Arthroscopy: The Journal of Arthroscopic and Related Surgery

Information Overload: Technology, the Internet, and Arthroscopy

James H. Lubowitz, Gary G. Poehling — 2010-09-01

Information overload. The term was popularized by Alvin Toffler in his 1970 best-seller, “Future Shock,” but the concept may be traced back to the 18th century French philosopher Diderot.

Growth Factor Confusion

Joshua S. Dines — 2010-09-01

I have read with interest several articles in the Journal concerning the use of biologics to enhance ligament and tendon healing. Clearly, the use of growth factors is at the forefront of orthopaedic research and is becoming much more prevalent. Like many orthopaedic surgeons, I am excited about the potential that these growth factors and cytokines may offer our patients, but there are several issues that must be addressed before they are clinically applicable.

Author's Reply

Mario Orrego, Catalina Larrain — 2010-09-01

We read with great interest the letter by Dr. Dines in reference to several publications that confuse and mix concepts regarding the language and conclusions when using autologous blood products to enhance ligament and tendon healing. After analyzing his arguments, we can say that we absolutely agree with his opinions, and even though in our article, we use the term “platelet concentrate,” we believe that in future publications the term “PRP” might be more appropriate, and “growth factors” should only be used when pure forms are applied.

Author's Reply

Matjaz Vogrin, Miroslav Haspl, Primoz Rozman — 2010-09-01

We read with interest the remarks of Dr. Dines concerning terminology used in articles by Nin et al., Radice et al., Orrego et al., and Vogrin et al. We must agree with Dines in his statement that “it is critical … to determine what exactly is being used to improve outcomes” after anterior cruciate ligament (ACL) reconstruction.

Computer-Simulation Training for Arthroscopic Surgery: What Is to Be Considered?

Viroj Wiwanitkit — 2010-09-01

I read the recent article on computer-simulation training for arthroscopy by Modi et al. with a great interest. The authors concluded that “Further studies are required to show the transfer and predictive validity of computer simulation within the operating theater to enable it to become established as a valid training tool.” Indeed, there are many considerations for using computer-simulation training. On the basis of the concept of medical education, a comparative experimental study between classical training and computer-simulation training should be carried out. Nevertheless, there must be a report on the learning curve of using computer-simulation training that can help identify the required number of training sessions to yield the preferred outcome. In addition, certainly, an important concern is the “sense of reality.” No rubber model or computer simulation can provide this sense compared with the actual human model (such as the classical cadaveric model).

Author's Reply

Chetan Suresh Modi, Guy Morris, Ronan Mukherjee — 2010-09-01

Professor Wiwanitkit has made some excellent points regarding computer-simulation training for knee and shoulder arthroscopic surgery that required further consideration. The current up-to-date evidence presented in our systematic review has shown that much more work needs to be carried out before firm recommendations can be made regarding the use of this technology as a training tool. This includes considering the benefits of force feedback and haptic technology with modern simulators, as well as the numbers and lengths of training sessions required, and more studies such as that by Howells et al. that identify the benefits of such training methods by improved performance in the operating theater. We agree entirely that a “sense of reality” is a vital requirement of the training process, and although the modern simulators encompass technology to maximize this, they are likely to fall short of the classic cadaveric models. These models, however, are now increasingly difficult to acquire because of limited supplies, rising costs, and bureaucracy. The further development of simulator technology is therefore a vital area of medical education research to enable the safe and timely acquisition of arthroscopic surgical skills by trainee surgeons of the future.

Anteromedial Portal Drilling for Anatomic Anterior Cruciate Ligament Reconstruction

Yuichi Hoshino, Freddie H. Fu — 2010-09-01

We read with interest the article by Bedi et al. The study clearly shows better obliquity of the tunnel as well as the risk of a short tunnel and posterior wall damage when the anteromedial (AM) portal is used for creating femoral tunnels.

Author's Reply

Asheesh Bedi — 2010-09-01

We thank Drs. Hoshino and Fu for their excellent and insightful comments. We completely agree with their assessment and recognize that meticulous attention to AM portal placement or use of an accessory medial portal may avoid many of the technical issues discussed in this study. In fact, we continue to use an AM portal reaming technique for independent socket preparation during anterior cruciate ligament reconstruction. Rather, the primary conclusion from this study is that there is a significant risk of short tunnel length or posterior wall compromise with use of conventional offset guides with AM portal reaming. When an AM portal drilling technique is used, the guide pin may be better placed by a freehand technique that references the native footprint anatomy. Use of an offset guide that indirectly references from osseous anatomy may paradoxically increase the risk of critically short tunnel length and provide a false sense of protection against posterior wall blowout.

Interscalene Block for Shoulder Surgery in Physician-Owned Community Ambulatory Surgery Centers

Jack M. Bert, Eric Khetia, Douglas A. Dubbink — 2010-06-30

Purpose: To retrospectively report on a series of patients who had interscalene block regional anesthesia performed for outpatient open and arthroscopic shoulder surgical procedures in a community-based ambulatory surgery center setting.Methods: We reviewed the cases of 1,945 patients who had interscalene block regional anesthesia performed during an 8-year period.Results: The complication rate was 0.63%, with all complications occurring in the immediate postoperative period, none of which were permanent.Conclusions: With an expert, experienced anesthesia team, the interscalene block can be a safe method (temporary complication rate, 0.63%) of intraoperative anesthesia and perioperative analgesia for outpatient open and arthroscopic shoulder surgery in physician-owned ambulatory surgery centers.Level of Evidence: Level IV, therapeutic case series.

A Biomechanical Analysis of the Native Coracoclavicular Ligaments and Their Influence on a New Reconstruction Using a Coracoid Tunnel and Free Tendon Graft

2010-04-23

Purpose: To understand and characterize the kinematic properties of the 2 coracoclavicular ligaments and to evaluate the biomechanical performance of a new 3-tunnel reconstruction of the coracoclavicular ligaments by use of a free tendon graft.Methods: Ten fresh-frozen cadaveric shoulders were tested. The kinematics and in situ forces of the coracoclavicular ligaments were tested with a robotic testing system. Kinematics of the shoulder in the intact state, in the sectioned state, and finally, after a coracoclavicular reconstruction and a coracoclavicular sling reconstruction were evaluated.Results: The conoid had higher in situ forces during anterior and superior loading of the clavicle when compared with the trapezoid ligament, whereas the trapezoid ligament had higher in situ forces during posterior loading. Sectioning the trapezoid ligament significantly increased translation of the clavicle in the posterior direction, whereas sectioning the conoid ligament significantly increased superior translation. When we compared the 2 reconstruction techniques, the coracoid tunnel reconstruction was superior in controlling anterior translation whereas the coracoclavicular sling reconstruction was inferior because of anterior displacement of the graft. There was no significant difference in posterior or superior translation between either reconstruction technique.Conclusions: The trapezoid and conoid ligaments have unique functions in normal shoulder kinematics because of their anatomic attachments. By more faithfully restoring these insertion sites on the clavicle and controlling motion of the graft on the coracoid, the 3-tunnel reconstruction technique more closely restores native shoulder kinematics than the coracoclavicular sling technique.Clinical Relevance: Understanding the unique roles of the conoid and trapezoid bundles of the coracoclavicular ligament may improve surgical techniques in the management of acromioclavicular joint injuries. The reconstructive technique presented more faithfully restores normal kinematics and forces across the acromioclavicular joint than the coracoclavicular sling technique.

Arthroscopic Posterior Labral Repair in Athletes: Outcome Analysis at 2-Year Follow-up

2010-07-08

Purpose: The purpose of this outcome analysis was to evaluate the clinical presentation of isolated posterior labral tears resulting from athletic injury and to use multiple outcome measurements to evaluate postoperative results after arthroscopic repair with respect to satisfaction, function, and return to sport.Methods: Seventy-five consecutive patients injured during athletic activity were treated surgically during the 2-year period from 2005 to 2006 for labral pathologies. Twenty-eight patients were treated for isolated posterior labral tears. Of these, all underwent arthroscopic repair of their tears. The mechanism of injury was trauma to a previously asymptomatic shoulder during sports. The patients' mean age was 21 years, and they were evaluated with American Shoulder and Elbow Surgeons; University of California, Los Angeles; Rowe; and visual analog scale scores, as well as active motion and dynamometric strength testing. Scores and measurements were obtained preoperatively and postoperatively at 3, 6, and 12 months and yearly thereafter.Results: In our athletic population undergoing surgical management for labral pathology, 37% of patients (28 of 75) were found to have purely posterior labral lesions after an athletic injury. On intraoperative examination, an element of posterior laxity was seen in only 29% of patients with these tears. At 24 months, significant improvements were observed in the American Shoulder and Elbow Surgeons; University of California, Los Angeles; Rowe; and visual analog scale scores. Increases in forward flexion and external rotation strength were also noted. Return to sport was achieved in 26 of 28 patients (93%). A 93% patient satisfaction rate was observed for arthroscopic posterior labral repairs at more than 24 months.Conclusions: Our patient-athletes presented with painful, dysfunctional shoulders that inhibited performance in their chosen sport. Arthroscopic evaluation and repair of these posterior labral lesions resulted in 26 of 28 patients (93%) returning to sport and 23 of 28 (82%) returning without any limitations.Level of Evidence: Level IV, therapeutic case series.

Arthroscopic Posterior Stabilization and Anterior Capsular Plication for Recurrent Posterior Glenohumeral Instability

Michael S. Bahk, Ronald P. Karzel, Stephen J. Snyder — 2010-09-01

Purpose: The purpose of this study was to evaluate the outcomes and identify predictors of success for arthroscopic posterior Bankart reconstruction with modern suture anchor repair and anterior capsulolabral plication in a well-defined patient population—recurrent, traumatic, involuntary, unidirectional posterior shoulder instability.Methods: Patients with recurrent, traumatic, involuntary, unidirectional posterior shoulder instability who underwent arthroscopic repair with a minimum of 2 years' follow-up were identified and evaluated retrospectively with outcome measures in the form of objective and subjective scores. Statistical analysis was performed to identify predictors of success with significance set at .05.Results: Twenty-nine consecutive patients with a mean age of 26.3 years underwent posterior reconstruction and anterior balancing capsulolabral plication as needed with a mean follow-up of 5.5 years. Outcome scores averaged as follows: American Shoulder and Elbow Surgeons, 90.7; University of California, Los Angeles, 32.6; Simple Shoulder Test, 11.7; and Western Ontario Shoulder Instability, 82.9% of normal. Recurrent instability occurred in 3.4% of patients, 84.6% returned to sports, and 96.6% of patients believed surgery was successful and worthwhile. Patients who were younger (<30 years) or patients with more extensive pathology who required additional surgical procedures or received supplemental anterior plication sutures had less reliable or worse outcomes (P ≤ .041).Conclusions: In a traumatic patient population with involuntary, unidirectional posterior shoulder instability, modern suture anchor repair of posterior labral lesions is effective and provides reliable outcomes. Younger patients and patients with worse pathology who required additional procedures had less reliable outcomes. Patients with supplemental anterior plication had more postoperative pain, and this adjunctive procedure may not be necessary for traumatic posterior labral tear surgery.Level of Evidence: Level IV, therapeutic case series.

Human Tendon Cell Response to 7 Commercially Available Extracellular Matrix Materials: An In Vitro Study

2010-07-15

Purpose: To evaluate the response of human tenocytes in culture to 7 commercially available extracellular matrix (ECM) patches.Methods: Four samples of each ECM were incubated in human tenocyte cultures by use of standard methods. Cell adhesion, cell proliferation, and cellular production of type I and type III collagen, decorin, and scleraxis were measured for each sample according to established experimental methods. Histologic samples were examined to measure the migration of the tenocytes into the ECM.Results: Tenocytes adhered more to samples of layered submucosal pig intestine than the 6 other ECM materials (P < .002). Tenocytes proliferated more and produced more matrix proteins when cultured on ECM derived from unaltered dermal specimens of human or porcine origin (P < .001). Cells were not seen to have migrated into the matrix of any ECM sample.Conclusions: Human tenocytes reacted most favorably to dermal ECM samples that were not chemically cross-linked by the manufacturer. Less favorable responses of the human cells were seen when cultured with equine or synthetic ECM, which showed favorable biologic responses in nonhuman models. Cellular migration into the matrix of the ECM is a complex process and cannot be replicated in this model entirely.Clinical Relevance: The results of this study suggest that dermal ECM may more favorably react with human tendon tissue than ECM of other origins. This may have great relevance as research continues in the field of augmenting surgical soft-tissue repair.

Anterior Shoulder Instability With Bristow Procedure Versus Conjoined Tendon Transfer Alone in a Simple Soft-Tissue Model

Peter R. Thomas, Brent G. Parks, Wiemi A. Douoguih — 2010-08-06

Purpose: We compared the Bristow procedure with a conjoined tendon transfer to investigate the role of the sling alone in restoring anterior translation in a simple soft-tissue instability model without bony defects.Methods: Ten matched cadaveric shoulder pairs were randomly assigned to receive a Bristow procedure or a conjoined tendon transfer alone. Specimens were tested in a simple soft-tissue model with low load simulating anterior translation of the glenohumeral joint. The conditions (intact, cut, and repaired) and treatments (Bristow and conjoined tendon transfer alone) were compared for anteroposterior translation.Results: Anterior translation increased from 3.4 ± 0.6 mm (mean ± SEM) to 12.0 ± 1.3 mm after the cut and decreased to 5.2 ± 0.7 mm with the Bristow procedure. Anterior translation increased from 2.8 ± 0.4 mm to 12.2 ± 1.9 mm after the cut and decreased to 4.9 ± 0.5 mm after conjoined tendon transfer alone. Although the repair increased the stability of the glenohumeral joint as reflected in significantly decreased anterior translation, anterior translation in the repaired joint was significantly greater than that in the intact condition for both procedures (P < .05). There were no significant differences in anterior translation between the 2 treatments at any test stage.Conclusions: There was no difference between the Bristow procedure and conjoined tendon transfer alone in restoring anteroposterior translation in a simple soft-tissue shoulder instability model with low load and no bony defect.Clinical Relevance: Further investigation of the described conjoined tendon procedure should be done to evaluate the procedure with significant bony defects.

Arthroscopic Synovectomy for the Rheumatoid Elbow

Hong Je Kang, Min Jong Park, Jin Hwan Ahn, Sang Hak Lee — 2010-07-08

Purpose: To describe an arthroscopic technique for complete removal of the synovium from the elbow joint and to investigate the clinical outcomes of arthroscopic synovectomy in patients with rheumatoid elbow.Methods: Arthroscopic synovectomy was performed on 26 rheumatoid elbows in 25 patients with radiographic changes of Larsen grade 3 or less. We performed total synovectomy of the elbow using multiple portals and by dividing the elbow into the anterior, posterior, and radiocapitellar compartments. At a mean follow-up of 33.9 months (range, 13 to 68 months), pain was evaluated with a visual analog scale and range of motion was measured. The Mayo Elbow Performance Score was used to assess total elbow function. Radiologic changes were determined according to the Larsen grading system.Results: The mean visual analog scale score for pain decreased from 6.5 to 3.1, and the mean flexion arc increased from 98.1° to 113.3° after the operation. The mean Mayo Elbow Performance Score improved from 58.5 to 77.4 points. There were 2 excellent, 17 good, 4 fair, and 3 poor results. Radiologic assessment showed no change in 13 elbows, improvement in 6, and progression in 7. Clinically apparent synovitis recurred in 4 elbows, in which the result was considered unsuccessful.Conclusions: Arthroscopic synovectomy of the elbow by use of multiple portals is a technically feasible procedure. It can effectively relieve pain, increase range of motion, improve Mayo Elbow Performance Score, and delay radiologic progression in rheumatoid elbows, resulting in a high satisfaction rate, although recurrent synovitis occurs in some patients.Level of Evidence: Level IV, therapeutic case series.

Intraoperative Comparison of Knee Laxity Between Anterior Cruciate Ligament–Reconstructed Knee and Contralateral Stable Knee Using Navigation System

2010-06-07

Purpose: The objective of this study was to compare knee laxity between anterior cruciate ligament (ACL)–reconstructed knees and contralateral stable knees by use of intraoperative navigation.Methods: Five patients with ipsilateral ACL-deficient knees with contralateral stable knees without any ligament injuries were included in this study. Anteroposterior (AP) knee laxity during anterior drawer force applied manually and range of tibial rotation and AP knee laxity during internal and external rotational torque applied manually in both the ACL-deficient knee and the contralateral stable knee were measured by use of a navigation system from 15° to 90° of knee flexion. After the temporary fixation of the posterolateral bundle, anteromedial bundle (AMB), or double-bundle (DB) reconstruction, knee laxity was measured again and compared with that of the stable knee.Results: The mean laxities for PLB reconstruction were significantly greater than those of the contralateral stable knee at more than 75° of knee flexion (P < .05). The mean laxities for AMB or DB reconstruction were not significantly different from those of the contralateral stable knee at all knee flexion angles. Those for AMB reconstruction were within +1.6 mm and those for DB reconstruction were within −2.0 mm of those of the contralateral stable knee. The mean rotations for all reconstructions were significantly less than those of the contralateral stable knee at less than 30° of knee flexion (P < .05).Conclusions: DB and AMB reconstructions could restore knee laxity closer to the level of the contralateral stable knee. Because normal knee laxity is different in each individual, evaluation of contralateral stable knee laxity during ACL reconstruction surgery would be helpful for restoration to the level of the specific preinjury knee laxity.Level of Evidence: Level IV, therapeutic case series.

Lower Extremity Compensatory Neuromuscular and Biomechanical Adaptations 2 to 11 Years After Anterior Cruciate Ligament Reconstruction

John Nyland, Scott Klein, David N.M. Caborn — 2010-06-17

Purpose: To determine whether compensatory neuromuscular and biomechanical adaptations exist after successful anterior cruciate ligament reconstruction and rehabilitation.Methods: Seventy subjects, 5.3 ± 3 years after surgery, participated in this study. Sagittal-plane lower extremity kinematic, gluteus maximus, vastus medialis, medial hamstring, and gastrocnemius electromyography (EMG) and vertical ground reaction force data were collected during single-leg countermovement jump (CMJ) performance.Results: Women had lower propulsive and landing forces, lower CMJ heights, less hip and knee flexion, and greater angular hip, knee, and ankle velocities than men (P ≤ .014). The involved lower extremity of men and women had decreased landing forces (P = .008). During propulsion, men and women had increased involved–lower extremity gluteus maximus (P < .0001) and decreased vastus medialis (P = .013) EMG amplitudes, whereas women had bilaterally increased gastrocnemius EMG amplitudes compared with men (P = .003). During propulsion, men had longer gluteus maximus and vastus medialis EMG durations than women (P < .0001). During landing, both men and women had increased gluteus maximus EMG amplitudes at the involved lower extremity (P < .0001). Women had increased vastus medialis (P = .01) and gastrocnemius (P < .0001) EMG amplitudes compared with men. During landing, men had longer gluteus maximus (P = .004), vastus medialis (P = .012), and gastrocnemius (P = .007) EMG durations than women and the involved–lower extremity vastus medialis EMG durations of both men and women were shorter than at the noninvolved lower extremity (P = .011).Conclusions: Decreased involved–lower extremity landing forces, decreased vastus medialis activation, and increased gluteus maximus and gastrocnemius activation suggest a protective mechanism to minimize knee loads that increase anterior translatory knee forces during single-leg jumping. Women showed more balanced gluteus maximus, vastus medialis, and gastrocnemius contributions to dynamic knee stability than men during CMJ landings but used shorter activation durations.Level of Evidence: Level IV, therapeutic case series.

Biomechanical Evaluation of a Novel Application of a Fixation Device for Bone-Tendon-Bone Graft (EndoButton CL BTB) to Soft-Tissue Grafts in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Shin Miyatake, Eiji Kondo, Harukazu Tohyama, Nobuto Kitamura, Kazunori Yasuda — 2010-07-08

Purpose: The purpose of this biomechanical study was to compare the structural properties of the flexor tendon graft connected to the EndoButton CL BTB (ECL-BTB) (Smith & Nephew Endoscopy, Andover, MA), which is newly developed to fix the bone-tendon-bone graft, with those of the same graft connected to the EndoButton CL (ECL) (Smith & Nephew Endoscopy), which is commonly used as a standard fixation device.Methods: We randomly divided 40 porcine flexor digitorum profundus tendons into 4 groups. An ECL and an ECL-BTB were attached to the doubled tendon measuring 6 mm in diameter in groups I and II, respectively. An ECL and an ECL-BTB were attached to the doubled tendon measuring 7 mm in diameter in the same manner in groups III and IV, respectively. Tensile testing was performed with a tensile tester.Results: The linear stiffness of the tendon-device composite (mean ± SD) was 131.8 ± 18.3 N/mm, 109.7 ± 14.9 N/mm, 132.4 ± 20.5 N/mm, and 123.8 ± 10.7 N/mm in groups I, II, III, and IV, respectively. The 2-way analysis of variance (ANOVA) showed a significant difference (P = .0058) between the ECL and the ECL-BTB. Concerning the maximum load and the elongation at failure of the tendon-device composite, the 2-way ANOVA showed no significant difference between the 2 fixation devices. Regarding the cross-sectional area, the 2-way ANOVA indicated no significant difference between the 2 fixation devices.Conclusions: This study has shown that the maximum load of the flexor tendon graft connected to the ECL-BTB is similar to that of the ECL whereas the stiffness of the ECL-BTB is inferior to that of the ECL.Clinical Relevance: This study has suggested that patients should not be permitted to perform vigorous activities in the early period after anterior cruciate ligament reconstruction by use of the ECL-BTB fixation technique, because of its low stiffness compared with the ECL device.

Energy Absorbed by Longitudinally Splitting a Tibialis Anterior Allograft: Implications for Double-Bundle Anterior Cruciate Ligament Reconstruction

Lindsey Clark, Craig Howard, Leslie J. Bisson — 2010-07-08

Purpose: Split tibialis anterior (TA) allografts have been proposed as a source for double-bundle anterior cruciate ligament reconstruction. We sought to determine whether longitudinally splitting a TA tendon leads to a change in the mechanical properties of the tendon.Methods: Seven cadaveric matched pairs of TA tendons were procured. One member of each pair was longitudinally pierced in its midportion and then bluntly split, creating 2 longitudinally divided grafts. The other member of the pair remained intact. Each tendon was then frozen into thermoelectrically cooled clamps and loaded to failure on an MTS machine (MTS Systems, Eden Prairie, MN) at a displacement of 1 mm/s. The area under the force-versus-displacement curve was calculated as an indicator of energy absorbed by the tendon before failure. The energy absorbed by the intact tendon was then compared with the summed energy absorbed by the 2 specimens obtained by splitting the sibling specimen.Results: Energy absorbed by the intact tendon was 10,300 ± 3,433 Nmm, whereas total energy absorbed by the 2 longitudinally split tendons was 10,530 ± 2,095 Nmm (P = .78).Conclusions: Longitudinal splitting of a TA allograft by the technique described does not significantly affect the graft's ability to absorb energy.Clinical Relevance: The splitting technique described can safely be used to create 2 grafts if surgeons wish to use a TA graft for a double-bundle anterior cruciate ligament reconstruction or for reconstruction by use of fixation devices requiring 2 looped tendon grafts.

Magnetic Resonance Imaging–Documented Chondral Injuries About the Knee in College Football Players: 3-Year National Football League Combine Data

Kurt C. Hirshorn, Taylor Cates, Scott Gillogly — 2010-07-15

Purpose: To evaluate the incidence and risk factors for knee cartilage injury in elite college football players invited to attend the US National Football League (NFL) Scouting Combine over a 3-year period.Methods: All players entering the NFL Scouting Combine (National Invitational Camp) from 2005 through 2007 were evaluated. “At-risk” knees underwent magnetic resonance imaging (MRI), and the results were evaluated for chondral injuries.Results: During the 3-year period reviewed, a total of 980 players were available for analysis, and a total of 516 players' knee MRI scans were obtained (53% of all players at the Combine). The total number of full-thickness chondral injuries evident on MRI was 197 (20.1%) among all players, or 38.2% of the players who had an MRI scan. Of the players, 30 (3.06% of all players at the Combine, or 5.8% of the players who had an MRI scan) had isolated medial compartment full-thickness chondral injuries, 41 (4.2%, or 7.9%) had isolated lateral compartment full-thickness chondral injuries, 48 (4.9%, or 9.3%) had patellofemoral compartment full-thickness chondral damage, and 78 (7.96%, or 15.1%) had full-thickness chondral injuries in more than 1 compartment.Conclusions: The epidemiologic and risk assessment data presented in this study offer a cross-section of a young and elite athletic population who were “prescreened” at the NFL Combine over a 3-year period and judged to have at-risk knees. The total number of full-thickness chondral injuries evident on MRI was 197 (20.1%) among all players, or 38.2% of the players who had an MRI scan: 30 players (3.06%, or 5.8%) had an isolated medial compartment full-thickness chondral injury, 41 players (4.2%, or 7.9%) had an isolated lateral compartment full-thickness chondral injury, 48 players (4.9%, or 9.3%) had isolated patellofemoral compartment full-thickness chondral damage, and 78 players (7.96%, or 15.1%) had full-thickness chondral injuries in more than 1 compartment.Level of Evidence: Level IV, diagnostic study.

Endoscopic Plantar Fascia Release by Hooked Soft-Tissue Electrode After Failed Shock Wave Therapy

2010-07-14

Purpose: The purpose of this study was to assess the outcome of endoscopic plantar fascia release (EPFR) after failed extracorporeal shock wave therapy (ESWT).Methods: Eighteen patients (twenty-one feet) had persistent painful heel after treatment by ESWT for at least 6 months. The treatment protocol included 2,000 pulses of 0.12 mJ/mm2 given in 1 session weekly for 7 sessions. Preoperative and postoperative assessment of pain and functional evaluation were done blindly by the second author using a visual analog scale (VAS) score and the modified American Orthopaedic Foot & Ankle Society (AOFAS) score for the hindfoot. EPFR was done without the use of a tourniquet under local ankle block. A monopolar hooked soft-tissue electrode (ConMed Linvatec, Largo, FL) was used to sever the plantar fascia and to control bleeding. The mean follow-up period was 25.8 months. Only 17 patients (20 feet) completed 2 years' follow-up.Results: The mean preoperative VAS score was 72.52, and the mean preoperative modified AOFAS score was 24.23. There was a statistically significant improvement in VAS score, modified AOFAS score, and morning pain at 2 years' follow-up (P < .05). Of the patients, 9 (50%) had excellent results, 6 (35%) had good results, 1 (10%) had a fair result, and 1 (5%) had failure of improvement of pain. No major complications were found; 2 patients had hyperkeratosis at the portal site, and 1 patient had paresthesia at the lateral border of the foot.Conclusions: EPFR yielded good to excellent outcomes in 85% of 17 patients with plantar fasciitis resistant to treatment by ESWT after 2 years' follow-up.Level of Evidence: Level IV, therapeutic case series.

Elbow Arthroscopy: A New Technique

Gary G. Poehling, Terry L. Whipple, Lance Sisco, Brian Goldman — 2010-09-01

Summary: Elbow arthroscopy is a useful diagnostic and therapeutic tool for the orthopaedic surgeon. In the standard technique, the patient is positioned supine with the arm suspended overhead and an anterolateral portal is used. We have modified this technique by placing the patient in a prone position and using a proximal medial portal. Use of the prone position improves scope mobility, facilitates joint manipulation, and provides more complete intra-articular visualization. This technique simplifies the treatment of a wide variety of elbow pathology, including loose bodies, osteochondritis dissecans, persistent synovitis, suspected cartilaginous lesions, posterior osteophytes, selected radial head fractures, and chronically undiagnosed painful elbows.

Osseous Deficits After Anterior Cruciate Ligament Injury and Reconstruction: A Systematic Literature Review With Suggestions to Improve Osseous Homeostasis

John Nyland, Brent Fisher, Emily Brand, Ryan Krupp, David N.M. Caborn — 2010-09-01

Purpose: This systematic review was performed to improve our understanding of the current evidence regarding the influence of anterior cruciate ligament (ACL) injury and reconstruction on involved lower extremity apparent bone mineral density, bone content, or bone area mass (bone integrity).Methods: Two independent reviewers performed a Medline search from 1966 to January 2010 using the terms “anterior cruciate ligament” or “ACL” combined with “wound” or “injury” and “bone density” or “osteoporosis.” Study inclusion criteria were English-language human studies. Reference sections of selected studies were also reviewed.Results: Ten studies were identified that met our inclusion criteria. Eight studies performed ACL reconstruction with bone–patellar tendon–bone autografts and interference screw fixation. One study performed ACL reconstruction by use of Achilles tendon allografts with interference screw and staple fixation. Two ACL injury studies either did not involve ACL reconstruction or attempted primary repair with sutures. All studies reported varying levels of decreased bone mineral density, bone content, or bone area mass (bone integrity) at the involved lower extremity after ACL injury that did not return to premorbid levels even with ACL reconstruction and rehabilitation. Sites of reduced bone integrity included the proximal and distal femur, proximal tibia, patella, and calcaneus. Bone loss was increased with limited weight bearing and prolonged disuse or immobilization; however, significant improvements were not observed with accelerated rehabilitation. Some studies reported relations between Lysholm, Tegner, International Knee Documentation Committee survey, or function scores and bone integrity, whereas others reported no or poor relations.Conclusions: Involved lower extremity bone integrity is decreased after ACL injury. Current evidence suggests that premorbid bone integrity is not re-established after ACL reconstruction even when accelerated rehabilitation is performed. Recommendations to improve osseous homeostasis and bone health after ACL injury and reconstruction are provided.

Simultaneous Reconstruction of Ruptured Anterior Cruciate Ligament and Medial Patellofemoral Ligament With Ipsilateral Quadriceps Grafts

Marko Macura, Matjaž Veselko — 2010-09-01

Abstract: Rupture of the anterior cruciate ligament is a well-known entity and causes anteroposterior and rotational instability of an injured knee. Rupture of the medial patellofemoral ligament is less frequent, and its insufficiency causes patellar instability. Several techniques have been described for the reconstruction of each ligament. The 2 lesions and following instabilities can coexist, and both ligaments can be reconstructed simultaneously. We report on 2 cases, 1 recreational sportswoman and 1 high-level sportswoman, with coexisting lesions treated surgically by a single-step procedure using ipsilateral graft of the quadriceps tendon for reconstruction of medial patellofemoral ligament and anterior cruciate ligament. The advantage of this procedure is that there is only 1 donor site, and thus lower donor-site morbidity, while the strength of either neoligament is not sacrificed. The technique is described here.

Glenoid Avulsion of the Glenohumeral Ligaments as a Cause of Recurrent Anterior Shoulder Instability

Eugene M. Wolf, Patrick N. Siparsky — 2010-09-01

Abstract: Although the Bankart lesion is accepted as the primary pathology responsible for recurrent shoulder instability, recognition of other soft-tissue lesions has improved the surgical treatment for this common problem. Whereas humeral avulsion of the glenohumeral ligaments has been acknowledged as a cause of anterior shoulder instability, we have not found any reported cases of glenoid avulsion of the glenohumeral ligaments. We describe 3 cases of recurrent anterior shoulder instability due to glenoid avulsion of the glenohumeral ligaments. The avulsed ligaments were repaired to the labrum and glenoid, restoring the glenohumeral ligament–labral complex.

Erratum

2010-09-01

In the article “pCMV-BMP-2-Transfected Cell-Mediated Gene Therapy in Anterior Cruciate Ligament Reconstruction in Rabbits” by Wang et al. in the July issue of Arthroscopy (2010;26:968-976), there was an omission in the authors' affiliation listing. The correct paragraph appears below.

Erratum

2010-09-01

In the article by Feeley et al. “Comparison of Posterolateral Corner Reconstructions Using Computer-Assisted Navigation” in the August issue of Arthroscopy (2010;26:1088-1095) there was an error in the second paragraph of the introduction on page 1089 in which the authors cite the 2005 study by Arciero. The phrase “oblique femoral tunnel” was used instead of “oblique fibular tunnel.” The corrected sentence appears below:

Announcements

2010-09-01

The Arthroscopy Association of North America 2010 Master's Experience Courses will be held on the following dates: September 10-12, 2010 (shoulder); September 25-26, 2010 (AANA/AOFAS foot & ankle); October 14-16, 2010 (senior resident/fellow); October 29-31, 2010 (shoulder); November 5-7, 2010 (hip). They will be held at the Orthopaedic Learning Center, Rosemont, IL. For more information, visit www.aana.org

Spanish Translated Abstracts

2010-09-01

Masthead

2010-09-01

Arthroscopy: The Journal of Arthroscopic and Related Surgery (ISSN 0749-8063) is published monthly by Elsevier Inc., 360 Park Avenue South, New York, NY 10010-1710. (For Post Office use only: Volume 26 issue 9 of 12.) Periodicals postage paid at New York, NY and additional mailing offices.

Editorial Board

2010-09-01

Cover Image

2010-09-01

On the Cover: This is an arthroscopic view through the anterolateral portal of a left knee in a 17-year-old snowboarder who injured his knee in a fall in terrain park. The picture shows a very large, displaced medial meniscus tear in the intercondylar notch adjacent to the ACL (right). The probe (left) shows the junction of the meniscus and the medial femoral condyle. This tear was repaired with an arthroscopic inside-out repair because of its size. Courtesy of Michael J. Rossi, M.D.

Instructions for Authors

2010-09-01

Arthroscopy: The Journal of Arthroscopic and Related Surgery seeks to provide readers with current information by publishing the best papers on clinical and basic research, review articles, technical notes, case reports, and editorials about the latest developments in arthroscopic surgery, knee surgery, and orthopaedic sports surgery. All articles are subject to peer review. Letters to the Editor and comments on the Journal's content or policies are always welcome.

Suggested Guidelines for the Practice of Arthroscopic Surgery

2010-09-01

This statement was prepared by the Committee on Ethics and Standards and the Board of Directors of the Arthroscopy Association of North America. The decision to grant and renew privileges in diagnostic arthroscopy and or arthroscopic surgery is typically made by individual hospitals with input from medical staff committees and appropriate department chairpersons, in accordance with individual hospital and medical staff bylaws, rules and regulations. In situations where arthroscopic surgical privileges are requested, a Board Certified orthopedic surgeon or equivalent specialist, with considerable experience in the field of arthroscopic surgery should be involved in the decision making process to grant these privileges.

Arthroscopy: The Journal of Arthroscopic and Related Surgery

Information Overload: Technology, the Internet, and Arthroscopy

Growth Factor Confusion

Author's Reply

Author's Reply

Computer-Simulation Training for Arthroscopic Surgery: What Is to Be Considered?

Author's Reply

Anteromedial Portal Drilling for Anatomic Anterior Cruciate Ligament Reconstruction

Author's Reply

Interscalene Block for Shoulder Surgery in Physician-Owned Community Ambulatory Surgery Centers

A Biomechanical Analysis of the Native Coracoclavicular Ligaments and Their Influence on a New Reconstruction Using a Coracoid Tunnel and Free Tendon Graft

Arthroscopic Posterior Labral Repair in Athletes: Outcome Analysis at 2-Year Follow-up

Arthroscopic Posterior Stabilization and Anterior Capsular Plication for Recurrent Posterior Glenohumeral Instability

Human Tendon Cell Response to 7 Commercially Available Extracellular Matrix Materials: An In Vitro Study

Anterior Shoulder Instability With Bristow Procedure Versus Conjoined Tendon Transfer Alone in a Simple Soft-Tissue Model

Arthroscopic Synovectomy for the Rheumatoid Elbow

Intraoperative Comparison of Knee Laxity Between Anterior Cruciate Ligament–Reconstructed Knee and Contralateral Stable Knee Using Navigation System

Lower Extremity Compensatory Neuromuscular and Biomechanical Adaptations 2 to 11 Years After Anterior Cruciate Ligament Reconstruction

Biomechanical Evaluation of a Novel Application of a Fixation Device for Bone-Tendon-Bone Graft (EndoButton CL BTB) to Soft-Tissue Grafts in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Energy Absorbed by Longitudinally Splitting a Tibialis Anterior Allograft: Implications for Double-Bundle Anterior Cruciate Ligament Reconstruction

Magnetic Resonance Imaging–Documented Chondral Injuries About the Knee in College Football Players: 3-Year National Football League Combine Data

Endoscopic Plantar Fascia Release by Hooked Soft-Tissue Electrode After Failed Shock Wave Therapy

Elbow Arthroscopy: A New Technique

Osseous Deficits After Anterior Cruciate Ligament Injury and Reconstruction: A Systematic Literature Review With Suggestions to Improve Osseous Homeostasis

Simultaneous Reconstruction of Ruptured Anterior Cruciate Ligament and Medial Patellofemoral Ligament With Ipsilateral Quadriceps Grafts

Glenoid Avulsion of the Glenohumeral Ligaments as a Cause of Recurrent Anterior Shoulder Instability

Erratum

Erratum

Announcements

Spanish Translated Abstracts

Masthead

Editorial Board

Contents

Cover Image

Instructions for Authors

Suggested Guidelines for the Practice of Arthroscopic Surgery