Arthroscopy: The Journal of Arthroscopic and Related Surgery

Rotator Cuff Repair: Obviously

James H. Lubowitz, Gary G. Poehling — 2010-03-01

In this issue, we include a diverse collection of articles considering current challenges, complications, and controversies surrounding that confluence of tendons connecting or otherwise conjoining the 4 muscles comprising the shoulder rotator cuff. With apologies for our continuing alliterative clarion, the collection culminates in a classification that we believe will become a Current Concepts classic guiding successful cuff closure. We'll conclude our exercise in consonant cuteness by concurring that, while our literature constantly confounds with conflicting conclusions, clever consideration can clarify the obvious.

In Memoriam: Robert Wilson Jackson, O.C., M.D., F.R.C.S.C., Hon. F.R.C.S. (UK & Edin)

Ronald M. Selby, Richard K.N. Ryu — 2010-03-01

Robert Jackson passed away peacefully at home in Toronto on January 6, 2010, surrounded by his devoted and loving wife, Marilyn, and his family, after battling cancer. To say that he had an extraordinary life and career would be a gross understatement. His modest and soft-spoken demeanor belied the magnitude of his accomplishments and contributions. His vision and contributions did nothing short of revolutionizing surgery as it is practiced across almost all fields.

Bob Jackson—A Tribute

Brian Day, Donald H. Johnson — 2010-03-01

On January 6, 2010, the world lost one of its truly great physicians, Dr. Robert W. Jackson. Bob was our mentor and teacher, friend and colleague, and his legacy as the undisputed father of arthroscopy in North America will never be forgotten.

Is a Magnetic Resonance Imaging Scan Necessary to Diagnose Knee Arthritis?

Ronald P. Grelsamer — 2010-03-01

Regarding the article “The Accuracy of Magnetic Resonance Imaging Scanning and Its Influence on Management Decisions in Knee Surgery” by Galea et al., which was published in the May 2009 issue, the elephant in the middle of the room is whether the patients ever really needed magnetic resonance imaging to detect their arthritis. Patients in this study underwent the following radiographs: “weight-bearing anteroposterior, lateral, and skyline.” With a standing-flexion posteroanterior view (Rosenberg, schuss), femorotibial arthritis would often have been detected without the need for magnetic resonance imaging.

Snapping Scapula

W. Ben Kibler — 2010-03-01

I read with interest the “Current Concepts” article on the diagnosis and treatment of the snapping scapula in the November 2009 issue. I am glad to see more articles that address all aspects on scapular function and dysfunction. I thank the authors for their interest and their efforts to improve understanding and treatment of the various scapular problems. The review of the literature and the suggestions about pathophysiology and treatment are extensive but incomplete. I would suggest that several points need expansion and clarification to make the article maximally useful to the readers.

Author's Reply

2010-03-01

We appreciate the letter from Dr. Kibler regarding our article, “The Snapping Scapula: Diagnosis and Treatment.” First, we would certainly like to acknowledge that Dr. Kibler is a world-recognized expert in the treatment of conditions affecting the scapula. He brings out some excellent points, and we believe that his comments should serve as an important supplement to some of our topics that were discussed in the article. We should point out that we were unable to provide an exhaustive review on the topic because of space constraints of the journal, and we believe that his points are important aspects that were not intentionally ignored. We agree with him that an understanding of the biomechanical function of the scapula is important to consider, especially coordinated muscular motion, as well as the importance of anterior/posterior tilting in the development of the bursitis associated with snapping scapula syndrome. Posterior tilt and the corrective measures that he has described are important aspects of understanding the pathophysiology and eventual treatment of the disorder, although the basis of this understanding is Level V expert opinion.

Arthroscopic Repair of Full-Thickness Rotator Cuff Tears: Is There Tendon Healing in Patients Aged 65 Years or Older?

Christophe Charousset, Laurence Bellaïche, Kunal Kalra, David Petrover — 2010-03-01

Purpose: The aim of this study was to assess tendon healing and clinical results of rotator cuff tears (RCTs) repaired arthroscopically in patients aged 65 years or older.Methods: Between January 2001 and December 2004, 88 patients with a mean age of 70 years (range, 65 to 85 years) had arthroscopic RCT repair. The repair was performed on 54 women (61%). The dominant arm was involved in 72 patients (82%). RCT included more than 2 tendons in 45 cases. Functional outcomes were assessed by use of the Constant score and Simple Shoulder Test. Tendon healing was estimated by use of a computed tomography (CT) arthrogram, which was obtained 6 months postoperatively, and was classified into 3 categories: stage 1, watertight and anatomic healing; stage 2, watertight and partial healing; and stage 3, not watertight and retear.Results: The mean duration of follow-up was 41 months (range, 24 to 77 months). The mean clinical outcome scores all improved significantly at the time of the final follow-up (P < .01). Computed tomography arthrogram imaging showed 27 shoulders with a stage 1 repair, 20 with a stage 2 repair, and 34 with a stage 3 repair. The retear rate was 42% (34 of 81). The patients with tendon healing stage 1 or 2 had a significantly superior functional outcome in terms of overall scores and strength compared with the stage 3 repairs (P < .01). In our study we had 39 isolated supraspinatus tears (small or medium tears); 11 (28.9%) had a retear (stage 3).Conclusions: Arthroscopic repair in patients aged 65 years or older can yield tendon healing resulting in significant functional improvement. Our data suggest that arthroscopic repair can be considered successful for the older patient specifically when the tear is limited to the supraspinatus tendon.Level of Evidence: Level IV, therapeutic case series.

The Incidence of Early Metallic Suture Anchor Pullout After Arthroscopic Rotator Cuff Repair

Eric C. Benson, Joy C. MacDermid, Darren S. Drosdowech, George S. Athwal — 2010-01-25

Purpose: The purpose of this study was to identify the incidence of metallic suture anchor pullout after arthroscopic rotator cuff repair and determine the impact of tear size on the risk of pullout.Methods: A retrospective review of 269 patients (550 metallic suture anchors) who underwent arthroscopic rotator cuff repair between January 2006 and January 2009 was conducted. Inclusion criteria included patients aged 18 years or older, a minimum of 6 weeks' radiographic follow-up, and the use of 1 or more metallic suture anchors for partial or complete rotator cuff repair. The mean age of the cohort at the time of surgery was 55 years (range, 29 to 86 years), and there were 189 men and 80 women.Results: Early anchor pullout occurred in 6 patients (9 anchors). The overall incidence of early metallic suture anchor pullout in this cohort was 2.4% (95% confidence interval, 0.5% to 4.3%). The incidence in rotator cuff tears less than or equal to 3 cm was 0.5%, and the incidence in tears greater than 3 cm was 11%. Patients undergoing arthroscopic rotator cuff repair of a tear greater than 3 cm in size were at a significantly higher risk of having early metallic suture anchor pullout than patients undergoing repair of a smaller tear (relative risk, 22; P = .001). Among the 61 patients undergoing arthroscopic subscapularis repair, no suture anchor failures were observed at the lesser tuberosity. Of the 9 anchors that failed, 8 (89%) pulled out of the posterior aspect of the greater tuberosity.Conclusions: There is a minimal risk of suture anchor pullout in small- to medium-sized tears; however, this risk increases with larger tear sizes. We recommend routine radiographic follow-up after use of metallic anchors to ensure identification of early failure by anchor pullout.Level of Evidence: Level III, prognostic case series.

Biomechanical Advantages of Triple-Loaded Suture Anchors Compared With Double-Row Rotator Cuff Repairs

2009-12-28

Purpose: To evaluate the strength and suture-tendon interface security of various suture anchors triply and doubly loaded with ultrahigh–molecular weight polyethylene–containing sutures and to evaluate the relative effectiveness of placing these anchors in a single-row or double-row arrangement by cyclic loading and then destructive testing.Methods: The infraspinatus muscle was reattached to the original humeral footprint by use of 1 of 5 different repair patterns in 40 bovine shoulders. Two single-row repairs and three double-row repairs were tested. High-strength sutures were used for all repairs. Five groups were studied: group 1, 2 triple-loaded screw suture anchors in a single row with simple stitches; group 2, 2 triple-loaded screw anchors in a single row with simple stitches over a fourth suture passed perpendicularly (“rip-stop” stitch); group 3, 2 medial and 2 lateral screw anchors with a single vertical mattress stitch passed from the medial anchors and 2 simple stitches passed from the lateral anchors; group 4, 2 medial double-loaded screw anchors tied in 2 mattress stitches and 2 push-in lateral anchors capturing the medial sutures in a “crisscross” spanning stitch; and group 5, 2 medial double-loaded screw anchors tied in 2 mattress stitches and 2 push-in lateral anchors creating a “suture-bridge” stitch. The specimens were cycled between 10 and 180 N at 1.0 Hz for 3,500 cycles or until failure. Endpoints were cyclic loading displacement (5 and 10 mm), total displacement, and ultimate failure load.Results: A single row of triply loaded anchors was more resistant to stretching to a 5- and 10-mm gap than the double-row repairs with or without the addition of a rip-stop suture (P < .05). The addition of a rip-stop stitch made the repair more resistant to gap formation than a double row repair (P < .05). The crisscross double row created by 2 medial double-loaded suture anchors and 2 lateral push-in anchors stretched more than any other group (P < .05).Conclusions: Double-row repairs with either crossing sutures or 4 separate anchor points were more likely to fail (5- or 10-mm gap) than a single-row repair loaded with 3 simple sutures.Clinical Relevance: The triple-loaded anchors with ultrahigh–molecular weight polyethylene–containing sutures placed in a single row were more resistant to stretching than the double-row groups.

Effect of Suture Size and Type on Bone Cutout in Transosseous Tendon Repairs

2010-01-25

Purpose: We compared bone cutout of polyester and polyblend suture in 2 suture sizes with static and cyclic loading in a Sawbone model (Pacific Research Laboratories, Vashon, WA).Methods: Polyester and polyblend sutures in both No. 2 and No. 5 sizes were placed through transosseous tunnels in closed-cell polyurethane foam and tied over the bar of an electromechanical load frame at a fixed height. Seven sutures in each group were pulled at a rate of 1 mm/s until bone cutout occurred. Another set of 28 sutures were cyclically loaded at increasing loads until failure.Results: With static and cyclic loads, No. 5 polyester suture (Ethibond; Ethicon, Somerville, NJ) and No. 5 polyblend suture (FiberWire; Arthrex, Naples, FL) had a higher cutout load than the No. 2 sutures (P < .001). No. 2 polyblend suture had a higher static failure load than No. 2 polyester suture (P = .02). With cyclic loading, No. 2 polyblend suture had a higher load to cutout than No. 2 polyester suture (P = .01), and No. 5 polyblend suture had a higher load to cutout than No. 5 polyester suture (P = .003).Conclusions: No. 2 sutures showed bone cutout at lower forces under static and cyclic loading as compared with No. 5 sutures in this Sawbone model, and no decrease in performance with regard to bone cutout was noted with polyblend as compared with polyester.Clinical Relevance: No. 5 polyester or polyblend suture may be preferable to No. 2 suture to avoid bone cutout in tendon-to-bone repair, and No. 5 polyblend may be preferable to No. 5 polyester to avoid bone cutout.

Factors Affecting Recovery After Arthroscopic Labral Debridement of the Hip

Ho H. Lee, Alison K. Klika, Boris Bershadsky, Viktor E. Krebs, Wael K. Barsoum — 2009-12-28

Purpose: The purpose of this study was to develop and validate a model predicting whether patients would have shorter-than-typical or longer-than-typical recoveries after hip arthroscopy for labral tears.Methods: We retrospectively reviewed 268 cases of hip arthroscopy implemented between 2000 and 2007 by 2 orthopaedic surgeons at our institution. The development cohort consisted of patients with magnetic resonance angiography–identified labral tears and a history and physical examination consistent with either labral pathology or loose bodies. Univariate analysis targeted preoperative patient characteristics correlated with the risk of longer-than-typical recoveries. Multivariate logistic regression was applied to generate an algorithm predicting risk of longer-than-typical recovery based on baseline characteristics. The algorithm was tested in the validation sample of 52 patients who were treated in 2007 and was found to be valid.Results: Five predictors for longer-than-typical recovery were identified: Workers' Compensation status, female gender, use of pain medications, presence of a limp, and presence of a lateral labral tear. The multivariate algorithm was developed and successfully validated.Conclusions: This study identifies many new predictors of recovery, and it also corroborates those that have already been identified. The 5 predictors for longer-than-typical recovery identified by our validated multivariate algorithm were Workers' Compensation status, female gender, use of pain medications, presence of a limp, and presence of a lateral labral tear.Level of Evidence: Level IV, therapeutic case series.

A Biomechanical Comparison of 3 Reconstruction Techniques for Posterolateral Instability of the Knee in a Cadaveric Model

2009-12-31

Purpose: The objective of this study was to compare the varus and external rotatory laxity of reconstructed knees by use of 3 different reconstruction techniques that address posterolateral instability of the knee: popliteus tendon (PT) and lateral collateral ligament (LCL) reconstruction, PT and popliteofibular ligament (PFL) reconstruction, and PFL and LCL reconstruction.Methods: We divided 36 fresh-frozen cadaveric knees into 3 groups of 12, and each group was assigned to a reconstruction technique: PT-LCL reconstruction with the posterior tibialis tendon, PT-PFL reconstruction with the patellar tendon and bone (Warren technique), and PFL-LCL reconstruction with the semitendinosus tendon (Larson technique). Each specimen was fixed with an Ilizarov external fixator and mounted on a custom-designed apparatus that was made to measure posterolateral instability of the knee, that is, external rotatory and varus laxity in the intact state, after cutting, and in the postoperative state at every 30° from 0° to 90°.Results: There were no significant differences between the 3 techniques with external rotation and varus laxity in all specimens.Conclusions: PT-LCL reconstruction was comparable to the other 2 established techniques: PT-PFL reconstruction (Warren technique) and PFL-LCL reconstruction (Larson technique). However, the original strength of the native knee could not be achieved with any of the techniques.Clinical Relevance: All techniques restored the posterolateral stability of the knee to near normal, with none of them being superior.

Transtibial Versus Anteromedial Portal Drilling for Anterior Cruciate Ligament Reconstruction: A Cadaveric Study of Femoral Tunnel Length and Obliquity

Asheesh Bedi, Brad Raphael, Alex Maderazo, Helene Pavlov, Riley J. Williams — 2010-03-01

Purpose: To compare the obliquity and length of femoral tunnels prepared with transtibial versus anteromedial portal drilling for anterior cruciate ligament (ACL) reconstruction and identify potential risks associated with the anteromedial portal reaming technique.Methods: We used 18 human cadaveric knees (9 matched pairs) without ACL injury or pre-existing arthritis for the study. Femoral tunnels for ACL reconstruction were prepared by either a transtibial (n = 6) or anteromedial portal (n = 12) technique. For the anteromedial portal technique, a guidewire was advanced through the medial portal in varying degrees of knee flexion (100° [n = 4], 110° [n = 4], or 120° [n = 4]) as measured with a goniometer. By use of a 6-mm femoral offset guide, two 6-mm femoral tunnels were reamed with the guide placed (1) as far posterior and lateral in the notch as possible and (2) as far medial and vertical in the notch as possible to define the range of maximal and minimal achievable coronal obliquity for each technique. All knees were imaged with high-resolution, 3-dimensional fluoroscopy to define (1) coronal tunnel obliquity relative to the lateral tibial plateau, (2) sagittal tunnel obliquity relative to the long axis of the femur, (3) intraosseous tunnel length, and (4) the presence of posterior cortical wall blowout. Data analysis was performed with a paired t-test and repeated-measures analysis of variance, with P < .05 defined as significant.Results: Preparation of a vertical tunnel was possible with both transtibial and anteromedial portal drilling. The maximal achievable coronal obliquity, however, was significantly better with an anteromedial portal compared with transtibial drilling. However, 7 of 36 tunnels (19.4%) showed violation of the posterior tunnel wall, and all of these cases occurred with the anteromedial portal drilling technique. In addition, 1 of 6 oblique femoral tunnels (16.7%) drilled with the transtibial technique and 5 of 12 oblique femoral tunnels (41.7%) drilled with the anteromedial portal had an intraosseous length less than 25 mm. Increasing knee flexion with anteromedial portal drilling was associated with a significant reduction in tunnel length, increase in coronal obliquity, increase in sagittal obliquity, and increased risk of posterior wall blowout (P < .05).Conclusions: The anteromedial portal technique allows for slightly greater femoral tunnel obliquity compared with transtibial drilling. However, there is a substantially increased risk of critically short tunnels (<25 mm) and posterior tunnel wall blowout when a conventional offset guide is used. Increasing knee flexion with anteromedial portal drilling allows for greater coronal obliquity of the femoral tunnel but is accompanied by a greater risk of critically short tunnels and posterior wall compromise.Clinical Relevance: Our findings provide insight into the potential risks and advantages of a transtibial versus an anteromedial femoral tunnel drilling technique in ACL reconstruction.

Evaluation of a New Femoral Fixation Device in a Simulated Anterior Cruciate Ligament Reconstruction

Andrew Speirs, David Simon, Peter Lapner — 2010-01-25

Purpose: The purpose of this in vitro biomechanical study was to determine the cyclic elongation and failure properties of a new anterior cruciate ligament (ACL) reconstruction device and compare the results with several devices that are currently available.Methods: We performed 10 ACL reconstructions in 4 groups using fresh porcine femurs and doubled lateral extensor of the toes tendons. Manufacturer guidelines were followed for fixation by use of either of 2 cortical suspension devices (XO Button [ConMed Linvatec, Largo, FL] and EndoButton CL [Smith & Nephew, Andover, MA]), a bio-interference screw (BioScrew; ConMed Linvatec), or a corticocancellous fixation device (Pinn-ACL; ConMed Linvatec). Reconstructions were subjected to cyclic loading to 150 N for 2,000 cycles, followed by static failure tests.Results: The two cortical suspension devices performed similarly to one another: the XO Button device had a significantly lower elongation amplitude than the EndoButton (P < .05). There were no significant differences in longer-term creep performance or static strength or stiffness. Compared with an interference screw, the XO Button had significantly less creep and higher failure load (P < .05). The corticocancellous device had the lowest creep and cyclic elongation amplitude and the highest strength and stiffness of the devices tested.Conclusions: In this in vitro evaluation, reconstructions with the XO Button and EndoButton exhibited very similar biomechanical performance, and our hypothesis was not supported: the XO Button did not limit creep more than the EndoButton.Clinical Relevance: The results of this preclinical in vitro testing suggest that the new device is expected to provide clinical results similar to those of the EndoButton, a well-established device for ACL reconstruction.

The Effect of a Nonanatomic Repair of the Meniscal Horn Attachment on Meniscal Tension: A Biomechanical Study

Christian Stärke, Sebastian Kopf, Karl-Heinz Gröbel, Roland Becker — 2010-01-04

Purpose: The purpose of this biomechanical study was to investigate the potential effect of a nonanatomic repair of the meniscal horn attachment on the resultant circumferential tension in a large animal model and to show that the circumferential tension of the meniscus affects the local stress of the cartilage.Methods: All investigations were done in the medial compartment of porcine knees. First, the anterior horn attachment of the meniscus was mechanically separated from the surrounding tibial bone and fitted with a force transducer (n = 8). The femorotibial joint was loaded in compression at different flexion angles, and the resultant tension at the horn attachment was recorded. The measurements were done with the horn attachment at its anatomic position and repeated with the horn attachment being displaced medially or laterally by 3 mm. In the second part the local deformation of the cartilage under a femorotibial compressive load was measured at different levels of meniscal hoop tension (n = 5).Results: A nonanatomic position of the horn attachment had a significant effect on the resultant tension (P < .01). Placing the horn attachment 3 mm medially decreased the tension at the horn attachment by 49% to 73%, depending on flexion angle and femorotibial load. The opposite placement resulted in a relative increase in the tension by 28% to 68%. Lower levels of meniscal hoop tension caused increased deformation of the cartilage (P < .05), indicating increased local stress.Conclusions: A nonanatomic position of the horn attachment strongly affects conversion of femorotibial loads into circumferential tension. There is a narrow window for a functionally sufficient repair of meniscal root tears.Clinical Relevance: Although clinical inferences are limited because the specimens used were from a different species, there seems to be only a narrow window for a mechanically sufficient repair of root tears.

The Actual Tendon-Bone Interface Strength in a Rabbit Model

2009-12-28

Purpose: The purpose of this study was to evaluate the strength of the interface throughout the entire integration process by use of tendon graft reinforced with a suture material compared with nonreinforced tendon graft.Methods: Using 60 skeletally mature female Japanese white rabbits, we performed biomechanical testing and histologic evaluation to compare tendon grafts reinforced with a suture material (suture group) and nonreinforced grafts (control group). The tendon graft was drawn through a bone tunnel measuring 2.5 mm in diameter and was tightly fixed. For biomechanical testing, the tendon graft was tested in tensile loading along the axis of the bone tunnel at a crosshead speed of 100 mm/min.Results: On biomechanical testing, at 4, 6, 8, and 12 weeks, tendon grafts had pulled out of the bone tunnel in the suture group. In the control group all tendon grafts had pulled out at 4 and 6 weeks, and rupture at the midsubstance was seen at 8 and 12 weeks. The failure load–to–tunnel length ratio was significantly larger in the suture group compared with the control group at 8 and 12 weeks. On histologic evaluation, both groups had similar findings with direct attachments to bone by 12 weeks.Conclusions: In this study of the healing characteristics of augmented and nonaugmented tendon grafts placed in a bone tunnel, we found that the suture-augmented tendons had superior failure load–to–tunnel length ratios at 8, 12, and 16 weeks compared with nonaugmented tendons. The failure mode in the augmented grafts was tendon pullout at all time points except 16 weeks, whereas the nonaugmented grafts failed by midsubstance rupture after 8 weeks. Histologically, both groups had similar findings with direct attachments to bone by 12 weeks.Clinical Relevance: The tendon graft has the potential to be pulled out of the bone tunnel after complete integration.

Electrospun Synthetic Polymer Scaffold for Cartilage Repair Without Cultured Cells in an Animal Model

2009-12-31

Purpose: The purpose of our study was to explore the possibility that an electrospun bioabsorbable scaffold could be used in the treatment of a full-thickness articular defect without the addition of exogenous cells in a rabbit model.Methods: Two types of poly(D,L-lactide-co-glycolide) (PLG) scaffolds, a solid cylindrical type and a cannulated tubular type, were made with the electrospinning method. Osteochondral defects, 5 mm in diameter and 5 mm in depth, made on the femoral condyles of rabbits were filled with these scaffolds, and the repair process was investigated histologically.Results: In the groups in which the defect was filled with the scaffold, fibrous tissue at the articular surface of the scaffold was observed at postoperative week 2. Thereafter cartilage at the articular surface and bone at the subchondral zone were regenerated, and the repaired cartilage was maintained through postoperative week 24. By contrast, the untreated defect was filled with hematoma at postoperative week 2; thereafter regenerated cartilage and bone were observed. However, the surface of the articular cartilage was not regular, and regenerated cartilage was not well organized. The histologic scores of the groups in which the defect was filled with cannulated tubular electrospun PLG scaffolds were significantly higher than those of the untreated defect group at postoperative weeks 12 and 24 (P < .01).Conclusions: The electrospun PLG scaffold could repair a 5-mm osteochondral defect created in the rabbit model without exogenous cultured cells.Clinical Relevance: The electrospun PLG scaffold could repair full-thickness osteochondral defects. The cannulated type of PLG scaffold has the possibility to lead not only to good regeneration of cartilage but also to easy transplantation by use of a guidewire through the cannulas in the scaffold.

Open Versus Endoscopic Excision of a Symptomatic Os Trigonum: A Comparative Study of 41 Cases

Qin Wei Guo, Yue Lin Hu, Chen Jiao, Ying Fang Ao, De Xiang Tian — 2010-03-01

Purpose: To compare the clinical results of a consecutive series of 43 cases of excision of a symptomatic os trigonum performed with an open versus hindfoot endoscopic technique.Methods: From 1994 to 2007, 43 patients underwent a symptomatic os trigonum excision. A subjective satisfaction questionnaire and a visual analog scale score for pain were obtained, and the American Orthopaedic Foot & Ankle Society ankle and hindfoot score and the time to return to previous sports level were determined in 41 of 43 patients at follow up. Of the ankles, 16 had an open os trigonum excision and 25 had hindfoot endoscopic surgery. Group A (16 ankles, open surgery) and group B (25 ankles, endoscopic excision) were comparable concerning age, sex, profession, and concomitant injury of the ankle.Results: At follow-up evaluation (12 to 86 months after surgery), group B had a significantly shorter mean time to return to previous sports level. There was no difference in postoperative visual analog scale score, American Orthopaedic Foot & Ankle Society score, subjective satisfaction rating, or rating of sensory nerve loss between the 2 groups.Conclusions: Both open surgery and hindfoot endoscopic excision of a symptomatic os trigonum were effective and safe. Patients with an endoscopic excision had a shorter time to return to previous sports level.Level of Evidence: Level IV, therapeutic case series.

Arthroscopic Treatment of Medial Shelf Syndrome

Gene L. Muse, William A. Grana, Susan Hollingsworth — 2010-03-01

Abstract: Medial shelf or “plica” syndrome is a pathological condition of the knee that often follows knee injury in young athletes, the symptoms of which often mimic other internal derangements of the knee. Its anatomy, pathomechanics, and clinical presentation along with treatments suggested in the orthopedic literature are reviewed here. Two-year follow-up studies on the treatment of this syndrome by arthroscopic resection in 51 knees in 42 patients are presented as well.

Does the Literature Confirm Superior Clinical Results in Radiographically Healed Rotator Cuffs After Rotator Cuff Repair?

2010-01-18

Purpose: Because recurrent or persistent defects in the rotator cuff after repair are common, we sought to clarify the correlation between structural integrity of the rotator cuff and clinical outcomes through a systematic review of relevant studies.Methods: Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials were searched for all literature published from January 1966 to December 2008 that used the key words shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, integrity, healed, magnetic resonance imaging (MRI), computed tomography arthrography (CTA), and ultrasound. The inclusion criteria were studies (Levels I to IV) that reported outcomes after arthroscopic rotator cuff repair in healed and nonhealed repairs based on ultrasound, CTA, and/or MRI. Exclusionary criteria were studies that included open repair or subscapularis repair and studies that did not define outcomes based on healed versus nonhealed but rather used another variable (i.e., repair technique). Data were abstracted from the studies including patient demographics, tear characteristics, surgical procedure, rehabilitation, strength, range of motion, clinical scoring systems, and imaging studies.Results: Thirteen studies were included in the final analysis: 5 used ultrasound, 4 used MRI, 2 used CTA, and 2 used combined CTA/MRI for diagnosis of a recurrent tear. Statistical improvement in patients who had an intact cuff at follow-up was seen in Constant scores in 6 of 9 studies; in University of California, Los Angeles scores in 1 of 2 studies; in American Shoulder and Elbow Surgeons scores in 0 of 3 studies; and in Simple Shoulder Test scores in 0 of 2 studies. Increased range of motion in forward elevation was seen in 2 of 5 studies and increased strength in forward elevation in 5 of 8 studies.Conclusions: The results suggest that some important differences in clinical outcomes likely exist between patients with healed and nonhealed rotator cuff repairs. Further study is needed to conclusively define this difference and identify other important prognostic factors related to clinical outcomes.Level of Evidence: Level IV, systematic review.

Femoral Nerve Block Use in Anterior Cruciate Ligament Reconstruction Surgery

Nathan A. Mall, Rick W. Wright — 2010-01-25

Purpose: The goal of this study was to determine whether femoral nerve blocks (FNBs) provide patients undergoing anterior cruciate ligament reconstruction greater pain relief or other benefits compared with more standard pain medication regimens.Methods: We searched PubMed, EMBASE, and the Cochrane Database using the following search terms: “ACL or anterior cruciate ligament” and “femoral nerve block or peripheral nerve block” or “regional anesthesia.” Thirteen studies were found that fit the inclusion criteria of being randomized controlled trials with a Level of Evidence of I or II, comparing FNB or 3-in-1 blocks with control groups undergoing various multimodal pain regimens.Results: Only 5 of the 13 studies found a significant difference in pain relief with FNB compared with the control groups; however, the difference in several of the studies may not be clinically relevant. Of the 13 studies, 6 examined parameters other than pain, and only 1 study found a greater incidence of nausea and sedation in its control group. Patient satisfaction was examined in 2 studies, with both finding no difference between groups. Nine studies used a single graft type, and the two studies using multiple graft types accounted for this in their analyses.Conclusions: On the basis of the available Level I and II data from randomized controlled trials, there appears to be no evidence that FNBs add additional benefit over multimodal analgesia. FNBs have not been shown to significantly affect patient pain, readiness for discharge, or outcome scores. There is a small but identifiable risk associated with performing FNBs, with potentially catastrophic effects.Level of Evidence: Level II, systematic review of Level I and II randomized controlled trials with minimal heterogeneity.

The Geometric Classification of Rotator Cuff Tears: A System Linking Tear Pattern to Treatment and Prognosis

James Davidson, Stephen S. Burkhart — 2009-12-28

Abstract: A valuable classification system allows for communication among surgeons and/or other investigators and offers information on treatment and prognosis. It provides a means for comparison of epidemiologic data and treatment outcomes. There is no current standard classification for rotator cuff tears. Authors and practicing orthopaedists use a variety of descriptions when communicating about cuff tears. Older classifications do not use 3-dimensional information derived from the present use of arthroscopy and magnetic resonance imaging. The new geometric classification offers guidance on treatment and prognosis. Type 1, crescent-shaped tears are repaired end to bone and have a good to excellent prognosis. Type 2, longitudinal (L- or U-shaped) tears are repaired side to side with margin convergence and have a good to excellent prognosis. Type 3, massive contracted tears have coronal and sagittal dimensions greater than 2 × 2 cm on preoperative magnetic resonance imaging; are repaired with interval slides or partial repair; and have a fair to good prognosis. Type 4, rotator cuff arthropathy tears have end-stage degenerative changes of the glenohumeral joint and have articulation of the humeral head with the undersurface of the acromion; are irreparable; and require arthroplasty if surgery is considered. This classification describes complete tears of the superior and posterior rotator cuff, supraspinatus, infraspinatus, and teres minor. Additional notation can be made regarding the presence of related pathology including tears of the subscapularis, biceps, or labrum; instability or arthritic change of the glenohumeral or acromioclavicular joints; or fatty degeneration of the cuff.

Arthroscopically Induced Posterior Capsular Fibrosis to Correct Symptomatic Hyperextension of the Knee

Henry E. Bourke, Iain A.R. MacLeod, James C. Lewis, Andy M. Williams — 2010-03-01

Abstract: We present a technical note on 2 patients with post-traumatic symptomatic hyperextension of the knee treated with a new arthroscopic technique. Both patients were of similar ages with similar injuries resulting in an excess of hyperextension at the knee with resulting instability and pain. Both patients had not improved with a variety of nonoperative measures and 1 attempt each at simple arthroscopic debridement of the damaged tissue. Our technique involves carefully scarring the damaged posterior capsule arthroscopically, followed by extension block bracing for 12 weeks. In 2 patients who had not improved with previously described techniques, we achieved a correction of the excess hyperextension with resulting improvement in their symptoms. Two years after surgery, both patients had significantly improved Lysholm and Tegner activity scores and had returned to work. We believe this technique to be reliable and reproducible.

Medial-Row Failure After Arthroscopic Double-Row Rotator Cuff Repair

2010-01-04

Abstract: We report 4 cases of medial-row failure after double-row arthroscopic rotator cuff repair (ARCR) without arthroscopic subacromial decompression (ASAD), in which there was pullout of mattress sutures of the medial row and knots were caught between the cuff and the greater tuberosity. Between October 2006 and January 2008, 49 patients underwent double-row ARCR. During this period, ASAD was not performed with ARCR. Revision arthroscopy was performed in 8 patients because of ongoing symptoms after the index operation. In 4 of 8 patients the medial rotator cuff failed; the tendon appeared to be avulsed at the medial row, and there were exposed knots on the bony surface of the rotator cuff footprint. It appeared that the knots were caught between the cuff and the greater tuberosity. Three retear cuffs were revised with the arthroscopic transtendon technique, and one was revised with a single-row technique after completing the tear. ASAD was performed in all patients. Three of the four patients showed improvement of symptoms and returned to their preinjury occupation. Impingement of pullout knots may be a source of pain after double-row rotator cuff repair.

Announcements

2010-03-01

Arthroscopy Journal Video Prize. At the recommendation of the Journal Board of Trustees and with the approval of the AANA Board, we are pleased to announce that the annual Journal prize in 2010 will be the ArthroscopyJournal Video Prize. Recognizing the value and taking advantage of what the Internet has to offer, we have exhorted our authors to “Go to the Video” in our effort to provide our readers with the highest quality, most instructive video supplements to published articles possible. And so, we will award a prize of $5,000 to the best video with narration to accompany an article published in Arthroscopy in 2010. The award will be judged by the Journal's Editors and Associate Editors, who have recused themselves from the competition. Please see the Instructions for Authors for file type, length, and file size limits.

Spanish Translated Abstracts

2010-03-01

Masthead

2010-03-01

Arthroscopy: The Journal of Arthroscopic and Related Surgery (ISSN 0749-8063) is published monthly by Elsevier Inc., 360 Park Avenue South, New York, NY 10010-1710. (For Post Office use only: Volume 26 issue 3 of 12.) Periodicals postage paid at New York, NY and additional mailing offices.

Editorial Board

2010-03-01

Instructions for Authors

2010-03-01

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

Suggested Guidelines for the Practice of Arthroscopic Surgery

2010-03-01

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

Rotator Cuff Repair: Obviously

In Memoriam: Robert Wilson Jackson, O.C., M.D., F.R.C.S.C., Hon. F.R.C.S. (UK & Edin)

Bob Jackson—A Tribute

Is a Magnetic Resonance Imaging Scan Necessary to Diagnose Knee Arthritis?

Snapping Scapula

Author's Reply

Arthroscopic Repair of Full-Thickness Rotator Cuff Tears: Is There Tendon Healing in Patients Aged 65 Years or Older?

The Incidence of Early Metallic Suture Anchor Pullout After Arthroscopic Rotator Cuff Repair

Biomechanical Advantages of Triple-Loaded Suture Anchors Compared With Double-Row Rotator Cuff Repairs

Effect of Suture Size and Type on Bone Cutout in Transosseous Tendon Repairs

Factors Affecting Recovery After Arthroscopic Labral Debridement of the Hip

A Biomechanical Comparison of 3 Reconstruction Techniques for Posterolateral Instability of the Knee in a Cadaveric Model

Transtibial Versus Anteromedial Portal Drilling for Anterior Cruciate Ligament Reconstruction: A Cadaveric Study of Femoral Tunnel Length and Obliquity

Evaluation of a New Femoral Fixation Device in a Simulated Anterior Cruciate Ligament Reconstruction

The Effect of a Nonanatomic Repair of the Meniscal Horn Attachment on Meniscal Tension: A Biomechanical Study

The Actual Tendon-Bone Interface Strength in a Rabbit Model

Electrospun Synthetic Polymer Scaffold for Cartilage Repair Without Cultured Cells in an Animal Model

Open Versus Endoscopic Excision of a Symptomatic Os Trigonum: A Comparative Study of 41 Cases

Arthroscopic Treatment of Medial Shelf Syndrome

Does the Literature Confirm Superior Clinical Results in Radiographically Healed Rotator Cuffs After Rotator Cuff Repair?

Femoral Nerve Block Use in Anterior Cruciate Ligament Reconstruction Surgery

The Geometric Classification of Rotator Cuff Tears: A System Linking Tear Pattern to Treatment and Prognosis

Arthroscopically Induced Posterior Capsular Fibrosis to Correct Symptomatic Hyperextension of the Knee

Medial-Row Failure After Arthroscopic Double-Row Rotator Cuff Repair

Announcements

Spanish Translated Abstracts

Masthead

Editorial Board

Table of Contents

Instructions for Authors

Suggested Guidelines for the Practice of Arthroscopic Surgery