doi: 10.4103/0973-6042.59972Early pullout of lateral row knotless anchor in rotator cuff repairAuthor information Copyright and License information AbstractUse of lateral row anchors in rotator cuff repair as a means of enhancing the strength of the repair; and improving footprint tendon contact, thus promoting healing, is becoming more popular in current arthroscopic practice. In our knowledge, failures of lateral row knotless anchors have not yet been reported. We present a case of double row rotator cuff repair using a Swivelock anchor (Arthrex) as a lateral row anchor that failed two weeks after surgery.Keywords: INTRODUCTIONVarious surgical techniques are described in literature that attempt to recreate the anatomical rotator cuff footprint when performing an arthroscopic rotator cuff repair, with double row repairs being the subject of controversy. We report the failure of a lateral knotless anchor.CASE REPORTA fifty nine year old female was admitted for repair of her non dominant left rotator cuff tear.
Arthroscopy revealed a Superior Labrum Anterior Posterior (SLAP) lesion, which was unstable as well as a full-thickness tear of the supraspinatus tendon, completely off the attachment at the greater tuberosity.The SLAP tear was secured with simple sutures via a 3.5 mm absorbable copolymer suture anchor (Lactoscrew, BIOMET) inserted at the 12-o'clock position behind the long head of biceps. The torn supraspinatus tendon was first secured with two sets of mattress sutures from the medial 5.5 mm absorbable copolymer suture anchor (Lactoscrew, BIOMET) that was inserted in the articular margin of the greater tuberosity. All four strands of the two sutures of the medial anchor were then thread through a second row 5.5 mm Poly-(L-lactide) (PLLA) knotless anchor (Swivelock, Arthrex) that was inserted into the lateral wall of the tuberosity cortex, 1 cm away from the first anchor []. The shoulder was immobilized in a sling for 2 weeks, after which physiotherapy was started.At that time, she developed a painful red swelling in her axilla resembling an inflamed lymph node, but there were no clinical or biochemical signs of infection.
Shoulder movements, though painful, were not restricted. A crepitus, however, was felt in the subacromial space on rotation. Ultrasound examination revealed one of the anchors had backed out. An urgent MRI scan confirmed that the lateral row anchor had migrated.Subsequent repeat arthroscopy showed that a good repair of the supraspinatus tendon was achieved with the medial anchor []. The lateral row anchor was prominent above the lateral cortex []. The protruding anchor and the redundant sutures were removed [].DISCUSSIONAs arthroscopic rotator cuff repair is more commonly practiced,[1,] the importance of restoring the anatomical footprint to enhance healing is emphasized.Double row tendon repair is an accepted method of recreating the cuff footprint,[1,,4] biomechanically stronger,[] and it offers higher structural integrity.[] There is, however, no evidence that these advantages have clinical implications.[] Meanwhile, the introduction of knotless anchors as lateral row fixation or suture bridge devices facilitates the double row technique.
Biomechanical testings have shown that these 'push in' anchors have equivalent pullout strength when compared with the traditional suture anchors in this situation. The Swivelock was the latest knotless design with the highest pullout strength at 712 N. Its failure mode is secondary only to eyelet or suture breakage but not due to anchor pulled out.[]We hypothesized that the anchor failed in our case for the following reasons.After a mattress repair to the torn tendon, we placed all four strands of sutures from the single medial anchor to be carried by the lateral row anchor. When the Swivelock was screwed into position, it may have generated high tension in the sutures between the two anchors. When the tendon started to contract with mobilization, all the traction forces on the medial anchor were then transmitted across to the lateral anchor. This tension may be beyond the level of tension that the bone of the lateral cortex can withstand. Whereas if it was just one set of sutures, only part of the tension would be transmitted to the lateral anchor.
Further biomechanical testing of this hypothesis is needed.Secondly, the effectiveness of the device is directly related to the quality of bone into which it is inserted. Reduced bone density of the tuberosity secondary to disuse, e.g., after injury, may have contributed to a weak fixation.[] In addition, it is well recognized that the pullout strength of anchors is reduced in osteoporotic bone.[] With the mean age of the patients requiring arthroscopic repair of their rotator cuffs rising, we are likely to come across patients with some degree of osteopenia in their greater tuberosity more often.We therefore recommend that caution should be exercised when placing lateral anchors into greater tuberosities with suspected osteopenia, particularly in cases of postmenopausal female patients whose medial anchor insertion does not inspire secure fixation. In addition, we should not put all four strands of suture from the same medial anchor into the lateral anchor in double row fixation.FootnotesSource of Support: Nil Conflict of Interest: None declared.
Yamaguchi K, Levine WN, Marra G, Galatz LM, Klepps S, Flatow EL. Transitioning to arthroscopic rotator cuff repair: The pros and cons. [PubMed]3. Lafosse L, Brozska R, Toussaint B, Gobezie R. The outcome and structural integrity of arthroscopic rotator cuff repair with use of the double-row suture anchor technique. 5. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair.A prospective outcome study. 6. Grasso A, Milano G, Salvatore M, Falcone G, Deriu L, Fabbriciani C. Single-row versus double-row arthroscopic rotator cuff repair: A prospective randomized clinical study. 7. Barber FA, Herbert MA, Beavis RC, Barrera Oro F. Suture anchor materials, eyelets, and designs: update 2008. 8. Burns JP, Snyder SJ, Albritton M. Arthroscopic rotator cuff repair using triple-loaded anchors, suture shuttles, and suture savers. Frozen shoulder, also known as adhesive capsulitis, isn't as official as it sounds. Frozen shoulder just refers to shoulder pain that leads to restricted range of motion.
It is a catch-all diagnosis for shoulder pain and immobility for which the underlying cause is unknown. Janet Travell, the author of Myofascial Pain and Dysfunction: The Trigger Point Manual, speaking of the medical literature on frozen shoulder, says, "When so many authors agree that the cause of a disease is enigmatic, there is good reason to expect that a major etiologic factor is being overlooked." This major factor, according to Travell, is trigger points in the subscapularis muscle. Acupuncture can eliminate these trigger points, wiping out frozen shoulder for good and offering people an alternative to the common -- yet usually only temporarily effective -- protocol of pain killers, cortisone shots, and surgery. Olympic swimmers who recently dazzled us with their performances: Take heed! Freestyle swimming is one of the most common causes of subscapularis trigger points. The Signature Pain-Referral Pattern of Subscapularis Trigger Points The subscapularis is one of the four muscles that comprise the rotator cuff.
It attaches to the inner surface of the scapula and to the front of the humerus bone. Its primary responsibility is to hold the humerus in place during arm movements, preventing displacement. It also helps internally rotate the head of the humerus. Trigger points are sensitive nodules in the musculature that cause referred pain. In the subscapularis muscle, they produce a signature pain-referral pattern. Pain concentrates on the back of the deltoid muscle. From there, it can extend onto the back, over the scapula, and/or down the back side of the upper arm. Pain usually skips the forearm but appears again as a band around the wrist (see picture here). Early-stage subscapularis trigger points normally don't prevent people from reaching up. However, reaching backward -- as if you were getting ready to throw a ball -- tends to be painful. This is why frozen shoulder and adhesive capsulitis are sometimes referred to as pitcher's arm. Another tell-tale sign of early-stage subscapularis trigger points is wrist pain that concentrates on the back of the wrist, sometimes making it uncomfortable to wear a watch.
Common Causes of Shoulder Pain from Trigger Points in the Subscapularis Is it sounding like your shoulder pain might be coming from trigger points in the subscapularis muscle? Here are some common ways in which these trigger points get activated: 1. Overdoing it at activities that require medial rotation of the arm. Examples include freestyle swimming and throwing a baseball. 2. Forceful overhead lifting while adducting the arm (bringing it closer to your body). An example is the kettleball swing exercise, where you use outstretched arms to raise the kettleball from between the legs. 3. Sudden stress placed on the shoulder muscles due to a humerus fracture or shoulder joint tear, or breaking a fall. Once a trigger point is activated -- in the subscapularis or any muscle -- it's commonly perpetuated or exaggerated by everyday movements. Sleeping on one's side or having slumped-forward posture can make subscapularis trigger points worse. Remedies for Subscap-Related Shoulder Pain
Once you've identified subscapularis trigger points as the source of your shoulder pain and immobility, there are several steps you can take to reduce them. Trigger points in the subscapularis can be released by inserting acupuncture needles directly into the muscle. While extremely effective at eliminating shoulder pain, having these trigger points needled can be uncomfortable due to the location of the subscapularis. To access the muscle, the acupuncturist needs to palpate somewhat forcefully inside the underarm (see picture here). Another acupuncture technique for addressing pain from trigger points includes needling away from the actual pain site, choosing points along the acupuncture meridians that transverse the painful part of the body. For example, the small intestine meridian runs directly along the signature pain-referral pattern for subscapularis trigger points. An acupuncturist might choose to needle an acupuncture point on the small intestine meridian that's farther down the body.
Small Intestine 3, for example, is an acupuncture point on the side of the hand (see picture here) that's frequently used to alleviate shoulder and upper back pain around the scapula. You can massage this point yourself to help reduce pain in that area. Something else you can do yourself to reduce subscapularis-related shoulder pain is adjust your posture -- while awake and sleeping. During waking hours, try and avoid the slumped-forward posture that so many of us have unfortunately developed as a result of sustained computer use. This postion forces the arms into a medially-rotated position, which perpetuates trigger points in the subscapularis. When standing, try hooking your thumbs into your belt or pants to prevent your arms from touching your sides. And when you're at your desk, remember to frequently move your arms -- a simple movement of reaching the arm up and behind the head will do it -- to help keep the subscapularis muscle stretched. 3. Sleep with a pillow.
At bedtime, grab an extra pillow. If you're sleeping on the painful side, place the pillow between your elbow and side of the body. Again, this abducts the arm away from the body, which stretches the subscapularis muscle. If you sleep on the pain-free side, put the pillow in front of you so that the painful arm can rest on it (pretend you're hugging the pillow). 4. Do the doorway stretch. A final self-care technique for reducing subscapularis trigger points is the doorway stretch. Stand in a doorway and place both hands on either side of the door, at about shoulder height. Lean forward to give a nice passive stretch to the subscapularis. If your shoulder pain is coming from trigger points in the subscapularis muscle, no amount of pain killers, cortisone shots nor surgeries is going to solve the problem. Those treatments have their place, but why not try the less-invasive path first? For more articles on how acupuncture can help you lead a healthier, simpler, more meaningful life, visit AcuTake, the only non-professional publication dedicated exclusively to acupuncture.