Arthroscopy: The Journal of Arthroscopic and Related Surgery

Our New Journal: Arthroscopy Techniques

James H. Lubowitz, Matthew T. Provencher, Gary G. Poehling — 2012-02-01

There is no doubt that the electronic age is upon us. We carry devices as small as a piece of paper or even the size of our palm that serve as telephones, picture phones, watches and clocks, encyclopedias, cameras, video cameras, global positioning navigation devices, newspapers, books, magazines, medical journals, radios, television and movie viewers, games, calendars, appointment books, contact lists, memo pads, voice recorders, task lists, calculators, alarm clocks, compasses, maps, and the contents of our entire computers, photo albums, our entire music collections, and more. First we searched; now we can socialize.

Outcome Score Validation

James H. Lubowitz, Matthew T. Provencher, Gary G. Poehling — 2012-02-01

In December, we announced the award-winning paper “The German Hip Outcome Score: Validation in Patients Undergoing Surgical Treatment for Femoroacetabular Impingement” by Naal et al. The Editors agreed that this outstanding research was most worthy of the award because of the excellent methods, and to iterate the important point that the use of joint- or condition-specific validated outcome measures are required to minimize recording bias and best allow comparison of diverse published investigations.

Problems With “Validation of a Measurement Device for Instrumented Quantification of Anterior Translation and Rotational Assessment of the Knee”

Mahbub Alam, D'jon Lopez, Akash Patel — 2012-02-01

We read with interest the recent article by Mayr et al. However, there are two related problems we would like to discuss. The first is regarding the accuracy of the “Laxitester.” The authors used the t test for independent and dependent samples to analyze the differences between the readings from healthy and pathologic knees. In addition, reliability was analyzed by use of intratester and intertester correlation according to the Cronbach α. However, neither of these methods assesses the accuracy of the measuring device; that is, how closely do the readings from the Laxitester reflect the translations and rotations occurring at the knee? What is reported is a comparison between measurements of foot and ankle rotations between subjects with normal and abnormal knees, as well as correlation of these foot and ankle rotations between testers.

Author's Reply

Hermann O. Mayr — 2012-02-01

We thank Dr. Alam and his associates for their critical attention and comments. The Cronbach α was not used to verify the accuracy of the measured values but was used to validate the reproducibility.

Inter-Rater Agreement of the Goutallier, Patte, and Warner Classification Scores Using Preoperative Magnetic Resonance Imaging in Patients With Rotator Cuff Tears

2011-10-24

Purpose: The purpose of this study was to determine the interobserver reliability of 3 commonly used classification systems in describing preoperative magnetic resonance imaging (MRI) studies of patients undergoing surgery for full-thickness rotator cuff tears. Methods: Thirty-one patients who underwent arthroscopic rotator cuff repair and had preoperative MRI studies available were selected over a 2-year period. Three board-certified shoulder surgeons independently reviewed these images. Each was instructed in the published method for determining the Patte score on the T2 coronal images, supraspinatus and infraspinatus atrophy on the T1 sagittal images as described by Warner et al., and the Goutallier score of fatty infiltration of the supraspinatus on the T1 coronal/sagittal images. Statistical analysis was then performed to determine the interobserver agreement using the κ statistic, with the level of significance set a priori at P < .01. Results: None of the classification systems studied yielded excellent or high interobserver reliability. The strongest agreement was found with the Patte classification assessing tendon retraction in the frontal plane (κ = 0.58). The Goutallier classification, which grades fatty infiltration of the supraspinatus, showed moderate interobserver agreement (κ = 0.53) when dichotomized into none to mild (grades 0, 1, and 2) and moderate to severe (grades 3 and 4). Muscle atrophy of both the supraspinatus and infraspinatus yielded the worst interobserver reliability, with only 28% agreement. Conclusions: The Goutallier, Patte, and Warner MRI classification systems for describing rotator cuff tears did not have high interobserver reliability among 3 experienced orthopaedic surgeons. Fatty infiltration of the supraspinatus and tendon retraction in the frontal planes showed only moderate reliability and moderate to high reliability, respectively. These findings have potential implications in the evaluation of the literature regarding the preoperative classification of rotator cuff tears and subsequent treatment algorithms. Level of Evidence: Level III, diagnostic agreement study with nonconsecutive patients.

The Clinical Results of Arthroscopic Transtendinous Repair of Grade III Partial Articular-Sided Supraspinatus Tendon Tears

Xavier A. Duralde, Walter B. McClelland — 2011-11-14

Purpose: The purpose of this study was to evaluate the clinical results of arthroscopic transtendinous repair of deep partial articular-sided rotator cuff tears. Methods: We retrospectively evaluated the results of 53 patients who underwent arthroscopic transtendinous repair for Ellman grade III articular-sided rotator cuff tears (>50% of the thickness of the rotator cuff). The intact bursal side of the cuff was not detached, and all associated pathology was treated. Fifty patients available for follow-up were evaluated with the American Shoulder and Elbow Surgeons (ASES) questionnaire. Results: American Shoulder and Elbow Surgeons scores improved from a mean of 48.0 to 89.4 (+41.4) (P < .0001). Pain scores on a visual analog scale improved from 5.7 to 1.0 (P < .0001). Ninety-eight percent of patients were satisfied with the results of surgery. Results for the 50 patients available for follow-up were excellent in 32 (64%), good in 6 (12%), fair in 6 (12%), and poor in 6 (12%). Articular-sided rotator cuff tears rarely occurred in isolation but were typically found in association with coexisting pathology suggestive of the tears' etiology. Most common were impingement lesions, seen in 94% of patients, and instability lesions such as labral tears, seen in 30% of patients. Associated procedures included acromioplasty in 47, distal clavicle resection in 29, treatment of biceps pathology in 7, and instability repair in 15. One patient sustained a postoperative pulmonary embolism, which represented the only complication. Tears varied in size from 50% to 90% of the thickness of the cuff insertion. Significant differences were identified in the results of Workers' Compensation patients. Preoperative magnetic resonance imaging and magnetic resonance arthrography were accurate in identifying a partial-thickness rotator cuff tear in less than 40% of cases. Conclusions: Arthroscopic transtendinous repair of partial articular-sided rotator cuff tears is a safe and effective treatment that allows identification of commonly associated pathology and reliable improvement in pain and function. Level of Evidence: Level IV, therapeutic case series.

Comparison of a Novel Bone-Tendon Allograft With a Human Dermis–Derived Patch for Repair of Chronic Large Rotator Cuff Tears Using a Canine Model

2011-12-05

Purpose: This study tested a bone-tendon allograft versus human dermis patch for reconstructing chronic rotator cuff repair by use of a canine model. Methods: Mature research dogs (N = 15) were used. Radiopaque wire was placed in the infraspinatus tendon (IST) before its transection. Three weeks later, radiographs showed IST retraction. Each dog then underwent 1 IST treatment: debridement (D), direct repair of IST to bone with a suture bridge and human dermis patch augmentation (GJ), or bone-tendon allograft (BT) reconstruction. Outcome measures included lameness grading, radiographs, and ultrasonographic assessment. Dogs were killed 6 months after surgery and both shoulders assessed biomechanically and histologically. Results: BT dogs were significantly (P = .01) less lame than the other groups. BT dogs had superior bone-tendon, tendon, and tendon-muscle integrity compared with D and GJ dogs. Biomechanical testing showed that the D group had significantly (P = .05) more elongation than the other groups whereas BT had stiffness and elongation characteristics that most closely matched normal controls. Radiographically, D and GJ dogs showed significantly more retraction than BT dogs (P = .003 and P = .045, respectively) Histologically, GJ dogs had lymphoplasmacytic infiltrates, tendon degeneration and hypocellularity, and poor tendon-bone integration. BT dogs showed complete incorporation of allograft bone into host bone, normal bone-tendon junctions, and well-integrated allograft tendon. Conclusions: The bone-tendon allograft technique re-establishes a functional IST bone-tendon-muscle unit and maintains integrity of repair in this model. Clinical Relevance: Clinical trials using this bone-tendon allograft technique are warranted.

Comparable Biomechanical Results for a Modified Single-Row Rotator Cuff Reconstruction Using Triple-Loaded Suture Anchors Versus a Suture-Bridging Double-Row Repair

2011-11-24

Purpose: To compare the biomechanical properties and footprint coverage of a single-row (SR) repair using a modified suture configuration versus a double-row (DR) suture-bridge repair in small to medium and medium to large rotator cuff tears. Methods: We created 25- and 35-mm artificial defects in the rotator cuff of 24 human cadaveric shoulders. The reconstructions were performed as either an SR repair with triple-loaded suture anchors (2 to 3 anchors) and a modified suture configuration or a modified suture-bridge DR repair (4 to 6 anchors). Reconstructions were cyclically loaded from 10 to 60 N. The load was increased stepwise up to 100, 180, and 250 N. Cyclic displacement and load to failure were determined. Furthermore, footprint widths were quantified. Results: In the 25-mm rupture, ultimate load to failure was 533 ± 107 N for the SR repair and 681 ± 250 N for the DR technique (P ≥ .21). In the 35-mm tear, ultimate load to failure was 792 ± 122 N for the SR reconstruction and 891 ± 174 N for the DR reconstruction (P ≥ .28). There were no statistically significant differences for both tested rupture sizes. Cyclic displacement showed no significant differences between the tested configurations at 60 N (P = .563), 100 N (P = .171), 180 N (P = .211), and 250 N (P = .478) for the 25-mm tear. For the 35-mm tear, cyclic displacement showed significantly lower gap formation for the SR reconstruction at 180 N (P = .037) and 250 N (P = .020). No significant differences were found at 60 N (P = .296) and 100 N (P = .077). A significantly greater footprint width (P = .028) was seen for the DR repair (16.2 mm) compared with the SR repair (13.8 mm). However, both reconstructions were able to achieve complete footprint coverage compared with the initial footprint. Conclusions: The tested SR repair using a modified suture configuration was similar in load to failure and cyclic displacement to the DR suture-bridge technique independent of the tested initial sizes of the rupture. The tested DR repair consistently restored a larger footprint than the SR method. However, both constructs achieved complete footprint coverage. Clinical Relevance: SR repairs with modified suture configurations might combine the biomechanical advantages and increased footprint coverage that are described for DR repairs without increasing the overall costs of the reconstruction.

Optimizing Pressurized Contact Area in Rotator Cuff Repair: The Diamondback Repair

Stephen S. Burkhart, Patrick J. Denard, Elifho Obopilwe, Augustus D. Mazzocca — 2011-10-31

Purpose: The purpose of this study was to compare tendon-bone footprint contact area over time under physiologic loads for 4 different rotator cuff repair techniques: single row (SR), triangle double row (DR), chain-link double row (CL), and diamondback double row (DBK). Methods: A supraspinatus tear was created in 28 human cadavers. Tears were fixed with 1 of 4 constructs: SR, DR, CL, or DBK. Immediate post-repair measurements of pressurized contact area were taken in neutral rotation and 0° of abduction. After a static tensile load, pressurized contact area was observed over a 160-minute period after repair. Cyclic loading was then performed. Results: The DBK repair had the highest pressurized contact area initially, as well as the highest pressurized contact area and lowest percentage decrease in pressurized contact area after 160 minutes of testing. The DBK repair had significantly larger initial pressurized contact than CL (P = .003) and SR (P = .004) but not DR (P = .06). The DBK technique was the only technique that produced a pressurized contact area that exceeded the native footprint both at initial repair (P = .01) and after 160 minutes of testing (P = .01). DBK had a significantly larger mean pressurized contact area than all the repairs after 160 minutes of testing (P = .01). DBK had a significantly larger post–cyclic loading pressurized contact area than CL (P = .01) and SR (P = .004) but not DR (P = .07). Conclusions: This study showed that a diamondback repair (a modification of the transosseous repair) can significantly increase the rotator cuff pressurized contact area in comparison with other standard rotator cuff repair constructs when there is sufficient tendon mobility to perform a double-row repair without excessive tension on the repair site. Clinical Relevance: The persistent pressurized contact area of a DBK repair may be desirable to enhance healing potential when there is sufficient tendon mobility to perform a double-row repair, particularly for large or massive rotator cuff tears where it is important to optimize footprint area and contact to encourage biologic healing.

Arthroscopic Reduction and Percutaneous Fixation of Perilunate Dislocations and Fracture-Dislocations

Jong Pil Kim, Jae Sung Lee, Min Jong Park — 2011-12-01

Purpose: The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations and fracture-dislocations treated with arthroscopic reduction and percutaneous fixation. Methods: Twenty patients who had an acute dorsal perilunate dislocation or fracture-dislocation were treated with an arthroscopic technique at a median interval of 3.9 days from the time of injury. They were retrospectively reviewed at a mean follow-up of 31.2 months (range, 18 to 61 months). Range of motion and grip strength were measured. Radiographic evaluations included time to scaphoid union, measurement of radiologic parameters, and any development of arthritis. Functional outcomes were determined by the modified Mayo wrist score; Disabilities of the Arm, Shoulder and Hand questionnaire; and Patient-Rated Wrist Evaluation score. Results: The flexion-extension motion arc and grip strength of the injured wrist averaged 79% and 78%, respectively, of the corresponding values for the contralateral wrists. The mean Disabilities of the Arm, Shoulder and Hand score was 18, and the mean Patient-Rated Wrist Evaluation score was 30. According to modified Mayo wrist scores, overall functional outcomes were rated as excellent in 3 patients, good in 8, fair in 7, and poor in 2. Nonunion developed in 2 patients with a trans-scaphoid perilunate injury; 1 of the 2 underwent scaphoid excision and midcarpal fusion. On the basis of radiographic parameters, reduction obtained during the operation was maintained within normal ranges in 15 patients. Arthritis had not developed in any patient by the last follow-up. Conclusions: This study suggests that arthroscopic reduction with percutaneous fixation is a reliable minimally invasive surgical method for acute perilunate injuries in that it provides proper restoration and stable fixation of carpal alignment and results in satisfactory functional and radiologic outcomes on a midterm basis. Level of Evidence: Level IV, therapeutic case series.

Computer-Assisted Modeling of Osseous Impingement and Resection in Femoroacetabular Impingement

2012-02-01

Purpose: The purpose of this study was to evaluate the utility of computer-assisted 3-dimensional modeling in diagnosing and treating symptomatic hip impingement. Methods: Eight patients with symptomatic, focal cam and/or pincer impingement lesions underwent high-resolution computed tomography scans and computer-assisted, 3-dimensional modeling of the involved hip. Cam location, alpha angle, neck-shaft angle, femoral version, and acetabular version at the 12-o'clock through 3-o'clock positions were measured. The model was subsequently dynamized to define the preoperative range of motion and location of impingement with hip flexion, internal rotation, and internal rotation at 90° of hip flexion. Virtual cam and pincer osteoplasty was performed to establish normal head-neck offset and head sphericity and to eliminate focal rim impingement lesions. Range of motion and location of impingement were reassessed after resection in the defined area of impingement. Results: The cam lesion was located between the 12-o'clock and 4-o'clock positions in all cases. The mean alpha angle was 66.4° (range, 53° to 80°). Mean femoral version was 14.6° (range, 5° to 23°). Mean preoperative hip flexion was 109.7° (range, 87.5° to 125.5°), and mean internal rotation at 90° of hip flexion was 16.2° (range, 1.7° to 25.5°). The location of impingement was unique in each case and not predictable based on radiographic measures alone. Virtual osteoplasty in the defined regions of impingement resulted in significant improvements in both hip flexion and internal rotation (P < .05). Conclusions: Computed tomography–based computer modeling can localize regions of anticipated mechanical impingement in symptomatic patients with hip pain. Computer-assisted navigation may be a valuable surgical tool to more accurately and reliably eliminate offending impingement lesions. Level of Evidence: Level IV, diagnostic study.

Anterior Cruciate Ligament Reconstruction With Bone–Patellar Tendon–Bone Graft: Comparison of Autograft, Fresh-Frozen Allograft, and γ-Irradiated Allograft

2012-02-01

Purpose: To compare clinical follow-up results of anterior cruciate ligament (ACL) reconstruction using (1) autologous, (2) fresh-frozen allogeneic, and (3) γ-irradiated allogeneic bone–patellar tendon–bone (BPTB). Methods: From February 2002 to January 2006, 187 patients received BPTB ACL reconstruction at our center. One hundred forty-two consecutive patients who had received single-bundle BPTB ACL reconstruction were included in this study. Of these patients, 41 had autografts, 33 had fresh-frozen allografts, and 68 had γ-irradiated allografts. Clinical results were evaluated with the KT-1000 maximum displacement test (MEDmetric, San Diego, CA), Lachman test, and Lysholm, Irrgang, and Larson activity scales. Results: The mean duration of follow-up was 6.7 ± 1.5 years (range, 4.2 to 8.2 years). There were 3 cases of acute synovitis due to immunologic rejection (fresh-frozen allografts) and 6 cases of failure (γ-irradiated allografts). KT-1000 examination showed more anterior laxity in the γ-irradiated allograft group compared with the autograft and fresh-frozen allograft groups (P < .05). The Lysholm, Irrgang, and Larson activity scales showed no difference among the 3 groups (P > .05). Conclusions: The study showed a statistically poorer KT-1000 result and higher failure rate in the γ-irradiated allograft group compared with the autograft and fresh-frozen allograft groups. This may suggest that γ-irradiated allograft is not a good candidate graft for ACL reconstruction. Power analysis showed that the study was underpowered, so further research and longer follow-up study are needed to make this point clearer. Level of Evidence: Level III, retrospective comparative study.

Diagnostic Knee Arthroscopy: A Pilot Study to Evaluate Surgical Skills

2011-10-31

Purpose: To develop a scoring system to evaluate individual proficiency at diagnostic knee arthroscopy. Methods: This was a prospective blinded study. Subjects included residents in postgraduate year (PGY) 1 through PGY 5 (n = 20) and staff surgeons (n = 10). All subjects performed a diagnostic arthroscopy on a cadaveric knee. Subjects were evaluated on both completeness and time required to complete the arthroscopy. The examiner viewed the arthroscopy from a remote location and was blinded to the level of training of the subjects. During the arthroscopy, 15 areas required assessment to achieve a score of 75 points. An additional 25 points were awarded depending on the time it took to complete the arthroscopy. A maximum of 100 points were available (Total score = Arthroscopy score + Time score). Results: Thirty subjects were divided into 3 groups: group 1 (PGY 1 or 2) (n = 12), group 2 (PGY 3, 4, or 5) (n = 8), and group 3 (staff) (n = 10). In group 1 the mean total score was 28.25 points, the mean time to complete arthroscopy was 11.9 minutes, and the mean number of structures not examined was 8.67. In group 2 the mean total score was 76 points, the mean time to complete arthroscopy was 8.2 minutes, and the mean number of structures not examined was 1.75. In group 3 the mean total score was 100 points, the mean time to complete arthroscopy was 4.6 minutes, and the mean number of structures not examined was 0. Statistically significant differences by use of an analysis of variance test were noted for the total score, total time, and number of missed structures (P < .001). Conclusions: Using our skills assessment tool, we were able to evaluate subjects and determine their relative technical skill level in performing a diagnostic arthroscopy. This tool was able to distinguish among the novice, experienced, and expert levels in performing diagnostic arthroscopy. Level of Evidence: Level III, development of diagnostic criteria on the basis of consecutive subjects.

A Pilot Study of the Use of an Osteochondral Scaffold Plug for Cartilage Repair in the Knee and How to Deal With Early Clinical Failures

2011-10-21

Purpose: To present our short-term experience with an osteochondral scaffold plug (TruFit plug; Smith & Nephew, Andover, MA) for cartilage repair in the knee and, more importantly, to discuss our approach to treat early clinical failures. Methods: Twenty patients were consecutively treated for their cartilage lesions with the plug technique. These patients were prospectively clinically evaluated at 6 and 12 months of follow-up. Magnetic resonance imaging (MRI) was used for morphologic analysis of the cartilage repair. Biopsy samples were taken from 3 cases during revision surgery, allowing histologic assessment of the repair tissue. Results: The short-term clinical and MRI outcome of this pilot study are modest. No signs of deterioration of the repair tissue were observed. Of the 15 patients followed up during 1 year, 3 (20.0%) showed persistent clinical symptoms or even more clinical symptoms after insertion of the plug. These patients were considered as failures and therefore eligible for revision surgery. During revision surgery, the repair tissue was carefully removed. The remaining osteochondral defect was filled with autologous bone grafts. Immediate and persistent relief of symptoms was observed in all 3 patients. Histologic assessment of biopsy specimens taken during revision surgery showed fibrous vascularized repair tissue with the presence of foreign-body giant cells. Conclusions: The overall short-term clinical and MRI outcome of the osteochondral scaffold plug for cartilage repair in the knee is modest. In this pilot study a modest clinical improvement became apparent at 12 months of follow-up. MRI data showed no deterioration of the repair tissue. Of the 15 patients, 3 (20%) had persistent clinical symptoms after surgery. These patients were successfully treated with removal of the osteochondral plug remnants and the application of autologous bone grafts. Level of Evidence: Level IV, therapeutic case series.

Correlation Between Anterior Cruciate Ligament Graft Obliquity and Tibial Rotation During Dynamic Pivoting Activities in Patients With Anatomic Anterior Cruciate Ligament Reconstruction: An In Vivo Examination

2011-11-14

Purpose: To investigate the effect of coronal- and sagittal-plane anterior cruciate ligament (ACL) graft obliquity on tibial rotation (TR) range of motion (ROM) during dynamic pivoting activities after ACL reconstruction with bone–patellar tendon–bone (BPTB) autograft. Methods: We evaluated 19 ACL-reconstructed patients (mean age, 29 years; age range, 18 to 38 years; mean time interval postoperatively, 19.9 months) and 19 matched control subjects (mean age, 30.6 years; age range, 24 to 37 years) using motion analysis during (1) descending a stairway and pivoting and (2) landing from a jump and pivoting. Magnetic resonance imaging was used to measure the coronal and sagittal ACL graft angle. The dependent variables were TR ROM during pivoting and the side-to-side difference (SSD) in TR ROM between the reconstructed knee and the contralateral intact knee. Results: TR ROM of the ACL-reconstructed knee was significantly increased compared with both the contralateral intact knee and the healthy control knee (P < .05). A significant positive correlation was observed between TR ROM and coronal ACL graft angle (r = 0.727, P = .0006 for descending and pivoting; r = 0.795, P = .0001 for landing and pivoting) as well as between SSD of TR ROM and coronal ACL graft angle (r = 0.789, P < .0001 for descending and pivoting; r = 0.799, P < .0001 for landing and pivoting). No correlation was found with the sagittal ACL graft angle. Conclusions: After ACL reconstruction with a BPTB graft, patients' knees showed higher TR values than their uninjured knees and the knees of uninjured control volunteers during dynamic pivoting activities. The findings of this study show that TR was better restored in ACL-reconstructed patients with a more oblique graft in the coronal plane. A similar relation was not observed for graft orientation in the sagittal plane. Although these data do not imply a cause-and-effect relation between the 2 variables, they may indicate that a more oblique placement of a single BPTB ACL graft in the coronal plane is correlated with better control of TR. Level of Evidence: Level IV, case series.

Biomechanics of the Human Triple-Bundle Anterior Cruciate Ligament

2011-10-24

Purpose: To investigate the biomechanics of the intermediate (IM), anteromedial (AM), and posterolateral (PL) bundles in the human anterior cruciate ligament (ACL). Methods: Eighteen human cadaveric knees were tested with a robotic/universal force-moment sensor testing system. Anterior tibial translation (ATT) was determined under an 89-N anterior tibial load. Coupled ATT was determined under a combined rotatory load of 7-Nm valgus and 5-Nm internal rotation torque (pivot moment). Each bundle's in situ forces were measured under identical external loading conditions. Results: Under anterior load, the PL bundle's in situ force was highest at 0° and decreased during flexion. Under the anterior load, the AM bundle's in situ force was significantly higher than the IM and PL bundles' force at 15°, 30°, and 60°. Under the pivot moment, the AM bundle's in situ force was significantly higher than the PL and IM bundles' force at 0° and 15°, and the IM bundle had the lowest in situ force at 0° but higher in situ force than the AM and PL bundles at 30° and 45°. IM and AM bundle removal increased ATT under the anterior load at all angles. Cutting the PL bundle after IM and AM bundle removal (whole ACL removal) significantly increased ATT under the anterior load at 0°, 15°, and 30° of knee flexion and increased coupled ATT under the pivot moment at 0° and 15°. Conclusions: The biomechanical role of each of the 3 ACL bundles (AM, IM, and PL) was measured with a robotic/universal force-moment sensor testing system. The AM bundle stabilized the knee against both the anterior and rotatory loads. The PL bundle stabilized the knee especially near full extension. The IM bundle supported the AM and PL bundles through all flexion angles, especially from 30° to 45°, against the rotatory load. Clinical Relevance: Knowledge of functions of the different ACL bundles will help improve ACL reconstruction techniques to enable restoration of normal knee function.

Biodegradable Gelatin Hydrogels Incorporating Fibroblast Growth Factor 2 Promote Healing of Horizontal Tears in Rabbit Meniscus

2011-11-28

Purpose: The purpose of this study was to investigate the in vivo effects of gelatin hydrogels (GHs) incorporating fibroblast growth factor 2 (FGF-2) on meniscus repair in a rabbit model. Methods: FGF-2 was biologically stabilized by incorporation into GHs. This system enables FGF-2 to be released with its biologic activity intact. A total of 64 skeletally mature female Japanese white rabbits were used. A horizontal tear was made in the medial meniscus, and these tears were divided into 4 groups: GH-FGF, GH–no FGF, FGF (FGF-2 alone), and no treatment. The meniscus was evaluated histologically at 2, 4, 8, and 12 weeks after surgery. Cell density and the percentages of proliferating cell nuclear antigen–positive cells and terminal deoxynucleotidyl transferase–mediated dUTP nick-end labeling–positive cells were measured, and a scoring system ranging from 5 points (complete healing) to 0 points (no evidence of healing) was used. Results: Cell density was significantly higher in the GH-FGF group than in the other 3 groups at 2, 4, 8, and 12 weeks (P < .01). The percentage of proliferating cell nuclear antigen–positive cells was significantly higher whereas the percentage of terminal deoxynucleotidyl transferase–mediated dUTP nick-end labeling–positive cells was significantly lower in the GH-FGF group at 2 and 4 weeks after surgery (P < .05). At 4, 8, and 12 weeks after surgery, healing scores were significantly higher in the GH-FGF group (2.5 points, 2.7 points, and 3.0 points, respectively) than in the GH–no FGF group (1.3 points, 1.4 points, and 2.0 points, respectively) (P < .05). Conclusions: GHs incorporating FGF-2 significantly stimulated proliferation and inhibited the death of meniscal cells until 4 weeks, thereby increasing meniscal cell density and enhancing meniscal repair in a rabbit model. Clinical Relevance: GHs incorporating FGF-2 are able to enhance the healing of meniscal injury.

Biomechanical Evaluation of an Anatomic Double-Bundle Posterior Cruciate Ligament Reconstruction

2011-10-24

Purpose: The purpose of this study was to evaluate the effect of the anatomic double-bundle reconstruction (ADBR) of the posterior cruciate ligament (PCL) with 2 femoral tunnels and 2 tibial tunnels. Methods: Eight fresh-frozen human knees were used. Bone tunnels were created based on the PCL anatomic footprints. A 9-mm looped semitendinosus and gracilis tendon for anterolateral bundle reconstruction (ALR), a 7-mm looped semitendinosus tendon for posteromedial bundle reconstruction (PMR), and the same grafts for the ADBR were used. Under a 100-N posterior tibial load and under a 100-N posterior tibial load and 5 Nm of external tibial torque, the posterior tibial translation (PTT) was measured. Results: Under posterior tibial load, at 0°, the PTT of the ALR was larger than that of the intact knee (P = .04) and the ADBR (P = .03); however, there were no significant differences between the PTT of the PMR and that of the ADBR (P = .28) and intact knee (P = .99). At 30°, the PTT of the ADBR was smaller than that of the ALR (P = .02) and PMR (P = .02). At 60°, the PTT of the PMR was larger than that of the ADBR (P = .02). At 90°, the PTT of the PMR was larger than that of the ADBR (P = .02). Under posterior tibial load and external tibial torque, at 0°, the PTT of the ALR was larger than that of the ADBR (P = .04). Conclusions: Although the graft size of the ADBR was larger than other reconstructions, the ADBR was better than the ALR at 0° and 30° of knee flexion under the posterior tibial load and at 0° under the combination of posterior tibial load and external tibial torque, as well as better than the PMR at 30°, 60°, and 90° of knee flexion under the posterior tibial load. Clinical Relevance: The clinical outcome of PCL reconstruction might improve by reducing posterior knee laxity in knee extension with the ADBR.

Evidence-Based Indications for Elbow Arthroscopy

2012-02-01

Purpose: The purpose was to review the literature on the outcomes of elbow arthroscopy and to make evidence-based recommendations for or against elbow arthroscopy for the treatment of various conditions. Our hypothesis was that the evidence would support the use of elbow arthroscopy in the management of common elbow conditions. Methods: A literature search was performed by use of the PubMed database in October 2010. All therapeutic studies investigating the results of treatment with elbow arthroscopy were analyzed for outcomes and complications. The literature specific to common elbow arthroscopy indications was summarized and was assigned a grade of recommendation based on the available evidence. Results: There is fair-quality evidence for elbow arthroscopy in the treatment of rheumatoid arthritis of the elbow and lateral epicondylitis (grade B recommendation). There is poor-quality evidence for, rather than against, the arthroscopic treatment of degenerative arthritis, osteochondritis dissecans, radial head resection, loose bodies, post-traumatic arthrofibrosis, posteromedial impingement, excision of a plica, and fractures of the capitellum, coronoid process, and radial head (grade Cf recommendation). There is insufficient evidence to give a recommendation for or against the arthroscopic treatment of posterolateral rotatory instability and septic arthritis (grade I recommendation). Conclusions: The available evidence supports the use of elbow arthroscopy in the management of the majority of conditions where it is currently used. The quality of the evidence, however, is generally fair to poor. Level of Evidence: Level IV, systematic review of Level II-IV studies.

Surgical Treatment of Chronic Retrocalcaneal Bursitis

Johannes I. Wiegerinck, Aimee C. Kok, C. Niek van Dijk — 2012-02-01

Purpose: The purpose of this systematic review was to analyze the results of surgical treatments for chronic retrocalcaneal bursitis (RB). Methods: Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, and the Cochrane Library (1945 to December 2010) were systematically searched for the following terms: calcaneal AND (prominence OR exostosis) OR ((retrocalcaneal OR calcan*) AND (burs* OR exosto* OR prominence)) OR Haglund[tw] OR Haglund's[tw] OR ((retrocalcaneal OR calcan*) AND (ostectom* OR osteotom* OR resect*)). Therapeutic studies on 10 or more subjects with RB were eligible. Quality was assessed by use of the GRADE scale and Downs and Black scale. Results: Of 876 reviewed abstracts, 15 trials met our inclusion criteria evaluating 547 procedures in 461 patients. Twelve trials reported an open surgical technique; three studies evaluated endoscopic techniques. Differences in patient satisfaction favored the endoscopic technique. The complication rate differed substantially, favoring endoscopic surgery over open surgery. Conclusions: There are many different surgical techniques to treat RB. Regardless of technique, resecting sufficient bone is essential for a good outcome. Even though the level of evidence of included studies is relatively low, it can be concluded that endoscopic surgery is superior to open intervention for RB. More evidence is a necessity to be more conclusive regarding the best surgical treatment. Level of Evidence: Level IV, systematic review of Level III and IV studies.

Popliteal Venotomy During Posterior Cruciate Ligament Reconstruction in the Setting of a Popliteal Artery Bypass Graft

2012-02-01

Abstract: Injury to the vascular structures in the popliteal fossa during arthroscopic cruciate ligament reconstruction can be limb threatening or even life threatening. We present the first report, to our knowledge, of an isolated injury to a popliteal vein during arthroscopic posterior cruciate ligament reconstruction. Unfortunately, the venotomy led to cardiopulmonary arrest and flash pulmonary edema in this patient. Preoperative planning is paramount to assess risk of injury to vascular structures, which may be increased in patients who have had prior procedures on the affected knee. Furthermore, vascular surgery consultation preoperatively after a magnetic resonance angiogram or venogram and avoiding the use of epinephrine in the arthroscopy fluid should be considered when performing these higher-risk procedures.

Announcements

2012-02-01

The Arthroscopy Association of North America 2012 Master's Experience Courses will be held at the Orthopaedic Learning Center, Rosemont, Illinois: February 23-26, 2012 (fundamentals resident); March 9-11, 2012 (knee ligament); March 23-25, 2012 (hip); April 27-29, 2012 (shoulder); June 2-3, 2012 (wrist & elbow); June 8-10, 2012 (Society of Military Orthopaedic Surgeons/shoulder); July 20-22, 2012 (hip); September 7-9, 2012 (shoulder); September 29-30, 2012 (foot & ankle); October 5-7, 2012 (knee cartilage); October 19-21, 2012 (shoulder); December 6-9, 2012 (fundamentals resident). For more information, visit www.aana.org

Spanish Translated Abstracts

2012-02-01

Masthead

2012-02-01

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 28 issue 2 of 12.) Periodicals postage paid at New York, NY and additional mailing offices.

Editorial Board

2012-02-01

Cover Image

2012-02-01

On the Cover: Arthroscopic photograph from a posterior viewing portal in the subacromial space with patient in the beach-chair position. Sutures from each medial row anchor are combined with the two suture limbs from the biceps. These sutures are being placed into a 5.25-mm self-punching PEEK SwivelLock anchor. This image is from the first article of the new online journal Arthroscopy Techniques, launching this month, “Simultaneous Rotator Cuff Repair and Arthroscopic Biceps Tenodesis Using Lateral Row Anchor” by Jonathan C. Levy, M.D.

Instructions for Authors

2012-02-01

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

2012-02-01

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

Our New Journal: Arthroscopy Techniques

Outcome Score Validation

Problems With “Validation of a Measurement Device for Instrumented Quantification of Anterior Translation and Rotational Assessment of the Knee”

Author's Reply

Inter-Rater Agreement of the Goutallier, Patte, and Warner Classification Scores Using Preoperative Magnetic Resonance Imaging in Patients With Rotator Cuff Tears

The Clinical Results of Arthroscopic Transtendinous Repair of Grade III Partial Articular-Sided Supraspinatus Tendon Tears

Comparison of a Novel Bone-Tendon Allograft With a Human Dermis–Derived Patch for Repair of Chronic Large Rotator Cuff Tears Using a Canine Model

Comparable Biomechanical Results for a Modified Single-Row Rotator Cuff Reconstruction Using Triple-Loaded Suture Anchors Versus a Suture-Bridging Double-Row Repair

Optimizing Pressurized Contact Area in Rotator Cuff Repair: The Diamondback Repair

Arthroscopic Reduction and Percutaneous Fixation of Perilunate Dislocations and Fracture-Dislocations

Computer-Assisted Modeling of Osseous Impingement and Resection in Femoroacetabular Impingement

Anterior Cruciate Ligament Reconstruction With Bone–Patellar Tendon–Bone Graft: Comparison of Autograft, Fresh-Frozen Allograft, and γ-Irradiated Allograft

Diagnostic Knee Arthroscopy: A Pilot Study to Evaluate Surgical Skills

A Pilot Study of the Use of an Osteochondral Scaffold Plug for Cartilage Repair in the Knee and How to Deal With Early Clinical Failures

Correlation Between Anterior Cruciate Ligament Graft Obliquity and Tibial Rotation During Dynamic Pivoting Activities in Patients With Anatomic Anterior Cruciate Ligament Reconstruction: An In Vivo Examination

Biomechanics of the Human Triple-Bundle Anterior Cruciate Ligament

Biodegradable Gelatin Hydrogels Incorporating Fibroblast Growth Factor 2 Promote Healing of Horizontal Tears in Rabbit Meniscus

Biomechanical Evaluation of an Anatomic Double-Bundle Posterior Cruciate Ligament Reconstruction

Evidence-Based Indications for Elbow Arthroscopy

Surgical Treatment of Chronic Retrocalcaneal Bursitis

Popliteal Venotomy During Posterior Cruciate Ligament Reconstruction in the Setting of a Popliteal Artery Bypass Graft

Announcements

Spanish Translated Abstracts

Masthead

Editorial Board

Contents

Cover Image

Instructions for Authors

Suggested Guidelines for the Practice of Arthroscopic Surgery