Recent advances and future trends in shoulder arthroscopy

Arthroscopic Bankart repair combined with remplissage procedure

In a systematic review of the treatment of subcritical glenoid bone loss, the addition of a Hill-Sachs remplissage procedure to anterior labral repair demonstrated favorable rates of recurrent instability and a negligible loss of external rotation when compared with isolated Bankart repair.^[12] At a minimum 10-year follow-up analysis, Bankart repair combined with remplissage showed better functional results (mobility and stability scores) than Bankart repair only without the limitations of pain and restriction of motion.^[13] Finally, a concomitant remplissage procedure did not correlate with subjective patient dissatisfaction.^[14] Newer remplissage techniques involve trans-tendon double-pulley techniques and specialized remplissage knots (double-barrel remplissage) and a tripod-pulley technique [Figure 1].^[15-17]

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Figure 1:

A double-barrel remplissage technique is demonstrated. Trans-tendon anchors are inserted into the Hill-Sachs lesion (left image) and a sliding self-retaining double-pulley knot (double- barrel knot) is used to approximate the infraspinatus into the humeral defect (right image). H: Humeral head, IS: Infraspinatus.

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Open bone grafting procedures

A prospective randomized study analyzed the Latarjet and iliac crest bone graft transfer procedures for the treatment of anterior shoulder instability with glenoid bone loss and found no difference in clinical and radiologic outcomes.^[18] Recent basic science studies have analyzed the restorative possibilities of Latarjet procedures (classic and congruent- arc modifications) and distal clavicular autograft (DCA) procedure for instability-related anterior glenoid bone loss.^[6,19] The classic Latarjet and DCA were suitable for glenoid defects of 20–25% and the congruent-arc Latarjet corrected all articular parameters even in 30–40% defects.

Arthroscopic bone grafting procedures

Open glenoid grafting can now be performed with arthroscopic techniques; several arthroscopic bone grafting procedures have emerged recently and mid-term results are encouraging [Figure 2]. Development of specialized instrumentation and graft fixation devices (cortical button and screws) has made these procedures safe and reproducible. A biomechanical evaluation of graft fixation techniques found that cortical button and screw fixation techniques exhibited comparable biomechanical strength for coracoid bone block fixation.^[20] A more recent analysis suggested that the cortical button fixation did not resist direct loads to the graft as much as traditional screw fixation; however, bony damage to the surrounding anatomy was more extensive in screw fixation.^[21] In a clinical study, button fixation for Latarjet showed higher rates of recurrent dislocation compared to screw fixation.^[22] Newer techniques include arthroscopic iliac crest grafting, implant-free J-bone grafting, and arthroscopic congruent- arc Latarjet procedure.^[23-25] A multicenter analysis of learning curves showed that surgical time in arthroscopic Latarjet significantly reduced after 20 cases; however, complication rates did not decrease over this time.^[26]

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Figure 2:

Arthroscopic Latarjet procedure is shown. G: Glenoid, Co: Coracoid.

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Rotator cuff repairs and healing

Bioinductive scaffolds and arthroscopic delivery techniques are emerging technologies that may enhance healing potential of partial and massive rotator cuff tears. In a preclinical canine model, biological scaffolds augmented healing of articular-sided partial-thickness supraspinatus tears when compared with debridement, and decellularized human dermal allograft and amnion matrix cord scaffolds were found to have advantages over the bovine collagen patch.^[27] A 2-year follow-up of large and massive rotator cuff repairs that were augmented with a bioinductive collagen scaffold patch suggested 96% radiological healing rate and no adverse events attributed to the implant.^[28] In a multicenter prospective study, use of a bioinductive collagen scaffold was found to be safe and effective for intermediate- to high- grade partial-thickness rotator cuff tears of the supraspinatus tendon.^[29]

Rotator cuff repair and autograft augmentation

Biceps autograft augmentation of the repaired rotator cuff has been used to recreate the superior capsular restraint and for simultaneous cuff augmentation during repair. In a large series of massive and potentially irreparable tears, the proximally attached long head of biceps tendon was used as an autograft in specific cases to augment poor quality tissue in posterosuperior tendons.^[30] In a recent study, structural and clinical outcomes of three surgical techniques for massive posterosuperior tears (double-row repair, transosseous-equivalent repair with absorbable patch reinforcement, and Superior Capsular Reconstruction (SCR) with biceps autograft) were analyzed; at 24 months, the infraspinatus tendon remained healed in three-fourths of the repair group and the patch augmented group and in 100% of the biceps autograft group.^[31] Biomechanical evaluation of the biceps autograft for SCR found that the biceps autograft with appropriate distal insertion on the greater tuberosity recentered the humeral head on the glenoid and provided stability in cuff deficiency [Figure 3].^[32]

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Figure 3:

Arthroscopic superior capsular reconstruction and cuff augmentation using the biceps autograft are demonstrated (SS: Supraspinatus, BT: Long biceps tendon).

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Superior Capsular Reconstruction

Arthroscopic superior capsular reconstruction (SCR) has gained popularity and several techniques with different reconstruction tissues are currently in use. Clinical outcomes using a dermal allograft at 2 years have shown successful outcomes in 72%; graft failure was found in 16%; and revision to replacement was necessary in 12% of patients.^[33]

A review of clinical outcomes comparing fascia lata autograft and human dermal allograft in arthroscopic SCR for irreparable rotator cuff tears suggested significant and clinically important improvements in clinical outcomes in both groups; however, the graft tear rate was found to be high (fascia lata autograft 5–32% and human dermal allograft 20–75%.).^[34]

Brachial plexus endoscopy

Lafosse et al. have described an all-endoscopic technique for infra- and supraclavicular brachial plexus (BP) neurolysis and have reported significant functional improvements in the selected patients suffering from non-specific neurogenic thoracic outlet syndrome.^[42] The authors suggest that endoscopy may be an advantageous tool in selected cases of BP nerve sheath tumors and have further reported an all- endoscopic resection of an infraclavicular BP schwannoma.^[43]

Endoscopic proximal humeral plate removal

Implant removal after proximal humerus fracture fixation can be performed endoscopically and may be combined with arthrolysis.^[44,45] These techniques involve endoscopic dissection in the subdeltoid and upper arm region and have several advantages over conventional open removal of implants [Figure 5].

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Figure 5:

Endoscopic proximal humeral plate removal is shown. Careful dissection is performed in the subdeltoid and upper arm region and the axillary nerve (arrow, left image) is identified and protected. The plate is dissected off (arrows, right image) from the humeral head (h) and retrieved through a “plate portal” in the upper arm.

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Scapulothoracic endoscopy

Scapulothoracic endoscopy and scapuloplasty can be performed using a new two-portal technique that uses intraoperative landmarks for accurate orientation.^[46] Arthroscopic management of snapping scapula syndrome yields improvement in pain, crepitus, and range of motion in a majority of patients; however, most patients experience residual symptoms. Lower pre-operative mental status score, longer duration of symptoms, and greater age were associated with poorer outcomes [Figure 6].^[47,48]

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Figure 6:

Scapulothoracic endoscopy is shown. Scapuloplasty and resection of the Luschka’s tubercle (TL) are demonstrated. Inset image shows the portals and position for the procedure.

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Tendon transfers

Endoscopic harvest and transfer of tendons (latissimus dorsi, teres major, and pectoralis minor) have been described by several authors and are a minimally invasive alternative to open surgery.^[49-51]