1. Revise failed arthroscopic stabilization of the shoulder.

2. Perform footprint reconstruction for arthroscopic rotator cuff repair.

3. Incorporate an understanding of biologic, mechanical, and clinical issues in considering double-row repairs.

4. Employ effective exposure techniques in primary and revision shoulder arthroplasty.

5. Remove cement and include allograft strut fixation in revising failed shoulder arthroplasties.

Revision Surgery for Failed Arthroscopic Stabilization: Operative Findings and Treatment
Jeffrey S. Abrams, MD, Clinical Associate Professor, Department of Orthopaedic Surgery, Seton Hall University School of Health and Medical Sciences, South Orange, NJ

Introduction: arthroscopic repair new gold standard (replacing open approach); anticipate treating patients for whom arthroscopic stabilization unsuccesful; failure rates should be <10% if patients carefully selected and tissue allowed to heal with rehabilitation and protective activities; examine patient to determine—nature of recurrence of instability, pain, functional deficits, and additional complications

Findings associated with failure: avulsion of soft tissue, with adherence to medial glenoid neck; further glenoid rim loss; larger Hill-Sachs lesions; failures of fixation (sutures broken or pulling through; failed eyelets of anchor); pouch (recreation or nonablation); capsular tears; hardware complications

Glenoid rim injuries: gradual erosion of Glenoid neck from repetitive instability; fractures; injuries possibly caused by stress risers, multiple holes, or absorbable anchors

Engaging Hill-Sachs lesion: combined humeral head and glenoid rim injuries; arm more neutral, elbow down below, and minimal external rotation; need to retension tissue—anatomic labral repair may not be adequate

Hardware complications: exposed suture anchor with damage to humeral head; suture knot rubbing on articular surface (possible placement of knot down anchor post, not soft tissue post; requires early intervention to avoid serious complications)

Capsular tear: midsubstance tear after medial repair; humeral avulsion of glenohumeral ligament (HAGL) lesion; in addition—capsular ablation from thermal damage

Cartilage problems: from exposed hardware; absence of articular cartilage (chondrolysis) associated with thermal or pain pump therapy

Patient evaluation (failed repair): obtain operative report from previous surgery—evaluate treatment and findings; etiology—traumatic etiology indicates favorable prognosis; with minimal trauma, speaker more pessimistic; time interval between surgery and recurrence—longer interval indicates better repair; other considerations—patient’s sport; range of motion; provocative postures and apprehension; imaging—magnetic resonance imaging (MRI) helpful

Indications for arthroscopic revision: over-the-head sport injury; traumatic injury in contact sport; evidence in previous operative report indicating potential for improvement; moderate bone loss

Technical pearl: use mattress suture pattern in inferior quadrant, with anchor on glenoid corner (rather than face)

Consider open Bankart repair: failed arthroscopic Bankart repair; HAGL lesion next to axillary nerve; some bone loss injuries; sports associated with greater capsular injuries; in bone grafting—capsular deficiency from thermal therapy; in front of glenoid (extra-articular or intra-articular); humeral head reconstruction

Conclusion: when patient presents, consider whether to repeat arthroscopic procedure or switch to open approach; allow adequate time for tissue healing after revision

Footprint Reconstruction for Arthroscopic Cuff Repair
Stephen S. Burkhart, MD, Clinical Associate Professor of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio

Double-row repair: speaker originated ≈10 yr ago to reduce floppy tendon during one routine surgery; results led to regular use; rationale—improved fixation strength; broader anatomic footprint contact

Guiding principle: biologic modalities no substitute for mechanical fixation

Anatomy of footprint: 12 mm average, medial to lateral; large-to-small range, 21 to 12 mm

Suture passing: retrograde approach—sutures enter cuff at angle, placing suture more medially on bursal than articular aspect (may lead to medial cuff disruption); may be only option in poor tissue; antegrade approach—for double-row repair; variety of antegrade passers available; passes suture at right angle to fibers of tendon (uniform tensioning from superficial to deep layers)

Improved methods: simplify double-row; transosseous equivalent—bridging sutures from medial to lateral; row of anchors medially; knotless anchors laterally; ultimate failure load significantly higher than with double-row; chain-link suture—screw-in anchor provides firmer fixation in soft bone; testing found yield load (suture begins to pull through tendon) close to ultimate load (catastrophic failure), demonstrating strong self- reinforcing construct

Self-reinforcing construct: as failure begins, construct harnesses deforming force into reinforcing force; resembles Chinese finger trap (trying to pull it apart makes it tighter)

Transosseous equivalent reconstruction: as muscle-tendon unit loaded, rectangular suture construct between medial and lateral anchors becomes parallelogram, compressing tissue below parallelogram; converts higher normal force into higher frictional force; wedges tendon between bone and suture construct

Diamondback contructs for larger tears: use double-needle passer to create repeating pattern of 2 anchors medially and 2 laterally; staggered criss-cross sutures resemble diamondback rattlesnake; provides good footprint reconstruction; center of reconstructed area (compression) stays in center of footprint over time

Mechanical, Biologic, and Clinical Issues of Double-row Repair
Robert A. Pedowitz, MD, PhD, Professor and Chair, Department of Orthopaedics and Sports Medicine, University of South Florida College of Medicine, Tampa

Biologic issues: healing—normal tissue does not tear; goal to get abnormal tissue to heal; retraction—torn tendon retracts under force of muscle; must manage resulting gap; muscle abnormally stiff; residual gap— between tendon and bone; biology cannot compensate for gap

Mechanical issues: secure fixation necessary—inadequate fixation leads to persistent tear or retear; patient factors—bone quality; tendon quality; muscle retraction; fat

Surgical principles: understand tear; determine method of fixation; remove offensive bone, eg, spurs; mobilize tendon; initiate healing response; fix securely; control rehabilitation

Optimize stress on repair: understand tear pattern

Minimize tension mismatch: often requires diagonal reduction

Side-to-side sutures: to offload tension at bone–tendon interface (with anchors); with range of motion, tension within cuff (and repair tension) not uniform; gap not uniform

Balance matters: first suture under peak tension weak link (initiating zipper effect); when cuff weak link, it fails in incremental fashion; optimize stress on repair

Bone: stimulating healing response requires punctate bleeding; preservation of cortical bone critical; anchors buried in weaker bone (suture might cut through; anchor can shift); newer anchors purchase cortical bone

Very strong sutures: improve load-to-failure; knot must be tied adequately

Double-row repair: intended to provide better fixation, improve surface healing of tendon to bone, and optimize clinical results

Challenge: tendon does not usually shear directly off bone; tears occur medial to footprint; bleeding induced by debriding footprint; consequently—edge may not belong laterally over footprint; if edge pulled over footprint, tendon may not match adjacent intact tendon; with retracted tear, may not be possible to pull edge over footprint without placing intense strain on tendon at bone

Speaker’s laboratory study: found no difference in gap formation or load-to-failure between double- and single-row repair; newer contructs—gap formation no better; higher load-to-failure

Clinical results: prospective controlled studies found no difference in outcome between single- and double- row repair

Speaker’s algorithm: current constructs improving, but uncertain whether this will cause improved clinical results

Pattern: think diagonal and side-to-side; take time to understand tear pattern to minimize tension on repair; balance repair

Three tear patterns

Small tear with minimal retraction: any repair likely successful

Medium tear with little retraction and low tension: double-row repair applicable; perform medial repair near articular surface; partial repair to restore couples; consider no repair

Large retracted tears: dragging out to footprint requires high tension

Exposure Techniques for Primary and Revision Arthroplasty
Sumant G. (Butch) Krishnan, MD, Attending Orthopaedic Surgeon, Shoulder Service, W.B. Carrell Clinic, Dallas, TX

Subscapularis: necessary to understand biology of this tendon to reproduce its functional integrity; shaped like human ear; can generate 250 N of force in full internal rotation (strongest muscle surrounding glenohumeral articulation); intact subscapularis may lack function (from denervation after operation or from osteoarthritic contraction); normal subscapularis controls and depresses humeral head

Deltopectoral approach: 3 possible ways of handling subscapularis

Tendon-to-tendon repair: classic technique used in open surgery

Tendon sleeve: tendon released in periosteal fashion from insertion on lesser tuberosity

Osteotomy: subscapularis not violated; releases bony insertion on lesser tuberosity

Biomechanical investigation: involved 15 cadaveric shoulders; tenotomy group—classic midtendon tenotomy; osteotomy group—removed small fleck of bone just medial to bicipital groove (tendinous insertion of subscapularis); released rest of subscapularis muscle in sleeve; single- and double-row repairs performed; findings—removing bone with subscapularis better than cutting tendon; with double-row repair, no gross rotational motion of bone fleck

Clinical applications: review of 100 consecutive primary repairs, using method above; findings—>80% of patients had normal shoulder kinematics; performed lift-off and belly-press tests; in internal rotation, patients able to tuck in shirt and reach second level of shelf; radiographically, healing anatomic in 97% of cases (3% healed to humeral shaft); conclusion—deltopectoral approach enables restoration of subscapularis function

Revision arthroplasty with implant removal: high potential for iatrogenic injury due to—humeral bone loss; neurovascular injury; osteopenic bone; poor soft tissues; 3 questions—how to remove implant; how to remove cement; how to reconstruct; humeral “episiotomy”—similar to extended trochanteric osteotomy of femur in hip arthroplasty; split humerus “like a book” to access medial and lateral aspects; removing cement—use power reamers (as in hip); avoid dangerous ultrasonic devices that “melt cement”

Reconstructing lost bone: allograft strut fixation—19 consecutive patients studied; bone augmented with freeze-dried tibial allograft cortical struts; findings—strut incorporated in ≈90% of patients at 6-mo follow- up; technique used in tumor surgery

Avoiding nerve damage: simple and reproducible approach includes 1) identify and demystify nerve; 2) split humerus in controlled fashion; 3) drill and ream cement mantle; 4) strut graft when necessary