Arthroscopy: The Journal of Arthroscopic and Related Surgery - Articles in Press

Thermal Stress Potentiates Bupivacaine Chondrotoxicity - Corrected Proof

Samantha L. Piper, Hubert T. Kim — 2012-05-14

Purpose: The primary objective of this study was to determine whether thermal stress potentiates the chondrotoxic effect of bupivacaine, resulting in decreased articular chondrocyte viability compared with exposure to bupivacaine alone. Methods: Bovine articular cartilage explants and cultured chondrocytes were treated with a range of thermal exposures (10 to 20 minutes at 37°C to 65°C) to create time/temperature viability curves and to determine threshold conditions for cell death. A second set of experiments was performed to determine whether subthreshold thermal stress potentiates bupivacaine toxicity. Explants were exposed to 37°C or 55°C for 10 or 20 minutes, and cultured chondrocytes were exposed to 37°C or 45°C for 10 or 20 minutes. Thirty minutes later, the explants and chondrocytes were treated with either 0.9% normal saline solution or 0.5% bupivacaine for 30 minutes. Chondrocyte viability was quantified 24 hours after treatment. Results: There was a temperature- and time-dependent decrease in chondrocyte viability above the thermo-toxicity threshold in both intact cartilage explants and cultured chondrocytes (55°C and 45°C, respectively; P < .05). Chondrocyte viability in cartilage explants was significantly lower after treatment with thermal stress for 10 or 20 minutes followed by bupivacaine for 30 minutes compared with treatment with bupivacaine at 37°C (bupivacaine and 55°C for 10 minutes, 0.09% ± 0%; bupivacaine and 55°C for 20 minutes, 0.08% ± 0%; bupivacaine and 37°C for 10 minutes, 37.4% ± 1.2% [P < .001]; and bupivacaine and 37°C for 20 minutes, 47.1% ± 0.8% [P < .001]). A similar trend was seen in cultured chondrocytes, although it was not statistically significant (P > .05). Conclusions: Thermal stress potentiates the chondrotoxic effects of bupivacaine in intact cartilage, leading to decreased chondrocyte viability compared with exposure to bupivacaine alone. Clinical Relevance: Intra-articular injection of bupivacaine after arthroscopic procedures during which cartilage is exposed to elevated temperatures, such as with prolonged use of radiofrequency probes, may increase the risk of chondrocyte toxicity.

Hamstring-Dominant Strategy of the Bone–Patellar Tendon–Bone Graft Anterior Cruciate Ligament–Reconstructed Leg Versus Quadriceps-Dominant Strategy of the Contralateral Intact Leg During High-Intensity Exercise in Male Athletes - Corrected Proof

2012-05-14

Purpose: The purpose of this study was to investigate the effect of anterior cruciate ligament (ACL) reconstruction on the quadriceps-dominant strategy as a parameter associated with the neuromuscular control of the knee joint. Methods: In this study 14 competitive soccer players who had undergone ACL reconstruction with bone–patellar tendon–bone autograft and 14 healthy competitive soccer players performed two 10-minute treadmill runs, 1 at moderate intensity and 1 at high intensity. Electromyographic recordings were acquired by use of a telemetric system at the third, fifth, seventh, and tenth minute of the runs from the vastus lateralis and the biceps femoris bilaterally. The dependent variable examined was the peak electromyographic amplitude during the stance phase. Analyses of variance were used to examine significant main effects and interactions. Results: Vastus lateralis electromyographic activity during high-intensity running increased for both the control leg and intact leg (F = 4.48, P < .01), whereas it remained unchanged for the reconstructed leg (P > .05). Biceps femoris electromyographic activity during high-intensity running increased for the reconstructed leg only compared with both the control leg (F = 3.03, P < .05) and intact leg (F = 3.36, P < .03). Conclusions: There is no presence of the quadriceps-dominant strategy in ACL-reconstructed athletes during moderate-intensity exercise. During high-intensity exercise, the intact contralateral leg develops the quadriceps-dominant strategy whereas the reconstructed leg does not. The reconstructed leg instead increases biceps femoris activity, developing a “hamstring-dominant” strategy, and this “asymmetry” may theoretically be in favor of the reconstructed knee.

Biomechanical Evaluation of Effect of Coracoid Tunnel Placement on Load to Failure of Fixation During Repair of Acromioclavicular Joint Dislocations - Corrected Proof

2012-05-07

Purpose: To evaluate the effect of entry and exit points of the coracoid tunnel on load to failure and mode of failure, to reduce the incidence of coracoid fractures and acromioclavicular joint repair failures. Methods: This study investigates 5 tunnel placements based on different entry and exit points in the coracoid process: center-center orientation represents perfect placement of the bone tunnel and served as perfect tunnel placement in our study. Four common errors in drilling were then tested and acted as the experimental groups in our study (medial-center, center-medial, lateral-center, and center-lateral). Using 35 cadaveric shoulders (mean age, 68.0 ± 13.0 years), we tested these 5 tunnel orientations using a single repair technique (cortical button) loaded to failure on an MTS 858 Servohydraulic test system (MTS Systems, Eden Prairie, MN). A control group of 7 cadaveric shoulders without the presence of a coracoid tunnel was also tested to determine the type of fracture pattern that occurred. Results: The coracoids without tunnel drilling fractured in patterns similar to traumatic coracoid injuries. With regard to the 5 tunnel groups, it was found that the loads to failure with center-center and medial-center tunnel placement were significantly higher than those with center-medial, center-lateral, and lateral-center tunnel placement. The failure modes of the former were primarily within the repair constructs, whereas those of the latter were primarily due to bony failure. Conclusions: Our biomechanical results showed a higher peak load to failure with a center-center or medial-center tunnel orientation, which may lessen the risk of coracoid fracture during drilling with a 6-mm cannulated drill bit. Clinical Relevance: Proper trajectory of the drill during formation of a coracoid bone tunnel can help reduce the risk of coracoid process fracture and repair failure.

Outcomes 2 to 5 Years Following Hip Arthroscopy for Femoroacetabular Impingement in the Patient Aged 11 to 16 Years - Corrected Proof

Marc J. Philippon, Leandro Ejnisman, Henry B. Ellis, Karen K. Briggs — 2012-05-07

Purpose: The purpose of this study was to evaluate clinical outcomes after treatment for femoroacetabular impingement in the pediatric and adolescent population with a minimum of 2 years' follow-up. Methods: Prospectively collected data on 60 consecutive pediatric and adolescent patients (65 hips), aged 16 years or younger, who underwent hip arthroscopy were retrospectively analyzed. Patients were excluded if they had previous surgery on the hip and if they presented a center-edge angle below 25°. Results: The mean age at the time of surgery was 15 years (range, 11 to 16 years), and 31% of patients were boys and 69% were girls. The femoral physis was open in 10% of patients, partially closed in 19%, and closed in 71%. Cam impingement was found in 10% of cases, pincer impingement in 15%, and mixed type in 75%. The mean center-edge angle was 36° (95% confidence interval [CI], 34° to 38°), and the mean alpha angle was 64° (95% CI, 60° to 69°). There was a significant association between age and alpha angle (r = 0.324, P = .02). After the index procedure, 8 patients (all girls) needed second-look diagnostic arthroscopies because of intra-articular adhesions. At a mean follow-up of 3 years (range, 2 to 5 years) with 91% follow-up, the modified Harris Hip Score increased from a mean of 57 (95% CI, 51 to 62) to a mean of 91 (95% CI, 88 to 94) (P < .001). The median rating for patient satisfaction with outcome was 10 (range, 5 to 10). Conclusions: Hip arthroscopy in the pediatric and adolescent population is a safe procedure, with excellent clinical outcomes at 2 to 5 years. In this study there was an association between alpha angle and age. Clinical scores showed a significant improvement after surgery; however, 13% of patients did require a second procedure for capsulolabral adhesions. Level of Evidence: Level IV, therapeutic case series.

Intratunnel Versus Extratunnel Fixation of Hamstring Autograft for Anterior Cruciate Ligament Reconstruction - Corrected Proof

Dave Lee Yee Han, John Nyland, Matthew Kendzior, Akbar Nawab, David N.M. Caborn — 2012-05-07

Purpose: To determine which is more effective: intratunnel or extratunnel anterior cruciate ligament soft-tissue graft fixation. A secondary purpose was to determine whether groups displayed differing relations between objective International Knee Documentation Committee (IKDC) grade and the timing of full weight bearing (FWB), jogging/running, and return to sports. The study hypotheses were that intratunnel fixation would display a greater percentage of normal or nearly normal objective IKDC grades and enable earlier FWB, return to jogging/running, and return to sports. Methods: We performed a systematic review of prospective, Studies with Level I or II evidence published from 2000 to 2011 with at least 2 years' follow-up that used interference screw hamstring autograft fixation (intratunnel group) or button, staple, or post hamstring autograft fixation (extratunnel group) for primary anterior cruciate ligament reconstruction. We also compared IKDC grades; Tegner and Lysholm scores; instrumented anterior laxity and pivot-shift test findings; timing of FWB, jogging/running, and return to sports; and modified Coleman Methodology Scores. Results: The groups showed comparable modified Coleman Methodology Scores, objective IKDC grades, Lysholm and Tegner scores, instrumented anterior laxity and pivot-shift test findings, and return-to-sports timing. The intratunnel group displayed earlier FWB and jogging/running; however, return-to-sports timing did not differ between groups. Early FWB and the percentage of patients with normal or nearly normal objective IKDC grades were directly related for the extratunnel group. Conclusions: Patients who received intratunnel fixation were released earlier to FWB and jogging/running, supporting the study hypotheses. Groups did not differ in return-to-sports timing or objective IKDC grades, not supporting the study hypotheses. Early FWB in the extratunnel group was related to a greater percentage of patients having normal or nearly normal objective IKDC grades. Return-to-sports timing and having a normal objective IKDC grade were related in both groups; however, this relation was stronger with intratunnel fixation. Level of Evidence: Level II, systematic review of Level I and II studies.

Long-Term Success in the Treatment of Diffuse Pigmented Villonodular Synovitis of the Knee With Subtotal Synovectomy and Radiotherapy - Corrected Proof

2012-05-04

Purpose: The objective of this study was to evaluate the effectiveness and long-term outcome of the treatment of patients with diffuse pigmented villonodular synovitis (PVNS) of the knee with subtotal arthroscopic and open synovectomy and subsequent external-beam radiotherapy. Methods: Eight patients diagnosed with diffuse PVNS by clinical and magnetic resonance imaging were treated surgically with subtotal arthroscopic synovectomy and an additional posterior incision for extra-articular lesions, followed by local adjuvant radiotherapy. These patients were followed up for a mean of 8.6 years to monitor remaining lesions and to detect new occurrences of the condition. Results: None of the patients presented with major postoperative complications or have had radiotherapeutic late effects. In no case was radiographic arthritis progression detected. Three patients exhibited late minor complications (peripatellar pain, articular effusion, and persistent quadricipital muscle atrophy). Only 1 patient (12.5%) presented with recurrence of the disease during the follow-up period. Conclusions: On the basis of our limited study, subtotal arthroscopic and open synovectomy with subsequent local external-beam radiotherapy had a recurrence rate of 12.5% at 8.6 years of follow-up for the treatment of diffuse PVNS of the knee joint. Level of Evidence: Level IV, therapeutic case series.

Protrusio Acetabuli: Contraindication or Indication for Hip Arthroscopy? And the Case for Arthroscopic Treatment of Global Pincer Impingement - Corrected Proof

Dean K. Matsuda — 2012-05-03

Abstract: Protrusio acetabuli has been considered a contraindication for hip arthroscopy. We present the case of a 33-year-old man with bilateral symptomatic protrusio acetabuli—the most extreme form of global pincer femoroacetabular impingement—and cam femoroacetabular impingement. We demonstrate the feasibility of the arthroscopic correction of severe deformities and describe key surgical steps permitting central compartment access, subtotal acetabuloplasty, labral reconstruction, and femoroplasty of the right hip, followed by later subtotal acetabuloplasty, labral refixation, and femoroplasty of the left hip, with improved outcomes at 2 and 1 years, respectively, as measured by the nonarthritic hip score. Though challenging, global pincer impingement, even acetabular protrusion, may be successfully treated with dual-portal outpatient hip arthroscopy. The modified midanterior portal enables central compartment access and extended posterior “reach” in the arthroscopic treatment of major global pincer femoroacetabular impingement, potentially making this contraindication a historical one while respectfully challenging the “global” recommendation for open surgery in this setting.

Reconstruction of the Posterior Oblique Ligament and the Posterior Cruciate Ligament in Knees With Posteromedial Instability - Corrected Proof

2012-04-30

Purpose: Posterior cruciate ligament (PCL) injuries are often associated with injuries of the posteromedial structures of the knee. The motivation for this study was the attempt to test different reconstruction techniques for the structures of the posteromedial corner in a biomechanical experiment. Methods: Kinematic studies were carried out on 10 cadaveric knees exposed to a 134-N posterior tibial load, 10-Nm valgus torque, and 5-Nm internal torque at 0°, 30°, 60°, and 90° of flexion. The resulting posterior tibial translation (PTT) was determined using a robotic/universal force-moment sensor testing system for (1) intact knees, (2) PCL-deficient knees, (3) knees with deficiency of the PCL and the posteromedial structures, (4) knees with only the PCL reconstructed, (5) knees with the PCL and posterior oblique ligament (POL) reconstructed, and (6) knees with the PCL, medial collateral ligament (MCL), and POL reconstructed. Kinematic data were analyzed by a 2-factor repeated analysis of variance. Results: When both the PCL and the posteromedial structures were cut, PTT increased significantly at all flexion grades under a posterior tibial load (P < .05). Reconstruction of only the PCL could not restore PTT at 0°, 30°, 60°, and 90° of flexion under loading conditions in a knee with combined injury of the PCL and the posteromedial structures (P > .05). Additional reconstruction of the POL improved PTT at all flexion angles in comparison with only the PCL-reconstructed knee. Reconstruction of the MCL had no significant effect on PTT. Conclusions: This study shows that reconstruction of the POL contributes significantly to the normalization of coupled PTT in knees with combined injury of the PCL and the posteromedial structures under valgus or internal rotational moment. The supplementary reconstruction of the MCL did not provide significant improvement in knee kinematics. Clinical Relevance: The POL should be addressed in the patient with combined injuries of the PCL and the posteromedial structures.

Surgical Indications for Arthroscopic Management of Femoroacetabular Impingement - Corrected Proof

2012-04-25

Purpose: The clinical literature was systematically reviewed to determine the consistently reported indications for arthroscopic management of femoroacetabular impingement (FAI). Methods: Two databases (Medline and EMBASE) were screened for clinical studies involving the arthroscopic surgical management of FAI. A full-text review of eligible studies was conducted, and the references were searched. Articles published from 1980 until June 2011 were included, and the inclusion criteria were as follows: studies of human patients of all ages and genders with FAI, studies with a minimum of 6 months of patient follow-up, and studies reporting clinical outcome data. A quality assessment of the included articles was conducted. Results: We included 20 articles in this review, involving a total of 1,368 patients. We identified a lack of consensus on clinical and radiographic indications for the arthroscopic management of FAI. The indications varied from a positive impingement sign (45%) and symptoms or pain for more than 6 months (35%) to a series of positive special tests (25%). Commonly reported radiographic indicators for arthroscopic FAI management included the following: results from a computed tomography scan or magnetic resonance imaging (60%), cam or pincer lesions evident on anteroposterior and/or lateral radiographs (50%), loss of sphericity of the femoral neck (30%), acetabular retroversion (30%), magnetic resonance arthrography (25%), reduction in head-neck offset (25%), an alpha angle greater than 50° (25%), and coxa profunda (25%). Conclusions: We found that there was great inconsistency among the indications for arthroscopic management of FAI. Clinical and radiographic indices remain largely unvalidated. This review highlights the need for more consistent reporting of surgical indications for the arthroscopic management of FAI. Future research should explore what combination of clinical and radiographic indications should be best used to determine arthroscopic FAI management. Level of Evidence: Level IV, systematic review of Level II to IV studies.

Midterm Results of Combined Acromioclavicular and Coracoclavicular Reconstruction Using Nylon Tape - Corrected Proof

Mohamed H. Sobhy — 2012-04-23

Purpose: The purpose of this study was to evaluate the radiologic and functional outcomes of an anatomic reconstruction of both acromioclavicular (AC) and coracoclavicular (CC) ligaments in types III to V AC injuries using nylon tape and no metal hardware. Methods: A prospective case-series study was performed on 17 cases with types III to V AC injuries treated by anatomic reconstruction of the AC ligaments (anterior and superior) and CC ligaments (conoid and trapezoid) using nylon tape and no metal hardware. Clinical assessments, radiologic findings, and visual analog scale, American Shoulder and Elbow Surgeons, and Constant scores were recorded for all patients. After a minimum postoperative period of 2 years, all cases were re-evaluated and rescored. Results: The case-series study comprised 17 cases with types III to V AC injuries. After a mean follow-up period of 28 months (minimum, 24 months), the patients had a significantly improved mean visual analog scale score (from 6.4 to 2.4 points), American Shoulder and Elbow Surgeons score (from 25 to 81.7 points), and Constant score (from 21 to 85 points), with overall 88.2% satisfaction. Radiographic superior displacement showed reduction from 13 to 2 mm whereas posterior displacement showed reduction from 5 to 2 mm, and both were statistically significant (P < .05). The rate of return to the patients' preinjury jobs was 82.4%, and there was 1 case of recurrent subluxation. Conclusions: Combined anatomic reconstruction of both AC and CC ligaments using nylon tape by the described technique provides overall 88.2% satisfaction, 94% radiologic reduction, and a low complication rate.

Patellofemoral Alignment and Anterior Knee Pain After Closing- and Opening-Wedge Valgus High Tibial Osteotomy - Corrected Proof

2012-04-23

Purpose: The purpose of this study was to compare the clinical and radiographic outcomes of opening- and closing-wedge valgus high tibial osteotomy (HTO) for the treatment of medial unicompartmental knee osteoarthritis with a minimum follow-up of 3 years, with a focus on patellofemoral alignment and anterior knee pain. Methods: We performed a retrospective comparison of 50 patients who underwent closing-wedge HTO and 50 patients who underwent opening-wedge HTO for isolated medial joint arthritis of the knee with varus deformity. All patients were evaluated and the 2 study groups were compared after a minimum follow-up of 3 years with a focus on patellofemoral alignment, patellofemoral osteoarthritis, and anterior knee pain while climbing stairs. Results: Patellar alignment (patellar tilt and lateral patellar displacement) was not significantly different in the 2 groups either preoperatively or at follow-up. Furthermore, there were no significant differences in the extent of patellofemoral arthritis and incidence of anterior knee pain at follow-up between the 2 groups. In addition, no significant intergroup difference was found in terms of the incidence of anterior knee pain (28% in closing-wedge group and 32% in opening-wedge group at follow-up). Conclusions: The results of closing- and opening-wedge valgus HTO were not found to be significantly different with respect to patellar alignment, osteoarthritis of the patellofemoral joint, or anterior knee pain. Level of Evidence: Level III, retrospective comparative study.

Anatomic Guidelines for Harvesting a Quadriceps Free Tendon Autograft for Anterior Cruciate Ligament Reconstruction - Corrected Proof

Julienne Lippe, Amy Armstrong, John P. Fulkerson — 2012-04-13

Purpose: The purpose of this study was to review the anatomy of the quadriceps tendon and provide guidelines for harvesting the quadriceps tendon for anterior cruciate ligament (ACL) reconstruction. Methods: Eleven cadaveric knees were dissected, and the quadriceps tendon was analyzed. Multiple measurements of length, depth, and width were taken in a standardized manner for each cadaver and recorded. Results: The quadriceps tendon superficial morphology showed 2 distinct peaks, with the maximum length correlating with the lateral peak. The mean tendon peak length was 88.3 ± 8.4 mm (range, 78.3 to 99.7 mm). The mean width of the quadriceps tendon at its insertion onto the patella was 43.3 ± 5.8 mm (range, 34.3 to 54.1 mm). The quadriceps tendon was noted to be asymmetric, with the maximum tendon length located at 61.6% ± 4.1% of the width from the medial border of the quadriceps tendon insertion. This point was also the maximum tendon depth at insertion. Conclusions: Quadriceps free tendon graft harvesting should begin by locating the apex (maximum length) of the quadriceps tendon (61% of the distance from the patella's medial edge). The surgeon should then harvest a 10-mm-wide graft centered about 2 mm medial to this point, using the depth of a No. 10 scalpel blade (7 mm) as a guide to thickness to harvest an optimal quadriceps free tendon graft for ACL reconstruction. Clinical Relevance: This anatomic study identifies the site of harvest of a quadriceps free tendon autograft (without a patellar bone block) to maximize the length and bulk of the graft for its use in ACL reconstruction.

Are Femoral Nerve Blocks Effective for Early Postoperative Pain Management After Hip Arthroscopy? - Corrected Proof

2012-04-13

Purpose: To evaluate the utility of femoral nerve blocks in postoperative pain control after hip arthroscopy. Methods: Forty consecutive patients scheduled for hip arthroscopy were randomized into 2 groups for postoperative pain control. Half were to receive routine intravenous narcotics for pain scores of 7 or above in the postanesthesia care unit (PACU), and the other half were to receive a femoral nerve block in the PACU for the same pain scores. Data were compared with respect to patient sex, patient age, traction times, type of procedure, nausea, overall patient satisfaction with analgesia, and duration of time in the PACU. Results: Thirty-six patients had initial pain scores of 7 of 10 or greater on a visual analog scale. Of these patients, 16 were randomized to receive postoperative morphine and 20 to receive a femoral nerve block. There were no significant differences between the 2 groups with respect to sex, age, traction times, or type of procedure performed. Patients who received morphine had a significantly longer time to discharge from the PACU (216 minutes) than the femoral nerve block group (177 minutes). The morphine group was also significantly more likely to report postoperative nausea (75%) than the femoral nerve block group (10%). Patients receiving femoral nerve blocks were significantly more likely to be satisfied with their postoperative pain control (90%) than those who had received morphine (25%). All of the patients receiving a femoral nerve block stated that they would undergo the block again if they needed another hip arthroscopy. Conclusions: On the basis of all criteria studied (quality of pain relief, length of stay in the PACU, side effects, and patient satisfaction), a femoral nerve block is an excellent alternative to routine narcotic pain medication in patients undergoing hip arthroscopy. Level of Evidence: Level II, randomized controlled trial.

Meniscus Transplantation Using Treated Xenogeneic Meniscal Tissue: Viability and Chondroprotection Study in Rabbits - Corrected Proof

Dong Jiang, Li-Heng Zhao, Ming Tian, Ji-Ying Zhang, Jia-Kuo Yu — 2012-04-09

Purpose: This was a preliminary study performed in vivo to evaluate the viability and the chondroprotective effects of irradiated deep-frozen xenogeneic meniscal tissue as a novel substitute for meniscus transplantation. Methods: Medial meniscectomies were performed on the right knees of 48 New Zealand white rabbits. The inner one-third of pig meniscus was harvested and then irradiated and deeply frozen. The treated xenogeneic meniscal tissues were then transplanted to 24 right knees (Xeno group), whereas 24 other knees received meniscus allograft transplantations (Allo group). The left knees of the Xeno group and Allo group received meniscectomies (Meni group) and sham operations (Sham group), respectively. The rabbits were killed at weeks 6, 12, and 24 postoperatively. The newly formed structure of the implanted tissue and cartilage of the medial compartment of each group was assessed by gross and semiquantitative histologic analysis. Results: After 24 weeks, the implanted xenogeneic meniscal tissue completely healed to the synovium and formed meniscus-like tissue. The chondrocyte-like cell infiltrated into the tissue with extracellular matrix including type II collagen and proteoglycans. The Xeno group showed significantly less cartilage degeneration than that of the Meni group in the medial tibial plateau at week 24 (P < .05). No significant difference was found between the Xeno group and the Allo group except for the meniscus-covered regions at week 24. From week 12 to week 24, almost no advanced cartilage degeneration was found in weight-bearing regions of the medial tibial plateau of the Xeno group. Conclusions: The treated xenogeneic meniscal tissue healed to the synovium with tissue regeneration and slowed down articular cartilage degeneration in the short-term. The chondroprotection of xenograft transplantation was similar to that of allograft transplantation. Clinical Relevance: The treated xenogeneic meniscal tissue showed the potential for viability and slowed cartilage degeneration, but more studies are required for application in humans in the future.

Revision Arthroscopic Rotator Cuff Repair: Systematic Review and Authors' Preferred Surgical Technique - Corrected Proof

Alexandre Lädermann, Patrick J. Denard, Stephen S. Burkhart — 2012-04-09

Purpose: Recurrent tear after rotator cuff repair is not uncommon. Advances in arthroscopic shoulder surgery have created opportunities to better evaluate and treat these failures. The purposes of this systematic review were to evaluate the reported results of revision arthroscopic rotator cuff repair (ARCR) and to describe our technique of revision ARCR. Methods: A PubMed search from 1950 to 2011 was performed to identify articles describing revision rotator cuff repair. Studies were included in this systematic review if (1) they focused on revision ARCR, (2) they provided Levels I-IV evidence relevant to the search terms, (3) at least a partial repair was performed, and (4) they had a minimum of 12 months' follow-up. Results: We identified 4 articles that discussed the techniques and the results of revision ARCR. In all studies there were improvements in postoperative motion and functional outcome scores. Poorer results were associated with female patients, tear recurrence after revision repair, preoperative active forward flexion of less than 135°, and preoperative pain score greater than 5 on a visual analog scale. Conclusions: This systematic review suggests that revision ARCR can frequently lead to improvement in functional outcome and reasonable patient satisfaction. Level of Evidence: Level IV, systematic review of Level IV studies.

Complications of Wrist Arthroscopy - Corrected Proof

Zahab S. Ahsan, Jeffrey Yao — 2012-04-09

Purpose: The purpose of this systematic review was to address the incidence of complications associated with wrist arthroscopy. Given the paucity of information published on this topic, an all-inclusive review of published wrist arthroscopy complications was sought. Methods: Two independent reviewers performed a literature search using PubMed, Google Scholar, EBSCO, and Academic Megasearch using the terms “wrist arthroscopy complications,” “complications of wrist arthroscopy,” “wrist arthroscopy injury,” and “wrist arthroscopy.” Inclusion criteria were (1) Levels I to V evidence, (2) “complication” defined as an adverse outcome directly related to the operative procedure, and (3) explicit description of operative complications in the study. Results: Eleven multiple-patient studies addressing complications of wrist arthroscopy from 1994 to 2010 were identified, with 42 complications reported from 895 wrist arthroscopy procedures, a 4.7% complication rate. Four case reports were also found, identifying injury to the dorsal sensory branch of the ulnar nerve, injury to the posterior interosseous nerve, and extensor tendon sheath fistula formation. Conclusions: This systematic review suggests that the previously documented rate of wrist arthroscopy complications may be underestimating the true incidence. The report of various complications provides insight to surgeons for improving future surgical techniques. Level of Evidence: Level IV, systematic review of Levels I-V studies.

Arthroscopic Matrix-Induced Autologous Chondrocyte Implantation: 2-Year Outcomes - Corrected Proof

2012-04-09

Purpose: To determine the safety and efficacy of a new arthroscopic technique for matrix-induced autologous chondrocyte implantation (MACI) for articular cartilage defects in the knee. Methods: We undertook a prospective evaluation of the first 20 patients treated with the MACI technique (including 14 defects on the femoral condyle and 6 on the tibial plateau), followed up for 24 months after surgery. A 12-week structured rehabilitation program was undertaken by all patients. Patients underwent clinical assessment (Knee Injury and Osteoarthritis Outcome Score, Short Form 36 Health Survey, visual analog pain scale, 6-minute walk test, knee range of motion) before surgery and at 3, 6, 12, and 24 months after surgery and underwent magnetic resonance imaging (MRI) assessment at 3, 12, and 24 months after surgery. MRI evaluation assessed 8 previously defined pertinent parameters of graft repair, as well as a combined MRI composite score. Results: A significant improvement (P < .05) was shown throughout the postoperative time line for all Knee Injury and Osteoarthritis Outcome Score subscales, the physical component score of the Short Form 36 Health Survey, the frequency and severity of knee pain, and the 6-minute walk test. An improvement in pertinent morphologic parameters of graft repair was observed to 24 months, whereas a good to excellent graft infill score and MRI composite score were observed at 24 months after surgery in 90% and 70% of patients, respectively. Conclusions: We report a comprehensive 24-month follow-up in the first 20 patients who underwent the arthroscopic MACI technique. This technique is a safe and efficacious procedure with improved clinical and radiologic outcomes over the 2-year period. Level of Evidence: Level IV, therapeutic case series.

Bipolar Radiofrequency Plasma Ablation Induces Proliferation and Alters Cytokine Expression in Human Articular Cartilage Chondrocytes - Corrected Proof

Lars Enochson, Henrik H. Sönnergren, Vipul I. Mandalia, Anders Lindahl — 2012-04-06

Purpose: The aim of the study was to determine the in vitro effects of plasma-mediated bipolar radiofrequency ablation on human chondrocyte compensatory proliferation and inflammatory mediator expression. Methods: Human articular cartilage biopsy specimens, from total knee replacement, and human chondrocytes in alginate culture, from patients undergoing autologous chondrocyte implantation, were exposed to plasma ablation with a Paragon T2 probe (ArthroCare, Austin, TX). Instantaneous chondrocyte death was investigated with live/dead assays of biopsy specimens and cell cultures. Chondrocyte proliferation was determined by Hoechst staining of DNA on days 3 and 6. Messenger RNA expression of IL-1β, IL-6, IL-8, tumor necrosis factor α, high-mobility group protein B1, matrix metalloproteinase 13, type IIA collagen, and versican was determined on days 3 and 6. Results: Live/dead imaging showed a well-defined local margin of cell death ranging from 150 to 200 μm deep, both in the alginate gel and in the biopsy specimens exposed to plasma ablation. The ablation-exposed group showed a significant proliferation increase compared with control on day 3 (P < .043). There were significant increases compared with control in IL-6 expression on day 3 (P < .020) and day 6 (P < .045) and in IL-8 expression on day 3 (P < .048). No differences were seen for IL-1β, tumor necrosis factor α, high-mobility group protein B1, matrix metalloproteinase 13, type II collagen, or versican. Conclusions: This study has shown that exposure to plasma-mediated ablation induces a well-defined area of immediate cell death and a short-term increase in proliferation with human articular chondrocytes in vitro. The exposure also alters cytokine expression for the same period, causing upregulation of IL-6 and IL-8. Clinical Relevance: The results show the potential of plasma-mediated ablation to cause the onset of a tissue regeneration response with human articular cartilage.

Medial Meniscus Tear Morphology and Chondral Degeneration of the Knee: Is There a Relationship? - Corrected Proof

2012-03-22

Purpose: The purpose of this study was to examine the association of medial meniscus tear morphology with the pathogenesis of articular cartilage degeneration. Methods: From May 2006 to December 2007, we prospectively evaluated 103 patients diagnosed with an isolated medial meniscus tear. Meniscus tear morphology and location, cartilage degeneration according to the Noyes score, and covariates including age, body mass index, gender, and injury date were documented. The relationship between severity of articular cartilage degeneration and meniscus tear morphology was analyzed by analysis of variance. Regression analysis was used to analyze predictors of severity of cartilage lesions. Results: Analysis of variance showed significant differences in the severity of articular cartilage lesions based on medial meniscus tear morphology (P < .05). Compared with bucket-handle/vertical tears, root and radial/flap tears were associated with significantly greater degeneration on the medial femoral condyle; root and complex tears were associated with significantly greater degeneration on the medial tibial plateau; and radial/flap tears were associated with significantly greater degeneration on the lateral tibial plateau. Age and gender were significant predictors of the Noyes medial-compartment score, and age, body mass index, and meniscus tear morphology were significant predictors of the Noyes lateral-compartment score. Conclusions: Meniscus tears with increasing disruption of the circumferential meniscal fibers were significantly associated with cartilage lesions of increasing severity in both the medial and lateral compartments of the knee. Level of Evidence: Level IV, prognostic case series.

The Femoral Insertion of the Anterior Cruciate Ligament: Discrepancy Between Macroscopic and Histological Observations - Corrected Proof

2012-03-22

Purpose: To observe the femoral anterior cruciate ligament (ACL) insertion macroscopically, histologically, and immunohistologically. Methods: We used 20 embalmed cadaveric knees (mean age, 69.8 ± 5.3 years) for this study. The femoral ACL insertion was observed macroscopically, and areas were measured with digital calipers. The morphology of the ACL insertion was subsequently observed, and the areas were measured histologically and immunohistologically (stained for types I and III collagen). Finally, the macroscopic and microscopic measurements were compared. Results: Macroscopically, in 16 knees, the proximal ACL fibers spread in a fanlike manner on the medial aspect of the lateral femoral condyle and the femoral insertion was oval. The lengths of the long and short axes of the insertion were 17.7 ± 2.7 mm and 4.6 ± 0.7 mm, respectively. Microscopically, the insertion was located just behind the lateral intercondylar ridge (resident's ridge) and could be divided into the direct and indirect insertions. The direct insertion was 5.3 ± 1.1 mm wide and did not continue to the posterior cartilage. The indirect insertion was located behind the direct insertion, and the posterior ACL fiber stained for type I collagen blended into the posterior cartilage on immunohistologic observations. Another bony ridge was found at the posterior margin of the direct insertion. The widths of the direct insertion were similar between microscopic and macroscopic measurements. Conclusions: The femoral ACL insertion observed macroscopically corresponded to the direct insertion observed microscopically. The posterior portion behind the lateral intercondylar posterior ridge was the indirect insertion microscopically and appeared membrane-like macroscopically. Clinical Relevance: Findings from observation of the lateral intercondylar posterior ridge during arthroscopy and consideration of the distance from the posterior cartilage border may contribute to surgeons' decisions about femoral tunnel placement during anatomic ACL reconstruction.

Arthroscopic Arthrolysis for Recalcitrant Frozen Shoulder: A Lateral Approach - Corrected Proof

2012-03-15

Purpose: The purpose of this study was to evaluate a new all-arthroscopic technique in the management of recalcitrant globally stiff frozen shoulders. This adopts an initial extra-articular approach followed by intra-articular entry to perform a 360° capsular release. Methods: Ten patients with global adhesive capsulitis were prospectively evaluated. All patients had not improved after undergoing a minimum of 6 months of physiotherapy, and 5 received intra-articular injections of steroids. The mean age was 47 years (range, 33 to 56 years). Patients were examined preoperatively and postoperatively for range of motion. A Constant score and visual analog scale score for pain were recorded. We described an all-arthroscopic technique by entering the subacromial space laterally and opening the rotator interval from the outside in, followed by a complete 360° capsular release and biceps tenotomy. Results: The mean follow-up was 42 months (range, 18 to 90 months), and the mean Constant score improved from 21 to 72 (P < .01). Preoperative abduction improved from a mean of 40° to 165°, elevation improved from 55° to 175°, and external rotation improved from 6° to 58°. The visual analog scale pain score improved from 7 to 1.6, and all patients reported an excellent outcome after surgery. There were no complications particularly regarding axillary nerve injury, fracture, or infection. Conclusions: This study shows a combined extra-articular and intra-articular approach that is controlled and anatomic and achieves excellent results that were maintained at the midterm. The technique permits anatomic debridement of the rotator interval, enabling excellent intra-articular access, a circumferential capsular release, and biceps tenotomy. There were no complications, and no manipulations were required, which pose a risk of creating soft-tissue lesions, fractures, or dislocations. We recommend this 360° capsular release technique for releasing globally stiff shoulders where the surgeon is experienced in arthroscopy. Level of Evidence: Level IV, therapeutic case series.

Is Femoral Tunnel Length Correlated With the Intercondylar Notch and Femoral Condyle Geometry After Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Transportal Technique? An In Vivo Computed Tomography Analysis - Corrected Proof

2012-03-15

Purpose: To analyze femoral tunnel geometry using computed tomography (CT) imaging and evaluate the anatomic factors affecting femoral tunnel length after anterior cruciate ligament (ACL) reconstruction by the transportal technique. Methods: Twenty-nine patients underwent an anatomic double-bundle ACL reconstruction with a femoral tunnel drill by the transportal technique. CT imaging with OsiriX software (version 3.8; Pixmeo, Geneva, Switzerland) was used to measure femoral tunnel length (anteromedial [AM], posterolateral [PL], and central), femoral tunnel divergent angle, and femoral condyle size and intercondylar notch size parameters. Correlations between femoral tunnel length and femoral condyle size and intercondylar notch size parameters were analyzed. Results: The mean AM, PL, and central femoral tunnel lengths were 33.3 ± 3.9 mm, 33.6 ± 3.6 mm, and 34.3 ± 3.2 mm, respectively. A femoral tunnel length of less than 30 mm developed in 7 cases (24.1%) in the AM aspect and 4 cases (13.8%) in the PL aspect. The mean femoral tunnel divergent angle was 14.4° ± 4.1°. A positive correlation was found between AM, not PL or central, femoral tunnel length and medial femoral condyle anteroposterior (AP) distance (P = .01, r = 0.46), lateral femoral condyle AP distance (P = .01, r = 0.43), medial-to-lateral epicondylar distance (P = .03, r = 0.39), middle notch width (P = .009, r = 0.47), notch height (P = .001, r = 0.57), and notch area (P < .001, r = 0.58). Conclusions: After double-bundle ACL reconstruction with the transportal technique through the accessory anteromedial portal, the AM and PL femoral tunnels showed mean tunnel length greater than 30 mm and a divergent angle. However, a femoral tunnel length of less than 30 mm developed in some cases. AM femoral tunnel length was correlated with femoral condyle size (medial femoral condyle AP distance, lateral femoral condyle AP distance, and medial-to-lateral epicondylar distance) and intercondylar notch size (notch width, notch height, and notch area). Level of Evidence: Level IV, therapeutic case series.

Relation Between Anterior Cruciate Ligament Graft Obliquity and Knee Laxity in Elite Athletes at the National Football League Combine - Corrected Proof

Nathan A. Mall, Matthew J. Matava, Rick W. Wright, Robert H. Brophy — 2012-03-14

Purpose: The purposes of this study were to determine the incidence of vertical anterior cruciate ligament (ACL) reconstructions in elite athletes and to determine whether graft obliquity correlates with knee stability in this population. Methods: One hundred thirty-seven knees in 125 athletes at the 2005-2009 National Football League Combine were identified as having had previous ACL reconstructions. The graft type, fixation, and physical examination findings were recorded for each athlete. Graft obliquity was measured by previously described methods based on plain radiography and magnetic resonance imaging (MRI). Radiographic measurements included tibial tunnel and femoral tunnel locations, as well as a sum of these tunnel positions on the lateral radiograph (sum score). MRI measurements included sagittal and coronal ACL angles and the ACL–Blumensaat line angle. The relation of graft obliquity to physical examination findings was assessed. Results: Sixty-four percent of knees had vertical grafts based on radiography and 35% based on MRI criteria. The average tibial tunnel location on radiography was 33% from the anterior tibial plateau in the oblique group compared with 42% in the vertical group (P < .0001). Knees with a sum score of 66 or less, tibial tunnel 37% or less from the anterior tibial plateau, and sagittal obliquity of 60° or less were less likely to have increased translation on the Lachman examination than knees with a sum score greater than 66, tibial tunnel greater than 37% from the anterior tibial plateau, and sagittal obliquity greater than 60° (P < .05). Conclusions: There was a wide range of ACL graft obliquity in the examined cohort of elite athletes who continued to perform at high levels. Less oblique (more vertical) grafts were associated with greater anterior tibial translation on Lachman testing. ACL graft obliquity, which is particularly sensitive to tibial tunnel placement, can influence knee stability. Level of Evidence: Level IV, therapeutic case series.

Long-Term Results of Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone: An Analysis of the Factors Affecting the Development of Osteoarthritis - Corrected Proof

Jin Hwan Ahn, Jae Gyoon Kim, Joon Ho Wang, Chul Hee Jung, Hong Chul Lim — 2012-03-14

Purpose: To evaluate the clinical outcomes and incidence of knee osteoarthritis (OA) and the factors associated with the onset of OA in the 3 compartments of the knee joint separately after anterior cruciate ligament (ACL) reconstruction with bone–patellar tendon–bone autograft. Methods: Clinical and radiologic assessments were obtained from 117 patients (80.1%). At follow-up, knee function was evaluated with the Lysholm score, Hospital for Special Surgery (HSS) score, Tegner score, and International Knee Documentation Committee (IKDC) 2000 forms. We also evaluated stability and donor-site morbidity. On the follow-up radiographs, OA was assessed by IKDC grading. The factors affecting the onset of OA in the 3 compartments of the knee joint were evaluated. Results: The mean follow-up period was 10.3 ± 1.0 years. The mean Lysholm and HSS scores significantly increased at final follow-up (P < .001). The mean IKDC subjective score was 90.6, and 93.9% of patients had grade A or grade B knees on the objective evaluation. The mean side-to-side difference measured by KT-2000 arthrometer (MEDmetric, San Diego, CA) was 1.6 ± 1.7 mm, with 82.0% of patients showing a difference of less than 3 mm. Discomfort from knee walking on hard ground and skin numbness were reported by 38.4% and 37.6% of patients, respectively. OA developed in the medial, lateral, and patellofemoral compartments in 30.7%, 9.3%, and 7.6% of patients, respectively. The onset of OA was associated with partial meniscectomy (odds ratio [OR], 20.73; P = .005) or sagittal tibial tunnel position (OR, 1.18; P = .02) in the medial compartment and body mass index (BMI) (OR, 1.56; P = .02) in the lateral compartment. Conclusions: ACL reconstruction with bone–patellar tendon–bone autograft showed satisfactory clinical results after a mean of 10.3 years. However, pain when walking on hard ground (38.4%) and numbness of the skin (37.6%) were reported. Moreover, the onset of OA appeared in over 40% of the patients. The onset of OA in the medial compartment was correlated with partial meniscectomy and sagittal tibial tunnel position, and the onset of OA in the lateral compartment was correlated with higher BMI. Level of Evidence: Level IV, therapeutic case series.

Arthroscopic Management of Proximal Humerus Malunion With Tuberoplasty and Rotator Cuff Retensioning - Corrected Proof

Alexandre Lädermann, Patrick J. Denard, Stephen S. Burkhart — 2012-03-12

Purpose: To report the mid- to long-term results of arthroscopic tuberoplasty and rotator cuff retensioning for proximal humerus malunion. Methods: Between August 2001 and October 2009, 9 patients with a mean age of 49 years underwent shoulder arthroscopy with tuberoplasty and rotator cuff advancement for malunion of the proximal humerus and were included in this study. The mean delay between the initial fracture and our surgery was 19 months. We developed a systematic technique to take down the rotator cuff over the malunited proximal humerus, perform a tuberoplasty, and then retension and repair the rotator cuff by advancing it on the greater tuberosity. The mean follow-up was 50 months (range, 12 to 108 months). Results: Patients showed mean active forward elevation of 164° (range, 90° to 180°; gain of 43°), recovery of mean active external rotation of 45° (range, 30° to 60°; gain of 16°), and a mean pain score of 1.8 points (range, 0 to 5 points; reduction of 3.8 points). The overall functional results according to the University of California, Los Angeles score were excellent in 3 cases, good in 3, and fair in 3. No patient required additional surgery. Of the 9 patients, 8 (89%) were able to return to their previous sports or activities. All patients declared themselves as being satisfied with the result. Conclusions: Arthroscopic tuberoplasty and rotator cuff retensioning for proximal humerus malunion comprise a viable alternative to traditional open methods, particularly in young patients. A comprehensive approach is recommended that addresses stiffness, associated pathology, and impingement, and re-establishes rotator cuff function. Although the technique is technically demanding, it allows preservation of the native humeral head, is associated with a very low complication rate, and avoids concerns about long-term prosthetic survival in young patients. Level of Evidence: Level IV, therapeutic case series.

Comparison of 4 Femoral Tunnel Drilling Techniques in Anterior Cruciate Ligament Reconstruction - Corrected Proof

Andrew I. Larson, Daniel P. Bullock, Tomas Pevny — 2012-03-12

Purpose: The purpose of this study was to determine which femoral tunnel drilling technique most closely reproduces the anatomic femoral footprint and has acceptable tunnel length and tunnel orientation. Methods: We divided 20 cadaveric knees into 4 equal groups. Arthroscopically, the anatomic femoral footprint was marked with an awl as the tunnel starting point. In group 1 the femoral tunnel was drilled through a tibial tunnel. In groups 2 and 3 the femoral tunnel was drilled through the anteromedial arthroscopy portal, with a rigid drill and flexible drill, respectively. In group 4 the femoral tunnel was drilled with the outside-in technique over a pin positioned with an arthroscopic femoral guide. Measurements of the tunnel length, aperture, and placement were taken from 3-dimensional computed tomography scans. Results: Tunnel length for groups 1, 2, 3, and 4 averaged 42.08 mm, 37.73 mm, 28.92 mm, and 31.96 mm (P = .039). The mean coronal angle of the tunnels as measured from the line tangent to the posterior femoral condyles was 63.30°, 61.22°, 51.77°, and 45.00° (P = .007), and the mean distance from the inferior articular surface to the edge of the tunnel was 5.60 mm, 4.36 mm, 2.42 mm, and –0.63 mm (P = .008) for groups 1, 2, 3, and 4, respectively. There was no statistical difference in footprint length, width, area, or distance from the posterior articular margin. Conclusion: Drilling by the transtibial technique produces the most vertical and longest tunnels. Independent drilling techniques produce the most anatomic tunnels but at the expense of tunnel length. Clinical Relevance: When the orthopaedic surgeon is performing ACL reconstruction, it is critical to achieve anatomic placement of the graft, as well as maintain appropriate tunnel length.

Clinical Outcome After Suture Anchor Repair for Complete Traumatic Rupture of the Distal Triceps Tendon - Corrected Proof

Eric D. Bava, F. Alan Barber, Earl R. Lund — 2012-03-12

Purpose: To evaluate the clinical results of surgical repair of complete distal triceps tendon rupture using suture anchors and high-strength sutures by use of validated outcome measures. Methods: A consecutive series of traumatic distal triceps tendon ruptures at a single institution were studied. All cases were surgically repaired by use of suture anchors double loaded with ultrahigh-molecular-weight polyethylene–containing sutures. All patients were evaluated with a physical examination, radiographs, and questionnaires. The following postoperative validated outcome measures were used: the Disabilities of the Arm, Shoulder and Hand (DASH) score; the Oxford Elbow Score; the American Shoulder and Elbow Surgeons elbow assessment form; and the Mayo Elbow Performance Index. Results: Five male patients with a mean follow-up of 32 months underwent suture anchor repair for traumatic rupture of the distal triceps tendon. Of the repairs, 3 were in the dominant arm and 2 in the nondominant arm. The mean patient age was 47 years (range, 35 to 54 years). Postoperatively, the mean DASH score was 1.4, the mean American Shoulder and Elbow Surgeons elbow score was 99.2, the mean Mayo Elbow Performance Index was 95.8, the mean Oxford Elbow Score for pain was 98.8, the mean Oxford Elbow Score for function was 100, and the mean Oxford Elbow Score for the social domain was 96.2. A lower score for the DASH indicates less disability and better function. Conclusions: This retrospective case series of suture anchor repair of distal triceps tendon ruptures showed excellent elbow function based on validated clinical outcome measures. Level of Evidence: Level IV, therapeutic case series.

Hip Arthroscopy and Hypothermia - Corrected Proof

2012-03-05

Purpose: To determine the incidence of and factors that contribute to the development of hypothermia during hip arthroscopic surgery. Methods: An analytic observational study was carried out in a cohort of 73 consecutive patients. All patients underwent hip arthroscopy for the treatment of femoroacetabular impingement. The patients' core temperature (esophageal) was measured throughout the surgery. Relevant information was collected on the patients (age, gender, body mass index, blood pressure) and on the procedure (volume and temperature of saline solution, pressure of fluid pump, surgery time, room temperature). The corresponding statistical analysis was performed with Stata 10.0 (StataCorp, College Station, TX), by use of a repeated-measures generalized estimating equations model. Results: The patients' mean age was 33 years, and there were 39 female and 34 male patients. The mean body mass index was 23.9; systolic blood pressure, 97.5 mm Hg; and diastolic blood pressure, 52.2 mm Hg. The incidence of hypothermia below 35°C (95°F) was 2.7%. The multivariate statistical analysis of the results showed a direct relation between hypothermia and surgery time of more than 120 minutes (P < .001). There was an inverse relation between core body temperature and surgery time (P < .001), with a drop of 0.19°C/h (32.342°F/h). Of the patients, 68.22% had a decrease in temperature of more than 0.5°C (32.9°F) until the end of surgery. There was also a direct relation between core body temperature and saline solution temperature (P < .001), body mass index (P < .01), and diastolic blood pressure (P < .03). Conclusions: The incidence of hypothermia below 35°C (95°F) in patients who underwent hip arthroscopy for the treatment of femoroacetabular impingement is 2.7%. The factors that contribute toward the development of hypothermia during hip arthroscopic surgery are prolonged surgery time, low body mass index, low blood pressure during the procedure, and low temperature of the arthroscopic irrigation fluid. Level of Evidence: Level II, development of diagnostic criteria on the basis of consecutive patients with a universally applied reference gold standard.

Reliability of Early Postoperative Radiographic Assessment of Tunnel Placement After Anterior Cruciate Ligament Reconstruction - Corrected Proof

2012-03-02

Purpose: To evaluate the interobserver and intraobserver reliability of radiographic assessment of tunnel placement in anterior cruciate ligament reconstruction. Methods: Seven sports fellowship–trained orthopaedic surgeons in the Multicenter Orthopaedic Outcomes Network (MOON) group participated in the study. We prospectively enrolled 54 consecutive patients after primary anterior cruciate ligament reconstruction. Postoperative plain radiographs were obtained including a full-extension anteroposterior view of the knee, a lateral view of the knee in full extension, and a notch view at 45° of flexion (Rosenberg view). Three blinded reviewers performed 8 different radiographic measurements including those of Harner and Aglietti/Jonsson. Intraclass correlation coefficients were used to determine reliability of the measurements. Intrarater reliability was assessed by repeated measurements of a subset of 20 patient images from 1 institution, and inter-rater reliability was assessed by use of all 54 sets of films from a total of 4 institutions. Results: Intraobserver reliability for femoral measures ranged from none to substantial, with notch height having the worst results. Intraobserver reliability was moderate to almost perfect for tibial measures. Interobserver reliability ranged from slight to moderate for femoral measures. The Harner method for determining tunnel depth was more reliable than the Aglietti/Jonsson method. Interobserver reliability for tibial measures ranged from fair to substantial. The presence of metal interference screws did not improve reliability of measurements. Conclusions: Postoperative radiographs are easily obtained, but our results show that radiographic measurements are of quite variable reliability, with most of the results falling into the fair to moderate categories. Level of Evidence: Level III, diagnostic study.

Arthroscopic Evaluation of Preserved Ligament Remnant After Selective Anteromedial or Posterolateral Bundle Anterior Cruciate Ligament Reconstruction - Corrected Proof

2012-03-01

Purpose: The purpose of this study was to evaluate the clinical results and morphology of the preserved bundle remnants by second-look arthroscopy postoperatively 1 year after selective anteromedial (AM) or posterolateral (PL) bundle ACL reconstruction. Methods: Between July 2004 and September 2009, 1,000 patients underwent arthroscopic anterior cruciate ligament (ACL) reconstruction at our hospital. Among them, 20 (2%) underwent selective AM bundle (group A) or PL bundle (group P) ACL reconstruction surgery with hamstring tendon autografts. At 1 year after surgery, 19 patients (7 male and 12 female patients; age range, 15 to 57 years) underwent second-look arthroscopic evaluations. The follow-up mean was 40.2 months (range, 24 to 70 months). We evaluated the results of manual knee laxity, anterior knee laxity measured by a Telos device (Telos, Marburg, Germany) at 130 N, Lysholm scores, and International Knee Documentation Committee evaluation form and performed evaluations of morphology by second-look arthroscopy. Results: The side-to-side difference in anterior translation by use of the Telos device at 130 N was improved to 2 ± 2 mm (postoperatively) from 6 ± 2.3 mm (preoperatively) in group A and to 1.02 ± 1.26 mm from 4.93 ± 1.73 mm in group P. By second-look arthroscopy, the graft and preserved remnant of each case was considered to have acceptable synovial coverage and to be taut. Conclusions: The preserved ACL remnants possess acceptable morphology and the functions of anterior-posterior and rotational stability after surgery. Our procedure can be recommended for surgery on partial ACL tears. Level of Evidence: Level IV, therapeutic case series.

Exploring the Application of Stem Cells in Tendon Repair and Regeneration - Corrected Proof

Zafar Ahmad, John Wardale, Roger Brooks, Fran Henson, Ali Noorani, Neil Rushton — 2012-03-01

Purpose: To conduct a systematic review of the current evidence for the effects of stem cells on tendon healing in preclinical studies and human studies. Methods: A systematic search of the PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, and Embase databases was performed for stem cells and tendons with their associated terminology. Data validity was assessed, and data were collected on the outcomes of trials. Results: A total of 27 preclinical studies and 5 clinical studies met the inclusion criteria. Preclinical studies have shown that stem cells are able to survive and differentiate into tendon cells when placed into a new tendon environment, leading to regeneration and biomechanical benefit to the tendon. Studies have been reported showing that stem cell therapy can be enhanced by molecular signaling adjunct, mechanical stimulation of cells, and the use of augmentation delivery devices. Studies have also shown alternatives to the standard method of bone marrow–derived mesenchymal stem cell therapy. Of the 5 human studies, only 1 was a randomized controlled trial, which showed that skin-derived tendon cells had a greater clinical benefit than autologous plasma. One cohort study showed the benefit of stem cells in rotator cuff tears and another in lateral epicondylitis. Two of the human studies showed how stem cells were successfully extracted from the humerus and, when tagged with insulin, became tendon cells. Conclusions: The current evidence shows that stem cells can have a positive effect on tendon healing. This is most likely because stem cells have regeneration potential, producing tissue that is similar to the preinjury state, but the results can be variable. The use of adjuncts such as molecular signaling, mechanical stimulation, and augmentation devices can potentially enhance stem cell therapy. Initial clinical trials are promising, with adjuncts for stem cell therapy in development. Level of Evidence: Level IV, systematic review of Level II-IV studies.

Incidence of Bilateral Discoid Lateral Meniscus in An Asian Population: An Arthroscopic Assessment of Contralateral Knees - Corrected Proof

2012-02-27

Purpose: To investigate the incidence of bilateral discoid lateral meniscus (DLM) and to evaluate the arthroscopic features of lateral meniscus in asymptomatic contralateral knees in an Asian population who presented with symptomatic DLMs. Methods: This study prospectively enrolled 52 consecutive patients who underwent arthroscopic procedures for symptomatic DLMs (31 complete and 21 incomplete) and who consented to the examination of the contralateral knee at the time of arthroscopy. Types of DLMs and of meniscus tears were assessed by use of arthroscopic findings. Preoperative and postoperative functional outcomes were evaluated with Lysholm and Tegner activity scores. Results: Arthroscopic examinations showed 21 complete DLMs, 19 incomplete DLMs, 11 normal lateral menisci, and 1 ring-shaped lateral meniscus in contralateral knees. The incidence of bilateral DLM in our study population was 79% (41 of 52 contralateral knees). Furthermore, 65% of patients (34 pairs of knees) had the same DLM types. In addition, 3 pairs of knees with complete DLMs had menisci of different thicknesses. DLM tears were observed in 2 contralateral knees (1 radial and 1 longitudinal) and were treated by partial central meniscectomy. Conclusions: This study provides evidence of the high prevalence of bilateral DLM in an Asian population. Level of Evidence: Level I, testing of previously developed diagnostic criteria in a series of consecutive patients.

Diagnostics of Femoroacetabular Impingement and Labral Pathology of the Hip: A Systematic Review of the Accuracy and Validity of Physical Tests - Corrected Proof

Marsha Tijssen, Robert van Cingel, Linn Willemsen, Enrico de Visser — 2012-02-27

Purpose: Femoroacetabular impingement (FAI) and labral pathology have been recognized as causative factors for hip pain. The clinical diagnosis is now based on MRI-A (magnetic resonance imaging-arthrogram) because the physical diagnostic tests available are diverse and information on diagnostic accuracy and validity is lacking. The purpose of this systematic review was to identify the diagnostic accuracy and validity of physical tests that are used to assess FAI and labral pathology of the hip joint. Methods: We performed a computerized literature search using PubMed, Medline, Web of Science, PEDro, the Cochrane Library, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) (through EBSCO). Studies describing tests and diagnostic accuracy studies were included. All included studies were assessed by the Levels of Evidence for Primary Research Questions list. All diagnostic accuracy studies were assessed by the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) score. Results: We included 21 studies in which 18 different tests were described. For 11 of these tests, diagnostic accuracy figures were presented. Sensitivity was examined for all tests. Other diagnostic accuracy figures were often lacking, and when available, these were low. All articles describing tests had Level IV or V evidence. All diagnostic accuracy studies, except 1, had Level II or III evidence. Three articles had a good QUADAS score. Conclusions: In previous studies a wide range of physical diagnostic tests have been described. Little is known about the diagnostic accuracy and validity of these tests, and if available, these figures were low. The quality of the studies investigating these tests is too low to provide a conclusive recommendation for the clinician. Thus, currently, no physical tests are available that can reliably confirm or discard the diagnoses of FAI and/or labral pathology of the hip in clinical practice. Level of Evidence: Level III, systematic review of Level III studies.

Open Capsular Shift and Arthroscopic Capsular Plication for Treatment of Multidirectional Instability - Corrected Proof

Mark E. Jacobson, Michael Riggenbach, Adam N. Wooldridge, Julie Y. Bishop — 2012-02-27

Purpose: To compare the results of open inferior capsular shift with arthroscopic capsular plication for multidirectional instability in patients without a Bankart lesion. We hypothesized that there is no difference with regard to the specific clinical outcomes evaluated, including recurrent instability, range of motion, return to sport, and complications. Methods: We conducted a comprehensive literature search. Databases searched included PubMed from 1966 to 2010, the Cochrane Database of Systematic Reviews and Controlled Trials, CINAHL (Cumulative Index to Nursing and Allied Health Literature) from 1982 to 2010, and SPORTDiscus from 1975 to 2010. Limits included English language, human subjects, and title. Results: We found 7 articles with a total of 197 patients (219 shoulders) that met our inclusion criteria. The data did not clearly show open treatment to be superior to arthroscopic treatment. No study reported a consistent loss of greater than 40° of external rotation. No technique showed significantly less external rotation loss over the other. Whereas there was a slight trend toward increased return to sport for patients treated arthroscopically, no clear conclusion can be drawn given the variability of reporting in the reviewed studies. Analysis of complications shows that both procedures are reliably safe with minimal complications. Conclusions: When one is evaluating patients with traumatic or atraumatic onset of shoulder instability in 2 directions and no structural lesions, arthroscopic capsular plication yields comparable results to open capsular shift with regard to recurrent instability, return to sport, loss of external rotation, and overall complications. Level of Evidence: Level IV, systematic review of Level IV studies.

Long-Term Outcome of Arthroscopic Massive Rotator Cuff Repair: The Importance of Double-Row Fixation - Corrected Proof

Patrick J. Denard, Alisha Z. Jiwani, Alexandre Lädermann, Stephen S. Burkhart — 2012-02-27

Purpose: The purpose of this study was to (1) evaluate the long-term functional outcome of arthroscopic rotator cuff repair of massive rotator cuff tears (RCTs) and (2) compare double-row (DR) and single-row (SR) repairs. Methods: This was a retrospective review of massive RCTs treated with an arthroscopic rotator cuff repair over an 8-year period. Minimum 5-year follow-up was available for 126 repairs at a mean of 99 months. Among 107 complete repairs, there were 62 SR and 45 DR repairs. Functional outcome was determined by University of California, Los Angeles (UCLA) and American Shoulder and Elbow Surgeons scores. A multivariate analysis was performed to examine the role of a DR repair. Results: For all repairs combined, improvements were observed in forward flexion (132° v 168°), pain (6.3 v 1.3), UCLA score (15.7 v 30.7), and American Shoulder and Elbow Surgeons score (41.7 v 85.7) (P < .001). A good or excellent outcome, obtained in 78% of cases, was associated with a complete repair (P = .035) and a DR repair (P = .008). When we excluded partial repairs, postoperative UCLA gain was greater after a DR repair (P = .007). Patients reported their shoulder as feeling closer to normal after a DR repair compared with an SR repair (93.5% v 84.4%, P = .006). A DR repair was 4.9 times more likely to lead to a good or excellent outcome (P = .021). Conclusions: When a DR repair of a massive RCT is possible, on the basis of the ability to mobilize the tendons, a better long-term functional outcome can be expected compared with an SR repair. Given the known high risk of recurrence after repair of massive RCTs and the knowledge that functional outcome is related to recurrence, a DR repair of massive RCTs should be performed when there is sufficient tendon mobility. Level of Evidence: Level III, retrospective comparative study.

Computed Tomography of the Ankle in Full Plantar Flexion: A Reliable Method for Preoperative Planning of Arthroscopic Access to Osteochondral Defects of the Talus - Corrected Proof

2012-02-20

Purpose: The purpose of this study was to determine whether preoperative computed tomography (CT) of the ankle joint in full plantar flexion is a reliable and accurate tool to determine the anterior arthroscopic accessibility of talar osteochondral defects (OCDs). Methods: Twenty consecutive patients were prospectively studied. All patients had an OCD of the talar dome and had a preoperative CT scan of the affected ankle in maximum plantar flexion. Accessibility of the OCD was defined by the distance between the anterior border of the OCD and the anterior distal tibial rim. This distance was measured on sagittal CT reconstructions by 2 investigators. The reference standard was the distance between the same landmarks measured during anterior ankle arthroscopy by an orthopaedic surgeon blinded to the CT scans. Intraobserver and interobserver reliability of CT, as well as the correlation and agreement between CT and arthroscopy, were calculated. Results: The measured distance between the anterior border of the OCD and the anterior distal tibial rim ranged from −3.1 to 9.1 mm on CT and from −3.0 to 8.5 mm on arthroscopy. The intraobserver and interobserver reliability of the measurements made on CT scans (intraclass correlation coefficients >0.99, P < .001), as well as the correlation between CT and arthroscopy, were excellent (r = 0.98, P < .001). Conclusions: Measurements on CT scans of the ankle in full plantar flexion are a reliable and accurate preoperative method to determine the in situ arthroscopic location of talar OCDs. Level of Evidence: Level II, development of diagnostic criteria based on consecutive patients.

Treatment of Bankart Lesions in Traumatic Anterior Instability of the Shoulder: A Randomized Controlled Trial Comparing Arthroscopy and Open Techniques - Corrected Proof

2012-02-20

Purpose: The objective of this study was to compare the functional assessments of arthroscopy and open repair for treating Bankart lesion in traumatic anterior shoulder instability. Methods: Fifty adult patients, aged less than 40 years, with traumatic anterior shoulder instability and the presence of an isolated Bankart lesion confirmed by diagnostic arthroscopy were included in the study. They were randomly assigned to receive open or arthroscopic treatment of an isolated Bankart lesion. In all cases of both groups, the lesion was repaired with metallic suture anchors. The primary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Results: After a mean follow-up period of 37.5 months, 42 patients were evaluated. On the DASH scale, there was a statistically significant difference favorable to the patients treated with the arthroscopic technique, but without clinical relevance. There was no difference in the assessments by University of California, Los Angeles and Rowe scales. There was no statistically significant difference regarding complications and failures, as well as range of motion, for the 2 techniques. Conclusions: On the basis of this study, the open and arthroscopic techniques were effective in the treatment of traumatic anterior shoulder instability. The arthroscopic technique showed a lower index of functional limitation of the upper limb, as assessed by the DASH questionnaire; this, however, was not clinically relevant. Level of Evidence: Level II, randomized controlled trial.

Health-Related Quality of Life and Direct Costs in Patients With Anterior Cruciate Ligament Injury: Single-Bundle Versus Double-Bundle Reconstruction in a Low-Demand Cohort—A Randomized Trial With 2 Years of Follow-up - Corrected Proof

2012-02-20

Purpose: To evaluate health-related quality of life (HRQL) in patients undergoing anterior cruciate ligament (ACL) reconstructive surgery by use of 2 procedures and to estimate the direct costs of surgery. Methods: We performed a 2-year randomized, prospective intervention study of 2 surgical ACL reconstruction techniques (anatomic single bundle [SB] v double bundle [DB]). Fifty-five consecutive outpatients, with a mean age of 30.88 years, were randomized to SB or DB ACL reconstruction. The Medical Outcomes Study 36-item Short Form Health Survey (SF-36) was used to measure HRQL (primary outcome). ACL injuries were assessed by the International Knee Documentation Committee (IKDC) score (secondary outcome). The use of medical resources and their costs were evaluated. Results: We included 52 patients in the final analyses (23 in the SB group and 29 in the DB group). At baseline, there were no significant differences in study variables. At 2 years of follow-up, there were no significant differences in SF-36 and IKDC scores between groups. However, compared with baseline, the SF-36 physical function, physical role, bodily pain, social function, and emotional role scores were significantly better in the SB group (P < .05), whereas only the physical function dimension score was better in the DB group (P = .047). IKDC scores at 2 years improved significantly in the SB group (P < .001) and DB group (P = .004) compared with baseline. There was a significant correlation between the SF-36 physical function, physical role, and bodily pain dimensions and the IKDC score at 2 years (P < .05). The costs were €3,251 for the SB group and €4,172 for the DB group. Conclusions: HRQL and medical outcomes were similar between SB and DB ACL reconstruction techniques, 2 years after surgery. However, the SB technique was more cost-effective. Level of Evidence: Level I, randomized controlled trial.

The Lateral Tibial Tunnel in Revision Anterior Cruciate Ligament Surgery: A Biomechanical Study of a New Technique - Corrected Proof

2012-02-13

Purpose: To evaluate the cortical entry point and the length of a revision lateral tibial tunnel (LTT) in a human cadaveric study and to investigate knee stability after a revision anterior cruciate ligament (ACL) reconstruction with an LTT. Methods: Ten human cadaveric knee specimens were used to perform a preliminary investigation. Twenty-two human proximal tibias were used to compare the length of a revision LTT with a classical medial tibial tunnel (MTT). Another 5 human cadaveric knees were used to investigate knee stability after a revision LTT and to compare it with a primary ACL repair with an MTT performed in the same knees. Stability was evaluated with computer navigation. Results: An LTT is statistically significantly longer (45.0 mm) than an MTT (35.2 mm) (P < .001). There was no evidence of a length difference between the intact bone tube length of a revision LTT (36.5 mm) and an MTT. For nearly all measurements, the difference between the ACL repair with an MTT and the revision surgery with an LTT was not only nonsignificant but also small in magnitude. Only for internal rotation at 30° of knee flexion and for internal rotation in extension was a significant difference detected (P = .029 and P = .044, respectively). Conclusions: An LTT can easily be drilled and provides a bony tunnel that is statistically significantly longer than an MTT. A revision LTT has an intact bone tube as long as that of a primary MTT. Similar stability is obtained after revision ACL surgery with an LTT compared with a primary ACL repair with a standard MTT. Clinical Relevance: LTT placement is a new technique for ACL revision surgery that can help to overcome problems related to tunnel enlargement in the distal part of the tibial tunnel.

Evaluation of Tunnel Position of Posterolateral Corner Reconstruction Using 3-Dimensional Computed Tomogram - Corrected Proof

2012-02-13

Purpose: To evaluate the isometry of different tunnel positions in posterolateral corner (PLC) reconstruction using 3-dimensional computed tomography. Methods: In 10 fresh-frozen cadaveric knees, fibular tunnels were made from the anterodistal surface of the fibular neck to the posteroproximal fibular tip. Tibial tunnels were made from just medial to the Gerdy tubercle to a point 1 to 1.5 cm medial to the proximal tibiofibular joint. Femoral condyles were marked at 3 different locations: (1) epicondyle, (2) 5 mm distal-anterior to the epicondyle, and (3) 18 mm distal-anterior to the epicondyle. All specimens were scanned by computed tomography at different ranges of motion. Relative length changes between the tunnels were calculated by use of medical imaging software, and the center of rotation (COR) of each distal tunnel was obtained by use of a least-squares circle-fitting algorithm. Results: The anterior fibular tunnel to lateral epicondyle and the posterior fibular or posterior tibial tunnel to 5 mm distal-anterior to the lateral epicondyle showed the best results in terms of isometry. The COR of the posterior fibular tunnel is distal and anterior to the epicondyle, whereas the COR of the posterior tibial tunnel is distal and slightly posterior to the epicondyle (8.4 mm away from the epicondyle, with a −8.4° angle along the longitudinal axis of the femur). The COR of the anterior fibular tunnel is located posterior and distal to the epicondyle. Conclusions: Contrary to our hypothesis, the distal tunnels for PLC reconstruction each have different isometric points. The isometric point of the posterior fibular tunnel is distal and anterior to the epicondyle, whereas the isometric points of the posterior tibial and anterior fibular tunnels are distal and posterior to the epicondyle. Clinical Relevance: The isometric pattern of each tunnel combination should be considered in PLC reconstruction; currently, popliteus tendon reconstruction is non-isometric.

Open Lateral Patellar Retinacular Lengthening Versus Open Retinacular Release in Lateral Patellar Hypercompression Syndrome: A Prospective Double-Blinded Comparative Study on Complications and Outcome - Corrected Proof

2012-02-10

Purpose: To compare complication rates and outcome of open lateral retinacular (LR) lengthening and open LR release in the treatment of lateral patellar hypercompression syndrome (LPHS). Methods: In a prospective double-blinded study, 28 patients (mean age, 48 years; 21 women and 7 men) received either LR release (14 patients) or LR lengthening (14 patients) in alternating fashion over the same lateral parapatellar skin incision for LPHS (blinding of patients to surgical procedure [i.e., single blinding]). Strict inclusion criteria (retinacular pain, tight retinaculum, decreased patellar mobility) were used to exclude other reasons for anterior knee pain (patellar instability, leg malalignment or maltorsion, trochlear dysplasia, patella alta). The surgeon and postsurgical rehabilitation were the same. Preoperatively and at 3, 6, 12, and 24 months postoperatively, complications, muscle atrophy, and Kujala patellofemoral outcome score were documented by examiners blinded to the surgical procedure (double blinding). All patients completed 2 years of follow-up. Results: The results of 2 years of follow-up showed that recurrence of LPHS, as indicated by the patellar tilt test and decreased medial patellar glide test, developed in 2 cases after LR release and 1 case after LR lengthening (P > .999). Medial patellar subluxation, as indicated by the gravitation-subluxation test and increased medial patellar glide test, developed in 5 cases after LR release and no case after LR lengthening (P = .041). Quadriceps atrophy, as indicated by the mean circumference difference compared with the healthy contralateral side, was significantly higher (P = .001) in the LR release group (1.8 cm) than in the LR lengthening group (0.2 cm). The mean Kujala score was significantly lower (P = .035) in the LR release group (77.2 points) than in the LR lengthening group (88.4 points). Conclusions: In this prospective double-blinded study, retinacular lengthening showed less medial instability, less quadriceps atrophy, and a better clinical outcome at 2 years compared with retinacular release. We believe that this may be explained by the controlled preservation of the lateral patellar muscle-capsuloligamentous continuity after retinacular lengthening. Level of Evidence: Level II, prospective double-blinded comparative study.

Arthroscopic Side-to-Side Repair of Massive and Contracted Rotator Cuff Tears Using a Single Uninterrupted Suture: The Shoestring Bridge Technique - Corrected Proof

2012-02-10

Purpose: This study was performed to evaluate the clinical effectiveness of a new side-to-side repair technique for massive rotator cuff tears using a single uninterrupted suture in the configuration of a shoestring in a medial-to-lateral progression. Methods: Thirty-one consecutive patients with a mean age of 59 years (SD, 4.7 years) had primary arthroscopic repair of their massive, U-shaped, contracted supraspinatus and infraspinatus tear by the shoestring bridge technique. Preoperatively and postoperatively, we measured active forward flexion and determined the visual analog scale score for pain, Simple Shoulder Test score, and Disabilities of the Arm, Shoulder and Hand (DASH) score. Repair integrity was evaluated by ultrasonography. Results: At a mean follow-up of 26.5 months, all scores had significantly improved: active forward flexion, mean of 70° (SD, 29°) preoperatively to 139° (SD, 39°) postoperatively (P < .001); visual analog scale score for pain, 8.0 ± 1.4 points to 2.5 ± 1.8 points (P < .001); Simple Shoulder Test score, 15% ± 19% to 72% ± 23% (P < .001); and Disabilities of the Arm, Shoulder and Hand score, 62 ± 17 points to 21 ± 14 points (P < .001). Ultrasound evaluation showed that 25 of 31 patients (81%) had heeled tendons. Of 31 patients, 6 (19%) had a complete retear. Only 3 of these 6 patients were not satisfied with the result. Conclusions: Arthroscopic side-to-side repair by the shoestring bridge technique is effective in the treatment of massive, U-shaped, contracted supraspinatus and infraspinatus tears. It provides the shoulder surgeon a treatment modality with significant improvement in pain and function, high patient satisfaction, and a low retear rate. Level of Evidence: Level IV, therapeutic case series.

Full-Thickness Knee Articular Cartilage Defects in National Football League Combine Athletes Undergoing Magnetic Resonance Imaging: Prevalence, Location, and Association With Previous Surgery - Corrected Proof

Jeffrey J. Nepple, Rick W. Wright, Matthew J. Matava, Robert H. Brophy — 2012-02-10

Purpose: To better define the prevalence and location of full-thickness articular cartilage lesions in elite football players undergoing knee magnetic resonance imaging (MRI) at the National Football League (NFL) Invitational Combine and assess the association of these lesions with previous knee surgery. Methods: We performed a retrospective review of all participants in the NFL Combine undergoing a knee MRI scan from 2005 to 2009. Each MRI scan was reviewed for evidence of articular cartilage disease. History of previous knee surgery including anterior cruciate ligament reconstruction, meniscal procedures, and articular cartilage surgery was recorded for each athlete. Knees with a history of previous articular cartilage restoration surgery were excluded from the analysis. Results: A total of 704 knee MRI scans were included in the analysis. Full-thickness articular cartilage lesions were associated with a history of any previous knee surgery (P < .001) and, specifically, previous meniscectomy (P < .001) but not with anterior cruciate ligament reconstruction (P = .7). Full-thickness lesions were present in 27% of knees with a previous meniscectomy compared with 12% of knees without any previous meniscal surgery. Full-thickness lesions in the lateral compartment were associated with previous lateral meniscectomy (P < .001); a similar relation was seen for medial meniscus tears in the medial compartment (P = .01). Conclusions: Full-thickness articular cartilage lesions of the knee were present in 17.3% of elite American football players at the NFL Combine undergoing MRI. The lateral compartment appears to be at greater risk for full-thickness cartilage loss. Previous knee surgery, particularly meniscectomy, is associated with these lesions. Level of Evidence: Level IV, therapeutic case series.

Arthroscopic Partial Repair of Irreparable Large to Massive Rotator Cuff Tears - Corrected Proof

Sung-Jae Kim, In-Sung Lee, Seung-Hyun Kim, Won-Yong Lee, Yong-Min Chun — 2012-02-10

Purpose: The aim of this study was to evaluate the outcome of arthroscopic partial repair and margin convergence of irreparable large to massive rotator cuff tears. Methods: Between January 2003 and July 2008, 27 patients who met the inclusion criteria underwent arthroscopic partial repair and margin convergence of irreparable large to massive rotator cuff tears. An irreparable tear was defined as a tear with a minimum anterior-to-posterior width of 3 cm or larger, where it was not feasible to completely cover the humeral head with the cuff at the time of surgery. Results: The mean preoperative tear size was 42.1 ± 6.2 mm. The mean size of the postoperative residual defect in the repaired tendon along the medial margin of the greater tuberosity was 12.0 ± 5.5 mm. All shoulder scores showed improvement. The Simple Shoulder Test improved from 5.1 ± 1.2 to 8.8 ± 2.1 (P < .001), the Constant score from 43.6 ± 7.9 to 74.1 ± 10.6 (P < .001), and the University of California, Los Angeles score from 10.5 ± 3.0 to 25.9 ± 5.0 (P < .001). Both Constant and University of California, Los Angeles shoulder scores also showed an inverse correlation with defect size. We compared muscle strength between the affected and contralateral sides and found that the strength of the affected side was not restored to the same level as the contralateral side (P < .001). Conclusions: Arthroscopic partial repair and margin convergence showed satisfactory short-term outcomes in irreparable large to massive rotator cuff tears. Thus it is suggested that, even in a large to massive tear that appears irreparable, attempting to repair it as much as possible to possibly convert it into a functional rotator cuff tear by re-creating a balanced forced couple can be helpful in reducing pain, as well as improving functional outcomes. Level of Evidence: Level IV, therapeutic case series.

Biomechanical and Magnetic Resonance Imaging Evaluation of a Single- and Double-Row Rotator Cuff Repair in an In Vivo Sheep Model - Corrected Proof

2012-02-10

Purpose: To investigate the biomechanical and magnetic resonance imaging (MRI)–derived morphologic changes between single- and double-row rotator cuff repair at different time points after fixation. Methods: Eighteen mature female sheep were randomly assigned to either a single-row treatment group using arthroscopic Mason-Allen stitches or a double-row treatment group using a combination of arthroscopic Mason-Allen and mattress stitches. Each group was analyzed at 1 of 3 survival points (6 weeks, 12 weeks, and 26 weeks). We evaluated the integrity of the cuff repair using MRI and biomechanical properties using a mechanical testing machine. Results: The mean load to failure was significantly higher in the double-row group compared with the single-row group at 6 and 12 weeks (P = .018 and P = .002, respectively). At 26 weeks, the differences were not statistically significant (P = .080). However, the double-row group achieved a mean load to failure similar to that of a healthy infraspinatus tendon, whereas the single-row group reached only 70% of the load of a healthy infraspinatus tendon. No significant morphologic differences were observed based on the MRI results. Conclusions: This study confirms that in an acute repair model, double-row repair may enhance the speed of mechanical recovery of the tendon-bone complex when compared with single-row repair in the early postoperative period. Clinical Relevance: Double-row rotator cuff repair enables higher mechanical strength that is especially sustained during the early recovery period and may therefore improve clinical outcome.

Biomechanical Testing of Suture-Based Meniscal Repair Devices Containing Ultrahigh-Molecular-Weight Polyethylene Suture: Update 2011 - Corrected Proof

F. Alan Barber, Morley A. Herbert, Eric D. Bava, Otis R. Drew — 2012-02-10

Purpose: To evaluate the biomechanical characteristics of recently introduced ultrahigh-molecular-weight polyethylene suture–based, self-adjusting meniscal repair devices. Methods: Updating a prior study published in 2009, we made vertical longitudinal cuts 3 mm from the periphery in fresh-frozen adult human menisci to simulate a bucket-handle meniscus tear. Each tear was then repaired by a single repair technique in 10 meniscus specimens. Group 1 menisci were repaired with a vertical mattress suture of No. 2-0 Ethibond (Ethicon, Somerville, NJ). Group 2 menisci were repaired with a vertical mattress suture of No. 2-0 OrthoCord (DePuy Mitek, Raynham, MA). Group 3 menisci were repaired with a single OmniSpan device with No. 2-0 OrthoCord suture (DePuy Mitek). Group 4 menisci were repaired with a single Meniscal Cinch device with No. 2-0 FiberWire suture (Arthrex, Naples, FL). Group 5 menisci were repaired with a single MaxFire device inserted with the MarXmen gun (Biomet Sports Medicine, Warsaw, IN). Group 6 menisci were repaired with a Sequent device with No. 0 Hi-Fi suture (ConMed Linvatec, Largo, FL) in a “V” suture configuration. Group 7 menisci were repaired with a single FasT-Fix 360 device (Smith & Nephew Endoscopy, Andover, MA). By use of a mechanical testing machine, all samples were preloaded at 5 N and cycled 200 times between 5 and 50 N. Those specimens that survived were destructively tested at 5 mm/min. Endpoints included maximum load, displacement, stiffness, and failure mode. Results: Mean failure loads were as follows: Ethibond suture, 73 N; OrthoCord suture, 88 N; OmniSpan, 88 N; Cinch, 71 N; MarXmen/MaxFire, 54 N; Sequent, 66 N; and FasT-Fix 360, 60 N. Ethibond was stronger than MarXmen/MaxFire. The mean displacement after 100 cycles was as follows: Ethibond, 2.58 mm; OrthoCord, 2.75 mm; OmniSpan, 2.51 mm; Cinch, 2.65 mm; MarXmen/MaxFire, 3.67 mm; Sequent, 3.35 mm; and FasT-Fix 360, 1.13 mm. The MarXmen/MaxFire showed greater 100-cycle displacement than Ethibond and FasT-Fix 360. No difference in stiffness existed for these devices, and failure mode varied without specific trends. Conclusions: The biomechanical properties of meniscal repairs using the OmniSpan, Cinch, Sequent, and FasT-Fix 360 devices are equivalent to suture repair techniques. However, the MarXmen/MaxFire meniscal repair device showed significantly lower failure loads and survived less cyclic loading in the human cadaveric meniscus than other tested repairs. Clinical Relevance: Most commercially available devices for all-inside meniscal repair using ultrahigh-molecular-weight polyethylene suture provide fixation comparable to the classic vertical mattress suture repair technique in human cadaveric meniscus.

Anterior Cruciate Ligament Femoral Footprint Anatomy: Systematic Review of the 21st Century Literature - Corrected Proof

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

Purpose: The purpose of our study was to systematically review current arthroscopic and related literature and to characterize the anatomic centrum of the anterior cruciate ligament (ACL) femoral footprint. Methods: On June 2, 2011, 2 independent reviewers performed a Medline search using the terms “anterior cruciate ligament” or “ACL,” “femur” or “femoral,” and “anatomy” or “origin” or “footprint.” We included anatomic, cadaveric, and radiographic studies of adult, human, ACL femoral 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 and quantitatively synthesized to define the anatomic centrum of the ACL femoral footprint. Results: The Medline search produced 533 articles. After application of inclusion and exclusion criteria and reference search, 20 articles were included and systematically reviewed. With regard to arthroscopically measurable landmarks, the anatomic centrum of the ACL femoral footprint is, on average, (1) in the sagittal plane, 43% of the distance from the proximal articular margin (arthroscopically visualized osteochondral junction) to the distal articular margin on the lateral wall of the intercondylar notch, and (2) in the axial plane, socket radius plus 2.5 mm anterior to the posterior articular margin, with a 2.5-mm rim of bone between the posterior ACL fibers and the posterior articular cartilage margin. Conclusions: Our results show that the anatomic centrum of the ACL femoral footprint is 43% of the proximal-to-distal length of lateral, femoral intercondylar notch wall and femoral socket radius plus 2.5 mm anterior to the posterior articular margin. 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.

Clinical Outcomes After Arthroscopic Psoas Lengthening: The Effect of Femoral Version - Corrected Proof

Peter D. Fabricant, Asheesh Bedi, Katrina De La Torre, Bryan T. Kelly — 2012-02-10

Purpose: The purpose of this study was to examine the association between femoral anteversion and clinical outcomes after arthroscopic lengthening of a symptomatic, snapping psoas tendon in young patients. Methods: Sixty-seven consecutive patients with symptomatic coxa saltans underwent arthroscopic psoas tendon lengthening through a transcapsular approach during a 3-year period by a single arthroscopic hip surgeon. Demographic and clinical variables were collected. Patients were divided into low/normal femoral version and high femoral version groups and analyzed for association of femoral version with clinical outcomes as measured by the modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS) preoperatively and postoperatively with a minimum of 6 months' follow-up (range, 6 to 24 months). Two-sample t tests were used for data analysis, with P < .05 defined as significant. Results: Preoperative evaluation showed excessive anteversion (>25°) associated with worse HOS sports subscale scores (26.6 v 50.0 for excessive v low/normal anteversion, P = .013) and no difference in mHHS and HOS activities–of–daily living subscale scores. Postoperative mHHS scores were significantly different (76.9 v 86.1 for excessive v low/normal anteversion, P = .031). No association was noted between clinical outcome measures and any other clinical or demographic variable (P > .05). Conclusions: Patients with increased femoral anteversion may be at greater risk for inferior clinical outcomes after arthroscopic lengthening of a symptomatic, snapping psoas tendon. The psoas tendon may be an important passive and dynamic stabilizer of the hip in these patients, and release may result in a greater alteration of kinematics with high-demand activities, particularly terminal extension and external rotation when the tendon is typically at its highest tension. These results may help surgeons identify which patients may be at risk for inferior clinical outcome after psoas lengthening. Level of Evidence: Level IV, therapeutic, case series.

Arthroscopic Management of Selective Loss of External Rotation After Surgical Stabilization of Traumatic Anterior Glenohumeral Instability: Arthroscopic Restoration of Anterior Transverse Sliding Procedure - Corrected Proof

2012-01-30

Purpose: The purpose of this study was to clarify the effectiveness of an arthroscopic procedure for restoration of anterior transverse sliding (RATS) mechanism of the subscapularis tendon in patients with loss of external rotation after surgical stabilization of anterior glenohumeral instability. Methods: Seven patients who underwent an arthroscopic RATS procedure for loss of external rotation after surgical stabilization of anterior glenohumeral instability were retrospectively reviewed. There were 4 male and 3 female patients with a mean age of 30.7 years. The original procedure was arthroscopic Bankart repair and rotator interval closure in 5 patients, open Bankart repair in 1, and an open Bristow procedure in 1. The arthroscopic RATS procedure was performed as follows: (1) removal of the fibrous tissue in the rotator interval; (2) release of the subscapularis tendon from the glenoid neck; and (3) incision of the superior part of the inferior glenohumeral ligament until a sufficient external rotation angle was obtained without causing anterior instability. We evaluated the mean forward flexion and external and internal rotation angles, Constant score, and University of California, Los Angeles score before the arthroscopic RATS procedure and at final follow-up (mean, 24 months). Results: The mean forward flexion and external and internal rotation angles improved from 162.1° ± 9.5° to 171.4° ± 3.8° (P < .05), from 2.9° ± 4.9° to 47.9° ± 9.1° (P < .005), and from T10 to T8 (P < .05), respectively. The mean Constant and University of California, Los Angeles scores improved from 81.0 ± 13.6 points to 95.1 ± 4.0 points and from 24.0 ± 3.7 points to 33.9 ± 2.0 points, respectively (P < .005). Conclusions: The arthroscopic RATS mechanism procedure is a useful treatment option with minimum morbidity in patients with loss of external rotation after surgical stabilization of traumatic anterior glenohumeral instability. Level of Evidence: Level IV, therapeutic case series.

Flexible Instruments Outperform Rigid Instruments to Place Anatomic Anterior Cruciate Ligament Femoral Tunnels Without Hyperflexion - Corrected Proof

Mark E. Steiner, L. Ryan Smart — 2012-01-30

Purpose: This study evaluated the ability of flexible instruments compared with rigid instruments to place anatomic femoral tunnels in anterior cruciate ligament reconstructions by use of both transtibial drilling and anteromedial drilling without hyperflexion. Methods: Rigid and flexible pins were placed in 12 matched pairs of cadaveric knees with transtibial drilling (6 pairs) and anteromedial drilling (6 pairs) at 110° of flexion. Intraosseous pin lengths, femoral exit locations, and tunnel alignment were measured. Results: Transtibial drilling with rigid pins placed relatively vertical femoral tunnels 5.8 ± 1.0 mm superior to the central anterior cruciate ligament insertion. Transtibial drilling with flexible pins placed tunnels in the center of the femoral attachment, but the tunnels were relatively close to the posterior femoral cortex, with a mean distance of 8.0 ± 5.9 mm (P < .05), compared with transtibial drilling with rigid pins. Anteromedial drilling resulted in central anatomic pin placements with rigid and flexible instruments. Tunnel lengths with flexible pins were longer (42.0 ± 7.2 mm) compared with tunnel lengths with rigid pins (32.5 ± 7.1 mm) (P < .01). Flexible pins exited farther from the posterior cortex compared with rigid pins (P < .01). In 3 of 6 knees with rigid pins, the exit point was at the posterior border of the femoral cortex. All flexible pins exited a safe distance from the posterior femoral cortex. Conclusions: Transtibial drilling with rigid instruments did not produce anatomic femoral tunnels. Transtibial drilling with flexible pins produced anatomic tunnels, but the tunnels were close to the posterior femoral cortex. Anteromedial drilling without hyperflexion produced anatomic tunnels by use of rigid and flexible instruments, but with flexible instruments, the tunnels were longer and were farther from the posterior femoral cortex. Anteromedial drilling with flexible pins produced tunnels with good length and the best position. Clinical Relevance: Flexible instruments compared with rigid instruments can facilitate the creation of anatomic femoral tunnels by use of anteromedial drilling without hyperflexion.