Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 24, Issue 11 , Pages 1203-1204, November 2008

Keeping Up With the Literature: Knee Ligament, Wrist Triangular Fibrocartilage Tear, and Suture Bridge Rotator Cuff Technique Questions

Article Outline

 

Keeping up with the literature in Arthroscopy this month is keeping us clinically and intellectually engaged.

For self-assessment, we ask: what is the likely diagnosis when a patient has physical examination signs of a positive anterior drawer test, but a relatively normal Lachman and pivot-shift test? Or, what is the likely diagnosis when a patient has physical exam signs of a positive Lachman and pivot-shift test, but a relatively normal anterior drawer?

Those of you who were reading the Journal in 2006 may have correctly remembered the answer of “partial rupture of the anterior cruciate ligament,” which was well reviewed by Peterson and Zantop.1 Specifically, the patient with a positive anterior drawer test, but a relatively normal Lachman and pivot-shift test, may have an anteromedial (AM) bundle rupture, whereas the patient with a positive Lachman and pivot-shift test, but a relatively normal anterior drawer, may have a posterolateral (PL) bundle rupture. However, some readers may view the entity of partial rupture of the ACL with skepticism, let alone the concept of augmentation of partial ruptures with isolated AM or PL bundle reconstruction. Yet, skeptics may reconsider the validity of “Assessment and Augmentation of Symptomatic Anteromedial or Posterolateral Bundle Tears of the Anterior Cruciate Ligament” after study of the fine review of this topic by Siebold and Fu in the current issue.2 Even the most cynical disbelievers may be convinced by the compelling photos from our colleagues from Heidelberg and Pittsburgh. Research is still required to evaluate concerns regarding intrasubstance elongation of the remaining, intact bundle. Putting it bluntly, we don't want to preserve tissue that may appear grossly normal but is actually stretched out.

For you out-of-the-box thinkers, we ask: what is the knee reconstruction procedure that requires four bundles and an amazing eight tunnels?

Zhao et al.3 from Shanghai aren't joking when they describe that the answer is “Simultaneous double-bundle anterior cruciate ligament and posterior cruciate ligaments reconstruction with autogenous hamstring tendons.” In fact, they've described an impressively powered series of 21 of these cases. And there is more; in fact, isolated ACL and PCL ruptures are rare. Multiligament knee injuries usually also involve injury to the posteromedial or posterolateral corners (PMC or PLC) of the knee. Readers may be even more amazed to learn that Zhao et al. performed 125 additional simultaneous double-bundle ACL and PCL reconstructions, in patients excluded from the reported series, because the excluded patients also required PMC and/or PMC reconstruction. In these additional patients, the eight cruciate reconstruction tunnels were just a part of the reconstruction. We reiterate: amazing.

Turning to wrist arthroscopy, we pose a trick question: what is the best treatment for triangular fibrocartilage complex (TFCC) repair?

We admit our trick, because our answer is that we are not sure. Reiter et al.4 nicely demonstrate that inside-out TFCC suture repair technique outcomes are not diminished by positive or neutral ulnar variance. This is good news for patients (and arthroscopic surgeons) who may avoid an ulnar shortening operation. Yet, the authors do not address statistical power. Readers should remember that when study authors report no difference in outcomes between groups, we must be sure to address the possibility of beta error (failure to detect a difference, when a difference exists, due to inadequate sample size). Furthermore, Reiter et al., like most authors contributing to the surgical literature, report Level IV evidence with regard to their primary outcome measure. Without a control group, how can we be sure that inside-out TFCC suture repair technique outcomes are preferable to other treatment options, like debridement, for example, or to no treatment at all?

We exhort all of our contributing researchers to be mindful of beta error when reporting “no differences,” and to be mindful that we prefer therapeutic studies to include a control group to achieve higher levels of evidence to better answer our clinical questions. That said, we acknowledge that Reiter and his colleagues in Germany, with special acknowledgement of corresponding author Unglaub, have provided a thoughtful contribution to our understanding of TFCC tear treatment that we deem well worthy of publication and study. All studies have limitations; as editors, we must sometimes emphasize these limitations, not to be critical, but to encourage our contributing researchers to continue to raise the bar in the future.

The suture-bridge has been a hot topic in Arthroscopy in the last 3 years,5, 6, 7, 8, 9, 10, 11, 12, 13, 14 so readers who have been keeping up with the literature, or adapting this state-of-the-art rotator cuff repair technique to their clinical practices, may ponder: how is it possible to reduce central bird-beak or marginal dog ear deformities associated with the suture-bridge technique for full-thickness rotator cuff tears?

Kim et al.5, 6 make another fine contribution to our understanding of suture-bridge15 and suggest evidence-based recommendations that these deformities can be reduced by attending to the number of suture-anchors inserted in the medial and lateral rows. Specifically, a 3 medial × 2 lateral suture-anchor configuration may reduce deformities when treating a large tear, while a 2 × 2 configuration appears adequate for medium-sized tears.

Finally, we love controversial Letters to the Editor—Please keep them coming. The letters in this issue suggest a controversial question: how can we determine when a complication is a result of a device failure16, 17 or is a result of improper surgical technique?18

In this case, readers must review the letters and posit their own conclusion. We simply cannot be sure what caused the described device failure,16 and a definite answer may never be determined (as is often the case). Yet, while we are steering clear of becoming embroiled in this controversy, we certainly desire to highlight a consensus. It seems apparent that both parties17, 18 agree that the device in question is generally reliable, and both advocate for the use of the device in clinical practice.

In summary, keeping up with the literature allows us to answer some questions yet keeps us guessing on others. But there's no doubt that keeping up with the literature keeps us interested.

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References 

  1. Petersen W, Zantop T. Partial rupture of the anterior cruciate ligament. Arthroscopy. 2006;22:1143–1145
  2. Siebold R, Fu FH. Assessment and augmentation of symptomatic anteromedial or posterolateral bundle tears of the anterior cruciate ligament. Arthroscopy. 2008;24:1289–1298
  3. Zhao J, Huangfu X, He Y, Yang X, Zhu Y. Simultaneous double-bundle anterior cruciate ligament and posterior cruciate ligament reconstruction with autogenous hamstring tendons. Arthroscopy. 2008;24:1205–1213
  4. Reiter A, Wolf MB, Schmid U, Frigge A, Dreyhaupt J, Hahn P, et al. Arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears. Arthroscopy. 2008;24:1244–1250
  5. Kim K-C, Rhee K-J, Shin H-D, Kim Y-M. A modified suture-bridge technique for a marginal dog-ear deformity caused during rotator cuff repair. Arthroscopy. 2007;23:562.e1–562.e4
  6. Kim K-C, Rhee K-J, Shin H-D, Kim Y-M. Arthroscopic fixation for displaced greater tuberosity fracture using the suture-bridge technique. Arthroscopy. 2008;24:120.e1–120.e3
  7. Park MC, ElAttrache NS, Ahmad CS, Tibone JE. “Transosseous-equivalent” rotator cuff repair technique. Arthroscopy. 2006;22:1360.e1–1360.e5
  8. Song HS, Williams GR. Arthroscopic reduction and fixation with suture-bridge technique for displaced or comminuted greater tuberosity fractures. Arthroscopy. 2008;24:956–960
  9. Neubauer JM, Bartz BA, Pennington WT. Comparison of early results of rotator cuff repair: Single row MAC configuration versus double row suture bridge technique. Arthroscopy. 2008;24(suppl):e15;(abstr SS-27)
  10. Cole BJ, ElAttrache NS, Anbari A. Arthroscopic rotator cuff repairs: An anatomic and biomechanical rationale for different suture-anchor repair configurations. Arthroscopy. 2007;23:662–669
  11. Milano G, Grasso A, Zarelli D, Deriu L, Piras S, Fabbriciani C. Comparison between single and double-row rotator cuff repair: A biomechanical study. Arthroscopy. 2006;22(suppl):e13–e14(abstr SS-24)
  12. Arrigoni P, Brady PC, Stephen S. Burkhart SS (The double-pulley technique for double-row rotator cuff repair). Arthroscopy. 2007;23:675.e1–675.e4
  13. Nho SJ, Yadav H, Pensak M, Dodson CC, Good CR, MacGillivray JD. Biomechanical fixation in arthroscopic rotator cuff repair. Arthroscopy. 2007;23:94–102
  14. Labbé MR. Arthroscopic technique for patch augmentation of rotator cuff repairs. Arthroscopy. 2006;22:1136.e1–1136.e6
  15. Kim K-C, Rhee K-J, Shin H-D. Deformities associated with the suture-bridge technique for full-thickness rotator cuff tears. Arthroscopy. 2008;24:1251–1257
  16. Metcalfe AJ, James SH, Fairclough JA. Spontaneous locking of the knee following anterior cruciate ligament reconstruction as a result of a broken tibial fixation device. Arthroscopy. 2008;24:1195–1197
  17. Metcalfe AJ, James SH. Authors' reply to Sklar. Arthroscopy. 2008;24:1315;(letter)
  18. Sklar J. A case of Bio-Intrafix migration: An alternative explanation. Arthroscopy. 2008;24:1314–1315(letter)

PII: S0749-8063(08)00685-3

doi:10.1016/j.arthro.2008.09.001

Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 24, Issue 11 , Pages 1203-1204, November 2008

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