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Background: Neer and Foster’s open inferior capsular shift to treat acquired cases of anteroinferior shoulder instability due to an overstretched and redundant capsule is described with good results. Recently, new arthroscopic techniques were described to manage this problem.

Purpose: To assess the results of a new arthroscopic reinforced inferior capsular shift technique based on Neer and Foster’s open inferior capsular shift.

Study Design: Case series; Level of evidence, 4.

Methods: This new technique of arthroscopic inferior capsular shift was used to treat 108 patients with anteroinferior shoulder instability due to capsular redundancy as confirmed clinically and during arthroscopy. It reduces the size of the redundant capsular pouch and reinforces the thinned-out capsule. Intraoperatively, patients with associated labral tears (n = 25) and patients with open rotator intervals (n = were excluded, and only 75 patients with pure capsular redundancy were included in this study.

Results: Patients were followed for a minimum of 7 years. All 75 patients had patulous and redundant capsules. Three patients (4.0%) had a redislocation after a significant trauma. The range of motion preoperatively was 168.1° ± 7.5° in forward elevation, 64.7° ± 7.9° in external rotation, and T5.0 ± T0.8 in internal rotation. Postoperatively, it was 167.2° ± 5.8° in forward elevation, 59.95° ± 4.9° in external rotation, and T7.1 ± T1.0 in internal rotation. The American Shoulder and Elbow Surgeons (ASES) (70.76 to 97.53; P < .001), Constant (90.02 to 99.24; P < .001), and University of California, Los Angeles (UCLA) (21.97 to 33.84; P < .001) scores demonstrated significant improvement postoperatively.

Conclusion: This novel technique of arthroscopic capsular shift addresses the problem of capsular redundancy present in many cases of anteroinferior shoulder instability. It tries to achieve a capsular shift based on the principles of Neer. The long-term results are very good.

Background: High retear rates of arthroscopic massive rotator cuff repair have been reported with relatively satisfactory functional outcomes.

Purpose: To assess the clinical and radiological outcomes of an arthroscopic repair of massive rotator cuff tears using a suture bridge technique. We also aimed to explore the various factors that may affect retears.

Study Design: Case-control study; Level of evidence, 3.

Methods: Sixty-six patients included in the study were divided into 2 groups according to the presence of retears on magnetic resonance imaging (MRI) evaluation at a minimum of 1 year after surgery. We evaluated the visual analog scale (VAS) for pain during motions, the University of California, Los Angeles (UCLA) score, and the absolute and relative Constant scores (mean follow-up, 25.4 months).

Results: Twenty-eight of the 66 patients (42.4%) in this study had a retear. At the final follow-up visit, pain VAS, UCLA score, and absolute and relative Constant scores in the completely healed group were significantly superior to those in the retear group, with 2, 29.5, 76.0, and 95.2 points and 4, 26.0, 70.6, and 87.3 points, respectively (P < .05). From univariate analysis, the preoperative mean acromiohumeral distance, extent of retraction, and degree of fatty infiltration of the supraspinatus and infraspinatus were significantly different between the completely healed (7.83 mm, 2.97 cm, 1.74, and 0.71, respectively) and the retear group (6.36 mm, 3.97 cm, 2.54, and 2.07, respectively; P < .05). From multivariate logistic regression analysis, the preoperative degree of fatty infiltration of the infraspinatus and extent of retraction were the 2 most important factors associated with retears.

Conclusion: Arthroscopic repair of massive rotator cuff tears using a suture bridge technique has a relatively high retear rate, and these structural failures appear to have a significant difference in clinical outcomes compared with the healed group. Degree of fatty infiltration of the infraspinatus and extent of retraction are the 2 most important factors associated with a retear. Orthopaedic surgeons should predict the possibility of retear before surgery and counsel patients about their expected functional results.

Background: Despite its importance, few studies regarding health-related quality of life (HRQOL) after rotator cuff repair have been reported.

Purpose: To evaluate the outcomes of rotator cuff repair in terms of HRQOL using SF-36 and to analyze factors affecting postoperative HRQOL.

Study Design: Case series; Level of evidence, 4.

Methods: We included 309 patients who were followed-up for a mean 26.3 months (range, 12-48 months) after arthroscopic rotator cuff repair, between November 2004 and August 2008, and who underwent periodic measurement of HRQOL using SF-36 preoperatively, 1 year postoperatively, and at the final follow-up. The correlation between SF-36 and shoulder-specific functional outcome measures (American Shoulder and Elbow Surgeons [ASES], Simple Shoulder Test [SST], and Constant score) was evaluated using correlation analysis, and the relationship between various clinical factors, including rotator cuff healing and HRQOL, was assessed using univariate and multivariate analyses.

Results: The SF-36 scores for physical HRQOL and mental HRQOL showed significant improvement, from 40.40 to 47.53 and from 44.45 to 50.55 at 12 months after surgery, respectively (all P < .001), and improvement was maintained with 48.24 and 50.45, respectively, at the final follow-up (all P < .001). Scores also showed improvement according to all clinical variables, even after stratification of each variable. The correlation between SF-36 and shoulder-specific functional outcome measures was fair to moderate (Pearson correlation coefficients, 0.199-0.528). Various factors had significant effects on preoperative physical and mental HRQOL; however, postoperatively (at 12 months and final follow-up, respectively), only older age (P = .008 and .013), female sex (P = .036 and .043), presence of diabetes (P = .026 and .027), and low level of sports activity (P = .049 at final follow-up) had a negative effect on postoperative physical HRQOL in multivariate analysis, and female sex (P = .010 and .001) was the only factor leading to worse postoperative mental HRQOL.

Conclusion: Arthroscopic rotator cuff repair significantly improved the patients’ HRQOL both physically and mentally. Older age, female sex, diabetes, and low level of sports activity were related to low postoperative physical HRQOL, and female sex was also related to low postoperative mental HRQOL.

Background: Calcifying tendinitis is a common and painful disorder of the shoulder characterized by the presence of calcific deposits in the tendons of the rotator cuff. When nonoperative treatment over a prolonged period of time fails, surgical treatment should be considered. Midterm success rates are inconsistent, and the role of subacromial decompression is still unclear.

Hypothesis: Our hypotheses were that the rate of supraspinatus tears after arthroscopic treatment of calcifying tendinitis is comparable with that in the contralateral uninvolved shoulder and that subacromial decompression does not have beneficial effects compared with calcium removal alone.

Study Design: Case series; Level of evidence, 4.

Methods: In 70 shoulders of 62 patients with a mean age of 54 years, arthroscopic removal of calcium deposits of the supraspinatus tendon was performed. In 44 shoulders, additional subacromial decompression was performed. After a mean follow-up of 6 years (range, 2-13 years), patients were clinically investigated, and function was statistically evaluated using Constant and American Shoulder and Elbow Surgeons (ASES) scores. Affected and contralateral shoulders were examined by ultrasound in 48 shoulders, and rotator cuff tears were documented.

Results: The mean Constant scores of the operated shoulders were significantly lower than those of the healthy shoulders (P < .001). The ASES scores significantly (P < .001) increased after surgery but were still lower than the ASES scores of the healthy shoulders (P < .001). Concerning the additional subacromial decompression, there were no significant differences in the overall ASES and Constant scores; the subitem “pain” was significantly better in the subacromial decompression group (P = .048). Ultrasound examination at last follow-up (48 shoulders) showed a partial supraspinatus tendon tear in 11 operated and 3 contralateral shoulders.

Conclusion: Although the good clinical results after arthroscopic treatment of calcifying tendinitis of the shoulder persist midterm, the affected shoulders present significantly lower clinical scores than healthy shoulders. The rate of partial supraspinatus tendon tears seems to be higher after calcium removal. Additional subacromial decompression seems to reduce postoperative pain.

Background: There are few long-term studies evaluating functional outcomes and rates of arthrosis after arthroscopic Bankart repair with bioabsorbable tacks.

Purpose: We evaluated the clinical and radiographic results of arthroscopic Bankart repair using intra-articular bioabsorbable tacks at a minimum of 10 years’ follow-up.

Study Design: Case series; Level of evidence, 4.

Methods: Thirty-two consecutive patients were retrospectively identified. Twenty patients (63%) were evaluated at a mean follow-up of 13.5 years (range, 10.75-17.5 years) and average age of 43 years (range, 28-73 years). The surgical shoulder (SS) was compared with a healthy control shoulder (CS) in 15 of 20 patients. Outcome tools included the Western Ontario Shoulder Instability Index (WOSI) and Disabilities of the Shoulder, Arm, and Hand (DASH). Blinded, independent evaluators performed physical examinations and reviewed radiographs.

Results: Thirteen patients (65%) had stable shoulders, 5 of 7 (25%) failed by dislocation, and 2 of 7 (10%) failed by signs of anterior instability on examination. Three patients underwent revision stabilization surgery. Average time to failure was 4.2 years (range, 0.25-14.7 years). Average WOSI and DASH scores were 80% and 7.3, respectively. The CS faired better than SS in WOSI scores (97% vs 83%, respectively; P = .008), main DASH scores (0.39 vs 6.79, respectively; P = .024), and the DASH sports module (0.00 vs 10.94, respectively; P = .043). Patients lost 5.9° of passive forward flexion (P = .031) and 4.3° of passive external rotation (P = .001). Forty percent returned to their preoperative sports level. Higher grades of arthrosis were seen in the SS (20% absent, 40% mild, 25% moderate, and 15% severe) versus CS (P = .002).

Conclusion: At long-term follow-up, 65% of patients treated with an arthroscopic Bankart repair using bioabsorbable tacks had a well-functioning, stable shoulder. Disability scores were greatest with sports; however, the majority of patients had well-preserved ranges of motion and good functional WOSI scores. Despite this, 40% had evidence of moderate to severe glenohumeral arthrosis.

Background: The outcome of rotator cuff repair correlates with tendon healing. Early studies of arthroscopic rotator cuff repair demonstrate lower healing rates than traditional open techniques. Transosseous-equivalent repair techniques (suture bridge) were developed to improve the initial fixation strength.

Purpose: To compare the initial in vitro tensile fixation strength of a transosseous-equivalent suture bridge (TOE-SB) rotator cuff repair construct to a traditional transosseous (TO) suture construct.

Study Design: Controlled laboratory study.

Methods: Identical simulated rotator cuff tears were created on 8 matched pairs of humeri. Each matched pair underwent repair with 4 sutures using either the TOE-SB or TO technique. Initial fixation strength was tested in a custom testing jig. Each shoulder underwent 1000 cycles each of low and then high load testing. Gap displacement was measured at anterior and posterior sites of the repair with digital video tracking of paired reflective markers and recorded at predetermined cycle intervals.

Results: There were no statistically significant differences in gap formation at the repair sites under low or high load conditions between TOE-SB and TO techniques. The mean maximal gap formation of the repairs during low load testing in the TOE-SB and TO constructs was 0.93 ± 0.88 mm and 0.55 ± 0.22 mm, respectively (P = .505). The mean maximal gap formation during high load testing in the TOE-SB and TO constructs was 2.04 ± 1.10 mm and 2.28 ± 1.62 mm, respectively (P = .517). The most significant increase in gap distance occurred at the transition from low load to high load in both constructs. Most of the incremental displacement occurred within the first 100 cycles for both high and low load testing (P < .001).

Conclusion: The arthroscopic TOE-SB technique is comparable in initial fixation strength to the traditional TO simple suture repair technique.

Clinical Relevance: Arthroscopic techniques can achieve initial fixation strength comparable with traditional TO techniques performed without suture anchors.

Background: The Snyder classification scheme is the most commonly used system for classifying superior labral injuries. Although this scheme is intended to be used for arthroscopic visual classification only, it is thought that other nonarthroscopic historical variables also influence the classification.

Purpose: This study was conducted to evaluate the intrasurgeon and intersurgeon agreement in classifying variable presentations of the superior labrum and to evaluate the influence of clinical variables on the classification and treatment choices of surgeons.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: A group of arthroscopic shoulder surgeons were asked to rank in order of importance clinical variables considered in diagnosing and treating the superior labrum. The surgeons then watched 50 arthroscopic videos of the superior labrum, ranging from normal to pathologic, on 3 different occasions. The first and third viewings were accompanied by no clinical information. The second viewing was accompanied by a detailed clinical vignette for each video. The surgeons selected a classification and treatment for each video.

Results: A patient’s job/sport, age, and physical examination findings were considered the most important clinical variables surgeons consider during management of the superior labrum. Comparing the 2 viewings without clinical information, surgeons selected a different classification 28.5% of the time from the first to the second time. A different classification was chosen 71.5% of the time when the surgeon was supplied a clinical vignette at the subsequent viewing. Similarly, the treatment selected changed in 36% and 69.1% of cases when viewed again without vignettes and with vignettes, respectively. Intersurgeon agreement was moderate without clinical vignettes and fair with vignettes. Historical, physical examination, and surgical observations were found to influence the odds of change of classification.

Conclusion: There is significant intrasurgeon and intersurgeon variability in classification and treatment of the superior labrum. Clinical historical, examination, and surgical findings influence classification and treatment choices.

Background: Arthroscopic stabilization using suture anchors is widely used to restore stability after anterior shoulder dislocations and is associated with low recurrence rates in short-term follow-up studies.

Purpose: To evaluate the long-term follow-up after arthroscopic stabilization for traumatic recurrent anterior instability using suture anchors with emphasis on both redislocations and subjective shoulder function.

Study Design: Case series; Level of evidence, 4.

Methods: We included 67 consecutive patients with 70 affected shoulders. After 8 to 10 years, patients were asked to report the presence and course of their redislocations. Subjective shoulder function was addressed using the Oxford Instability Score (OIS), the Western Ontario Shoulder Instability Index (WOSI), and the Simple Shoulder Test (SST). Patients rated their health status using the Short Form-36 (SF-36).

Results: Sixty-five patients with 68 affected shoulders (97%) were evaluated for follow-up; 35% reported a redislocation. Median shoulder function scores were 16 of 12 to 60, 22 of 0 to 210, and 12 of 0 to 12 for the OIS, WOSI, and SST, respectively. There was a significant difference in subjective function between patients with and without recurrent instability, respectively, 16 versus 24 for the OIS (P = .004), and 16 versus 47 for the WOSI (P = .05). We found a trend for an inverse relationship between the number of suture anchors and recurrent instability, with 2 having a higher recurrence rate than 3 or more (P = .06). Another trend was found with the presence of a Hill-Sachs defect slightly increasing the risk of a redislocation (P = .07).

Conclusion: With a follow-up of 97%, about one third of the stabilized shoulders experienced at least one redislocation after 8 to 10 years. The presence of a Hill-Sachs defect and the use of less than 3 suture anchors might increase the chance of a redislocation. Patients without a redislocation have a significantly better shoulder function compared with patients with a redislocation.

Background: Platelet-rich plasma (PRP) has been recently used to enhance and accelerate the healing of musculoskeletal injuries and diseases, but evidence is still lacking, especially on its effects after rotator cuff repair.

Hypothesis: Platelet-rich plasma accelerates recovery after arthroscopic rotator cuff repair in pain relief, functional outcome, overall satisfaction, and enhanced structural integrity of repaired tendon.

Study Design: Cohort study; Level of evidence, 2.

Methods: Forty-two patients with full-thickness rotator cuff tears were included. Patients were informed about the use of PRP before surgery and decided themselves whether to have PRP placed at the time of surgery. Nineteen patients underwent arthroscopic rotator cuff repair with PRP and 23 without. Platelet-rich plasma was prepared via plateletpheresis and applied in the form of a gel threaded to a suture and placed at the interface between tendon and bone. Outcomes were assessed preoperatively and at 3, 6, 12, and finally at a minimum of 16 months after surgery (at an average of 19.7 ± 1.9 months) with respect to pain, range of motion, strength, and overall satisfaction, and with respect to functional scores as determined using the following scoring systems: the American Shoulder and Elbow Surgeon (ASES) system, the Constant system, the University of California at Los Angeles (UCLA) system, the Disabilities of the Arm, Shoulder and Hand (DASH) system, the Simple Shoulder Test (SST) system, and the Shoulder Pain and Disability Index (SPADI) system. At a minimum of 9 months after surgery, repaired tendon structural integrities were assessed by magnetic resonance imaging.

Results: Platelet-rich plasma gel application to arthroscopic rotator cuff repairs did not accelerate recovery with respect to pain, range of motion, strength, functional scores, or overall satisfaction as compared with conventional repair at any time point. Whereas magnetic resonance imaging demonstrated a retear rate of 26.7% in the PRP group and 41.2% in the conventional group, there was no statistical significance between the groups (P = .388).

Conclusion: The results suggest that PRP application during arthroscopic rotator cuff repair did not clearly demonstrate accelerated recovery clinically or anatomically except for an improvement in internal rotation. Nevertheless, as the study may have been underpowered to detect clinically important differences in the structural integrity, additional investigations, including the optimization of PRP preparation and a larger randomized study powered for healing rate, are necessary to further determine the effect of PRP.