 and group B, 33.15, without statistical significance (p = 0.416).

Conclusion

The functional outcomes of the patients who only presented complete rotator cuff tearing after traumatic shoulder dislocation, which underwent arthroscopic repair, were similar to the outcomes of those who presented an associated with a Bankart lesion that was corrected simultaneously with the rotator cuff injury. The extent of the original rotator cuff injury did not alter the functional results in the postoperative evaluation.

Current Practice for the Diagnosis of a SLAP Lesion: Systematic Review and Physician Survey

PURPOSE

To evaluate current practice reported in the literature for making a SLAP lesion diagnosis and compare the findings with a survey sent to experienced shoulder surgeons assessing how they make a SLAP diagnosis.

METHODS

We performed a systematic review of articles reporting surgical repair of SLAP lesions, documenting the use of 4 diagnostic areas of evaluation: history, clinical examination, imaging, and diagnostic arthroscopy. A survey was distributed electronically to 175 surgeons with expertise in shoulder surgery. The survey listed common components within the 4 diagnostic areas and asked surgeons to indicate components they used in establishing the diagnosis. The 4 diagnostic areas were ranked from 1 to 4 (most to least important).

RESULTS

Of the articles, 23% reported using all 4 diagnostic areas, 58% used 3 areas, and 19% used 2 areas or fewer. Thirty-five percent did not report history components, 31% did not report clinical examination elements, 27% did not report imaging findings, and 4% did not report arthroscopic findings. Eight percent reported using a comprehensive history and examination but without describing specific symptoms or tests. The most common components reported in the literature were pain (42%), the active compression test (65%), magnetic resonance imaging/arthrography (65%), and tear/unstable biceps-labral complex (27%). A total of 70 surgeons (40%) responded to the survey. More specific history components, examination maneuvers, and imaging/arthroscopy variants were reported on the survey compared with the literature. Diagnostic arthroscopy and history ranked as the most important for a SLAP diagnosis.

CONCLUSIONS

The current literature and practice for making the SLAP diagnosis are variable and inconsistent. The SLAP diagnosis appears to be a clinical impression; however, the criteria described within the literature vary among the evaluation areas and differ from the results of the survey. These types of variability may have a significant influence on consistency and accuracy in making the diagnosis of the SLAP injury, developing the subsequent treatment, and maximizing outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies with cross-sectional survey.

SPORTS INJURIES OF THE UPPER LIMBS

Sports injuries of the upper limbs are very common in physical activities and therefore, they need to be studied in detail, taking into consideration specific aspects of the types of sports practiced. Special attention should be paid to the dynamics of the shoulder girdle and the entire scapular belt, since the most appropriate treatment for athletes can only be provided in this manner. This can also help to prevent recurrences, which can occur in some cases because athletes always seek to return to their pre-injury level of sports activity. This article will focus primarily on the management of upper-limb tendon injuries, from the physiopathology through to the new methods of injury treatment that are more prevalent in sports practice in Brazil.

Superior labral anterior posterior lesions of the shoulder: Current diagnostic and therapeutic standards

Surgical treatment of superior labral anterior posterior (SLAP) lesion becomes more and more frequent which is the consequence of evolving progress in both, imaging and surgical technique as well as implants. The first classification of SLAP lesions was described in 1990, a subdivision in four types existed. The rising comprehension of pathology and pathophysiology in SLAP lesions contributed to increase the types in SLAP classification to ten. Concerning the causative mechanism of SLAP lesions, acute trauma has to be differed from chronic degeneration. Overhead athletes tend to develop a glenohumeral internal rotation deficit which forms the basis for two controversial discussed potential mechanisms of pathophysiology in SLAP lesions: Internal impingement and peel-back mechanism. Clinical examination often remains unspecific whereas soft tissue imaging such as direct or indirect magnetic resonance arthrography has technically improved and is regarded to be indispensable in detection of SLAP lesions. Concomitant pathologies as Bankart lesions, rotator cuff tears or perilabral cysts should be taken into consideration when planning a personalized therapeutic strategy. In addition, normal variants such as sublabral recess, sublabral hole, Buford complex and other less common variants have to be distinguished. The most frequent SLAP type II needs a sophisticated approach when surgical teatment comes into consideration. While SLAP repair is considered to be the standard operative option, overhead athletes benefit from a biceps tenodesis because improved patient-reported satisfaction and higher rate of return to pre-injury level of sports has been reported.

Three-dimensional analysis versus goniometric measurement of total active elevation in normal subjects

BACKGROUND

Multiple planes of motion have been reported for shoulder elevation performed by visual inspection with a goniometer. It is typically measured by a clinician who is standing or sitting at the side of the patient. Instead, accurate assessment of shoulder elevation must be performed by using a plane of reference that is perpendicular to the plane of motion being measured.

METHODS

Three repetitions of humeral elevation in the sagittal, scapular, and coronal planes were performed in a random order and measured by goniometry and three-dimensional (3D) electromagnetic sensors. A guide bar was used to control the initial plane of motion for the sagittal and coronal planes. The plane of motion at 90° and at peak elevation was recorded for each of the 3 defined planes. A goniometer was used to measure the range of maximal elevation performed in each plane, for each subject, by visual inspection.

RESULTS

The 3D data revealed that subjects consistently moved toward scaption as the extremity moved above 90° of elevation, regardless of the initial plane of motion. Significant differences were seen in the goniometric data for the plane of motion at 90° (P = .00) in flexion, abduction, and scaption. Goniometric measurements revealed greater maximum elevation angles in comparison to the 3D kinematic measurements.

CONCLUSIONS

Maximal glenohumeral elevation occurred near the plane of the scapula in all subjects, regardless of the plane in which elevation was initiated. Goniometric measurement of total elevation resulted in greater range of motion measurements than actually occurred because the observer was not routinely positioned in a plane perpendicular to the plane of actual elevation of the upper extremity.

SLAP Repairs With Combined Procedures Have Lower Failure Rate Than Isolated Repairs in a Military Population: Surgical Outcomes With Minimum 2-Year Follow-up

BACKGROUND

Injuries to the superior glenoid labrum represent a significant cause of shoulder pain among active patients. The physical requirements of military service may contribute to an increased risk of injury. Limited data are available regarding the success of superior labral anterior posterior (SLAP) repairs in an active military population.

PURPOSE

To quantify the rate of clinical failure and surgical revision after isolated and combined SLAP repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All consecutive active-duty servicemembers undergoing arthroscopic repair of type II SLAP lesions at a single institution between 2006 and 2012 were identified. Patients with less than 2-year clinical follow-up and nonmilitary status were excluded. Demographic variables, surgical variables, and occupational outcomes were extracted from electronic medical records and confirmed with the US Army Physical Disability Agency database. Failure was defined as subsequent revision surgery or medical discharge with persistent shoulder complaints.

RESULTS

A total of 192 patients with SLAP repair were identified with a mean follow-up of 50.0 months (SD, 17.0 months). Isolated SLAP repair occurred in 31.3% (n = 60) versus 68.8% (n = 132) with concomitant procedures. At final follow-up, 37.0% (n = 71) of patients reported some subjective activity-related shoulder pain. Postoperative return to duty occurred in 79.6% (n = 153), and only 20.3% (n = 39) were discharged with continuing shoulder disability. The combined rotator cuff repair (96%; P = .023) and anteroinferior labral repair group (88%; P = .056) had a higher rate of functional return than isolated SLAP repair (70%). Thirty-one (16.1%) patients were classified as surgical failure and required revision. Of these, the majority of patients undergoing biceps tenodesis (76%) returned to active duty, as compared with revision SLAP repair (17%). Lower demand occupation and the presence of combined shoulder injuries (P = .011 and .016, respectively) were significantly associated with a lower risk of medical discharge and revision surgery, respectively.

CONCLUSION

Favorable outcomes can be anticipated in the majority of military servicemembers after arthroscopic SLAP repair, particularly with combined shoulder injuries. Revision surgery occurred in 16% of patients after primary SLAP repair.

CLINICAL RELEVANCE

Isolated repair of unstable SLAP lesions and/or increased upper extremity demands are associated with higher failure rates in this population.

Labrum and rotator cuff injuries in the throwing athlete

The large amount of force imparted across the shoulder during the act of throwing makes the glenohumeral joint highly susceptible to injury in the athlete performing overhead throwing motions. The bony incongruity of the shoulder enables greater range of motion than any other joint in the body, but it also results in significant strain on the surrounding soft tissues during the throwing motion. Throwers can present with acute injuries, but more commonly they suffer from chronic overuse conditions resulting from repetitive overload. Proper management requires early recognition with treatment directed toward the athlete's safe return to sports. Failure to institute an appropriate management strategy may result in significant complications, including prolonged disability, progression of symptoms, and further injury. We discuss the functional anatomy, pathophysiology, clinical presentation, evaluation, and treatment of common injuries of the glenoid labrum and rotator cuff in the overhead throwing athlete.

Identification and treatment of existing copathology in anterior shoulder instability repair

Recurrent anterior instability is a common finding after traumatic glenohumeral dislocation in the young, athletic patient population. A variety of concomitant pathologies may be present in addition to the classic Bankart lesion, including glenoid bone loss; humeral head bone loss; rotator interval pathology; complex/large capsular injuries including humeral avulsions of the glenohumeral ligaments (HAGL lesions), SLAP tears, near circumferential labral tears, and anterior labral periosteal sleeve avulsions (ALPSA lesions); and rotator cuff tears. Normal anatomic variations masquerading as pathology also may be present. Recognition and treatment of these associated pathologies are necessary to improve function and symptoms of pain and to confer anterior shoulder stability. This review will focus on the history, physical examination findings, imaging findings, and recommended treatment options for common sources of copathology in anterior shoulder instability repair.

Functional and imaging outcomes of arthroscopic simultaneous rotator cuff repair and bankart repair after shoulder dislocations

BACKGROUND

Previous studies have investigated outcomes of simultaneous rotator cuff (RC) repair and superior labral injury repair; however, there is limited information in the literature on outcomes of simultaneous RC repair and Bankart lesion repair after acute shoulder dislocations.

PURPOSE

To determine functional and imaging outcomes of simultaneous arthroscopic RC repair and Bankart repair after acute shoulder dislocations and to compare functional outcomes to contralateral, asymptomatic shoulders.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Consecutive patients who underwent arthroscopic simultaneous RC repair and Bankart repair with a minimum of 2 years' follow-up were recruited. All patients had suffered an acute shoulder dislocation. The American Shoulder and Elbow Surgeons (ASES), Constant-Murley, and Short Form (SF)-36 scores were obtained. The affected shoulder also underwent ultrasound imaging to assess the integrity of the RC.

RESULTS

Thirteen patients (mean age, 58.8 ± 11.2 years; mean follow-up, 38.5 ± 12.3 months) were recruited. In a comparison of the affected versus unaffected shoulder, there were no significant differences in the mean ASES score (89.7 ± 12.6 vs 95.0 ± 6.7, respectively), mean Constant score (80.5 ± 18.9 vs 86.8 ± 7.9, respectively), or mean abduction strength (15.4 ± 6.4 lb vs 15.4 ± 5.2 lb, respectively) (P > .05). The mean SF-36 physical component summary was 48.4. According to ultrasound imaging, there were persistent/recurrent full-thickness tears in 4 patients, and 1 patient had a new full-thickness tear. At follow-up, patients with full-thickness RC tears in the affected shoulder compared with their unaffected shoulder showed similar mean ASES scores (90.9 ± 11.8 vs 97.6 ± 4.3, respectively), mean Constant scores (77.8 ± 20.3 vs 84.8 ± 7.2, respectively), and mean abduction strength (11.5 ± 5.3 lb vs 12.6 ± 4.5 lb, respectively) (P > .05).

CONCLUSION

After simultaneous arthroscopic repair of the RC and a Bankart lesion in patients after shoulder dislocations, the affected extremity had similar functional outcomes compared to the noninjured, asymptomatic side at a mean of 3 years after surgery. Persistent or recurrent RC tears involving the operative extremity were common, but they did not significantly affect functional outcomes in this small study.

Rotator cuff tear and glenohumeral instability : a systematic review

BACKGROUND

The rotator cuff plays a significant role in the static and dynamic stability of the glenohumeral joint. Rotator cuff tears may occur after shoulder dislocations, whether in younger athletes or older patients with age-related tendon degeneration. Untreated tears may cause persistent pain, dysfunction, instability, and degenerative changes. A thorough understanding of when to look for rotator cuff tears after shoulder dislocations and how best to manage them may decrease patients' pain and improve function.

QUESTIONS/PURPOSES

We systematically reviewed the available literature to better understand (1) when a rotator cuff tear should be suspected after a dislocation, (2) whether surgical or nonsurgical approaches result in better scores for pain and satisfaction in patients with rotator cuff tears resulting from shoulder dislocations, and (3) whether intraarticular lesions, rotator cuff tears, or both should be addressed when surgery is performed.

METHODS

We systematically searched MEDLINE(®), CINAHL, and EMBASE for studies published from 1950 to 2012. We included studies reporting outcomes after treatment in patients with rotator cuff tears and shoulder dislocations. We excluded case reports, studies without any treatment, and studies about patients treated with arthroplasty. Five Level III and six Level IV studies were ultimately selected for review.

RESULTS

Patients with persistent pain or dysfunction after a shoulder dislocation often had a concomitant rotator cuff tear. Surgical repair resulted in improved pain relief and patient satisfaction compared to nonoperative management. Repair of the rotator cuff, along with concomitant capsulolabral lesions, helped restore shoulder stability. While these findings are based on Level III and IV evidence, better long-term studies with larger cohorts are needed to strengthen evidence-based recommendations.

CONCLUSIONS

Persistent pain and dysfunction after a shoulder dislocation should prompt evaluation of the rotator cuff, especially in contact or overhead athletes, patients older than 40 years, or those with nerve injury. Surgery should be considered in the appropriately active patient with a rotator cuff tear after dislocation. While the current literature suggests improved stability and function after surgical repair of the rotator cuff, higher-quality prospective studies are necessary to make definitive conclusions.

Surgical Trends in the Treatment of Superior Labrum Anterior and Posterior Lesions of the Shoulder: Analysis of Data From the American Board of Orthopaedic Surgery Certification Examination Database

BACKGROUND

After failure of nonoperative treatment, repair has long been the primary treatment option for symptomatic superior labrum anterior and posterior (SLAP) lesions of the shoulder. There is growing evidence to support both biceps tenotomy and tenodesis as effective alternative treatments for SLAP lesions.

HYPOTHESES

For patients with isolated SLAP lesions, the frequency of SLAP repair has decreased, while treatment with biceps tenodesis and tenotomy has increased. Similar trends are expected in patients with SLAP lesions undergoing concomitant rotator cuff repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A query of the American Board of Orthopaedic Surgery part II database was performed from 2002 to 2011. The database was searched for patients with isolated SLAP lesions undergoing SLAP repair, open biceps tenodesis, arthroscopic biceps tenodesis, or biceps tenotomy. The database was then queried a second time for patients undergoing arthroscopic rotator cuff repair with concomitant SLAP repair, biceps tenodesis, or biceps tenotomy.

RESULTS

From 2002 to 2011, there were 8963 cases reported for the treatment of an isolated SLAP lesion and 1540 cases reported for the treatment of SLAP lesions with concomitant rotator cuff repair. For patients with isolated SLAP lesions, the proportion of SLAP repairs decreased from 69.3% to 44.8% (P < .0001), while biceps tenodesis increased from 1.9% to 18.8% (P < .0001), and biceps tenotomy increased from 0.4% to 1.7% (P = .018). For patients undergoing concomitant rotator cuff repair, SLAP repair decreased from 60.2% to 15.3% (P < .0001), while biceps tenodesis or tenotomy increased from 6.0% to 28.0% (P < .0001). There was a significant difference in the mean age of patients undergoing SLAP repair (37.1 years) versus biceps tenodesis (47.2 years) versus biceps tenotomy (55.7 years) (P < .0001).

CONCLUSION

Practice trends for orthopaedic board candidates indicate that the proportion of SLAP repairs has decreased over time, with an increase in biceps tenodesis and tenotomy. Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair.

Return to play after treatment of superior labral tears in professional baseball players

BACKGROUND

The published return-to-play (RTP) rates for athletes who have undergone surgical repair of superior labrum anterior-posterior (SLAP) tears vary widely and are generally accepted to be lower in the subset of competitive throwers. The efficacy of nonsurgical treatment for this group is unknown.

HYPOTHESIS

Nonsurgical treatment of SLAP tears in professional baseball players leads to RTP before consideration of surgical treatment. Incorporating performance statistics and level of competition will result in lower calculated RTP rates than have been previously reported.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of 119 consecutive patients in a single professional baseball organization with persistent shoulder pain that limited the ability to compete was performed. Sixty-eight patients had magnetic resonance imaging-documented SLAP lesions. All patients had failed 1 attempt at rehabilitation but had continued with supervised physical therapy. Treatment was according to an algorithm focusing on the correction of scapular dyskinesia and posterior capsular contracture with glenohumeral internal rotation deficit (GIRD), followed by pain-free return to throwing. Those who failed 2 cycles of nonsurgical treatment were treated surgically. Success was defined by 2 different standards: (1) RTP, in accordance with previous studies; and (2) a more stringent standard of return to the same level/quality of professional competition (A, AA, AAA, etc) with the incorporation of a return to preinjury individual performance statistics (earned run average, walks plus hits per inning pitched), termed "return to prior performance" (RPP).

RESULTS

Sixty-eight athletes were identified with SLAP lesions. Twenty-one pitchers successfully completed the nonsurgical algorithm and attempted a return. Their RTP rate was 40%, and their RPP rate was 22%. The RTP rate for 27 pitchers who underwent 30 procedures was 48%, and the RPP rate was 7%. For 10 position players treated nonsurgically, the RTP rate was 39%, and the RPP rate was 26%. The RTP rate for 13 position players who underwent 15 procedures was 85%, with an RPP rate of 54%.

CONCLUSION

Nonsurgical treatment correcting scapular dyskinesia and GIRD had a reasonable success rate in professional baseball players with painful shoulders and documented SLAP lesions. The rate of return after surgical treatment of SLAP lesions was low for pitchers. The RTP and RPP rates were higher for position players than for pitchers. Nonsurgical treatment should be considered for professional baseball players with documented SLAP lesions, as it can lead to acceptable RTP and RPP rates.

Retrospective analysis of arthroscopic superior labrum anterior to posterior repair: prognostic factors associated with failure

Background. The purpose of this study was to report on any prognostic factors that had a significant effect on clinical outcomes following arthroscopic Type II SLAP repairs. Methods. Consecutive patients who underwent arthroscopic Type II SLAP repair were retrospectively identified and invited to return for follow-up examination and questionnaire. Statistical analysis was performed to determine associations between potential prognostic factors and failure of SLAP repair as defined by ASES of less than 50 and/or revision surgery. Results. Sixty-two patients with an average age of 36 ± 13 years met the study criteria with a mean followup of 3.3 years. There were statistically significant improvements in mean ASES score, forward elevation, and external rotation among patients. Significant associations were identified between ASES score less than 50 and age greater than 40 years; alcohol/tobacco use; coexisting diabetes; pain in the bicipital groove on examination; positive O'Brien's, Speed's, and/or Yergason's tests; and high levels of lifting required at work. There was a significant improvement in ASES at final followup. Conclusions. Patients younger than 20 and overhead throwers had significant associations with cases requiring revision surgery. The results from this study may be used to assist in patient selection for SLAP surgery.

Surgical repair and rehabilitation of a combined 330° capsulolabral lesion and partial-thickness rotator cuff tear in a professional quarterback: a case report

STUDY DESIGN

Case report.

BACKGROUND

Traumatic glenohumeral dislocations with concomitant rotator cuff and capsular injuries present a unique and challenging surgical and rehabilitative condition, particularly in the overhead-throwing athlete. Multiple injuries of the shoulder complex create the potential for complications in the course of recovery and place a full return to high-level sport at risk. The purpose of this case report is to present the multiphased rehabilitation approach of an elite professional quarterback after an acute 330° capsulolabral reconstruction and rotator cuff repair as a result of a luxatio erecta injury.

CASE DESCRIPTION

A 26-year-old male professional football player, a quarterback, sustained a right luxatio erecta shoulder dislocation while trying to recover a fumble during a regular-season game. The injury occurred when he was hit in the back of his throwing shoulder, which was in an abducted and externally rotated position, while lying on the ground. Five days postinjury, he underwent a 330° capsulolabral repair, with concomitant rotator cuff repair and subacromial decompression. He completed 28 weeks of a multiphased rehabilitation program.

OUTCOMES

The patient returned to play in the National Football League (NFL) 8 months later, for the start of the next season, during which he had his most productive year as a professional quarterback, leading the league in passing yards and finishing third in the league for the number of touchdowns. Since the injury, the patient has played 6 consecutive seasons, starting over 96 consecutive, regular-season games and maintaining a very high level of play.

DISCUSSION

This case report highlights the clinical decision-making process and management of this rare, severe injury.

Diagnosis and management of superior labral anterior posterior tears in throwing athletes

Injury to the superior glenoid labrum is increasingly recognized as a significant source of shoulder pain and dysfunction in the throwing athlete. Several theories have been proposed to explain the pathogenesis of superior labral anterior posterior (SLAP) tears. The clinical examination of the superior labrum-biceps tendon complex remains challenging because of a high association of other shoulder injuries in overhead athletes. Many physical examination findings have high sensitivity and low specificity. Advances in soft tissue imaging such as magnetic resonance arthrography allow for improved detection of labrum and biceps tendon lesions, although correlation with history and physical examination is critical to identify symptomatic lesions. Proper treatment of throwers with SLAP tears requires a thorough understanding of the altered biomechanics and the indications for nonoperative management and arthroscopic treatment of these lesions.

The effect on external rotation of an anchor placed anterior to the biceps in type 2 SLAP repairs in a cadaveric throwing model

PURPOSE

This study examined whether there is a difference in external rotation (ER) between type 2 SLAP repairs consisting of anchors placed only posterior to the biceps insertion compared with repairs with an additional anchor placed anterior to the biceps.

METHODS

Seven cadaveric shoulders from donors with a mean age of 39.4 years were tested. Type 2 SLAP lesions were created, followed by a 3-anchor repair: a standard repair with 2 anchors posterior to the biceps plus an additional anchor anterior to the biceps. The specimens were placed on a material testing system machine and rotation was measured under a constant torque. The sutures were then removed sequentially from anterior to posterior during testing.

RESULTS

The average ER of the intact shoulder was 115.7° ± 2.6°. After SLAP tear creation and cyclic loading, the ER was 118.5° ± 2.6°, which decreased to 116.5° ± 2.6° after repair. This corresponds to a reduction of 2.0° of ER (P < .0001) with the repair. After release of the anterior anchor, the ER increased to 117.9° ± 2.6°, which corresponds to an increase in shoulder motion of 1.4° of ER (P = .0011). Additional release of the middle anchor, leaving only the posterior anchor intact, resulted in 118.0° ± 2.7° of ER, which corresponds to an increase of only 0.1° of ER (P = .7667).

CONCLUSIONS

Following type 2 SLAP repair in the cadaveric shoulder, removing the effect of the anchor anterior to the biceps resulted in a small but statistically significant increase in ER. The anterior anchor had the greatest effect on ER. The presence of 1 or 2 anchors posterior to the biceps did not have a significant effect on rotation.

CLINICAL RELEVANCE

When performing SLAP repairs on those in whom even a small loss of ER would be detrimental, such as baseball pitchers, avoidance of the use of an anchor anterior to the biceps should be considered.

A new technique of arthroscopic fixation using double anchors for SLAP lesions

PURPOSE

The aim of this study was to evaluate the clinical and structural outcome of the new fixation technique of type-II SLAP repair using double anchors compared with conventional method.

METHODS

Twenty-eight patients with 29 shoulders, who were followed up for at least 1 year after surgery, were enrolled. Fourteen shoulders were treated using the new technique (group 1), and 15 shoulders using the conventional technique (group 2). The clinical outcomes were evaluated using two different functional scores, the pain VAS and range of motion. The postoperative labral integrity was determined by magnetic resonance imaging at 1 year after surgery.

RESULTS

At postoperative 6 months, all functional scores of group 1 were superior to group 2, particularly in pain VAS and Constant Scoring System. All ranges of motion in group 1 showed a better result than in group 2, particularly in forward flexion and external rotation at 90° abduction (88° ± 4.8 in group 1 and 84° ± 9.2 in group 2, P = 0.03). At postoperative 12 months and the last visit, all functional scores in group 1 were superior to those in group 2 and all external rotations at 90° of abduction in group 1 showed significantly better results than those of group 2. All patients in group 1 showed complete healing of the repaired SLAP lesion but one patient in group 2 showed partial detachments on the MRI.

CONCLUSIONS

This new technique provides anatomical restoration of a SLAP lesion and yields successful clinical and structural outcomes at a short-term follow-up.

LEVEL OF EVIDENCE

Randomized controlled trials, level II.

Early Results of Concurrent Arthroscopic Repair of Rotator Cuff and Type II Superior Labral Anterior Posterior Tears

Background:

Recent reports on concurrent arthroscopic rotator cuff and type II superior labral anterior posterior (SLAP) repair have raised concerns over postoperative stiffness and patient satisfaction. However, it is unclear if the observed stiffness relates to the repair of degenerative SLAP tears in older adults, the surgical technique, the postoperative rehabilitation, or to a combination of these factors.

Purpose:

The purpose of this study was to evaluate the outcome and repair integrity of concurrent arthroscopic rotator cuff and type II SLAP repair.

Study Design:

Case series.

Methods:

Of 11 patients identified, 7 had a full-thickness rotator cuff tear and 4 had a high-grade partial thickness tear that was completed. A cannula placed through the rotator cuff tear improved the trajectory for posterior suture anchor placement during SLAP repair. Postoperative rehabilitation employed continuous passive motion to prevent stiffness.

Results:

At minimum of 1-year follow-up, mean yes responses on the Simple Shoulder Test improved from 5.4 to 10.7 (out of 12; P < .01), and mean American Shoulder and Elbow Surgeons scores improved from 40 to 87 (out of 100; P < .01). Mean forward elevation improved from 148° to 161° (P < .01) and external rotation from 58° to 67° (P < .01). Magnetic resonance imaging, obtained at most recent follow-up in 10 patients, demonstrated a healed SLAP tear in all patients and a persistent rotator cuff defect in 1 patient.

Conclusions:

Arthroscopic rotator cuff repair can be successfully combined with type II SLAP repair in relatively young patients who have sustained traumatic injury to their shoulders. Allowing early passive motion may help prevent postoperative stiffness without compromising rotator cuff healing.

Return to play after Type II superior labral anterior-posterior lesion repairs in athletes: a systematic review

BACKGROUND

Superior labral anterior-posterior (SLAP) lesions are a common cause of pain and disability in athletes. Individual studies have suggested low patient satisfaction with SLAP repairs in throwing athletes in particular and it is unclear how frequently athletes return to their previous level of competetion.

QUESTIONS/PURPOSES

We systematically reviewed the literature to determine (1) patient satisfaction and (2) return to play at previous level of competition among throwing athletes compared to all athletes who underwent repair of Type II SLAP tears using various types of fixation.

METHODS

We searched databases for English-language articles in peer-reviewed journals from 1950 to 2010 reporting Type II SLAP repairs with 2-year followup for our systematic review. A total of 506 patients with Type II SLAP tears were reviewed from 14 studies; of these, 327 had SLAP lesions repaired by anchor, 169 by tacks, and 10 by staples. Of the 506 patients, 198 were overhead athletes with a pooled subset of 81 identified baseball players.

RESULTS

For the entire patient population, 83% had "good-to-excellent" patient satisfaction and 73% returned to their previous level of play whereas only 63% of overhead athletes returned to their previous level of play. Anchor repair in overhead athletes resulted in a higher percentage of "good-to-excellent" patient satisfaction (88% versus 74%) and a slightly higher return to play rate (63% versus 57%) compared with tack repair.

CONCLUSIONS

Repair of Type II SLAP tears leads to a return to previous level of play in most patients. Overhead athletes appear to have a lower rate of return to level of previous of play. Anchor fixation appears to be the most favorable fixation in both subjective scores and return to previous level of play.

Biomechanical and histological analysis after tenotomy of the long head of the biceps in the rabbit shoulder model

Tenotomy of the long head of the biceps tendon (LHBT) is gaining popularity in shoulder surgery. We evaluated biomechanical and histological changes after tenotomy in a rabbit LHBT tenotomy model to confirm that autotenodesis is a phenomenon that occurs after the procedure. Twenty-three rabbits were included. The right shoulder was harvested from 10 randomly selected rabbits. The shoulders were tested to determine the pullout strength of LHBT at the bicipital groove immediately after being tenotomized. The left shoulder of three of these rabbits also underwent histological analysis. The other 13 rabbits underwent LHBT tenotomy (tenotomy model). Six weeks post-operatively, 10 were assigned for biomechanical study, and three underwent histological analysis. The pullout strength and histology were compared with the immediate post-tenotomy data. The pullout strength of the immediate post-tenotomy (5.53 ± 2.22 N) was significantly (p < 0.001) less than the pullout strength of the 6 weeks post-tenotomy model (44.07 ± 7.75 N). On histological analysis, marked fibrosis was noted around the LHBT at the bicipital groove in the 6 weeks post-tenotomy model. Adhesion of the LHBT at the bicipital groove after tenotomy, which is called "autotenodesis," is a definite phenomenon that could help the tendon resist distal migration of the LHBT after tenotomy. These results support execution of biceps tenotomy in shoulder surgery.

EVALUATION OF RESULTS AND COMPLICATIONS FROM ARTHROSCOPIC SUTURE OF SLAP LESIONS

Objective: To evaluate the results and complications from arthroscopic suturing of SLAP lesions. Methods: Seventy-one patients who underwent arthroscopic suturing of SLAP lesions between July 1995 and May 2008 were evaluated. The procedures were performed by the Shoulder and Elbow Surgery Group of the Department of Orthopedics and Traumatology, Fernandinho Simonsen Wing, Santa Casa de São Paulo, Brazil. Associated lesions were seen in 68 of the 71 patients evaluated (96%), and the other three (4%) had SLAP lesions alone. Results: The associated lesions most frequently found in the patients under 40 years of age were labral lesions (69%), while in patients aged 40 years or over, impact syndrome with or without rotator cuff injury was the most commonly associated condition (71.4%). According to the UCLA method, 79% of our results (56 cases) were good or excellent. Postoperative complications occurred in 15 cases (21%); among these, the most common was the presence of residual pain (46.6%), followed by adhesive capsulitis (33.3%). Conclusions: There was a great association between SLAP lesions and other shoulder lesions, which varied according to the patients' age groups. Arthroscopic suturing of the SLAP lesions provided excellent results in the majority of the cases, but complications occurred in 21%.

Results of concomitant rotator cuff and SLAP repair are not affected by unhealed SLAP lesion

HYPOTHESIS

To verify the anatomic results of combined repair of a full-thickness rotator cuff tear and superior labral anterior and posterior (SLAP) lesion. In addition, we compared the anatomic and functional outcomes according to the status of the repaired SLAP lesion.

METHODS

We enrolled 61 patients who underwent cuff repair with concomitant SLAP repair and were available for both functional and radiologic outcome evaluation at least 1 year after the operation. There were 40 male and 21 female patients with a mean age of 57.4 years (range, 39-70 years). We measured various clinical outcomes and evaluated the structural outcomes of the rotator cuff and the superior labrum and rotator cuff using computed tomography arthrography at the final follow-up visit. We also evaluated the functional outcome according to anatomic healing of the superior labrum.

RESULTS

Labral healing to the bony glenoid was achieved in 49 patients (80.3%), and anatomic healing of the rotator cuff was observed in 44 patients (72.1%). The retear rate of the rotator cuff was not statistically different with respect to labral healing status. All functional outcomes improved significantly (P < .001), and there were no statistical differences in functional outcome with respect to postoperative healing of the superior labrum.

CONCLUSIONS

An unhealed SLAP lesion did not preclude the successful outcome of concomitant rotator cuff repair. Therefore, repair of a concomitant SLAP lesion may not be an essential procedure for a successful outcome of a rotator cuff repair.

Percutaneous SLAP lesion repair technique is an effective alternative to portal of Wilmington

Athletes with superior labral tear from anterior to posterior (SLAP) lesions place large demands on their rotator cuff and often have partial articular-sided rotator cuff tears as part of an internal impingement process. A percutaneous technique that facilitates SLAP repair may decrease the rotator cuff morbidity associated with establishment of the standard Wilmington portal. The current study reports the clinical outcome of patients with SLAP lesions treated with a percutaneous repair technique. Twenty-two patients with SLAP lesions underwent percutaneous repair. Mean patient age was 26.9 years. Standard posterior viewing and anterior working portals were used. Anchor placement and suture passing were performed with a 3-mm percutaneous and transtendinous approach to the superior labrum. Knot tying was performed via the standard anterior working portal. Clinical outcomes were assessed with validated shoulder evaluation instruments. Mean follow-up was 31.1 months (±6.6 months). Improvement of shoulder evaluation scores from pre- to postoperative were as follows: American Shoulder and Elbow Surgeons score improved from 49.5 to 83.6, visual analog scale improved from 5.4 to 1.5, and Simple Shoulder Score improved from 6.4 to 11.0. All were significant improvements (P<.05). There was no significant difference in functional scores between Type II lesions versus combined lesions, or between patients with or without a concurrent low-grade rotator cuff tear. Ninety percent of athletes were able to return to sport at pre-injury level of function. Percutaneously-assisted arthroscopic SLAP lesion repair may minimize surgical morbidity to the rotator cuff and provides excellent results.

Outcomes of type II superior labrum, anterior to posterior (SLAP) repair: prospective evaluation at a minimum two-year follow-up

HYPOTHESIS

Patients with type II superior labrum, anterior to posterior (SLAP) lesions will have improved function and decreased pain at a minimum of 2 years after arthroscopic SLAP repair using bioabsorbable suture anchor fixation.

MATERIALS AND METHODS

The study population consisted of 48 patients who underwent arthroscopic SLAP repair. Subjective shoulder scores, range of motion, and strength (postoperative only) were assessed preoperatively and at a minimum of 2 years postoperatively.

RESULTS

At an average of 3.4 years after surgery, statistically significant improvement was seen in American Shoulder and Elbow Surgeons score, University of California, Los Angeles score, Simple Shoulder Test scores, Constant activities of daily living, visual analog scale for pain, and Short Form-12 Health Survey physical outcome scores. Improvements were made in forward flexion, abduction, external rotation, and internal rotation. Subgroup analysis of nonathletes, nonoverhead athletes, recreational overhead athletes, and collegiate overhead athletes showed preoperative to postoperative improvements in subjective outcomes scores. Overhead laborers and nonlaborers also showed preoperative to postoperative improvements in subjective shoulder scores.

DISCUSSION

No differences were seen between the outcomes of nonathletes, nonoverhead athletes, recreational overhead athletes, and collegiate overhead athletes, suggesting that SLAP type II repair is successful independent of the patient's vocation or sport.

CONCLUSION

These results show that arthroscopic SLAP repair of type II lesions with bioabsorbable suture anchors provides a significant improvement in functional capacity and pain relief.

Concomitant arthroscopic SLAP and rotator cuff repair

BACKGROUND

The outcomes of combined arthroscopic repairs of a SLAP (superior labral anterior-posterior) lesion and a rotator cuff tear are not known. We compared the outcomes in a cohort of patients who had undergone concomitant arthroscopic repairs of a SLAP lesion and a rotator cuff tear with those in a cohort of patients with a stable biceps anchor who had undergone an isolated rotator cuff repair. We hypothesized that the results would be similar between the two cohorts with respect to the range of motion and preoperative and postoperative function.

METHODS

Thirty-four patients (average age, 56.9 years) underwent an arthroscopic repair of an unstable SLAP lesion along with a concomitant arthroscopic rotator cuff repair. Twenty-eight patients (average age, 59.6 years) underwent an isolated arthroscopic rotator cuff repair. The average durations of follow-up for the two groups were 40.9 and 42.7 months, respectively. All patients in both groups had a symptomatic full-thickness rotator cuff tear for which initial conservative treatment had failed. Patients with advanced supraspinatus fatty infiltration or advanced muscle atrophy were excluded from the study. American Shoulder and Elbow Surgeons (ASES) and Constant scores were determined preoperatively and postoperatively, as were measurements of the ranges of forward flexion, abduction, external rotation, and internal rotation. Dynamometer strength testing was performed on all patients as an adjunct to qualitative assessments, and normalized Constant scores were calculated to perform sex and age-matched functional assessments.

RESULTS

In the group treated with concomitant repairs of a SLAP lesion and a rotator cuff tear, the average ASES score improved from 22.6 to 96.4 points and the average normalized Constant score improved from 55.1 to 101.0 points. In the group treated with an isolated arthroscopic rotator cuff repair, the average ASES score improved from 34.3 to 92.3 points and the average normalized Constant score improved from 60.7 to 95.8 points. The average preoperative ASES score in the group with the concomitant repairs was significantly worse than that in the group with the isolated rotator cuff repair (p = 0.027). This difference is also probably clinically relevant. There was no significant difference between the groups with regard to the preoperative normalized Constant scores, but postoperatively the normalized Constant score was significantly higher in the group with the concomitant repairs (p = 0.006). The active range of motion did not differ between the groups, preoperatively or postoperatively.

CONCLUSIONS

Controversy surrounds the treatment of a SLAP lesion with concomitant treatment of a full-thickness rotator cuff tear. This study suggests that, in middle-aged patients, the results of combined SLAP lesion and rotator cuff repair can be comparable with those achieved with rotator cuff repair alone.

The effect of rotator cuff tears on surgical outcomes after type II superior labrum anterior posterior tears in patients younger than 50 years

BACKGROUND

Rotator cuff injury in the setting of type II superior labrum anterior posterior lesions is a common finding. Although predictable surgical outcomes can be expected after type II superior labrum anterior posterior repair, the effect of rotator cuff tears on surgical outcome is unknown.

HYPOTHESIS

Rotator cuff tears will not negatively affect surgical outcome of type II superior labrum anterior posterior repairs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The study group included 93 patients younger than 50 years who underwent arthroscopic type II superior labrum anterior posterior repair and were available for review at a minimum of 2 years after surgery. Group 1 patients were identified as having normal rotator cuffs at the time of repair. Group 2 patients were identified as having rotator cuff injury at the time of repair (either partial-thickness or full-thickness tears). Statistical analysis was performed comparing the postoperative University of California, Los Angeles shoulder scores and overall improvement in University of California, Los Angeles score using the Student t test for significance.

RESULTS

Mean follow-up was 2.54 years; 52.7% of patients had evidence of rotator cuff tears at the time of surgery. The mean postoperative University of California, Los Angeles score for group 1 was 32.9 (improvement of 11.0), and the mean postoperative University of California, Los Angeles score for group 2 was 33.3 (improvement of 12.2). There was not a significant difference in any of the outcome measures between groups.

CONCLUSION

Predictable short-term surgical results and return to activity can be expected after repair of type II superior labrum anterior posterior lesions in patients younger than 50 years who have coexistent rotator cuff tear. Although cuff lesions did not have a negative effect on the short-term outcome in patients with type II superior labrum anterior posterior lesions, longer-term follow-up is needed to determine natural history of this pathologic condition.

Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment

Lesions of the superior glenoid labrum and biceps anchor are a well-recognized cause of shoulder pain. Advances in shoulder arthroscopy have led to improvements in recognizing and managing superior labral anterior-posterior (SLAP) tears. Recent biomechanical studies have postulated several theories for the pathogenesis of SLAP tears in throwing athletes and the effect of these injuries on normal shoulder kinematics. Advances in soft-tissue imaging techniques have resulted in improved accuracy in diagnosing SLAP tears. However, the diagnosis of clinically relevant SLAP tears remains challenging because of the lack of specific examination findings and the frequency of concomitant shoulder injuries. Definitive diagnosis of suspected SLAP tears is confirmed on arthroscopic examination. Advances in surgical techniques have made it possible to achieve secure repair in selected patterns of injury. Recent outcomes studies have shown predictably good functional results and an acceptable rate of return to sport and/or work with arthroscopic treatment of SLAP tears.

[Shoulder instability and rotator cuff tear]

A rotator cuff tear as a complication of anterior shoulder dislocation is well known in patients over 40 years old. The incidence of this accompanying injury correlates with the patient's age and the number of redislocations. The tear localization and dimension depend on the patient's age. To what extent these tears are a complication of shoulder dislocation is often unclear, as rotator cuff tears and glenohumeral instability interact. Reports on this combined injury pattern are rare, but based on the patient's age, activity level, and functional demand, therapeutic concepts have been devised. In active patients younger than 60 years and in cases of redislocation, both the rotator cuff tear and the capsule-labrum-ligament lesion should be reconstructed arthroscopically. In lesser active patients age 60 years or older, an isolated rotator cuff reconstruction is often sufficient to stabilize the glenohumeral joint. This treatment concept shows a predominantly good outcome.As a special form of anterior shoulder dislocation, a rotator cuff tear and a plexus brachialis lesion--the"terrible triad of the shoulder"--is described here.