Arthroscopy: The Journal of Arthroscopic and Related Surgery

AAOS Rotator Cuff Clinical Practice Guideline Misses the Mark

James H. Lubowitz, Louis F. McIntyre, Matthew T. Provencher, Gary G. Poehling — 2012-05-01

The American Academy of Orthopaedic Surgeons Clinical Practice Guideline (CPG) on Optimizing the Management of Rotator Cuff Problem was developed using the best available evidence to improve treatment in keeping with current evidentiary practice standards. This is a laudable and necessary effort. Unfortunately, the CPG process produces inconclusive recommendations supported by relatively low-levels of evidence. The CPG “assessment of the current scientific and clinical information” does not result in an accurate description of “accepted approaches to treatment.” This is because accepted approaches to treatment, or guidelines, must be based on adequate evidence to set standards of practice. Yet significant high-level evidence does not exist. Our rationales for treatment rest on a wealth of lower level evidence that demonstrate the efficacy of our treatments for rotator cuff repair. The dilemma is to produce meaningful direction for clinical decision making and at the same time make sure such recommendations are based on rigorous scientific analysis. The CPG process as currently configured unnecessarily calls our treatments into question, notwithstanding the Clinical Practice Guideline Disclaimer.

Assessing and Reporting Anchor Performance

Laurie A. Hiemstra, Treny M. Sasyniuk — 2012-05-01

We read with interest the article “Poly-L/D-Lactic Acid Anchors Are Associated With Reoperation and Failure of SLAP Repairs” by Park et al. in the October 2011 issue. This was a Level III, retrospective study investigating factors associated with reoperation after SLAP repair. The authors concluded that bioabsorbable poly-L/D-lactic acid anchor material led to significantly more SLAP repair failures and reoperations compared with nonabsorbable anchors. We believe there are some reporting and statistical flaws in this article that must be considered before the authors' conclusions can be accepted.

Author's Reply

G. Russell Huffman — 2012-05-01

We appreciate the letter to the editor from Hiemstra and Sasyniuk regarding our article. They are correct in reiterating that this was an observational study with inherent limitations. In our study, as in all observational studies, errors in inference may arise from chance, confounding, and bias. We performed a statistical evaluation of a concurrent cohort of patients undergoing superior glenoid labrum repairs over a 10-year period. The term “nonconcurrent prospective study” is, in fact, synonymous with a “retrospective, concurrent cohort of patients” whose data are collected in real time but not examined until a later date. The cohort is nonconcurrent because it was not ongoing at the time the study's epidemiologic analysis was performed.

The Development and Validation of a Self-Administered Quality-of-Life Outcome Measure for Young, Active Patients With Symptomatic Hip Disease: The International Hip Outcome Tool (iHOT-33)

2012-05-01

Purpose: The purpose of this study was to develop a self-administered evaluative tool to measure health-related quality of life in young, active patients with hip disorders. Methods: This outcome measure was developed for active patients (aged 18 to 60 years, Tegner activity level ≥4) presenting with a variety of symptomatic hip conditions. This multicenter study recruited patients from international hip arthroscopy and arthroplasty surgeon practices. The outcome was created using a process of item generation (51 patients), item reduction (150 patients), and pretesting (31 patients). The questionnaire was tested for test-retest reliability (123 patients); face, content, and construct validity (51 patients); and responsiveness over a 6-month period in post-arthroscopy patients (27 patients). Results: Initially, 146 items were identified. This number was reduced to 60 through item reduction, and the items were categorized into 4 domains: (1) symptoms and functional limitations; (2) sports and recreational physical activities; (3) job-related concerns; and (4) social, emotional, and lifestyle concerns. The items were then formatted using a visual analog scale. Test-retest reliability showed Pearson correlations greater than 0.80 for 33 of the 60 questions. The intraclass correlation statistic was 0.78, and the Cronbach α was .99. Face validity and content validity were ensured during development, and construct validity was shown with a correlation of 0.81 to the Non-Arthritic Hip Score. Responsiveness was shown with a paired t test (P ≤ .01), effect size of 2.0, standardized response mean of 1.7, responsiveness ratio of 6.7, and minimal clinically important difference of 6 points. Conclusions: We have developed a new quality-of-life patient-reported outcome measure, the 33-item International Hip Outcome Tool (iHOT-33). This questionnaire uses a visual analog scale response format designed for computer self-administration by young, active patients with hip pathology. Its development has followed the most rigorous methodology involving a very large number of patients. The iHOT-33 has been shown to be reliable; shows face, content, and construct validity; and is highly responsive to clinical change. In our opinion the iHOT-33 can be used as a primary outcome measure for prospective patient evaluation and randomized clinical trials.

A Short Version of the International Hip Outcome Tool (iHOT-12) for Use in Routine Clinical Practice

2012-05-01

Purpose: The purpose of this study was to develop and validate a shorter version of the 33-item International Hip Outcome Tool (iHOT-33) that could be easily used in routine clinical practice to measure both health-related quality of life and changes after treatment in young, active patients with hip disorders. Methods: A development dataset (104 patients) was explored with forward-selection linear regression analysis to choose a reduced item set for the new scale. This was tested in a validation dataset (1,833 patients) and responsiveness subset (80 patients) to measure agreement between the shorter and longer versions and to test the sensitivity of the shorter instrument to change after treatment. Results: Twelve items were chosen for a short version of the International Hip Outcome Tool (iHOT-12). The iHOT-12 showed excellent agreement with the long version (iHOT-33). It captured 95.9% (95% confidence interval, 95.0% to 96.8%) of the variation of the iHOT-33 and showed equivalent sensitivity to change with a standardized effect size of 0.98 (95% confidence interval, 0.67 to 1.28). Conclusions: A short version of the International Hip Outcome Tool (iHOT-12) has been developed. It has very similar characteristics to the original rigorously validated 33-item questionnaire, losing very little information despite being only one-third the length. It is valid, reliable, and responsive to change. We suggest that it be used for initial assessment and postoperative follow-up in routine clinical practice.

Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination

2012-02-10

Purpose: The purpose of this study was to evaluate the correlation between computed tomography (CT) and magnetic resonance imaging (MRI) measurements of femoral anteversion, as well as the relation of anteversion with physical examination and radiographic findings. Methods: Preoperative CT and MRI measurements of anteversion along with clinical examination were performed on 129 consecutive hips before hip arthroscopy for nonarthritic hip injuries. All anteversion measurements were performed by 2 musculoskeletal radiologists. The radiographic findings and physical examination findings were analyzed for statistically significant correlations. For statistical analysis purposes, the patients were divided into 3 groups according to the mean CT anteversion measurement: group I (low), less than 10°; group II (medium), 10° to 22°; and group III (high), greater than 22°. Results: High interobserver correlation was found for femoral anteversion measurement by CT and MRI (r = 0.95 and r = 0.86, respectively; P < .0001 for both). CT and MRI measurements showed high correlation with each other (r = 0.80, P < .0001). However, in 96% of the cases, the CT measurement was larger, with a mean difference of 8.9° (range, −37° to 1.5°). A significant correlation coefficient was found between internal rotation and anteversion angles as measured by CT (r = 0.36, P < .0001). However, no correlation was found with other hip movement measurements. Abnormal femoral acetabular bony architecture of the hip was found in 64% of the patients; isolated cam impingement was more prevalent in group I, whereas isolated pincer impingement was more prevalent in group III (P = .01). Conclusions: Although high correlation was found between anteversion angle measurements by CT and MRI, significant discrepancies in the absolute anteversion number between the 2 techniques suggest that they may not be interchangeable. Furthermore, CT was found to have higher interobserver reliability than MRI. There was a significant correlation between CT and examination of internal rotation of the hip. Clinically, the findings of the study show that the diagnosis of excessive femoral anteversion or retroversion should have different thresholds according to MRI and CT measurements; moreover, the diagnosis should not rely exclusively on either examination or radiologic criteria. Level of Evidence: Level III, retrospective comparative study.

The Efficacy of Acromioplasty in the Arthroscopic Repair of Small- to Medium-Sized Rotator Cuff Tears Without Acromial Spur: Prospective Comparative Study

Sang-Jin Shin, Joo Han Oh, Seok Won Chung, Mi Hyun Song — 2012-01-20

Purpose: To assess the role of acromioplasty in the arthroscopic repair of small- to medium-sized rotator cuff tears. Methods: A prospective randomized trial of 120 patients who had small- to medium-sized rotator cuff tears and various types of acromions without spurs were included. Sixty patients received arthroscopic rotator cuff repair with acromioplasty (group I), and another sixty received the same procedure without acromioplasty (group II). The mean age at surgery was 57.8 ± 9.3 years in group I and 55.8 ± 8.0 years in group II. The shape of the acromion was flat in 18 patients, curved in 32, and hooked in 10 in group I, and it was flat in 15 patients, curved in 36, and hooked in 9 in group II. The mean tear size was similar in the two groups (14.6 ± 5.2 mm in group I and 15.3 ± 7.0 mm in group II). Pain and satisfaction were estimated and range of motion was measured at a mean of 35 months after surgery. Functional outcomes were assessed with American Shoulder and Elbow Surgeons: Constant; and University of California, Los Angeles scores. Tendon healing was evaluated by magnetic resonance imaging postoperatively. Results: Clinical outcome was significantly improved in both groups after arthroscopic rotator cuff repair (P < .05). There were no significant differences with respect to pain and range of motion between the groups at the final follow-up (1.1 ± 0.9 v 1.3 ± 1.4 on visual analog scale). Functional outcomes also showed no significant differences between the 2 groups (American Shoulder and Elbow Surgeons score, 90.7 ± 13.1 v 87.5 ± 12.0; Constant score, 85.0 ± 11.3 v 83.3 ± 13.0; and University of California, Los Angeles score, 33.4 ± 3.3 v 32.3 ± 3.5). Postoperative imaging showed that the retear rate was 17% in group I and 20% in group II (P = .475). Conclusions: Arthroscopic repair of small- to medium-sized rotator cuff tears provided pain relief and improved functional outcome with or without acromioplasty. Clinical outcomes were not significantly different, and acromioplasty may not be necessary in the operative treatment of patients with small- to medium-sized rotator cuff tears in the absence of acromial spurs. Level of Evidence: Level II, prospective comparative study.

The Accuracy of Magnetic Resonance Imaging and Magnetic Resonance Arthrogram Versus Arthroscopy in the Diagnosis of Subscapularis Tendon Injury

Abdullah Foad, Coen A. Wijdicks — 2012-01-27

Purpose: The main purpose of this study was to evaluate the accuracy of preoperative magnetic resonance imaging (MRI) in detecting subscapularis tears identified during the gold standard of arthroscopy and determine whether MRI can reliably predict which patients have subscapularis tears. A second purpose was to determine whether magnetic resonance (MR) arthrograms could better identify a subscapularis tear than conventional MRI. Methods: This was a retrospective study evaluating 39 consecutive patients (40 shoulders) who had a preoperative 1.5-T MRI study and underwent an arthroscopic subscapularis tendon repair. All cases were performed between December 2007 and November 2010. Results: Subscapularis tears were missed on preoperative MR scanning in 25 of 40 shoulders (62.5%). The sensitivity of noncontrast MRI was 40%, the sensitivity of MR arthrography was 36%, and the overall MR sensitivity was 37.5%. Conclusions: Preoperative 1.5-T MRI of the shoulder does not reliably predict subscapularis tendon tears, regardless of whether conventional MRI or MR arthrography is used. Level of Evidence: Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.

Biomechanical Evaluation of Classic Solid and Novel All-Soft Suture Anchors for Glenoid Labral Repair

2012-02-10

Purpose: To evaluate the biomechanical performance of an all-soft suture anchor (JuggerKnot; Biomet, Warsaw, IN) in comparison with a classic solid suture anchor (2.4-mm biocomposite SutureTak; Arthrex, Naples, FL) in an in vitro labral repair model. Methods: We dissected 12 cadaveric shoulders (mean age, 61 ± 9.4 years), leaving the labrum intact, and bone mineral density was obtained (mean, 0.375 ± 0.06 g/cm3). Simulated labral tears were made at the anteroinferior and posteroinferior edges of the labrum. Repairs used 2 all-soft suture anchors (JuggerKnot) or 2 solid anchors with free, high-strength No. 2 suture (FiberWire; Arthrex) spanning the operative construct to load the repair. Differential variable reluctance transducers were used to measure labral displacement for each specimen. The testing protocol consisted of a preconditioning phase at 10 N for 10 cycles (1 Hz) and then a final load-to-failure testing at a rate of 3 mm/min. Labral displacement of 2 mm was determined as the primary outcome. Results: There was no statistical difference (P = .22) in ultimate load to failure and displacement at ultimate failure (anchor pullout) between the all-soft JuggerKnot (146.0 ± 43.0 N and 19.8 ± 5.4 mm, respectively) and the solid SutureTak (171.9 ± 52.6 N and 22.3 ± 6.8 mm, respectively). The solid anchor had a significantly higher ultimate load at 2 mm of labral displacement than the all-soft suture anchor (84.1 ± 19.0 N and 39.2 ± 10.6 N, respectively; P < .001). Conclusions: Whereas both the solid SutureTak and the all-soft JuggerKnot displayed similar results on ultimate load-to-failure testing, the solid anchor required significantly greater load for 2 mm of labral displacement than the all-soft anchor. Clinical Relevance: The all-soft anchor (JuggerKnot) is similar in biomechanical performance to the classic solid anchor (SutureTak) with the exception of load at 2 mm of labral displacement, suggesting micromotion of the device.

Pain Management by Periarticular Multimodal Drug Injection After Anterior Cruciate Ligament Reconstruction: A Randomized, Controlled Study

2012-01-27

Purpose: We aimed to determine the efficacy of periarticular (PA) multimodal drug cocktail (MDC) infiltration for pain control after anterior cruciate ligament reconstruction with an autogenous bone–patellar tendon–bone graft. Methods: We randomly assigned 100 patients to five study groups (20 per group): control group, no injection; intra-articular (IA) ropivacaine group, IA injection of ropivacaine alone; IA MDC group, IA injection of MDC; PA MDC group, PA injection of MDC; and IA + PA MDC group, IA and PA injections of MDC. The MDC consisted of ropivacaine, morphine, ketorolac, epinephrine, and cefuroxime. The five groups were compared in terms of pain levels during the first night after surgery and on postoperative days 1, 2, and 14; patient satisfaction was assessed on postoperative day 14. Results: The PA MDC and IA + PA MDC groups had less pain during the first night than patients in the other three groups (P < .001) and were more likely to have the same amount of pain or less pain on postoperative day 1 than their preoperative expectation (P = .05). However, there were no group differences in patient satisfaction on postoperative day 14. No MDC-related side effect was reported. Conclusions: The MDC injection, particularly when delivered periarticularly, provides an effective, safe means of reducing early postoperative pain after anterior cruciate ligament reconstruction at minimal cost. In addition, a single IA injection would have no value in pain relief, regardless of types of drugs. Level of Evidence: Level I, randomized controlled trial.

Clinical Comparisons Between the Transtibial Technique and the Far Anteromedial Portal Technique for Posterolateral Femoral Tunnel Drilling in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Atsuo Nakamae, Mitsuo Ochi, Nobuo Adachi, Masataka Deie, Tomoyuki Nakasa — 2012-01-30

Purpose: The purpose of this study was to compare the clinical results of the transtibial and far anteromedial portal techniques for posterolateral (PL) femoral tunnel drilling in double-bundle anterior cruciate ligament reconstruction. Methods: This study involved 50 patients who underwent double-bundle anterior cruciate ligament reconstruction and were followed up for more than 2 years. The anteromedial bundle was reconstructed with the far anteromedial portal technique in all patients. However, the PL bundle was reconstructed with the transtibial and far anteromedial portal techniques in 22 patients (group T) and 28 patients (group F), respectively. The follow-up visits included evaluation of Lysholm knee scores, KT-2000 measurement of anterior knee laxity (MEDmetric, San Diego, CA), the pivot-shift test, and radiography. Results: The length of the PL femoral tunnel in group F (32.2 mm) was significantly shorter than that in group T (39.0 mm). Lateral knee radiographs showed that the positions of the EndoButtons (Smith & Nephew Endoscopy, Andover, MA) for the PL bundles were significantly more posterior (12.8 mm) and distal (3.1 mm) in group F than in group T. The mean KT-2000 side-to-side difference in group T (0.9 mm) and group F (0.7 mm) did not significantly differ. In addition, no significant difference was noted between the groups with respect to Lysholm knee scores and the pivot-shift test results. Conclusions: This study showed that the far anteromedial portal technique is as effective as the transtibial technique and results in good restoration of joint stability and knee scores despite shorter femoral tunnel length and inferoposterior position of the EndoButton. Level of Evidence: Level III, retrospective comparative study.

Micro-organism Colonization and Intraoperative Contamination in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Reconstruction

Hiroshi Nakayama, Masayoshi Yagi, Shinichi Yoshiya, Yoshio Takesue — 2012-01-30

Purpose: To investigate the status of preoperative micro-organism colonization and intraoperative contamination in patients undergoing anterior cruciate ligament (ACL) reconstruction. Methods: Fifty patients who underwent scheduled ACL reconstruction were included in the study. At the preoperative checkup, swabs were taken from the skin at the surgical site and the nose. During surgery, swab samples were taken from the skin adjacent to the incision and the surface of the graft and examined for contamination. Results: Preoperative examination for micro-organism colonization showed positive results in 23 of 50 samples (46%) taken from the skin and 45 of 50 samples (90%) taken from the nose. Intraoperative swab samples taken from the skin and the graft showed positive rates of 6% and 2%, respectively, which were significantly lower compared with the preoperative values (P < .05). The most frequently identified organism in both preoperative and postoperative examinations was coagulase-negative Staphylococcus (CNS), representing 93% of the positive results. Among those CNS strains, roughly one-third of the samples were shown to be methicillin resistant. During the study period, surgical-site infection with methicillin-resistant CNS occurred in 1 patient. In this patient the preoperative culture identified methicillin-sensitive CNS, whereas preoperative nasal culture and intraoperative examinations of the skin and the graft were negative. Conclusions: Preoperative examination of micro-organism colonization in patients undergoing ACL reconstruction showed positive results in 46% and 90% of the samples taken from the skin and the nose, respectively. In the intraoperative examination, 6% and 2% of the swabs taken from the adjacent skin and the graft, respectively, showed positive results. Level of Evidence: Level IV, therapeutic case series.

Biomechanical Outcomes After Bioenhanced Anterior Cruciate Ligament Repair and Anterior Cruciate Ligament Reconstruction Are Equal in a Porcine Model

2012-01-20

Purpose: The objective of this study was to compare the biomechanical outcomes of a new method of anterior cruciate ligament (ACL) treatment, bioenhanced ACL repair, with ACL reconstruction in a large animal model. Methods: Twenty-four skeletally immature pigs underwent unilateral ACL transection and were randomly allocated to receive bioenhanced ACL repair with a collagen-platelet composite, allograft (bone–patellar tendon–bone) reconstruction, or no further treatment (n = 8 for each group). The structural properties and anteroposterior laxity of the experimental and contralateral ACL-intact knees were measured 15 weeks postoperatively. All dependent variables were normalized to those of the contralateral knee and compared by use of generalized linear mixed models. Results: After 15 weeks, bioenhanced ACL repair and ACL reconstruction produced superior biomechanical outcomes to ACL transection. However, there were no significant differences between bioenhanced ACL repair and ACL reconstruction for maximum load (P = .4745), maximum displacement (P = .4217), or linear stiffness (P = .6327). There were no significant differences between the 2 surgical techniques in anteroposterior laxity at 30° (P = .7947), 60° (P = .6270), or 90° (P = .9008). Conclusions: Bioenhanced ACL repair produced biomechanical results that were not different from ACL reconstruction in a skeletally immature, large animal model, although the variability associated with both procedures was large. Both procedures produced significantly improved results over ACL transection, showing that both were effective treatments in this model. Clinical Relevance: Bioenhanced ACL repair may one day provide an alternative treatment option for ACL injury.

Biomechanical Comparison of Tibial Eminence Fracture Fixation With High-Strength Suture, EndoButton, and Suture Anchor

2012-01-30

Purpose: To biomechanically compare anterior cruciate ligament (ACL) tibial bony avulsion fixation by suture anchors, EndoButtons (Smith & Nephew, Andover, MA), and high-strength sutures subjected to cyclic loading. Methods: Type III tibial eminence fractures were created in 49 ovine knees, and 7 different types of repairs were performed. Each repair group contained 7 specimens. The repair groups were as follows: No. 2 FiberWire (Arthrex, Naples, FL); No. 2 UltraBraid (Smith & Nephew); No. 2 MaxBraid (Arthrotek, Warsaw, IN); No. 2 Hi-Fi (ConMed Linvatec, Largo, FL); No. 2 OrthoCord (DePuy Mitek, Raynham, MA); Ti-Screw suture anchor (Arthrotek); and titanium EndoButton. These constructs were cyclically loaded (500 cycles, 0 to 100 N, 1 Hz) in the direction of the native ACL and loaded to failure (100 mm/min). Endpoints included ultimate failure load (in Newtons); pullout stiffness (in Newtons per millimeter); cyclic displacement (in millimeters) after 100 cycles, between 100 and 500 cycles, and after 500 cycles; and mode of failure. Bone density testing was performed in all knees. Results: Bone density was not different among the groups. The EndoButton group had a higher ultimate failure load than the FiberWire, UltraBraid, Hi-Fi, and suture anchor groups (P < .05). The MaxBraid and OrthoCord groups had higher failure loads than the suture anchor group (P < .05). The MaxBraid group also had a higher failure load than the Hi-Fi group (P < .05). Stiffness was not statistically different for the various tested constructs. After 100 cycles, the EndoButton group had less displacement than the FiberWire, UltraBraid, MaxBraid, and Hi-Fi groups (P < .05). The suture anchor group had less displacement than the Hi-Fi and FiberWire groups (P < .05). The displacements of the different tested constructs between 100 and 500 cycles and total displacements after 500 cycles were not statistically different. The predominant failure mode was suture rupture. Conclusions: Under cyclic loading conditions in an ovine model, EndoButton fixation of tibial eminence fractures provided greater initial fixation strength than suture anchor fixation or fixation with various high-strength sutures except for OrthoCord. Clinical Relevance: During initial cyclic loading of ACL tibial eminence fractures, the strength of the repair construct should be taken into consideration because conventional suture repair even with ultrahigh-molecular-weight polyethylene sutures may not provide enough strength.

Repeated Platelet Concentrate Injections Enhance Reparative Response of Microfractures in the Treatment of Chondral Defects of the Knee: An Experimental Study in an Animal Model

2012-01-27

Purpose: To assess the histology and biomechanics of repair cartilage after microfractures with and without repeated local injections of platelet concentrate for the treatment of full-thickness focal chondral defects of the knee. Methods: A full-thickness chondral lesion on the medial femoral condyle was created in 30 sheep and treated with microfractures. Animals were divided into 2 groups, according to postoperative treatment: in group 1 we performed 5 weekly injections of autologous conditioned plasma, whereas group 2 did not undergo further treatments. Animals were killed at 3, 6, and 12 months after treatment. Macroscopic, histologic, and biomechanical evaluations were performed. Differences between groups at each time interval and differences over time within groups were analyzed for each outcome. Significance was set at P < .05. Results: Group 1 showed significantly better macroscopic, histologic, and biomechanical results than group 2 at each time interval. Analysis of time effect within groups showed that in group 1, quality of repair tissue significantly improved from 3 to 6 months after treatment and remained stable over time for all the outcomes; in group 2 a significant histologic and mechanical deterioration was observed between 6 and 12 months' follow-up. Conclusions: Five repeated local injections of autologous conditioned plasma after microfractures in the treatment of full-thickness cartilage injuries promoted a better and more durable reparative response than isolated microfractures, although they did not produce hyaline cartilage. Clinical Relevance: Periodical intra-articular injections of platelet concentrate after microfractures may improve cartilage repair and prevent further degenerative changes.

The Modified Finger-Trap Suture Technique: A Biomechanical Comparison of a Novel Suture Technique for Graft Fixation

Wei-Ren Su, Chun-Hui Chu, Cheng-Li Lin, Chii-Jen Lin, I-Ming Jou, Chih-Wei Chang — 2012-01-20

Purpose: The purpose of this study was to compare the tendon graft holding power of the newly devised modified finger-trap (MFT) suture technique with other currently used sutures. Methods: We used 40 fresh-frozen porcine flexor profundus tendons randomly divided into 4 groups of 10 specimens. The experimental procedure was designed to assess percent elongation of the suture-tendon construct across four different tendon-grasping techniques: MFT suture, Krackow stitch, locking SpeedWhip stitch (Arthrex, Naples, FL), and nonlocking SpeedWhip stitch. The suture configurations of the MFT suture and Krackow stitch were completed with a No. 2 FiberWire suture (Arthrex). The locking SpeedWhip and nonlocking SpeedWhip stitches were completed with a loop of No. 2 FiberWire suture and a FiberLoop needle (Arthrex). Each tendon was pre-tensioned to 100 N for three cycles and then cyclically loaded to 200 N for 200 cycles. Finally, each tendon was loaded to failure. Percent elongation, load to failure, and mode of failure for each suture-tendon construct were measured. Results: During the pre-tension phase, the MFT suture had the smallest percent elongation (P = .021) of the suture-graft construct (13.5% ± 1.9%) compared with the Krackow (16.9% ± 1.2%), locking SpeedWhip (17.6% ± 0.6%), and nonlocking SpeedWhip (33.3% ± 5.6%) stitches. During cyclic loading, the MFT suture also showed a significantly smaller percent elongation (P = .037) of the suture-graft construct (27.8% ± 4.9%) than the Krackow (35.8% ± 5.4%), locking SpeedWhip (33.7% ± 5.4%), and nonlocking SpeedWhip (43.8% ± 7.8%) stitches. The load to failure and cross-sectional area were not significantly different across all the suture groups. Conclusions: The newly devised MFT suture provided better percent elongation and equal load to failure compared with the Krackow and SpeedWhip suture techniques tested in this in vitro biomechanical evaluation. Clinical Relevance: The MFT suture is a simple method that is an attractive alternative to the Krackow and SpeedWhip suture techniques for tendon graft fixation in ligament reconstruction.

Corticosteroids and Local Anesthetics Decrease Positive Effects of Platelet-Rich Plasma: An In Vitro Study on Human Tendon Cells

2012-01-24

Purpose: To determine the effects of mixing anesthetics or corticosteroids with platelet-rich plasma (PRP) on human tenocytes in vitro. Methods: Two separate protocols (double spin and single spin) were used to obtain homologous PRP from the blood of 8 healthy volunteers. Discarded tendon acquired during biceps tenodesis served as tendon specimens for all experiments. After cell isolation, tenocytes were treated in culture with PRP alone or in combination with corticosteroids and/or anesthetics. Fetal bovine serum in concentrations of 2% and 10% served as controls. Cell exposure times of 5, 10, and 30 minutes were used. Radioactive thymidine and luminescence assays were obtained to examine cell proliferation and viability. Results: The presence of lidocaine, bupivacaine, or methylprednisolone resulted in significantly less proliferation than the negative 2% fetal bovine serum control (P < .05). When we compared groups, both lidocaine and bupivacaine had a greater inhibitory effect than methylprednisolone (P < .05). At all time points, viability was significantly decreased in the presence of lidocaine, bupivacaine, or methylprednisolone compared with the negative control (P < .05). Conclusions: The addition of either anesthetics or corticosteroids to PRP resulted in statistically significant decreases in tenocyte proliferation and cell viability. These results suggest that incorporation of anesthetics or corticosteroids, either alone or in combination, with PRP injection may compromise the potentially beneficial in vitro effects of isolated PRP on tendon cells and compromise cell viability at the site of tendon injury. Clinical Relevance: Anesthetics or corticosteroids either alone or in combination should be used carefully to preserve the proposed positive effects of PRP in the treatment of tendon injury.

The Role of Subacromial Decompression in Patients Undergoing Arthroscopic Repair of Full-Thickness Tears of the Rotator Cuff: A Systematic Review and Meta-analysis

2012-02-10

Purpose: The purpose of this study was to determine the efficacy of arthroscopic repair of full-thickness rotator cuff tears with and without subacromial decompression. Methods: We searched the Cochrane Central Register of Controlled Trials (third quarter of 2011), Medline (1948 to week 1 of September 2011), and Embase (1980 to week 37 of 2011) for eligible randomized controlled trials. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed by use of a random effects and relative risk model with computation of 95% confidence intervals. Results: We included 4 randomized trials and 373 patients. Methodologic quality was variable as assessed by the CLEAR NPT (Checklist to Evaluate a Report of a Non-pharmacological Trial) tool. One trial showed that there was no difference in disease-specific quality of life (Western Ontario Rotator Cuff questionnaire) between the 2 treatment groups. A meta-analysis of shoulder-specific outcome measures (American Shoulder and Elbow Surgeons or Constant scores) or the rate of reoperation between patients treated with subacromial decompression and those treated without it also showed no statistically significant differences. Conclusions: On the basis of the currently available literature, there is no statistically significant difference in subjective outcome after arthroscopic rotator cuff repair with or without acromioplasty at intermediate follow-up. Level of Evidence: Level I, systematic review of Level I studies.

Anterior Cruciate Ligament Tibial Footprint Anatomy: Systematic Review of the 21st Century Literature

Michael D. Hwang, Jason W. Piefer, James H. Lubowitz — 2012-02-10

Purpose: The purpose of this study was to systematically review current arthroscopic and related literature and to characterize the anatomic centrum of the anterior cruciate ligament (ACL) tibial footprint. Methods: On January 31, 2011, 2 independent reviewers performed a Medline search using the terms “anterior cruciate ligament” or “ACL,” “tibia” or “tibial,” and “anatomy” or “footprint.” We included anatomic, cadaveric, and radiographic studies of adult, human, ACL tibial anatomy. Studies not published in the English language, studies published before January 1, 2000, and review articles were excluded. References of included articles were also searched according to our inclusion/exclusion criteria. Included studies were subjectively synthesized, to define the anatomic centrum of the ACL tibial footprint. Results: The Medline search produced 1,224 articles. After application of our inclusion and exclusion criteria and additional search of article references, 19 articles were included and systematically reviewed. With regard to arthroscopically relevant landmarks, (1) in the anterior-to-posterior plane, the anatomic centrum of the ACL tibial footprint as a whole is 15 mm anterior to the posterior cruciate ligament (PCL), the anatomic centrum of the anteromedial bundle is 20 mm anterior to the PCL, and the anatomic centrum of the posterolateral bundle is 11 mm anterior to the PCL and (2) in the medial-to-lateral (ML) plane, the anatomic centrum of the ACL tibial footprint as a whole is two-fifths the ML width of the interspinous distance, the anatomic centrum of the anteromedial bundle is one-half the ML width of the interspinous distance, and the anatomic centrum of the posterolateral bundle is one-fourth the ML width of the interspinous distance. Conclusions: Our results show that the anatomic centrum of the ACL tibial footprint is 15 mm anterior to the PCL and two-fifths the ML width of the interspinous distance. Clinical Relevance: This systematic review of basic science studies may have clinical relevance for surgeons who believe that anatomic ACL reconstruction can result in improved outcomes.

Failure of Biceps Tenodesis With Interference Screw Fixation

Benjamin Shay Koch, Robert T. Burks — 2012-05-01

Abstract: Tenodesis is a common surgical procedure used to treat pain caused by inflammation or instability of the long head of the biceps tendon. Many studies have evaluated different forms of fixation and their biomechanical characteristics, but few have discussed clinical complications or failures as a result of these techniques. The purpose of this article is to report a case series of 3 patients with failures after undergoing arthroscopic biceps tenodesis with an interference screw.

Announcements

2012-05-01

The Arthroscopy Association of North America 2012 Master's Experience Courses will be held at the Orthopaedic Learning Center, Rosemont, Illinois: June 2-3, 2012 (wrist & elbow); July 20-22, 2012 (hip); August 17-19, 2012 (Society of Military Orthopaedic Surgeons/shoulder); 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

2012-05-01

Masthead

2012-05-01

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 28 issue 5 of 12.) Periodicals postage paid at New York, NY and additional mailing offices.

Editorial Board

2012-05-01

Cover Image

2012-05-01

On the Cover: Femoral physis as seen during hip arthroscopy. The patient was a 13-year-old girl with long-standing right hip pain. Her history and physical examination raised concerns about femoroacetabular impingement; advanced imaging confirmed this diagnosis. She underwent an acetabular take down with removal of the acetabular pincer and the corresponding cam lesion on the femoral head. At the time of the femoroplasty, the gross anatomy of the proximal femoral epiphysis, physis, and metaphysis were seen with amazing clarity. This image is a wonderful demonstration of the beautiful anatomy. Courtesy of Randy Clark, M.D., and Carlos A. Guanche, M.D.

Instructions for Authors

2012-05-01

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

2012-05-01

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

AAOS Rotator Cuff Clinical Practice Guideline Misses the Mark

Assessing and Reporting Anchor Performance

Author's Reply

The Development and Validation of a Self-Administered Quality-of-Life Outcome Measure for Young, Active Patients With Symptomatic Hip Disease: The International Hip Outcome Tool (iHOT-33)

A Short Version of the International Hip Outcome Tool (iHOT-12) for Use in Routine Clinical Practice

Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination

The Efficacy of Acromioplasty in the Arthroscopic Repair of Small- to Medium-Sized Rotator Cuff Tears Without Acromial Spur: Prospective Comparative Study

The Accuracy of Magnetic Resonance Imaging and Magnetic Resonance Arthrogram Versus Arthroscopy in the Diagnosis of Subscapularis Tendon Injury

Biomechanical Evaluation of Classic Solid and Novel All-Soft Suture Anchors for Glenoid Labral Repair

Pain Management by Periarticular Multimodal Drug Injection After Anterior Cruciate Ligament Reconstruction: A Randomized, Controlled Study

Clinical Comparisons Between the Transtibial Technique and the Far Anteromedial Portal Technique for Posterolateral Femoral Tunnel Drilling in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Micro-organism Colonization and Intraoperative Contamination in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Reconstruction

Biomechanical Outcomes After Bioenhanced Anterior Cruciate Ligament Repair and Anterior Cruciate Ligament Reconstruction Are Equal in a Porcine Model

Biomechanical Comparison of Tibial Eminence Fracture Fixation With High-Strength Suture, EndoButton, and Suture Anchor

Repeated Platelet Concentrate Injections Enhance Reparative Response of Microfractures in the Treatment of Chondral Defects of the Knee: An Experimental Study in an Animal Model

The Modified Finger-Trap Suture Technique: A Biomechanical Comparison of a Novel Suture Technique for Graft Fixation

Corticosteroids and Local Anesthetics Decrease Positive Effects of Platelet-Rich Plasma: An In Vitro Study on Human Tendon Cells

The Role of Subacromial Decompression in Patients Undergoing Arthroscopic Repair of Full-Thickness Tears of the Rotator Cuff: A Systematic Review and Meta-analysis

Anterior Cruciate Ligament Tibial Footprint Anatomy: Systematic Review of the 21st Century Literature

Failure of Biceps Tenodesis With Interference Screw Fixation

Announcements

Spanish Translated Abstracts

Masthead

Editorial Board

Contents

Cover Image

Instructions for Authors

Suggested Guidelines for the Practice of Arthroscopic Surgery