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Overlap endoscopic SLAP lesion repair
Abstract
The fixation of the superior labrum using the punch-chop needle overlap technique (Aeratec Inc, Uniondale, NY) for reattaching torn labral tissue to bone allows ease of suture placement for type II SLAP lesion repair with fixation overlapping the superior rim of the glenoid and without the use of anchors. The technique presented includes preparation of the superior glenoid rim, drilling of the glenoid tunnels for the punch needles, and peripheral suturing of the labrum.
... In der Literatur finden sich zahlreiche arthroskopische Techniken zur Refixation des Labrum-Bizepssehnen-Komplexes [9,11,14,18,20,22,24,33,38,41,44,46,49,51,57,60,62]. Die früher durchgeführte arthroskopische Over-the-top-Naht [22] ...
Our understanding of the conditions that affect the throwing shoulder continues to evolve. Surgical techniques also have advanced, and the arthroscopic repair of rotator cuff tears, superior labrum anterior to posterior (SLAP) lesions, and capsular ligament attenuation is now possible.
OBJECTIVE. The purpose of this study was to evaluate the clinical performance of newly implemented dynamic MR dacryocystography.CONCLUSION. Dynamic MR dacryocystography, which requires neither ionizing radiation nor chemical contrast media with high viscosity, may be a useful tool for depicting nasolacrimal obstructions.
Partial-thickness articular-surface rotator cuff tears in overhead throwing athletes have been previously described,and the most commonly reported treatment method has been arthroscopic debridement. As arthroscopic techniques have evolved, methods for a minimally invasive anatomic repair have become possible.
A new arthroscopic approach for traumatic instability has been developed with which avulsed capsulolabral tissue can be effectively attached to the glenoid articular rim with sutures, providing anatomic reattachment and effective deepening of the glenoid concavity similar to that achieved by open repair. This technique does not depend on fixation devices, trans-scapular drilling, or implantation of suture anchors. The fixation of the labrum using the punch-chop needle overlap technique (Aeratec Inc, Uniondale, NY) for reattaching torn labral tissue to bone allows ease of suture placement for Bankart lesion repair, with the fixation overlapping the rim of the glenoid. The technique presented here includes preparation of the glenoid rim, drilling of the glenoid tunnels, and peripheral suturing of the labrum.
Despite enormous advances in cross-sectional imaging over the past few decades, radiography remains the main-stay of diagnosis and evaluation of scoliosis. Knowledge of technical factors, measurement error, and measurement techniques is important in the comparison of serial radiographs and affects surgical decision making. This article focuses on adolescent idiopathic scoliosis as a framework for understanding the general concepts in the radiographic evaluation of the scoliotic spine.
Injuries of the shoulderjoint are frequent, particulary at athletes in throwing disciplines. In the last few years especially lesions of the labrum glenoidale and first of all the so called SLAP-lesion (superior labrum anterior and posterior lesion) came into the focus of sportsorthopaedics. In this study, in a first part, the labrum glenoidale was examined for the presence of nerval tissue, by using immunohistological methods (RT97) and the goldchlorid staining of de Crinis. The results showed no nerval structures into the labrum itself, but in the area of the exterior fibrous capsule. The second part proved, by a clinical outcome-study of 30 patients, that arthroscopic refixation of the labrum using resorbable tacks or suture-anchors showed a excellent outcome. It also showed, that most patients were satisfied with the treatment. Because of this the method is hihgly recommanded for the treatment of SLAP-lesions.
Objective:
Double-bundle and selective-bundle anterior cruciate ligament (ACL) reconstructions are increasingly performed to better reproduce the double-bundle anatomy of the native ACL and to improve knee stability and surgical outcomes. This article illustrates how to optimize visualization of the ACL bundle anatomy and the appearances of graft components and postoperative complications.
Conclusion:
It is important for the radiologist to be familiar with the appearance of double-bundle and selective-bundle ACL reconstructions and associated complications.
The use of a double-looped 5-mm Corkscrew anchor (Arthrex, Naples, FL) enables the surgeon to use a single anchor to perform a secure fixation of both the anterior labrum as well as the biceps insertion in a type II SLAP lesion. The technique involves tying 1 knot through the anterior portal and a second knot through the posterior portal.
Internal impingement is a primary cause of shoulder pain in throwers; however, instability, internal rotation deficit, scapula muscle dysfunction, and core muscle dysfunction are also important elements of the internal impingement process. Articular surface rotator cuff tears, posterior superior labrum tears, SLAP lesions, anterior capsular ligament attenuation, and posterior capsular ligament contracture are commonly seen in throwers. Each of these conditions must be recognized and appropriately treated to ensure the best possible outcome. There is little potential for spontaneous healing of rotator cuff tears and SLAP lesions after debridement.
A new arthroscopic approach for traumatic instability has been developed with which avulsed capsulolabral tissue can be effectively attached to the glenoid articular rim with sutures, providing anatomic reattachment and effective deepening of the glenoid concavity similar to that achieved by open repair. This technique does not depend on fixation devices, trans-scapular drilling, or implantation of suture anchors. The fixation of the labrum using the punch-chop needle overlap technique (Aeratec Inc, Uniondale, NY) for reattaching torn labral tissue to bone allows ease of suture placement for Bankart lesion repair, with the fixation overlapping the rim of the glenoid. The technique presented here includes preparation of the glenoid rim, drilling of the glenoid tunnels, and peripheral suturing of the labrum.
The aim of the study was to perform a clinical assessment of patients who had undergone arthroscopic repair of a type-2 SLAP lesion using one double-looped Corkscrew anchor. Fifteen consecutive patients who agreed to fill in a pre- and post-operative questionnaire were included in the study. The aetiology was traumatic in 10/15 patients and non-traumatic in 5/15. At the index operation four patients underwent a concomitant acromioplasty, while four patients underwent supplementary anterior labrum fixation using suture anchors. Thirteen/15 (87%) of the patients were physically re-examined by independent observers after a follow-up period of 25 months (11-32). The questionnaire involved a patient-administered assessment of ten common activities of daily living. At follow-up, the Rowe score was 84 points (51-98) and the Constant score was 83 points (35-100). The external rotation in abduction was 85 degrees (60-110) on the operated side and 90 degrees (80-110) on the non-operated side ( p<0.05). The isometric strength in abduction was 8.3 kg (0.8-14.4) on the operated side and 8.9 kg (2.7-15.5) on the non-operated side ( p=0.006). Significant improvements ( p<0.05) compared with the pre-operative assessments were found in 2/10 activities of daily living. Another 4/10 activities seemed to improve but did not reach statistical significance ( p<0.08). Eleven of 15 patients returned to their pre-injury activity level. In conclusion, the majority of patients returned to their pre-injury activity level and the subjective patient-administered evaluations appeared to improve after arthroscopic repair of type-2 SLAP lesions using one double-looped Corkscrew anchor. We feel encouraged to continue using this technique.
Under the hypothesis that the anatomic relationship of the tibialis anterior tendon and extensor retinaculum of the foot and ankle is relevant to the clinical aspects of a tear in that tendon, we assessed the anatomic details of these structures using MRI in cadavers and evaluated MRI in patients with a tibialis anterior tendon tear.
Seven cadaveric feet underwent detailed MRI using standard and oblique coronal planes with respect to the course of the tibialis anterior tendon and extensor retinaculum. Cadaveric sections subsequently provided an anatomic correlation. MR images of seven patients with tibialis anterior tendon tear were analyzed by consensus of two musculoskeletal radiologists.
Imaging-anatomic correlations allowed identification of the tibialis anterior tendon and extensor retinaculum. The tendon passed through three tunnels formed by the superior extensor retinaculum, oblique superomedial, and oblique inferomedial limbs of the inferior extensor retinaculum. Of seven patients with the tendon tear, three patients had complete tears and four patients had partial tears. In all partial tears, the level of the tear was at the ankle joint, corresponding to the approximate level of the oblique superomedial limb. In all complete tears, the proximal ends of torn tendons were retracted to a level below the oblique superomedial limb. In all tears, the oblique superomedial limb surrounding the torn tendon was seen with thickening in four patients and enhancement after IV gadolinium injection in two patients. Other findings included a bulbous appearance or swelling of the torn tendon in two complete and two partial tears and fluid collections within the tendon sheath and in an area confined by the extensor retinaculum in four patients.
The relationship of the tibialis anterior tendon and extensor retinaculum is well depicted on MRI, even in patients with a tibialis anterior tendon tear, and is clinically relevant to the tear of this tendon.
Our purpose was to compare 3 commonly used suture anchor configurations for repair of type II SLAP lesions.
Biomechanical testing was performed on 3 groups of 7 cadaveric shoulders by use of an optical linear strain measurement system. Standardized type II SLAP lesions were created and repaired via 3 suture anchor configurations: (1) a single simple suture anterior to the biceps; (2) two simple sutures, one anterior and one posterior to the biceps; and (3) a single mattress suture through the biceps anchor. Cyclic traction was applied to the biceps tendon, and strain failure (defined as 2 mm of permanent displacement), yield, and pullout loads were measured.
The mean load to strain failure was 63 N in group 1, 70 N in group 2, and 106 N in group 3. The mean load to ultimate failure was 140 N in group 1, 194 N in group 2, and 194 N in group 3. Strain failure load was significantly higher in the mattress suture group than in either of the other two groups (P < .05). Groups 2 and 3 both had a significantly higher load to ultimate failure than group 1.
When type II SLAP lesions were subjected to cyclic traction, the load to strain failure was greater with a single anchor and mattress suture than with one or two anchors with simple sutures around the labrum. Fixation with two simple sutures appears to provide intermediate load to strain failure.
The results of this study suggest that a single anchor with a mattress suture may be a biomechanically advantageous construct for the repair of type II SLAP lesions.
Complete detachment of the glenoid labrum from the superior pole of the glenoid, which is associated with a destabilization of the origin of the long biceps tendon, leads to altered function in the shoulder joint. This is especially noticeable when the shoulder is used in overhead activities. Two operative techniques are described for reattachment of the glenoid labrum to the glenoid. In the first six patients the glenoid labrum was reattached with small cannulated titanium screws. In five patients these screws were inserted under arthroscopic control from a cranial direction. The labrum was always reattached just behind the origin of the long biceps tendon. The most favorable portal was identified by percutaneous probing with a Kirschner wire. If the superior glenoid pole could not be reached via a portal placed anterior or medial to the acromion, a hole was drilled through the acromion, and a transacromial approach was used. The screws were removed by arthroscopy after 3 to 5 months. In the last eight patients, absorbable tacks were used instead of screws. Of 18 patients who showed a complete detachment of the glenoid labrum from the superior pole of the glenoid with destabilization of the attachment of the biceps tendon, 14 underwent reattachment as described previously. The minimum follow-up time was greater than 6 months (mean follow-up time 18 months, maximum follow-up time 30 months). At follow-up, eight patients felt completely rehabilitated and had resumed their previous overhead activities (overhead sports). Four patients believed their conditions were improved. Two patients had not experienced any improvement. Of the patients who had not undergone reattachment and who had undergone shaving of the free margin of the glenoid labrum, only one had experienced improvement, while the other three patients did not report any improvement.
Superior labral tears of the shoulder involve the biceps tendon and labrum complex which may be detached, displaced inferiorly, and interposed between the glenoid and the humeral head. We have treated ten young athletes with painful shoulders due to this lesion by arthroscopic stapling. Arthroscopy at the time of staple removal, after three to six months, showed that all the lesions had been stabilised. Clinical review at over 24 months showed an excellent or good result in 80%. The two relative failures were due in one to residual subacromial bursitis, and the other to multidirectional shoulder instability. Arthroscopic stapling can restore the shoulder anatomy, and it is recommended for active adolescent athletes with this lesion.
A specific pattern of injury to the superior labrum of the shoulder was identified arthroscopically in twenty-seven patients included in a retrospective review of more than 700 shoulder arthroscopies performed at our institution. The injury of the superior labrum begins posteriorly and extends anteriorly, stopping before or at the mid-glenoid notch and including the "anchor" of the biceps tendon to the labrum. We have labeled this injury a "SLAP lesion" (Superior Labrum Anterior and Posterior). There were 23 males and four females with an average age of 37.5 years. Time from injury to surgery averaged 29.3 months. The most common mechanism of injury was a compression force to the shoulder, usually as the result of a fall onto an outstretched arm, with the shoulder positioned in abduction and slight forward flexion at the time of the impact. The most common clinical complaints were pain, greater with overhead activity, and a painful "catching" or "popping" in the shoulder. No imaging test accurately defined the superior labral pathology preoperatively. We divided the superior labrum pathology into four distinct types. Treatment was performed arthroscopically based on the type of SLAP lesion noted at the time of surgery. The SLAP lesion, which has not been previously described, can be diagnosed only arthroscopically and may be treated successfully by arthroscopic techniques alone in many patients.
Twenty consecutive patients with superior labral anterior and posterior lesions of the shoulder involving the biceps attachment to the labrum (Snyder types II and IV) were repaired arthroscopically and reviewed post-operatively to evaluate the efficacy of the technique in the management of this recently described injury pattern. Follow-up time averaged 21 months (range, 12 to 42). All patients were managed by an arthroscopic repair technique that included debridement of the frayed labrum and abrasion of the superior glenoid neck, followed by the placement of multiple sutures into the torn labrum-biceps tendon complex using a Caspari suture punch. Patients were reexamined, and the results were quantitated with the shoulder evaluation form of the American Shoulder and Elbow Surgeons and with the Rowe rating scale. On evaluation, all patients obtained good or excellent results. This suture technique is recommended in the management of unstable superior labral detachment lesions of the shoulder.
The glenoid labrum of the shoulder has extensive anatomic variation but appears to be important for contributing to shoulder stability and for increasing the depth of contact between the glenoid labrum and the humeral head. Tears of the labrum are commonly seen in association with other pathologic entities, such as instability and rotator cuff tears, and treatment of the labral pathology may be incidental to treatment of the other more significant pathology. However, conditions isolated to the labrum do occur and can be a significant source of shoulder problems. Effective treatment of these lesions may result in significant improvement in the patient's symptoms. Labral lesions are difficult to diagnose, and special diagnostic studies and, frequently, arthroscopy are required. The recently described SLAP lesion is an uncommon but significant cause of shoulder disability that generally requires arthroscopic diagnosis. The arthroscopic treatment of this lesion depends on the type of SLAP lesion present. Recent techniques have permitted arthroscopic stabilization of the biceps labral detachment and type II SLAP lesions.
Slip knots are commonly used for arthroscopic knot tying techniques. Nicky's knot is a "ratchet" knot. It is a one-way slip knot. It has excellent initial holding capacity, maintaining tension on soft tissue while additional hitches are being tied.
A secure slip knot is very important in the field of arthroscopy. The new giant knot, developed by the first author, has the properties of being a one-way self-locking slip knot, which is secured without additional half hitches and can tolerate higher forces to be untied.
The giant knot: A new one-way self-locking secured arthroscopic slip knot FIGURE 6. (A) The lower limb is then pulled up lateral to the labrum through the anterior cannula with a ring forceps. (B) The two limbs are tied together posterior and anterior to the biceps
- Ba Fleega
- Sokkar
Fleega BA, Sokkar SH. The giant knot: A new one-way self-locking secured arthroscopic slip knot. Arthroscopy 1999;15: 451-452. FIGURE 6. (A) The lower limb is then pulled up lateral to the labrum through the anterior cannula with a ring forceps. (B) The two limbs are tied together posterior and anterior to the biceps. 798 B. A. FLEEGA
The giant knot: A new one-way self-locking secured arthroscopic slip knot FIGURE 6. (A) The lower limb is then pulled up lateral to the labrum through the anterior cannula with a ring forceps
- Fleega Ba
- Sokkar
- Sh
Fleega BA, Sokkar SH. The giant knot: A new one-way self-locking secured arthroscopic slip knot. Arthroscopy 1999;15: 451-452. FIGURE 6. (A) The lower limb is then pulled up lateral to the labrum through the anterior cannula with a ring forceps. (B) The two limbs are tied together posterior and anterior to the biceps.
Arthroscopic repair of superior glenoid labral detachment (the SLAP lesion).
- Resch H
- Golser K
- Thoeni H
- Spencer G
Arthroscopic stapling for detached superior glenoid labrum.
- Yoneda M
- Hirouka A
- Saito S
- Yamamato T
- Ochi T
- Shino K