The long head of the biceps tendon is a valuable autologous tissue for biologic augmentation in rotator cuff repair. Redirecting the long head of the biceps tendon can enhance its role as a humeral head depressor, limiting superior humeral head migration, and improving rotator cuff force couple and shoulder biomechanics. Incorporating the long head of the biceps tendon into the rotator cuff repair construct can enhance the repair by acting as a biologic internal brace, promoting load sharing and improving structural integrity. This technique may improve healing, repair durability, and functional outcomes, especially in large or revision tears with poor tissue quality.

Background:With the increasing popularity of shoulder arthroplasty, indications and usage has expanded to younger more physically active patients. Limited knowledge exists on return to outdoorsman sports after shoulder arthroplasty. Purpose:To determine return to outdoorsman sports, including fishing, shooting, archery, and rowing, after primary total shoulder arthroplasty at a minimum 2-year follow-up. Study Design:Case series; Level of evidence, 4. Methods:A retrospective study was performed on patients who underwent primary reverse or anatomic total shoulder arthroplasty between 2012 and 2022 who participated in outdoorsman sports, including fishing, shooting, archery, and rowing, with a minimum 2-year follow-up. Questionnaires were expanded to explore patients' preoperative and postoperative activity with regard to outdoorsman sports. Patient-reported outcomes (PROs), including visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES), and Subjective Shoulder Value, as well as active range of motion including forward flexion, external rotation, internal rotation, were collected pre- and postoperatively. Results:A total of 102 patients met study criteria and responded. Overall, 77% returned to outdoorsman sports, with 80%, 85%, 50%, and 68% returning to fishing, shooting, archery, and rowing, respectively. Of those who returned, 86% reported being mostly or completely satisfied with their performance postoperatively, with 77% reporting a return to at least the same level of activity. Among those who returned, 61% did so within 6 months postoperatively. Patients from all sports showed significant clinical improvement in forward flexion (P≤ .003), external rotation (P≤ .006), and PROs (P≤ .006) at a mean postoperative follow-up of 38 ± 12 months. Between sports, postoperative VAS (P = .04) and ASES (P = .03) values were significantly different, with shooting showing lower ASES (83) and higher VAS (1.5) scores, despite demonstrating the highest return rate (85%). When considering arm dominance, return rates were comparable between patients who had surgery on their dominant arm and those treated on their nondominant arm across each sport. Conclusion:Participants had a 77% return to outdoorsman sports, such as fishing, shooting, archery, and rowing, with >50% doing so within 6 months of primary total shoulder arthroplasty. Respondents who participated in rowing and archery returned at lower rates compared with fishing and shooting, despite shooting's showing higher pain postoperatively. Activities entailing greater shoulder demands may hinder a patient's ability to return after arthroplasty.

Background: Guidelines on return to wildlife sports including fishing, shooting, and archery after arthroscopic rotator cuff repairs (ARCRs) and shoulder arthroplasty are lacking. This study seeks to characterize surgeons' postoperative return to sport protocols for ARCR and shoulder arthroplasty with common wildlife sports such as fishing, shooting, and archery. Methods: One hundred and eighty-two fellowship-trained shoulder surgeons who are members of the PacWest Shoulder Study group were sent a Google Forms survey containing 7 global questions (with 5 sub questions each) specific to the return to wildlife sports after shoulder surgery. Responses to categorical variables were displayed as percentages and fractions. Results: Eighty-one (44.5%) of the 182 surgeons responded. Overall, no surgeons would apply a lifelong restriction on fishing, but 20 (24.7%) surgeons would limit casting techniques with massive rotator cuff tears. All 81 (100%) surgeons would allow their patients to return to shooting handguns, but 2 (2.5%)-5 (6.2%) surgeons respectively would prohibit returning to shooting shotguns and rifles after arthroplasty. Twenty-seven (33.3%) surgeons would delay return to archery until after 6 months for massive rotator cuff tears. In both the massive tear and reverse total shoulder arthroplasty groups, surgeons would limit bow weight restrictions to less than 18 kg (40 lbs) (22; 27.2%). The massive rotator cuff tear group was more often restricted to return within 6 months or later in all sports (fishing (75; 92.6%), handgun (70; 86.4%), shotgun (77; 95.1%), rifle (77; 95.1%), and archery (70; 86.4%)). Conclusion: Patients can have a high expectation of return to wildlife sports following shoulder surgery. Surgeons are most restrictive in return to wildlife sports following ARCR of massive tears.

Background:Shoulder pain following intramuscular administration of vaccine is common. However, a small number of patients experience prolonged pain and dysfunction atypical to normal transient postvaccination shoulder pain. Shoulder Injury Related to Vaccine Administration (SIRVA) remains incompletely understood, whether a robust immune response to vaccine antigen or inappropriate injection technique with needle placement in synovial or bursal tissue, or some combination of the two. Symptoms overlap with those of Cutibacterium acnes (C. acnes) infection but the relationship between the two, if any, has not been evaluated.Methods:Clinical case files were reviewed for 3 cases of SIRVA with positive cultures for C. acnes were reviewed. Presentation, treatment, and clinical outcomes were compared.Results:In all cases, patients were thin (body mass index < 23), females, who had high injection placement of a vaccine, all patients had positive magnetic resonance imaging findings of increased signal in the subacromial bursa, and/or greater tuberosity. All patients underwent arthroscopic débridement and culture harvest and cultures were positive for C. acnes. A combination of oral and intravenous antibiotics was used, and all patients demonstrated clinical improvement from the preoperative state.Discussion:This case series presents 3 patients with refractory SIRVA who ultimately underwent arthroscopic irrigation and débridement with culture biopsy. Each case had culture results positive for C. acnes and all responded, at least partially, to arthroscopic débridement and intravenous antibiotic therapy. The purpose of this manuscript is to raise awareness of potential coexistence of SIRVA and C. acnes which may be of assistance to surgeons treating refractory cases of SIRVA.

Treatment of full-thickness rotator cuff repairs vary in surgical technique depending on many factors including tear geometry, delamination of soft tissue, tissue quality, and rotator cuff retraction. The described technique presents a reproducible method of addressing tear patterns where the tear may be larger laterally, but the medial footprint exposure is small. This can be addressed with a single medial anchor combined with a knotless lateral-row technique to provide compression for small tears or two medial row anchors for moderate to large tears. In this modification of the standard knotless double row (SpeedBridge) technique, 2 medial row anchors are used, with 1 augmented with additional fiber tape and an additional lateral row anchor to create a triangular repair construct, increasing the size and stability of the footprint of the lateral row.

Discoid lateral meniscus (DLM) presents with differing pathoanatomy and may exhibit various types of tears. The treatment strategy is based on the presence and location of instability as a result of deficient capsular attachment. Recently, meniscal stabilization after saucerization has been recommended for DLM to preserve the meniscus shape, prevent extrusion, and mitigate against the progression of osteoarthritis. In addition to stabilization, the resection volume is important to prevent osteoarthritic changes. Although there was no tear and no displacement of the lateral meniscus on magnetic resonance imaging, some DLMs were found to have tears and peripheral instability during arthroscopy. Therefore, the assessment of peripheral instability during surgery is very important to achieve a desirable clinical outcome. This Technical Note describes an arthroscopic technique for anterior peripheral stabilization of the DLM, in which we highlight the surgical procedure for repair of the anterior horn, reassess the instability around the popliteal hiatus after the anterior horn is repaired, and the stabilization of the posterior horn, if necessary.

Treatment options for massive irreparable rotator cuff tears continue to evolve. Recently bursal acromial reconstruction (BAR) has been described as an additional option to reduce pain and improve comfort. As originally described, an acellular dermal allograft is secured to the underside of the acromion as an interposition graft. We describe a modified technique that facilitates suture passage, reduces entanglement, and optimizes contact between the bone-graft interface.

The middle glenohumeral ligament (MGHL) is well recognized as a primary stabilizer of the shoulder. Its role in shoulder pathologies such as adhesive capsulitis, subscapularis tendon tear, and glenohumeral arthritis is less understood. Biomechanically, the MGHL plays an important role in range of motion, specifically involving normal and pathologic external rotation in less than 45° of abduction. In this Technical Note, we present a technique for arthroscopic release of the MGHL in the setting of a stable shoulder with preoperative loss of external rotation and a patient at risk for postoperative restriction of external rotation.

Background: Acellular dermal matrix (ADM) allografts are commonly used in the surgical treatment of complex and irreparable rotator cuff tears. Multiple studies report that superior capsule reconstruction (SCR) using ADM has resulted in short-term clinical success as assessed via radiographic and patient-reported outcomes. However, limited information is available regarding the biologic fate of these grafts in human subjects. This case series describes histologic results from 8 patients who had reoperations, during which the previously implanted ADMs were removed. These explanted ADMs were subjected to histologic analysis with the hypothesis that they would have evidence of recellularization, revascularization, and active remodeling. Methods: Eight patients, 38-82 years old, underwent reoperation 6-38 months after undergoing SCR. ADM explants were voluntarily shipped to the manufacturer for histologic analysis. Each graft's structure and composition were qualitatively evaluated by 1 or more of the following histologic stains: hematoxylin and eosin, safranin O, and Russell-Movat pentachrome. Pan-muscle actin staining also assessed the level of neovascularization, potential myoblast or myocyte infiltration, and muscle tissue development in the graft, and was analyzed to determine the proportion of graft that had been recellularized in situ. Results: Grafts showed varying levels of gross and microscopic incorporation with the host. An uneven, but high, overall degree of recellularization, revascularization, and active remodeling was observed. The degree of remodeling correlated with implant duration. These results are consistent with successful biologic reconstruction of the superior shoulder capsule. Conclusions: The present histologic analysis suggests that ADMs used in SCR undergo active recellularization, revascularization, and remodeling as early as 6 months after implantation, and that graft recellularization positively correlates with duration of implantation. These results represent a significant advancement in our knowledge regarding biologic incorporation of ADMs used in SCR. (C) 2021 The Author(s).

Preservation of the meniscus has been shown to influence the progression of osteoarthritic changes in the knee. Discoid lateral meniscus (DLM) is classified on the basis of the presence and location of instability resulting from deficient capsular attachments. Recently, meniscal stabilization after saucerization was recommended in cases of DLM to preserve the meniscus shape and avoid the progression of osteoarthritis. However, it is difficult to identify the accurate resection volume and residual meniscal width during surgery, especially when there is an anterocentral shift of the DLM. This Technical Note describes an arthroscopic technique for an anterocentral shift of the DLM in which we highlight the resection point and confirm the methods of retaining an adequate volume of residual meniscus to restore and maintain the shape and function of the meniscus.

Rotator cuff tears involving the musculotendinous junction with a significant amount of tendon still attached to the footprint laterally represent a challenging scenario for shoulder arthroscopists. Because of these challenges, adjunctive techniques to bridge tissue gaps may be required, and biologic augmentation may be considered to improve the healing environment. The following technique presents a stepwise approach to accomplishing the dual goals of a stable anatomic repair and biologic augmentation of this difficult pattern of rotator cuff pathology.

Arthroscopic rotator cuff repairs (ARCRs) are common procedures that have been increasing in incidence. When performing ARCR, the surgeon often identifies an undesirable flap or fold, referred to as a "dog-ear" deformity, between sutures or knots. The height and/or thickness of a dog-ear deformity may decrease the rotator cuff-to-acromion distance, resulting in possible impingement and repair compromise. Furthermore, the goal of ARCR is to achieve complete restoration of the tendon-to-footprint relation. To restore the entire footprint, this lesion must be reduced and stabilized. We present a technique using looped sutures to augment the rotator cuff repair and prevent dog-ear formation.

Superior capsular reconstruction (SCR) is increasingly being used as a procedure for addressing irreparable rotator cuff tears. The procedure was initially described for failed rotator cuff repairs where the retears are severely retracted and when grade 3-4 fatty infiltration and atrophy exist. The SCR procedure can also be considered for irreparable rotator cuff tears in patients that are either too young or too high demand to be appropriate candidates for arthroplasty. Early short and medium term follow up studies support SCR with favorable outcomes compared with other salvage procedures.

Treatment of full-thickness rotator cuff tears vary in surgical technique dependent on the amount of retraction of the rotator cuff and/or delamination of the soft tissue. The described technique addresses both of those concerns. We present a modification of the SpeedBridge technique used to address retracted or delaminated repairs and effectively expand the indications for use of the double-row knotless technique. In this modification, the reduction is performed by an initial anchor with several stay sutures providing provisional reduction of the tissue in a controlled fashion. This is followed by compression through a standard double-row technique.

The history, physical examination and diagnosis of long head biceps tendon (LHBT) lesions is challenging. The LHBT has both intra-articular and extra-articular components, often engages only in specific arm positions and activities, takes a long oblique course across the shoulder joint and is adjacent to and associated with other critical structures around the glenohumeral joint. Previous reviews have described the limitations of examination and diagnosis of the LHBT through various modalities. The purpose of this review is to summarise the current tools available for LHBT diagnosis, assess their effectiveness and discuss emerging techniques to improve diagnostic accuracy. Directions for future study are described to improve preoperative planning and intraoperative detection of LHBT pathology.

The shoulder can humble you. It is often challenging in determining the extent of pathology even when there is an adequate magnetic resonance imaging performed preoperatively and even during the so-called diagnostic portion of the arthroscopy. Abnormalities of the long head of the biceps tendon and the rotator cuff especially the subscapularis can be difficult to diagnose definitively. Experience can be very helpful in predicting pathology based on patterns seen before and knowing certain pearls that can make diagnosis and ultimately treatment more accurate.

Shoulder stiffness can be caused by various etiologies such as immobilization, trauma, or surgical interventions. The Upper Extremity Committee of ISAKOS defined the term “frozen shoulder” as idiopathic stiff shoulder, that is, without a known cause. Secondary stiff shoulder is a term that should be used to describe shoulder stiffness with a known cause. The pathophysiology of frozen shoulder is capsular fibrosis and inflammation with chondrogenesis, but the cause is still unknown. Conservative treatment is the primary choice. Pain control by oral medication, intra-articular injections with or without joint distension, and physical therapy are commonly used. In cases with refractory stiffness, manipulation under anesthesia or arthroscopic capsular release may be indicated. Because of various potential risks of complications with manipulations, arthroscopic capsular release is preferred. After the capsular release, stepwise rehabilitation is mandatory to achieve satisfactory outcome. Level of Evidence: Level V, evidence-based review. The members of the Upper Extremity Committee of ISAKOS met in Amsterdam in May 2014 to create a consensus statement on the definition, classification, and treatment of the stiff shoulder. A detailed analysis was published in the monograph titled “Shoulder Stiffness: Current Concepts and Concerns.” This manuscript provides a summary of this meeting. Classification and Epidemiology The term “frozen shoulder” was coined by Codman to describe “many conditions which cause spasm of the short rotators or adhesions about the joint or bursae.” Previous authors have divided joint stiffness into intrinsic and extrinsic causes. Because of its unique position, the capsule is the structure most at risk of developing a contracture. Primary capsular pathology has a specific cause, treatment, and prognosis; thus, it is considered as a separate category. Our definitions are as follows: Stiff Shoulder This global term should be used to describe a patient who presents with a restricted range of motion. The etiology can be due to primary or secondary causes. 1. Frozen shoulder or primary idiopathic stiff shoulder. This term should be used exclusively to describe the primary idiopathic stiff shoulder. It develops without any trauma or specific shoulder disease period. If a patient has a condition that may be linked to a stiff shoulder, but not known to specifically cause the stiffness, it will still be considered idiopathic. Examples include predisposing factors such as diabetes, thyroid conditions, Dupuytren contracture, smoking, etc. From the Department of Orthopaedic Surgery, Tohoku University School of Medicine (E.I.), Sendai, Japan; Department of Orthopaedic Surgery, Instituto Argentino de Diagnóstico y Tratamiento (G.A.), Buenos Aires, Argentina; Department of Orthopedic Surgery, Flinders University (G.I.B.), Adelaide, South Australia, Australia; Sports Medicine Center, Department of Orthopaedic Surgery, University of Groningen (R.L.D.), Groningen, the Netherlands; Taos Orthopaedic Institute, Shoulder and Elbow Service (D.G.), Taos, New Mexico, U.S.A.; Department of Orthopaedic Sports Medicine, University of Munich (TUM), Hospital Rechts der Isar (A.B.I.), Munich, Germany; Department of Orthopaedic Surgery, UConn Musculoskeletal Institute (A.D.M.), Farmington, Connecticut, U.S.A.; Shoulder & Elbow Center, Funabashi Orthopaedic Hospital (H.S.), Funabashi, Chiba, Japan; and Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital (Y-S.Y.), Gyeonggi-Do, Republic of Korea. The authors report the following potential conflicts of interest or sources of funding: G.A. receives support from Mitek Sports Medicine. D.G. receives support from Arthrex, Pacira, Smith & Nephew, Donjoy, Breg, Stryker, Medacta, and Holy Cross Hospital. A.B.I. receives support from Arthrex, Arthrosurface, and Medi Bayreuth. E.I. receives support from ALCARE. A.D.M. receives support from Arthrex. Received January 13, 2016; accepted March 10, 2016. Address correspondence to Eiji Itoi, M.D., Ph.D., Chair of the Upper Extremity Committee, ISAKOS, Professor and Chair, Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan. E-mail: itoi-eiji@med.tohoku.ac.jp ! 2016 by the Arthroscopy Association of North America 0749-8063/1642/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.03.024 1402 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 32, No 7 (July), 2016: pp 1402-1414 Downloaded from ClinicalKey.com.au at Royal Australasian College of Surgeons JC August 23, 2016. For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved. 2. Secondary stiff shoulder. This term should be used to describe shoulder stiffness with a known cause, such as a stiff shoulder after trauma or surgery. Adhesive Capsulitis This term is not recommended, as it does not reflect the pathologic processes present. Normal movement of a joint requires all components of the motor and lever system to be functional. Abnormal joint motion is the result of pathologic changes to normal anatomic structures. The pathologic process that creates a decreased range of motion of the shoulder is the sum of the premorbid state, the initial insult, the healing response, and the secondary changes that occur with time. The ISAKOS Upper Extremity Committee developed a classification that divides the causes of secondary stiff shoulder into 4 groups: intra-articular, capsular, extra-articular, and neurologic causes. 1. Intra-articular causes such as chondral lesions, labral tears, synovitis, or loose bodies can all be managed with articular surgery, such as arthroscopic debridement or repair. 2. Capsular causes include contracture after capsular injury or immobilization. Capsular release or resection can be performed as an open or arthroscopic procedure. If this is an isolated capsular pathology, then the prognosis is good. 3. Extra-articular causes include muscle tightness, heterotopic ossification, or skin contracture from burns. A localized lesion can be managed with an extra-articular resection or release of the offending structures. The prognosis is usually good. 4. Neurologic causes need treatment directed to the primary neurologic disorder. The incidence of frozen shoulder is 2% to 5% of the general population. It affects 3.38 women and 2.36 men per 1,000 person-years. In a study in the Brazilian population on 88 stiff shoulder patients, ofwhom52.3%were female,with amean age at onset of 50.5 years, therewas a familyhistory of thedisease in9.5%of thepatients.Males with frozen shoulder are at greater risk for longer recovery and greater disability. Frozen shoulder can present bilaterally, especially in diabetics, but it rarely affects the same shoulder twice. The cause of frozen shoulder is not clearly understood. Comorbidities are present in 85% of the patients with a frozen shoulder, and 37.5% had more than 3 comorbidities. Multivariate analysis identified thyropathy (especially hypothyroidism), diabetes, nephrolithiasis, and cancer being statistically significant. Other possible factors related to stiff shoulder include Parkinson disease, Dupuytren contracture, immobility, smoking, and neck and cardiac surgery. Frozen shoulder has a strong association with diabetes mellitus (Table 1).

Shoulder stiffness can be caused by various etiologies such as immobilization, trauma, or surgical interventions. The Upper Extremity Committee of ISAKOS defined the term “frozen shoulder” as idiopathic stiff shoulder, that is, without a known cause. Secondary stiff shoulder is a term that should be used to describe shoulder stiffness with a known cause. The pathophysiology of frozen shoulder is capsular fibrosis and inflammation with chondrogenesis, but the cause is still unknown. Conservative treatment is the primary choice. Pain control by oral medication, intra-articular injections with or without joint distension, and physical therapy are commonly used. In cases with refractory stiffness, manipulation under anesthesia or arthroscopic capsular release may be indicated. Because of various potential risks of complications with manipulations, arthroscopic capsular release is preferred. After the capsular release, stepwise rehabilitation is mandatory to achieve satisfactory outcome.