BackgroundAlthough arthroscopic anchor suturing is commonly used for rotator cuff repair and achieves good results, certain shortcomings remain, including difficulty with reoperation in cases of retear, anchor dislodgement, knot impingement, and financial cost. In 2005, we developed an anchorless technique for arthroscopic transosseous suture rotator cuff repair.Description of TechniqueAfter acromioplasty and adequate footprint decortication, three K-wires with perforated tips are inserted through the inferior margin of the greater tuberosity into the medial edge of the footprint using a customized aiming guide. After pulling the rotator cuff stump laterally with a grasper, three K-wires are threaded through the rotator cuff and skin. Thereafter, five Number 2 polyester sutures are passed through three bone tunnels using the perforated tips of the K-wires. The surgery is completed by inserting two pairs of mattress sutures and three bridging sutures.MethodsWe investigated the retear rate (based on MR images at least 1 year after the procedure), total score on the UCLA Shoulder Rating Scale, axillary nerve preservation, and issues concerning bone tunnels with this technique in 384 shoulders in 380 patients (174 women [175 shoulders] and 206 men [209 shoulders]). Minimum followup was 2 years (mean, 3.3 years; range, 2–7 years). Complete followup was achieved by 380 patients (384 of 475 [81%] of the procedures performed during the period in question). The remaining 91 patients (91 shoulders) do not have 1-year postsurgical MR images, 2-year UCLA evaluation or intraoperative tear measurement, or they have previous fracture, retear of the rotator cuff, preoperative cervical radiculopathy or axillary nerve palsy, or were lost to followup.ResultsRetears occurred in 24 patients (24 shoulders) (6%). The mean overall UCLA score improved from a preoperative mean of 19.1 to a score of 32.7 at last followup (maximum possible score 35, higher scores being better). Postoperative EMG and clinical examination showed no axillary nerve palsies. Bone tunnel-related issues were encountered in only one shoulder.ConclusionsOur technique has the following advantages: (1) reoperation is easy in patients with retears; (2) surgical materials used are inexpensive polyester sutures; and (3) no knots are tied onto the rotator cuff. This low-cost method achieves a low retear rate and few bone tunnel problems, the mean postoperative UCLA score being comparable to that obtained by using an arthroscopic anchor suture technique.Level of EvidenceLevel IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.Electronic supplementary materialThe online version of this article (doi:10.1007/s11999-013-3148-7) contains supplementary material, which is available to authorized users.

Background:Repetitive tensile stresses from valgus torque can induce elbow injury in adolescent baseball players. Insufficient hip range of motion (ROM) can change throwing mechanics, reducing the transfer of energy from the lower to the upper extremities. Thus, hip ROM limitations may force the upper extremities to bear the burden of a strong throw. Improper pitching mechanics caused by insufficient hip ROM are thought to increase valgus torque on the elbow when throwing, increasing the risk of elbow injury.Purpose:To investigate the relationship between elbow pain and hip ROM in adolescent baseball players.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A total of 122 adolescent baseball players with a mean age of 12.0 years (range, 6-14 years) participated in this study. Elbow pain, hip flexion angle, and the internal rotation angles of the hip at 0° and 90° of flexion were assessed. Participants were divided into a pain group and a normal group based on the pain assessment, and each hip angle was compared between groups using Student t tests. P values <.05 were considered statistically significant.Results:Thirty-one of 122 players had elbow pain. The hip flexion angle of the trail leg was 121.9° ± 12.3° for the normal group and 111.2° ± 11.3° for the pain group (P = .0001). The plant leg hip flexion angles were 122.0° ± 12.4° and 113.6° ± 11.3° (P = .0014) for the normal and pain groups, respectively. The internal rotation angle at 0° of hip flexion of the trail leg was 49.4° ± 12.6° and 45.6° ± 8.8° (not significant), and of the plant leg was 49.1° ± 12.5° and 48.7° ± 11.5° (not significant), for the normal and pain groups, respectively. The internal rotation of the trail leg at 90° of hip flexion was 46.9° ± 13.3° in the normal group and 36.1° ± 15.7° in the pain group (P = .0005). In the plant leg, the internal rotation angle at 90° of hip flexion was 46.9° ± 12.2° and 36.4° ± 18.1° for the normal and pain groups, respectively (P = .0013).Conclusion:Limitations to hip flexion and internal rotation at 90° of hip flexion were risk factors for elbow injury. Differences in internal rotation angles between 0° and 90° of hip flexion may be important criteria for identifying adolescent baseball players at risk of elbow pain.

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To the editor,We appreciate the valuable comments of Bicanic and colleagues, which describe previously reported transosseous suture methods, limitations, costs, possible pullout of the sutures, and complexities of the suturing in the procedure we reported.The hybrid technique of anchor and transosseous sutures reported by Cicak et al. [2], and the transosseous suture technique using a hollow needle reported by Matis et al.[5], differ from our technique. We make a long straight bone tunnel from the lower margin of the greater tuberosity to the footprint. With our procedure, large tears where the stump of the torn rotator cuff does not emerge across the top of the humeral head under traction can be repaired by expanding decortication of the footprint to the inner side. However, there is a high retear rate.The extra cost of prolonged operation time is generally attributable to personnel expenses. Our technique requires two surgeons, one anesthesiologist, and three nurses. In our hospital, doctors and nurses are paid ¥ 12,500/hour and ¥ 3200/hour, respectively. Therefore, the total personnel costs are ¥ 47,100/hour (¥ 12,500 9 3 + ¥ 3200 9 3). The anchor method uses an average of 2.3 anchors [3]. These cost ¥34,300 each in Japan. The total cost of the anchors is ¥ 78,890 (¥ 34,300 9 2.3 anchors). The polyester threads used in our procedure cost ¥840. Therefore, the anchors cost ¥ 78,050 more (¥ 78,890 À ¥ 840) than the polyester threads. This is equivalent to personnel expenses for 99 minutes (¥ 78,050 7 ¥ 47,100 9 60).The anchor method is cheaper only if the procedure is 99 minutes shorter than our approach. The overall average operating time for our procedure is approximately 105 minutes in 384 cases [4]. In order for a procedure using anchors to be less expensive, it would have to be 99 minutes shorter than that, or about 6 minutes in length (105 minutes -99 minutes = 6 minutes), which seems quite unrealistic.In our procedure, knot tying is performed at the lower margin of the greater tuberosity where the bone cortex is solid. Additionally, the knots are not sliding, but static. Therefore, no rupture of sutures due to friction in the bone tunnel occurred in our cases. Breakage of (or pullout from) the bone tunnel occurred only in one osteoporotic patient (0.3%). In comparison, the frequency of anchor pullout is reportedly 2.4% [1]. Our procedure is more suitable for osteoporotic patients.