Arthroscopy: The Journal of Arthroscopic and Related Surgery

“I Found It on the Internet:” How Reliable and Readable is Patient Information?

Merrick J. Wetzler — 2013-06-01

The Internet has truly put information at our finger-tips, but can we trust all the information that is out there? The old saying, “Let the buyer beware” can easily be adapted to the Internet and now we say “Let the Internet surfer beware.” This concern has even been satirized in several TV commercials about not believing everything you read on the Internet, as in, “I found it on the Internet so it has to be true!”

A Biological Approach to Orthopaedic Surgery: Are They Lost in Translation?

Mikel Sánchez, Eduardo Anitua, Gorka Orive, Sabino Padilla — 2013-06-01

Despite the care and seriousness with which Ruiz-Moneo et al. conducted their study “Plasma Rich in Growth Factors in Arthroscopic Rotator Cuff Repair: A Randomized, Double-Blind, Controlled Clinical Trial,” there are methodologic and conclusive issues that we believe would affect the outcomes in this recently published study.

Authors' Reply

Jaime Algorta, Pedro Ruiz-Monedo, Jorge Molano — 2013-06-01

We read with interest the letter from Anitua et al. in response to our randomized, blinded, controlled, clinical trial evaluating the use of plasma rich in growth factors (PRGF) in the repair of the rotator cuff, recently published in Arthroscopy (January 2013). We are grateful for their contribution to improve the discussion on the topic, because we acknowledge that for the design of our randomized controlled trial (RCT), we took into consideration their previous results on the application of PRGF in maxillofacial surgery and orthopaedics and, thereafter, we strictly followed their guidance to prepare the PRGF and their advice for its use in the surgery.

Histomorphologic Changes of the Long Head of the Biceps Tendon in Common Shoulder Pathologies

2013-04-08

Purpose: To assess molecular and histologic differences between the proximal (intra-articular) and distal (extra-articular) portions of the long head of the biceps (LHB) tendon in 3 different disease states (biceps instability, tendinosis, and degenerative joint disease [DJD]) compared with a healthy tendon (fresh frozen).Methods: We used 32 LHB tendons of patients undergoing tenodesis (mean age, 54.7 ± 10.1 years) and 9 harvested tissue donors. Tendons were divided according to 4 diagnostic groups: (1) biceps instability, (2) tendinosis, (3) DJD, and (4) normal control. After sectioning, tendons were fixed in formalin and stained with H&E and alcian blue for histologic analysis. Measurements of collagen organization by use of polarized light microscopy was then performed, and protein expression for type I and type III collagen, tenascin C, and decorin was determined.Results: There were no statistical differences found for protein expression of type I or type III collagen, tenascin C, or decorin. The proximal and distal regions of the tendons had statistically significant differences in alcian blue staining, with the proximal portion containing a higher amount of proteoglycan (instability, P = .001; tendinosis, P = .005; DJD, P = .008; control, P = .011). When compared with the nonpathologic control tendons, a significant increase in alcian blue staining for the proximal region was seen in all 3 groups. Total polarized light analysis showed that the distal tendon had a significantly higher intensity (organization) compared with the proximal tendon (P < .001); this was also seen in all of the diagnostic groups (instability, P = .010; tendinosis, P = .013; DJD, P = .07; control, P = .028).Conclusions: This study showed a greater degree of degeneration of the proximal (intra-articular) regions of the LHB tendon when compared with the distal regions in all pathologic groups. However, no major differences at the cellular level were found among groups.Clinical Relevance: The pathomechanisms of the various forms of known LHB diagnoses are not yet fully understood and basic science studies may help in understanding their etiology and therefore optimizing treatment options.

Shoulder Arthroscopy Simulator Training Improves Shoulder Arthroscopy Performance in a Cadaveric Model

R. Frank Henn, Neel Shah, Jon J.P. Warner, Andreas H. Gomoll — 2013-04-15

Purpose: The purpose of this study was to quantify the benefits of shoulder arthroscopy simulator training with a cadaveric model of shoulder arthroscopy.Methods: Seventeen first-year medical students with no prior experience in shoulder arthroscopy were enrolled and completed this study. Each subject completed a baseline proctored arthroscopy on a cadaveric shoulder, which included controlling the camera and completing a standard series of tasks using the probe. The subjects were randomized, and 9 of the subjects received training on a virtual reality simulator for shoulder arthroscopy. All subjects then repeated the same cadaveric arthroscopy. The arthroscopic videos were analyzed in a blinded fashion for time to task completion and subjective assessment of technical performance. The 2 groups were compared by use of Student t tests, and change over time within groups was analyzed with paired t tests.Results: There were no observed differences between the 2 groups on the baseline evaluation. The simulator group improved significantly from baseline with respect to time to completion and subjective performance (P < .05). Time to completion was significantly faster in the simulator group compared with controls at the final evaluation (P < .05). No difference was observed between the groups on the subjective scores at the final evaluation (P = .98).Conclusions: Shoulder arthroscopy simulator training resulted in significant benefits in clinical shoulder arthroscopy time to task completion in this cadaveric model. This study provides important additional evidence of the benefit of simulators in orthopaedic surgical training.Clinical Relevance: There may be a role for simulator training in shoulder arthroscopy education.

Relationship of the Subscapular Nerves to the Base of the Coracoid

2013-04-22

Purpose: This study was performed to determine the relation of the subscapular nerves to the medial base of the coracoid when using an arthroscopic approach.Methods: Twenty human cadaveric shoulder specimens were dissected, and measurements were taken from the medial base of the coracoid to the innervation points of the upper and lower subscapular nerves. Measurements were obtained with the humerus in both neutral and maximal external rotation.Results: The average distance of the upper subscapular nerve from the coracoid base was 31.6 ± 6.6 mm (range, 22 to 45 mm) in neutral rotation and 24.2 ± 7.4 mm (range, 11 to 35 mm) in external rotation. The lower subscapular nerve's insertion point averaged 42.6 ± 7.6 mm (range, 25 to 55 mm) from the coracoid base in neutral rotation and 33.9 ± 6.9 mm (range, 24 to 45 mm) in external rotation. For both nerves, their distance from the coracoid significantly decreased when the humerus was placed in external rotation.Conclusions: The closest that the innervation point of either the upper or lower subscapular nerve came to the medial aspect of the coracoid was 11 mm.Clinical Relevance: Understanding the relationship of the subscapular nerves to the base of the coracoid allows a safe arthroscopic release of a retracted subscapularis muscle that has formed adhesions to the inferior aspect of the coracoid. Use of an arthroscopic elevator to release adhesions between the subscapularis and the inferior aspect of the coracoid does not appear to risk denervation of the subscapularis muscle.

The Effect of Humeral Avulsion of the Glenohumeral Ligaments and Humeral Repair Site on Joint Laxity: A Biomechanical Study

2013-04-25

Purpose: The aims of this cadaveric study were to assess the effect of different sizes of humeral avulsion of the glenohumeral ligament (HAGL) lesions on joint laxity and to investigate any difference between repairs with anchors placed in a juxtachondral position and repairs with anchors placed in the humeral neck.Methods: Glenohumeral specimens were tested on a shoulder laxity testing system with translations applied anteriorly up to 30 N, with the joint in 60° of glenohumeral abduction. Testing was conducted in neutral rotation and under 1-Nm external rotation for 5 specimen states: intact, medium HAGL lesion (4:30 to 5:30 clock-face position), large HAGL lesion (3:30 to 6:30 clock-face position), repair with juxtachondral suture anchors, and repair with humeral neck suture anchors.Results: Significant increases in translation were observed between the intact and large HAGL lesion states for neutral rotation (1.46 mm [SD, 2.33 mm] at 30 N; P = .049) and external rotation (0.81 mm [SD, 0.72 mm] at 30 N; P = .005). Significant reductions in translation were also observed between the large HAGL lesion and humeral neck repair states for neutral rotation (−1.78 mm [SD, 2.23 mm] at 30 N; P = .022) and external rotation (−0.33 mm [SD, 0.37 mm] at 30 N; P = .015).Conclusions: Large HAGL lesions can increase the passive motion of the glenohumeral joint in both neutral and external rotation, although these differences are small and may be difficult to measure clinically. A repair using anchors placed in the humeral neck is more likely to restore the normal restraint to anterior translation than a juxtachondral repair.Clinical Relevance: Medium HAGL lesions are unlikely to show significant increases in joint translation, and repair of large HAGL lesions should be achieved with anchors placed in the humeral neck if possible.

Addition of a Suture Anchor for Coracoclavicular Fixation to a Superior Locking Plate Improves Stability of Type IIB Distal Clavicle Fractures

2013-06-01

Purpose: The purpose of this study was to determine the effect of coracoclavicular (CC) fixation on biomechanical stability in type IIB distal clavicle fractures fixed with plate and screws.Methods: Twelve fresh-frozen matched cadaveric specimens were used to create type IIB distal clavicle fractures. Dual-energy x-ray absorptiometry (DEXA) scans ensured similar bone quality. Group 1 (6 specimens) was stabilized with a superior precontoured distal clavicle locking plate and supplemental suture anchor CC fixation. Group 2 (6 specimens) followed the same construct without CC fixation. Each specimen was cyclically loaded in the coronal plane at 40 to 80 N for 17,500 cycles. Load-to-failure testing was performed on the specimens that did not fail cyclic loading. Outcome measures included mode of failure and the number of cycles or load required to create 10 mm of displacement in the construct.Results: All specimens (12 of 12) completed cyclic testing without failure and underwent load-to-failure testing. Group 1 specimens failed at a mean of 808.5 N (range, 635.4 to 952.3 N), whereas group 2 specimens failed at a mean of 401.3 N (range, 283.6 to 656.0 N) (P = .005). Group 1 specimens failed by anchor pullout without coracoid fracture (4 of 6) and distal clavicle fracture fragment fragmentation (1 of 6); one specimen did not fail at the maximal load the materials testing machine was capable of exerting (1,000 N). Group 2 specimens failed by distal clavicle fracture fragment fragmentation (3 of 6) and acromioclavicular (AC) joint displacement (1 of 6); 2 specimens did not fail at the maximal load of the materials testing machine.Conclusions: During cyclic loading, type IIB distal clavicle fractures with and without CC fixation remain stable. CC fixation adds stability to type IIB distal clavicle fractures fixed with plate and screws when loaded to failure.Clinical Relevance: CC fixation for distal clavicle fractures is a useful adjunct to plate-and-screw fixation to augment stability of the fracture.

Footprint Contact Restoration Between the Biceps-Labrum Complex and the Glenoid Rim in SLAP Repair: A Comparative Cadaveric Study Using Pressure-Sensitive Film

Sung-Jae Kim, Sung-Hwan Kim, Su-Keon Lee, Jae-Hoo Lee, Yong-Min Chun — 2013-06-01

Purpose: To compare pressurized footprint contact and interface pressure between the biceps-labrum complex and the superior glenoid rim after SLAP repair using 3 different techniques.Methods: Twenty-four fresh-frozen human cadaveric shoulders were divided into 3 groups. SLAP lesions were repaired by (1) 2 single-loaded anchors in a simple suture configuration (group T), (2) a double-loaded anchor in a simple suture configuration in a V shape (group V), or (3) a double-loaded anchor by use of a hybrid simple and mattress suture configuration (group H). Pressure-sensitive film quantified pressurized contact areas and interface pressures between the biceps-labrum complex and the glenoid rim after SLAP repair.Results: Groups T and V showed significantly larger contact areas than group H (P < .0001). However, there was no significant difference between groups T and V. Despite a substantial contact area around the biceps-labrum complex in group T, there was a lack of sufficient contact area just below the biceps anchor. Group V showed a uniform contact area around the entire biceps-labrum complex, but in group H the contact area was concentrated only around the posterior superior labrum, where the simple suture was used.Conclusions: The methods using 2 single-loaded suture anchors and using 1 double-loaded suture anchor with a simple suture configuration showed significantly larger pressurized contact areas than the method using 1 double-loaded suture anchor with both a simple and mattress suture configuration. The interface pressure was not significantly different among groups.Clinical Relevance: Although there have been several kinds of repair techniques and biomechanical studies for the type II SLAP lesion, there has been no study about footprint restoration on the superior glenoid rim. This study analyzed and compared the footprint contact restoration after type II SLAP repair among 3 different techniques.

Cyclic Biomechanical Testing of Biocomposite Lateral Row Knotless Anchors in a Human Cadaveric Model

F. Alan Barber, Eric D. Bava, David B. Spenciner, Justin Piccirillo — 2013-04-11

Purpose: The purpose of this study was to assess the mechanical performance of biocomposite knotless lateral row anchors based on both anchor design and the direction of pull.Methods: Two lateral row greater tuberosity insertion sites (anterior and posterior) were identified in matched pairs of fresh-frozen human cadaveric shoulders DEXA (dual energy X-ray absorptiometry) scanned to verify comparability. The humeri were stripped of all soft tissue and 3 different biocomposite knotless lateral row anchors: HEALIX Knotless BR (DePuy Mitek, Raynham MA), BioComposite PushLock (Arthrex, Naples, FL), and Bio-SwiveLock (Arthrex). Fifty-two anchors were distributed among the insertion locations and tested them with either an anatomic or axial pull. A fixed-gauge loop (15 mm) of 2 high-strength sutures from each anchor was created. After a 10-Nm preload, anchors were cycled from 10 to 45 Nm at 0.5 Hz for 200 cycles and tested to failure at 4.23 mm/second. The load to reach 3 mm and 5 mm displacement, ultimate failure load, displacement at ultimate failure, and failure mode were recorded.Results: Threaded anchors (Bio-SwiveLock, P = .03; HEALIX Knotless, P = .014) showed less displacement with anatomic testing than did the nonthreaded anchor (BioComposite PushLock), and the HEALIX Knotless showed less overall displacement than did the other 2 anchors. The Bio-SwiveLock exhibited greater failure loads than did the other 2 anchors (P < .05). Comparison of axial and anatomic loading showed no maximum load differences for all anchors as a whole (P = .1084). Yet, anatomic pulling produced higher failure loads than did axial pulling for the Bio-SwiveLock but not for the BioComposite PushLock or the HEALIX Knotless. The nonthreaded anchor (BioComposite PushLock) displayed lower failure loads than did both threaded anchors with axial pulling.Conclusions: Threaded biocomposite anchors (HEALIX Knotless BR and Bio-SwiveLock) show less anatomic loading displacement and higher axial failure loads than do the nonthreaded (BioComposite PushLock) anchor. The HEALIX Knotless BR anchor showed less displacement than did the BioComposite PushLock and Bio-SwiveLock anchors. Neither axial nor anatomic loading had an effect on overall anchor displacement.Clinical Relevance: Because of the strength profiles exhibited, this study supports the use of biocomposite anchors, which have definite advantages over polyetheretherketone (PEEK) and metal products. However, the nonthreaded BioComposite PushLock anchor cannot be recommended.

Arthroscopic Excision of Dorsal Wrist Ganglion: Factors Related to Recurrence and Postoperative Residual Pain

Jong Pil Kim, Joong Bae Seo, Hee Gon Park, Young Ho Park — 2013-06-01

Purpose: The purpose of this study was to assess the recurrence rate and postoperative residual pain rate after arthroscopic excision of dorsal wrist ganglia and the risk factors for recurrence and residual pain.Methods: A total of 115 wrists (111 patients: 57 men, 54 women; average age 34 years; range, 9 to 72 years) treated with arthroscopic excision for wrist dorsal ganglia between April 2005 and December 2009 were enrolled. The follow-up averaged 32 months (range, 12 to 67 months). Demographic data and operative details, including the presence of a ganglion stalk, were retrospectively reviewed and tested against recurrence and residual pain at final follow-up.Results: The recurrence rate of dorsal wrist ganglia after arthroscopic excision was 11% (13 of 115 wrists). Recurrence was on the dominant side in 12 of 13 (91%) patients, which was the most important risk factor for recurrence (odds ratio [OR], 8.0; 95% confidence interval [CI], 0.94 to 68.49), followed by female sex (OR, 4.9; 95% CI, 0.84 to 28.39) and age 24 years or younger (OR, 3.1; 95% CI, 0.75 to 12.74). Twenty-seven wrists (23%) had postoperative residual pain at final follow-up. The results of logistic regression showed that pain before surgery was the most important risk factor for residual pain after surgery (OR, 4.9; 95% CI, 1.36 to 18.3), followed by female sex (OR, 3.2; 95% CI, 1.22 to 8.53).Conclusions: Dominant side, female sex, and age of 24 years or younger are considered to be the most influential risk factors for recurrence after arthroscopic excision of dorsal wrist ganglia. However, the presence or absence of the cyst stalk was not a significant factor for recurrence. Female patients who have preoperative pain around the dorsal wrist ganglia were most likely to experience residual pain after surgery.Level of Evidence: Level IV, therapeutic case series.

The Anterior Approach for a Non–Image-Guided Intra-articular Hip Injection

2013-04-15

Purpose: The purpose of this study was to investigate and validate the accuracy and safety of a technique using an anterior approach for non–image-guided intra-articular injection of the hip by use of anatomic landmarks.Methods: We enrolled 55 patients. Injections were performed before supine hip arthroscopy after landmarking and before application of traction. After the needle insertion, success was confirmed with an air arthrogram and by direct visualization after arthroscope insertion. Accuracy and difficulty achieving correct needle placement were correlated with age, weight, height, body mass index, body type, gender, and surgical indication, as well as femoral and pelvic morphology. Forty-five patients who underwent injection in the office were followed up separately to document injection side effects. Needle placement accuracy was correlated to patients' demographics. All statistical tests with P values were 2 sided, with the level of significance set at P < .05.Results: There were 51 correct needle placements and 4 misses, yielding a 93% success rate. The most common location for needle placement was the upper medial head-neck junction. Female gender was correlated with a more difficult needle placement and misses in relation to group size (P = .06). The reasons for misplacements of the needle were a high-riding trochanter, increased femoral version, thick adipose tissue over the landmarks, and variant of ilium morphology. Of 45 patients in the side effect study arm, 3 reported sensory changes of the lateral femoral cutaneous nerve that resolved within 24 hours.Conclusions: Hip injections by use of the direct anterior approach, from the intersection of the lines drawn from the anterior superior iliac spine and 1 cm distal to the tip of the greater trochanter, are safe and reproducible. Patient characteristics, such as increased subcutaneous adipose tissue or osseous anatomic variants, can lead to difficulty in placing the needle successfully. These characteristics can be predicted with the aid of physical examination and careful study of the pelvic radiographs.Level of Evidence: Level IV, therapeutic case series.

Synovial Membrane–Derived Mesenchymal Stem Cells Supported by Platelet-Rich Plasma Can Repair Osteochondral Defects in a Rabbit Model

2013-06-01

Purpose: The aim of this study was to determine the in vivo effectiveness of synovial membrane–derived mesenchymal stem cell (SDSC)–encapsulated injectable platelet-rich plasma (PRP) gel in the repair of damaged articular cartilage in the rabbit.Methods: An osteochondral defect was created in the trochlear groove of the rabbit femur, and the defects were divided into 3 treatment groups: untreated control group, PRP group, and PRP-SDSC group. After 4, 12, and 24 weeks, the tissue specimens were assessed by macroscopic examination and histologic evaluation and stained immunohistochemically for type II collagen and proliferating cell nuclear antigen. In addition, total glycosaminoglycan content was determined at 24 weeks.Results: Rabbit PRP contained a high concentration of platelets and high concentration of growth factors compared with those in whole blood. Twenty-four weeks after transplantation, there was fibrous tissue in the control group. In both the PRP group and the PRP-SDSC group, the defects were repaired with hyaline cartilage and exhibited significantly higher safranin O staining, type II collagen immunostaining, glycosaminoglycan content, cumulative histologic scores, and number of proliferating cell nuclear antigen–positive cells. However, incomplete bone regeneration and irregular cartilage surface integration were observed in the PRP group.Conclusions: Our results indicate that SDSC-embedded PRP gel could successfully resurface the defect with cartilage and restore the subchondral bone in the rabbit model.Clinical Relevance: This study indicates that in an animal model, the application of PRP and SDSC in combination for the treatment of local cartilage defects appears promising; however, PRP-SDSC products might be more or less appropriate to treat different types of tissues and pathologies. The clinical efficacy of PRP remains under debate. Therefore further research is needed at both the basic science and clinical levels.

Tunnel Positions in Transportal Versus Transtibial Anterior Cruciate Ligament Reconstruction: A Case-Control Magnetic Resonance Imaging Study

W.P. Yau, August W.M. Fok, Dennis K.H. Yee — 2013-04-15

Purpose: The purpose of this study was to examine the difference in the position of bone tunnels prepared by the transportal technique versus the transtibial technique in anterior cruciate ligament (ACL) reconstruction.Methods: A consecutive series of 42 patients receiving single-bundle ACL reconstructions were recruited between July 1, 2007, and December 31, 2008. The preparations of the femoral tunnel were performed by the transtibial technique in the first 21 cases and by the transportal technique in the subsequent 21 cases. Magnetic resonance imaging examination was performed in 39 patients (93%) 1 year after the index operation (20 transtibial and 19 transportal). Optimal tunnel position was defined as a lateralized femoral tunnel at a position of less than 11 o'clock for a right knee or more than 1 o'clock for a left knee, an adequate posteriorized femoral tunnel in the fourth quadrant of the modified Bernard line, and a tibial tunnel located in the second quadrant of the modified Amis line.Results: The average clock position was 10:18 in the transportal group and 10:54 in the transtibial group (P < .001). Five outliers were found in the transtibial group but none in the transportal group. Concerning the femoral tunnel position on the sagittal-cut magnetic resonance imaging scan, the average position along the modified Bernard line was 74% in the transportal group and 69% in the transtibial group (P = .029). Concerning the tibial tunnel position, the average tibial tunnel positions along the modified Amis line were 47% and 52%, respectively (P = .019).Conclusions: The adoption of the transportal technique in single-bundle ACL reconstruction produced improved positions in both the femoral and tibial tunnels when compared with the transtibial technique.Level of Evidence: Level III, case-control study.

Biomechanical Analysis of the Knee With Partial Anterior Cruciate Ligament Disruption: Quantitative Evaluation Using an Electromagnetic Measurement System

2013-04-22

Purpose: To investigate the biomechanical function of anterior cruciate ligament (ACL) remnants in ACL-deficient knees with both partial and complete tears.Methods: Twenty partial ACL–deficient (group P), 20 complete ACL–deficient (group C), and 40 contralateral ACL-intact knees were examined. The end point during the Lachman test, side-to-side differences of KT-1000 measurements, and the pivot shift test were evaluated. Additionally, the side-to-side difference of anterior tibial translation during the Lachman test and the acceleration during the pivot shift test were calculated using an electromagnetic measurement system (EMS).Results: The end point was found in 9 patients in group P, whereas it was not detected in group C. In KT-1000 measurements, the mean side-to-side differences were 3.8 ± 2.4 mm in group P and 5.4 ± 2.3 mm in group C. There was a significant difference between these 2 groups (P < .05). In the pivot shift test evaluation in group P, one patient was evaluated as grade 0, 17 patients as grade 1+, and 2 patients as grade 2+. In group C, 10 patients were evaluated as grade 1+, 9 patients as grade 2+, and one patient as grade 3+. Using the EMS, mean side-to-side differences during the Lachman test were 3.1 ± 2.1 mm in group P and 7.2 ± 3.2 mm in group C. The anterior-posterior displacement in group P was significantly less than that in group C (P < .05). In the quantitative pivot shift test, the mean acceleration in the contralateral ACL-intact knees was −632.7 ± 254.5 mm/s2, whereas it was −1107.5 ± 398.9 mm/s2 in group P and −1652.2 ± 754.9 mm/s2 in group C. Significant differences were detected between the 3 knee conditions (P < .05).Conclusions: The quantitative assessments of knees with partial ACL ruptures during the Lachman test and the pivot shift test using the EMS showed less laxity than did knees with complete ACL tears, whereas their laxity was greater than the contralateral knees with intact ACLs.Level of Evidence: Level III, diagnostic study of nonconsecutive patients.

Comparative Study of Medial Opening-Wedge High Tibial Osteotomy Using 2 Different Implants

2013-04-29

Purpose: The purpose of this study was to perform a retrospective clinical and radiographic evaluation after opening-wedge high tibial osteotomy (HTO) using a short spacer plate (Aescula; B. Braun Korea, Seoul, South Korea) and rigid long plate (TomoFix plate; Mathys, Bettlach, Switzerland) at follow-up 2 years postoperatively.Methods: We performed 94 opening-wedge HTOs with the Aescula plate (group I) and 92 HTOs with the TomoFix plate (group II). Patients underwent clinical and radiographic evaluations preoperatively and at 2 years postoperatively. Clinical evaluations were performed with Knee Society scores. Radiographic analysis included the mechanical tibiofemoral angle (mTFA) and the slope of the tibia angle with preoperative and postoperative full weight–bearing anteroposterior whole-leg views, as well as anteroposterior, lateral, and Merchant views of the knee. We measured the mTFA. In addition, we evaluated the complications in each group. The follow-up period was 2 years.Results: At follow-up 2 years postoperatively, we observed an overall complication rate of 38% in group I and 26% in group II (P = .083). We found plate-related complication rates of 20% in group I and 9% in group II (P = .039). Plate-related complications included loss of correction, fracture of the tibial plateau, screw failure, malunion, and fracture of the lateral cortical bone. The mean mTFA was −6.0° ± 3.2° in group I and −4.6° ± 2.8° in group II preoperatively (P = .262). The mean mTFA was 1.0° ± 3.1° in group I and 1.5° ± 2.3° in group II at the latest follow-up (P = .034). In group I, the mean Knee Society knee score and function score were 60.0 ± 12.9 and 57.9 ± 26.8, respectively, preoperatively. They improved to 92.1 ± 8.1 and 89.0 ± 15.1, respectively, at follow-up (P = .001 and P = .001, respectively). In group II, the mean Knee Society knee score and function score were 57.5 ± 14.8 and 57.4 ± 22.1, respectively, preoperatively. They improved to 95.5 ± 5.4 and 95.0 ± 7.6, respectively, at follow-up (P = .001 and P = .001, respectively). In addition, the mean postoperative knee score and function score in group II were higher than those in group I (P = .001 and P = .001, respectively).Conclusions: We have shown a high plate-related complication rate and a significant loss of correction during a short-term follow-up period (2 years) after opening-wedge HTO using the new short spacer HTO plate compared with the rigid long plate.Level of Evidence: Level IV, therapeutic case series.

The Importance of Tibial Tunnel Placement in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

2013-04-08

Purpose: The purposes of this study were to measure the anterior edge of the tibial tunnel after anatomic anterior cruciate ligament (ACL) reconstruction on lateral radiographs and to determine whether the difference in tibial tunnel placement affects postoperative outcomes.Methods: For 60 patients who underwent anatomic double-bundle ACL reconstruction with semitendinosus tendon, we evaluated the side-to-side difference in anterior tibial translation on stress radiographs, as well as rotational stability by the pivot-shift test, 2 years after surgery. Loss of extension (LOE) was evaluated on lateral radiographs of both knees in full extension, and graft integrity was assessed during second-look arthroscopy 1 to 2 years after surgery. On true lateral radiographs, we measured the anterior placement percentage of the tibial tunnel using the method described by Amis and Jakob. The cutoff value was set at 25% of the mean value of the anterior edge of the ACL that Amis and Jakob reported, and patients were divided into 2 groups (27 in the anterior group and 33 in the posterior group). Postoperative clinical results were compared between the groups.Results: The mean anterior placement percentage was 26.0% ± 4.1%. The postoperative mean side-to-side difference was 1.4 ± 2.7 mm for the anterior group and 3.0 ± 2.7 mm for the posterior group, a significant difference (P < .05). The positive ratio of the pivot-shift test was not significantly different between groups (P > .05). Mean LOE in the anterior and posterior groups was 0.9° ± 3.0° and −0.8° ± 4.0°, respectively; the difference was not significant (P > .05). Five of 27 knees in the anterior group and 5 of 33 knees in the posterior group had superficial graft laceration or elongation, which was not significantly different (P > .05).Conclusions: Anterior placement of the tibial tunnel in anatomic double-bundle ACL reconstruction leads to better anterior knee stability than posterior placement does. Anterior tibial tunnel placement inside the footprint did not increase the incidence of LOE and graft failure.Level of Evidence: Level IV, therapeutic case series.

Biological and Biomechanical Evaluation of the Ligament Advanced Reinforcement System (LARS AC) in a Sheep Model of Anterior Cruciate Ligament Replacement: A 3-Month and 12-Month Study

2013-06-01

Purpose: The purposes of this study were to assess tissue ingrowth within the Ligament Advanced Reinforcement System (LARS) artificial ligament (LARS AC; LARS, Arc sur Tille, France) and to study the biomechanical characteristics of the reconstructed knees in a sheep model of anterior cruciate ligament (ACL) replacement.Methods: Twenty-five female sheep underwent excision of the proximal third of the left ACL and intra-articular joint stabilization with a 44-strand polyethylene terephthalate ligament (mean ultimate tensile failure load, 2,500 N). Animals were killed either 3 or 12 months after surgery. Explanted knees were processed for histology (n = 10) or mechanical tests including tests of laxity and loading to failure in tension (n = 15).Results: Well-vascularized tissue ingrowth within the artificial ligament was only observed in the portions of the ligament in contact with the host's tissues (native ligament and bone tunnels). Ligament wear was observed in 40% of explanted knees. The ultimate tensile failure loads of the operated knees at both time points were inferior to those of the contralateral, intact knees (144 ± 69 N at 3 months and 260 ± 126 N at 12 months versus 1,241 ± 270 N and 1,218 ± 189 N, respectively) (P < .01). In specimens with intact artificial ligaments, failure occurred by slippage from the bone tunnels in all specimens explanted 3 months postoperatively and in half of the specimens explanted 12 months postoperatively.Conclusions: This study provides evidence that the LARS AC has a satisfactory biointegration but that it is not suitable for ACL replacement if uniform tissue ingrowth is contemplated. Despite good clinical performance up to 1 year after implantation, none of the reconstructions approached the mechanical performance of the normal ACL in the ovine model. Partial tearing of the artificial ligament, which led to a significant decrease in ultimate tensile strength, was observed in 40% of cases in the ovine model.Clinical Relevance: The LARS is not a suitable scaffold for ACL replacement. Further animal studies are needed to evaluate its potential for augmentation of ligament repair.

Proximity of Arthroscopic Ankle Stabilization Procedures to Surrounding Structures: An Anatomic Study

2013-04-15

Purpose: To examine the anatomy of the lateral ankle after arthroscopic repair of the lateral ligament complex (anterior talofibular ligament [ATFL] and calcaneofibular ligament [CFL]) with regard to structures at risk.Methods: Ten lower extremity cadaveric specimens were obtained and were screened for gross anatomic defects and pre-existing ankle laxity. The ATFL and CFL were sectioned from the fibula by an open technique. Standard anterolateral and anteromedial arthroscopy portals were made. An additional portal was created 2 cm distal to the anterolateral portal. The articular surface of the fibula was identified, and the ATFL and CFL were freed from the superficial and deeper tissues. Suture anchors were placed in the fibula at the ATFL and CFL origins and were used to repair the origin of the lateral collateral structures. The distance from the suture knot to several local anatomic structures was measured. Measurements were taken by 2 separate observers, and the results were averaged.Results: Several anatomic structures lie in close proximity to the ATFL and CFL sutures. The ATFL sutures entrapped 9 of 55 structures, and no anatomic structures were inadvertently entrapped by the CFL sutures. The proximity of the peroneus tertius and the extensor tendons to the ATFL makes them at highest risk of entrapment, but the proximity of the intermediate branch of the superficial peroneal nerve (when present) is a risk with significant morbidity.Conclusions: Our results indicate that the peroneus tertius and extensor tendons have the highest risk for entrapment and show the smallest mean distances from the anchor knot to the identified structure. Careful attention to these structures, as well as the superficial peroneal nerve, is mandatory to prevent entrapment of tendons and nerves when one is attempting arthroscopic lateral ankle ligament reconstruction.Clinical Relevance: Defining the anatomic location and proximity of the intervening structures adjacent to the lateral ligament complex of the ankle may help clarify the anatomic safe zone through which arthroscopic repair of the lateral ligament complex can be safely performed.

Assessment of the Quality and Content of Information on Anterior Cruciate Ligament Reconstruction on the Internet

2013-04-11

Abstract: The Internet has become a major source of health information for the public. However, there are concerns regarding the quality, accuracy, and currency of medical information available online. We assessed the quality of information about anterior cruciate ligament (ACL) reconstruction on the first 60 websites returned by the 4 most popular search engines. Each site was categorized by type and assessed for quality and validity using the DISCERN score, the Journal of the American Medical Association (JAMA) benchmark criteria, and a novel ACL reconstruction–specific content score. The presence of the Health On the Net Code (HONcode), a purported quality assurance marker, was noted. The quality of information on ACL reconstruction available online is variable, with many websites omitting basic information regarding treatment options, risks, and prognosis. Commercial websites predominate. Academic and allied health professional websites attained the highest DISCERN and JAMA benchmark scores, whereas physician sites achieved the highest content scores. Sites that bore the HONcode seal obtained higher DISCERN and ACL reconstruction content scores than those without this certification. The HONcode seal is a reliable indicator of website quality, and we can confidently advise our patients to search for this marker.

Evaluation of Information Available on the Internet Regarding Anterior Cruciate Ligament Reconstruction

2013-04-15

Abstract: Searching the Internet is one of the most popular methods for acquiring information related to health. The Internet offers physicians and patients easy access to a wide range of medical material from anywhere in the world. For many patients, this information helps formulate decisions related to their health and health care. An important caveat is that virtually anything can be published on the Internet. Although academic publications require rigorous peer review, Internet websites have no regulatory body monitoring quality and content. With a lack of external regulation, the information retrieved may be incorrect or outdated. The Internet can be a valuable asset for educating patients, but because of significant variability physicians should be familiar with the quality of information available. This article discusses both the strengths and weaknesses of information available on the Internet regarding anterior cruciate ligament repair.

Readability of Arthroscopy-Related Patient Education Materials From the American Academy of Orthopaedic Surgeons and Arthroscopy Association of North America Web Sites

Paul H. Yi, Abhishek Ganta, Khalil I. Hussein, Rachel M. Frank, Andrew Jawa — 2013-06-01

Abstract: We sought to assess the readability levels of arthroscopy-related patient education materials available on the Web sites of the American Academy of Orthopaedic Surgeons (AAOS) and the Arthroscopy Association of North America (AANA). We identified all articles related to arthroscopy available in 2012 from the online patient education libraries of AAOS and AANA. After performing follow-up editing, we assessed each article with the Flesch-Kincaid (FK) readability test. Mean readability levels of the articles from the AAOS Web site and the AANA Web site were compared. We also determined the number of articles with readability levels at or below the eighth-grade level (the average reading ability of the US adult population) and sixth-grade level (the widely recommended level for patient education materials). Intraobserver reliability and interobserver reliability of FK grade assessment were evaluated. A total of 62 articles were reviewed (43 from AAOS and 19 from AANA). The mean overall FK grade level was 10.2 (range, 5.2 to 12). The AAOS articles had a mean FK grade level of 9.6 (range, 5.2 to 12), whereas the AANA articles had a mean FK grade level of 11.4 (range, 8.7 to 12); the difference was significant (P < .0001). Only 3 articles had a readability level at or below the eighth-grade level and only 1 was at or below the sixth-grade level; all were from AAOS. Intraobserver reliability and interobserver reliability were excellent (intraclass correlation coefficient of 1 for both). Online patient education materials related to arthroscopy from AAOS and AANA may be written at a level too difficult for a large portion of the patient population to comprehend.

Anterior Cruciate Ligament Reconstruction With Autografts Compared With Non-irradiated, Non-chemically Treated Allografts

Cory J. Lamblin, Brian R. Waterman, James H. Lubowitz — 2013-03-25

Purpose: Allograft anterior cruciate ligament (ACL) reconstruction obviates donor site morbidity and may accelerate postoperative recovery. However, allograft use can lead to increased rates of surgical failure, particularly when chemical processing or irradiation is used. Few studies have rigorously evaluated the comparative outcomes of autografts and fresh-frozen allograft tissue for ACL reconstruction.Methods: We performed a PubMed search to identify and systematically evaluate outcomes of autograft and non–chemically treated non-irradiated allograft tissue in ACL reconstruction between 1980 and 2012. We included studies with Level of evidence of I to III, determinate graft treatment, a minimum of 25 patients per treatment arm, a minimum 2-year follow-up, and selected subjective and objective outcome measures.Results: After the exclusion of 585 citations, we isolated 11 studies for further review. All patients showed improvement in clinical outcome measures and knee stability end points from injury to definitive surgical management. No statistically significant differences were detected between autografts and non-chemically processed non-irradiated allografts in Lysholm scores, International Knee Documentation Committee (IKDC) scores, Lachman examinations, pivot-shift testing, KT-1000 measurements, or failure rates.Conclusions: Further large-scale, well-designed studies are required to better evaluate the comparative outcomes after fresh-frozen allograft ACL reconstruction. The current study suggests that the results after autograft ACL reconstruction are comparable to those using non-chemically processed nonirradiated allograft tissue.Level of Evidence: Systematic review of Level I to III studies.

Announcements

2013-06-01

The Arthroscopy Association of North America 2013 Master's Experience Courses will be held at the Orthopaedic Learning Center, Rosemont, Illinois: June 7-9 (knee ligament), June 28-30 (hip), July 19-21 (hip), August 23-25 (SOMOS knee), September 20-22 (shoulder), September 28-29 (foot/ankle), October 18-20 (knee cartilage), October 24-27 (resident). For more information, visit www.aana.org

Masthead

2013-06-01

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 29 issue 6 of 12.) Periodicals postage paid at New York, NY and additional mailing offices.

Editorial Board

2013-06-01

Cover Image

2013-06-01

On the Cover: Os trigonum and posterior facet calcaneus subtalar bipolar arthritis. Photographs taken during subtalar joint arthroscopy. The patient was a 39-year-old woman who had experienced right foot and ankle pain for over a year. She was no longer able to run or wear high heels and she complained of constant pain. A preoperative MRI of her hindfoot was notable for chronic moderategrade sprains of the lateral ligaments, some sinus tarsi fluid collection, edema in the os trigonum, and synovitis. Given her chronic ankle pain and advanced imaging findings, she was scheduled for ankle/subtalar arthroscopy. These images show the os trigonum while viewing from the central portal and instrumenting from the posterolateral portal. We were impressed to find a loose, arthritic os trigonum that articulated with the posterior facet of the calcaneus. Instead of a normal synchondrosis, there was a groove in the os trigonum and a corresponding groove in the calcaneus. The articulation had developed significant arthritis to the point of bone-on-bone changes. (Left) The os trigonum and subtalar joint as we saw it on starting the diagnostic exam. (Center) Removal of the os trigonum with a pituitary rongeur. (Right) After excision, showing the size of the os trigonum. See accompanying video at www.arthroscopyjournal.org.. Courtesy of Randy Clark, M.D., and Richard D. Ferkel, M.D.

Instructions for Authors

2013-06-01

Arthroscopy: The Journal of Arthroscopic and Related Surgery provides 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 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

2013-06-01

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

“I Found It on the Internet:” How Reliable and Readable is Patient Information?

A Biological Approach to Orthopaedic Surgery: Are They Lost in Translation?

Authors' Reply

Histomorphologic Changes of the Long Head of the Biceps Tendon in Common Shoulder Pathologies

Shoulder Arthroscopy Simulator Training Improves Shoulder Arthroscopy Performance in a Cadaveric Model

Relationship of the Subscapular Nerves to the Base of the Coracoid

The Effect of Humeral Avulsion of the Glenohumeral Ligaments and Humeral Repair Site on Joint Laxity: A Biomechanical Study

Addition of a Suture Anchor for Coracoclavicular Fixation to a Superior Locking Plate Improves Stability of Type IIB Distal Clavicle Fractures

Footprint Contact Restoration Between the Biceps-Labrum Complex and the Glenoid Rim in SLAP Repair: A Comparative Cadaveric Study Using Pressure-Sensitive Film

Cyclic Biomechanical Testing of Biocomposite Lateral Row Knotless Anchors in a Human Cadaveric Model

Arthroscopic Excision of Dorsal Wrist Ganglion: Factors Related to Recurrence and Postoperative Residual Pain

The Anterior Approach for a Non–Image-Guided Intra-articular Hip Injection

Synovial Membrane–Derived Mesenchymal Stem Cells Supported by Platelet-Rich Plasma Can Repair Osteochondral Defects in a Rabbit Model

Tunnel Positions in Transportal Versus Transtibial Anterior Cruciate Ligament Reconstruction: A Case-Control Magnetic Resonance Imaging Study

Biomechanical Analysis of the Knee With Partial Anterior Cruciate Ligament Disruption: Quantitative Evaluation Using an Electromagnetic Measurement System

Comparative Study of Medial Opening-Wedge High Tibial Osteotomy Using 2 Different Implants

The Importance of Tibial Tunnel Placement in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Biological and Biomechanical Evaluation of the Ligament Advanced Reinforcement System (LARS AC) in a Sheep Model of Anterior Cruciate Ligament Replacement: A 3-Month and 12-Month Study

Proximity of Arthroscopic Ankle Stabilization Procedures to Surrounding Structures: An Anatomic Study

Assessment of the Quality and Content of Information on Anterior Cruciate Ligament Reconstruction on the Internet

Evaluation of Information Available on the Internet Regarding Anterior Cruciate Ligament Reconstruction

Readability of Arthroscopy-Related Patient Education Materials From the American Academy of Orthopaedic Surgeons and Arthroscopy Association of North America Web Sites

Anterior Cruciate Ligament Reconstruction With Autografts Compared With Non-irradiated, Non-chemically Treated Allografts

Announcements

Masthead

Editorial Board

Contents

Cover Image

Instructions for Authors

Suggested Guidelines for the Practice of Arthroscopic Surgery