International Olympic Committee consensus statement on pain management in elite athletes

Pain is a common problem among elite athletes and is frequently associated with sport injury. Both pain and injury interfere with the performance of elite athletes. There are currently no evidence-based or consensus-based guidelines for the management of pain in elite athletes. Typically, pain management consists of the provision of analgesics, rest and physical therapy. More appropriately, a treatment strategy should address all contributors to pain including underlying pathophysiology, biomechanical abnormalities and psychosocial issues, and should employ therapies providing optimal benefit and minimal harm. To advance the development of a more standardised, evidence-informed approach to pain management in elite athletes, an IOC Consensus Group critically evaluated the current state of the science and practice of pain management in sport and prepared recommendations for a more unified approach to this important topic

Arthroscopic Panlabral Repair With Remplissage of Hill-Sachs Lesion

Recurrent shoulder instability in young contact athletes has been well established. The importance of bipolar bone loss in instability has come to the forefront in terms of proper management of this condition. It remains controversial, however, which patients would be better served with an arthroscopic versus open procedure and when additional procedures may reduce the risk of failure (i.e., remplissage). We present our arthroscopic technique of a panlabral repair with concomitant remplissage using the double-pulley technique. The purpose of this article is to provide insight into obtaining superior visualization while reviewing surgical pearls and pitfalls to efficiently perform a panlabral repair and remplissage

Superior Capsule Reconstruction Technique Using an Acellular Dermal Allograft

Chronic, massive, irreparable rotator cuff tears remain one of the most challenging pathologies in shoulder surgery to treat. Because of this, many treatment options exist for the management of chronic retracted rotator cuff tears. Superior capsule reconstruction is one option that provides the potential to restore and rebalance the force couples necessary for dynamic shoulder function. We describe an all-arthroscopic technique using an acellular dermal allograft for superior capsule reconstruction indicated for patients with a deficient superior rotator cuff. This technique provides an option for patients with an irreparable rotator cuff tear without compromising future treatment options. Although this is a relatively new and unproven method for treating chronic irreparable rotator cuff tears, our short-term results are promising. Nevertheless, larger studies with long-term follow-up are required to fully evaluate the success of this technique

Anterior Capsule Reconstruction Technique With an Acellular Dermal Allograft

An irreparable subscapularis may have a debilitating influence on glenohumeral joint biomechanics. Traditional treatment approaches are focused on tendon transfers, among which the most popular are pectoralis major and latissimus dorsi transfers. However, these techniques present significant retear rates, possible nerve injuries, and altered biomechanics. Other techniques like tibialis anterior or iliotibial autograft grafting also have many reported failures. We describe an all-arthroscopic anterior capsule reconstruction technique with an acellular dermal graft

Current concepts in the evolution of arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair has become one of the most common and successful surgeries performed in orthopedics. It represents the culmination of advances in many diverse fields such as optics, fluid dynamics, mechanical engineering, and most recently, orthobiologics. This article reviews the current state of the art of arthroscopic rotator cuff repair, through the lens of its historical context and evolution to our present understanding. We review the limitations in the current approach, and glance toward the future of rotator cuff regeneration with emerging technologies

Arthroscopic Reduction and Balloon Humeroplasty in the Treatment of Acute Hill-Sachs Lesions

Shoulder instability is often associated with an impaction fracture of the humeral head, commonly referred to as a “Hill-Sachs lesion.” This lesion is present in both anterior and posterior instability. Forty percent to 90% of anterior shoulder dislocations have associated Hill-Sachs lesions, whereas 29% to 86% of posterior shoulder dislocations have reverse Hill-Sachs lesions. Both of these lesions can contribute to recurrent instability of the shoulder and require surgery to be treated. Currently, the most common procedures to address Hill-Sachs lesions are the remplissage procedure (transfer of the infraspinatus into the posterior humeral head defect), capsular shift, disimpaction technique, humeral head resurfacing, bone block transfer, or shoulder arthroplasty. Reverse Hill-Sachs lesions are managed with similar procedures, such as the remplissage-equivalent technique described by McLaughlin, which involves transfer of the subscapularis tendon to fill the humeral head defect. The procedure has the advantage of “exteriorizing” the humeral head defect, but in the case of large lesions, it can result in significant loss of the articulating articular surface. The purpose of this article is to describe an arthroscopically assisted disimpaction technique with supplemental grafting using a balloon osteoplasty technique for a reverse Hill-Sachs lesion with bone cement to support and maintain the reduction

Split Pectoralis Major Transfer for Chronic Medial Scapular Winging

Scapular winging can be a significant source of chronic pain, weakness, and disability of the shoulder. Isolated serratus anterior palsy from long thoracic nerve injury, which is the most common cause of this condition, produces prominent winging and medial malpositioning of the inferior angle of the scapula. In the case of persistent symptoms despite conservative care, treatment options primarily include scapulothoracic fusion and pectoralis major transfer. Outcomes of scapulothoracic fusion are notable for a high complication rate and limited functional improvements. We describe our technique of indirect, split pectoralis major transfer to the inferolateral scapula with allograft tissue augmentation for the surgical treatment of chronic medial winging. This procedure provides dynamic stabilization of the scapula with secure and tension-free tendon transfer. Advantages over alternative treatments include a relatively low complication rate, acceptable cosmesis, and better range of motion. The rationale and technical aspects of this procedure are discussed. Additional clinical studies are warranted to compare outcomes for the direct and indirect split transfer methods

Arthroscopic Remplissage for Moderate-Size Hill-Sachs Lesion

Humeral bone loss has been shown to be a risk factor for failure after arthroscopic treatment of instability. We present the arthroscopic remplissage technique originally described by Koo and Burkhart et al. with a modification in the percutaneous anchor placement and suture tying that is reproducible and effective. We percutaneously place 2 suture anchors, which require no additional suture passing across the tissue, to create a double pulley technique, filling the defect with posterior capsule and rotator cuff. Therefore, the Hill-Sachs defect becomes extra-articular, eliminating the potential engagement of the anterior glenoid and contribution to recurrence of instability. This technique is applicable broadly for most Hill-Sachs lesions that need addressing. By not having to pass or shuttle any suture through tissue after anchor placement and by eliminating the necessity to go subacromially to retrieve or tie suture, the technique saves time and improves reproducibility. The compression of tissue into the Hill Sachs surface area also is improved by double-reinforced suturing through the double-pulley technique. The combination of these advantages creates a sound and efficient technique for remplissage