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

Restoring the Labral Height for Treatment of Bankart Lesions: A Comparison of Suture Anchor Constructs - Corrected Proof

Mark A. Slabaugh, Nicole A. Friel, Vincent M. Wang, Brian J. Cole — 2010-03-08

Purpose: The purpose of this study was to evaluate glenoid labral heights before injury and after repair with 2 suture anchors: (1) traditional suture anchor secured with knots and (2) knotless suture anchor.Methods: Ten matched pairs of human cadaveric glenoids were examined. In each specimen the labrum was detached from the 3-o'clock position to the 6:30 clock position on the anteroinferior glenoid, and labral repair was performed with either (1) traditional Bio-SutureTak suture anchors (n = 10) (Arthrex, Naples, FL) or (2) knotless PushLock suture anchors (n = 10, contralateral side) (Arthrex). By use of a 3-dimensional digitizer, the labral height, measured from the deepest point of the glenoid articular surface to the highest tip of the labrum, was measured in all specimens before injury and after repair at the 3:30, 4:30, and 5:30 clock positions. The degree of labral height increase was computed as a percent increase in labral height from before injury to after repair.Results: Labral height increased significantly for all specimens from before injury (5.35 mm) to after repair (8.05 mm) (159.1% ± 13.7%, P < .0001). Increases in labral height from before injury to after repair were similar (P > .05) for Bio-SutureTak suture anchors (164.6% ± 18.7%, P < .0001) and PushLock suture anchors (153.6% ± 5.8%, P < .0001). The amount of labral height increase did not vary by anatomic location (157.0% ± 50.2%, 168.9% ± 51.0%, and 150.4% ± 35.2% at 3:30, 4:30, and 5:30, respectively; P = .46).Conclusions: An increase in labral height can be achieved to create a significant height increase from before injury to after labral repair. The difference in labral height afforded by a traditional suture anchor and a knotless anchor is not statistically significant. Clinical Relevance: Both traditional and knotless suture anchor constructs provide a reliable restoration of labral height in an acute Bankart model.

Anterior Cruciate Ligament Tibial Guide Pin Accuracy and Surgical Precision: Comparing 3.0-mm and 2.4-mm Guide Pins - Corrected Proof

James H. Lubowitz — 2010-03-08

Purpose: The purpose of this study was to evaluate the accuracy of a 3.0-mm-diameter anterior cruciate ligament (ACL) tibial guide pin versus a standard, 2.4-mm drill-tipped guide pin. A secondary purpose was to evaluate surgeon precision in identifying the true (anatomic) center of the ACL tibial footprint using arthroscopic visualization.Methods: Five matched pairs of cadaveric knees were disarticulated, leaving a well-defined footprint of the ACL on the tibial plateau. The tibial footprint was digitally recorded by a bioengineer, and the true center of the footprint was calculated. Next, using arthroscopic visualization, a surgeon identified and marked his estimation of the true center of the ACL tibial footprint. This mark was then digitally recorded by the bioengineer and compared with the calculated center, allowing quantification of surgeon anatomic precision. Finally, under arthroscopic visualization, the surgeon was given 1 attempt to aim and drill the guide pin to his mark. Pin position was digitally recorded; the distance of the drill pin from the mark quantifies drill pin placement accuracy.Results: Mean accuracy for the 3.0-mm guide pin was 2.87 ± 1.19 mm versus 6.98 ± 1.29 mm for the 2.4-mm pin. The difference was significant (P = .005). Surgeon anatomic precision was 3.32 ± 2.10 mm.Conclusions: Our results show that a 3-mm ACL tibial guide pin is significantly more accurate than a 2.4-mm-diameter pin. The 3-mm pin accuracy is within the range of surgeon precision; the 2.4-mm pin accuracy is not.Clinical Relevance: Pin accuracy and surgeon precision are clinically relevant measures because anatomic tunnel placement is a determinant of ACL reconstruction outcome.

Fixation of Detached Osteochondritis Dissecans Lesions With Bioabsorbable Pins: Clinical and Histologic Evaluation - Corrected Proof

2010-03-08

Purpose: The purpose was to evaluate the effect of fixation of detached free fragments of osteochondritis dissecans (OCD) (International Cartilage Repair Society OCD IV) on not only the clinical outcome, including functional and radiographic assessment, but also postoperative second-look arthroscopic and histologic evaluation.Methods: Nine International Cartilage Repair Society OCD IV fragments were fixed with bioabsorbable pins made of poly-L-lactic acid after curettage of the bed and bone grafting. In 4 cases with severe cartilage damage in the fragments, after resection of the damaged part, trimmed fragments were fixed and osteochondral autologous transplantation was performed to cover the remaining defects. The follow-up period was at least 2 years (range, 2 to 3 years). Lysholm score and computed tomography (CT)/magnetic resonance imaging (MRI), second-look arthroscopy, and biopsy findings were examined postoperatively.Results: All patients ultimately could return to previous sports activity, and the mean postoperative Lysholm score was 97 (range, 90 to 100). At 6 months, CT/MRI scans showed complete union and smooth continuity of articular surface in all cases. Second-look arthroscopy in 7 cases showed that fixed fragments were stable and that there were no progressive degenerative changes in the cartilage. Postoperative histologic examination in 4 cases showed almost normal cartilage from surface to bottom in terms of viability and quality. In addition, new bone trabeculae were covering dead bone trabeculae, which is called creeping substitution.Conclusions: Our study shows good short-term clinical results, as well as confirmation of healing on CT/MRI and second-look arthroscopy.Level of Evidence: Level IV, therapeutic case series.

Comparison of Anatomic Versus Nonanatomic Placement of Femoral Tunnels in Achilles Double-Bundle Posterior Cruciate Ligament Reconstruction - Corrected Proof

David A. McGuire, Stephen D. Hendricks — 2010-03-04

Purpose: In this study, we compared femoral tunnel pairs that differ by group in a double-bundle Achilles tendon allograft posterior cruciate ligament (PCL) reconstruction.Methods: Group 1 patients had femoral tunnels drilled nearly within the footprint area most proximal and most distal to the axis of the femur. Group 2 patients had femoral tunnels drilled eccentrically within the footprint along an axis nearly perpendicular to the axis of the femur. Patient assessments were made subjectively with preoperative and postoperative assessments of Lysholm rating scale, posterior drawer test, and dial test. Objective assessments used range of motion and quadriceps circumference. Group 1 contained 7 patients with a mean age of 32 years (range, 20 to 46 years). Group 2 contained 10 patients with a mean age of 32 years (range, 20 to 46 years).Results: Group 2 patients had significantly less posterior laxity than group 1 patients. Postoperatively, 6 patients in group 1 (86%) had a positive posterior drawer test compared with 3 in group 2 (30%). Rotational laxity was identified by dial test results postoperatively in 3 patients in group 1 (43%) compared with 0% in group 2. Extension deficit occurred in 2 patients in group 1 (29%) and 1 patient in group 2 (10%). Flexion deficit occurred more than twice as frequently in group 1 (71% [5 patients]) than in group 2 (30% [3 patients]). There were no statistically significant differences for other comparisons.Conclusions: The clinical outcomes support the group 2 method with femoral tunnel placement at the anterior-most and posterior-most portions of the femoral PCL insertion. The group 2 procedure described in this study incorporates advanced principles for successful outcomes with Achilles double-bundle PCL reconstruction.Level of Evidence: Level III, case-control study.

The Effect of a Sequential Compression Device on Hemodynamics in Arthroscopic Shoulder Surgery Using Beach-Chair Position - Corrected Proof

Hyun J. Kwak, Jong S. Lee, Dong C. Lee, Hong S. Kim, Ji Y. Kim — 2010-03-04

Purpose: This study investigated the effect of intermittent compression by a sequential compression device (SCD) on the incidence of hypotension and other hemodynamic variables in the beach-chair position.Methods: Fifty healthy patients undergoing elective shoulder arthroscopy under general anesthesia were randomly assigned to either the control group (n = 25) or SCD group (n = 25). A standardized protocol for pre-hydration and anesthetic technique was followed. Hemodynamic variables were measured before (pre-induction values) and 5 minutes after the induction of anesthesia in the supine position (baseline values) and 1, 3, and 5 minutes after the patient was raised to a 70° sitting position. The incidence of hypotension was recorded and treated with ephedrine.Results: The incidence of hypotension was significantly higher in the control group (16 of 25) than that in the SCD group (7 of 25) (P = .022; odds ratio, 0.219; 95% confidence interval, 0.066 to 0.723). Between the groups, mean arterial pressure, cardiac index, and stroke volume index were significantly higher in the SCD group compared with values in the control group at 1 minute after patients were raised to a 70° sitting position (P = .035, P = .046, and P = .011, respectively).Conclusions: This study showed that the use of an SCD could reduce the incidence of hypotension from 64% to 28% and supports hemodynamic variables such as mean arterial pressure and stroke volume index when patients were changed from the supine to the beach-chair position in those undergoing shoulder arthroscopy.Level of Evidence: Level I, therapeutic randomized controlled trial.

Magnetic Resonance Imaging Characteristics of the Medial Patellofemoral Ligament Lesion in Acute Lateral Patellar Dislocations Considering Trochlear Dysplasia, Patella Alta, and Tibial Tuberosity–Trochlear Groove Distance - Corrected Proof

2010-03-04

Purpose: The objective of this study was to analyze the injury patterns of the medial patellofemoral ligament (MPFL) in acute lateral patellar dislocations (LPDs) considering the anatomically relevant factors of patellar instability.Methods: Knee magnetic resonance images were collected from 73 patients within 7 weeks after LPD, and the injury patterns of the MPFL were evaluated for trochlear dysplasia, for patellar height, and for the tibial tuberosity–trochlear groove (TT-TG) distance.Results: Injury to the MPFL was found in 98.6% of the patients (72 of 73) after the acute LPD, with a complete tear in 51.4% (37 of 72), most frequently localized at the femoral attachment site, and a partial tear in 48.6% (35 of 72). Injury to the femoral origin (Fem), to the midsubstance (Mid), and to the patellar insertion (Pat) of the MPFL was found in 50.0% (36 of 72), 13.9% (10 of 72), and 13.9% (10 of 72), respectively. More than 1 site of injury was found in 22.2% (16 of 72), most frequently as a combined injury at the femoral origin and at the patellar insertion sites (Pat+Fem) (13 of 16). The study population, as well as the Pat, Fem, and Pat+Fem subgroups, showed significantly different values of trochlear dysplasia and patellar height when compared with the control group, whereas the data of the Mid group were not significantly different. In addition, injury at the patellar insertion (Pat) was accompanied by a significantly increased TT-TG distance when compared not only with the control group but also with the Fem, Mid, and Pat+Fem groups.Conclusions: The data from our study indicate that patterns of MPFL injury depend on trochlear dysplasia, patellar height, and TT-TG distance. They show a new aspect in the complex interplay between active, passive, and static stabilizers of the patellofemoral joint.Level of Evidence: Level IV, diagnostic case-control study.

Arthroscopic Fixation Technique for Comminuted, Displaced Greater Tuberosity Fracture - Corrected Proof

2010-03-02

Purpose: The purpose of this retrospective study was to evaluate the early results of arthroscopic treatment in patients with comminuted, displaced greater tuberosity (GT) fractures using the arthroscopic double-row suture anchor fixation (ADSF) technique.Methods: Between August 2004 and December 2007, we used the ADSF technique in 16 cases of isolated comminuted, displaced GT fractures. The early clinical results were evaluated in these patients at a mean of 24 months (range, 16 to 51 months) after surgery. There were 11 male and 5 female patients with a mean age of 56.5 years (range, 27 to 82 years). These 16 cases had at least 5 mm of displacement of the fracture fragments in any plane. For measurement of clinical outcomes, we assessed range of motion and evaluated the visual analog scale score; the University of California, Los Angeles (UCLA) rating scale; and the shoulder index of the American Shoulder and Elbow Surgeons.Results: At final follow-up, the visual analog scale score improved from 9.4 (range, 8 to 10 points) to 1.2 (range, 0 to 4 points), the mean UCLA score improved to 31 points (range, 21 to 35 points) postoperatively, and the American Shoulder and Elbow Surgeons score improved to 88.1 points (range, 81.5 to 100 points). According to the UCLA score, there were 3 excellent results, 11 good results, and 2 poor results. Mean forward flexion was 148.7° (range, 120° to 170°), mean abduction was 145° (range, 120° to 170°), mean external rotation in the neutral position was 24° (range, 10° to 40°), and internal rotation improved to the first lumbar vertebral level (from L3 to T7) at last follow-up.Conclusions: The early results of the ADSF technique used for displaced, comminuted GT fractures are encouraging, and arthroscopists should attempt to expand the indications for arthroscopic treatment of these fractures.Level of Evidence: Level IV, therapeutic case series.

Outcome of Arthroscopic Single-Bundle Versus Double-Bundle Reconstruction of the Anterior Cruciate Ligament: A Preliminary 2-Year Prospective Study - Corrected Proof

2010-02-22

Purpose: The purpose of this study was to compare the clinical results of arthroscopic single-bundle and double-bundle anterior cruciate ligament (ACL) reconstruction.Methods: We designed a prospective study that included patients with an isolated ACL injury. From April 2004 to February 2007, of 147 patients who underwent ACL reconstruction, 113 were included in this study. We serially obtained clinical and radiologic data preoperatively and postoperatively. We compared preoperative data and data at 2 years postoperatively in patients who had undergone single-bundle ACL reconstruction versus patients who had undergone double-bundle ACL reconstruction. There were 50 single-bundle reconstructions and 63 double-bundle reconstructions. Anteroposterior stability was assessed objectively by anterior stress radiographs with the telos device (telos, Marburg, Germany) and the maximal manual test with the KT-2000 arthrometer (MEDmetric, San Diego, CA). Rotational stability was determined by lateral pivot-shift test. The clinical results were assessed by International Knee Documentation Committee and Orthopadische Arbeitsgruppe Knie scores and Tegner activity scale. In addition, we evaluated postoperative thigh circumference and range of motion.Results: Residual anteroposterior laxity determined at 2 years postoperatively by telos and KT-2000 was 1.74mm ± 1.67mm and 1.79mm ± 1.56mm, respectively, in the single-bundle reconstruction group and 1.63mm ± 1.50mm and 1.61mm ± 1.22mm, respectively, in the double-bundle reconstruction group. There were no statistically significant differences. For the lateral pivot-shift test done at 2 years postoperatively, there was no statistically significant difference. In addition, clinical results such as International Knee Documentation Committee score, Orthopadische Arbeitsgruppe Knie score, Tegner activity scale, thigh circumference, and range of motion showed no significant differences between the 2 groups.Conclusions: Double-bundle reconstruction of the ACL by a method using 2 femoral tunnel and 2 tibial tunnels showed no differences in stability results or any other clinical aspects or in terms of patient satisfaction.Level of Evidence: Level II, prospective comparative study.

The Effect of Posterosuperior Rotator Cuff Tears and Biceps Loading on Glenohumeral Translation - Corrected Proof

Wei-Ren Su, Jeffrey E. Budoff, Zong-Ping Luo — 2010-02-22

Purpose: To investigate the biomechanical effects of posterosuperior rotator cuff tear (RCT) size and of loading the long biceps tendon in the presence of various-sized RCTs.Methods: Ten cadaveric shoulders were subjected to loading in the superior and anterosuperior directions in the intact state and with sequentially larger RCTs. Glenohumeral translation was measured with and without biceps tendon loading.Results: As long as the inferior infraspinatus remained intact, there was no significant difference in glenohumeral translation for any load studied. Once the supraspinatus and the entire infraspinatus were released, 50 N of load led to significantly increased translation in both directions. When we compare the results of this study with those of a previous study, the subscapularis appears to be more effective than the infraspinatus in constraining both anterosuperior and superior translation. For the intact specimens and for all sizes of RCTs, biceps loading led to a significant decrease in both anterosuperior and superior glenohumeral translation. Depending on the size of the RCT and the direction of loading, this decrease in glenohumeral translation varied from 19% to 53%.Conclusions: Tears of the subscapularis have greater biomechanical consequences than do tears of the infraspinatus. Loading the long biceps tendon led to a significant decrease in anterosuperior and superior glenohumeral translation for all sizes of RCTs, with a greater decrease in the percentage of glenohumeral translation noted for larger tears.Clinical Relevance: Knowledge of the biomechanics of posterosuperior RCTs enhances our ability to treat them. Surgeons should be aware that, although biceps tenotomy or tenodesis may provide pain relief in shoulders with RCTs, there are biomechanical consequences to these procedures.

The Relation Between Tunnel Widening and Bone Mineral Density After Anterior Cruciate Ligament Reconstruction: An Experimental Study in Sheep - Corrected Proof

2010-02-17

Purpose: The aim of this study was to analyze the relation between bone mineral density (BMD) and femoral tunnel enlargement (TE) in a previously validated sheep model of soft-tissue anterior cruciate ligament (ACL) reconstruction.Methods: Thirty sheep underwent ACL reconstruction by use of a soft-tissue graft at the age of 4 months. Graft fixation was achieved with the EndoButton (Smith & Nephew Endoscopy, Andover, MA) and Suture Washer (Smith & Nephew Endoscopy). Six animals were killed at 0, 3, 6, 12, and 24 weeks postoperatively. Each ACL-reconstructed knee was examined both by computed tomography to analyze the bone tunnel cross-sectional area and by dual-energy x-ray absorptiometry to analyze BMD.Results: There was a significant increase in tunnel cross-sectional area. BMD decreased significantly within the first 3 weeks after surgery and increased thereafter. A positive correlation between TE and BMD was found. However, a subgroup analysis showed that there is no influence of BMD on the development of a tunnel widening.Conclusions: The hypothesis that a TE would be associated with a loss in BMD was not confirmed. Tunnel widening during the first 6 months after ACL reconstruction is not affected by the transient changes in BMD.Clinical Relevance: There is no correlation between TE and BMD in an experimental sheep model of ACL reconstruction. Translational investigations will determine whether this is also true in humans.

Biomechanical Comparison of Transosseous Versus Suture Anchor Repair of the Subscapularis Tendon - Corrected Proof

2010-02-17

Purpose: The purpose of this study was to compare the biomechanical properties of transosseous versus suture anchor repair of the subscapularis tendon. We also performed real-time measurement of contact area and pressure of the repair site under rotational loads.Methods: Six paired human cadaveric shoulders were subjected to rotational loading after repair of the subscapularis tendon. Both shoulders were randomized to transosseous or suture anchor repairs. Real-time pressure sensors were placed between the subscapularis tendon and lesser tuberosity. The repair was subjected to cyclical rotational loading and load-to-failure testing.Results: No significant difference was detected in initial pressurized contact area between transosseous repairs (1.70 ± 0.99 cm2, 57.88 ± 30.02% footprint) and suture anchor repairs (1.08 ± 0.58 cm2, 34.26% ± 17.32% footprint). Under cyclical loading, the conditioning elongation of transosseous repairs (0.64 ± 0.40 mm) was significantly lower (P < .05) than that of suture anchor repairs (2.38 ± 1.58 mm). No significant difference was found in mean pressurized contact area between the transosseous repairs (2.72 ± 1.25 cm2, 94.2% ± 37.4% footprint) and suture anchor repairs (2.01 ± 0.89 cm2, 65.9% ± 27.9% footprint). For suture anchor repairs, repair-site contact area was significantly (P < .05) smaller than the area of corresponding native insertional footprints; for transosseous repairs, no significant difference was detected. There were no significant differences in peak pressures between the 2 repairs. In the load-to-failure tensile test, there was no significant difference between transosseous repairs (453.2 ± 66.1 N) and suture anchor repairs (392.6 ± 78.0 N).Conclusions: Transosseous and suture anchor repairs of the subscapularis tendon have comparable biomechanical properties. Despite increased conditioning elongation in suture anchor repairs, we found no significant differences in mean contact area between the 2 repairs under cyclical loading. The suture anchor repairs do have a smaller contact area than the native insertional area. Real-time pressure and contact area measurements enabled mapping of the repair site throughout cyclical loading.Clinical Relevance: Rotational loading of the subscapularis tendon may provide a more accurate representation of subscapularis tendon injuries. Both techniques showed adequate repair strength; however, neither surgical technique exhibited normal insertional behavior in this time-zero biomechanical study.

Diagnostic Ultrasound Evaluation of Posterolateral Corner Knee Injuries - Corrected Proof

Jon K. Sekiya, Jennifer C. Swaringen, Edward M. Wojtys, Jon A. Jacobson — 2010-02-12

Purpose: The purpose of this study was to determine whether dynamic ultrasound (US) would be able to differentiate posterolateral corner knee injuries that would require surgical intervention.Methods: This is a single-group cohort study. A knee sonogram was obtained in patients referred to us with suspected posterolateral knee injury. In addition to static US imaging, a dynamic US stress test was performed by placement of maximum varus stress on the knee at 30° of flexion. The tibiofemoral separation was then measured with US. Results from US and surgery were then compared.Results: Sixteen patients had US and underwent surgery, and twelve patients had surgical findings requiring surgical intervention to the posterolateral knee structures. With regard to static US images, the sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were 92%, 75%, 92%, 75%, and 88%, respectively, for the lateral collateral ligament; 33%, 100%, 100%, 33%, and 50%, respectively, for the popliteus; and 67%, 75%, 67%, 75%, and 69%, respectively, for the popliteofibular ligament. The dynamic US stress test showing 10.5 mm of lateral joint space width or more during varus stress showed a sensitivity of 83% and specificity of 100% for injury to the lateral collateral ligament and posterolateral corner structures, with a positive predictive value of 100%, negative predictive value of 75%, and accuracy of 88%.Conclusions: A positive dynamic US stress test (≥10.5 mm) positively predicted the need for posterolateral knee surgery in 100% of patients in this study who required posterolateral corner repair or reconstruction.Level of Evidence: Level I, testing of previously developed diagnostic criteria in series of consecutive patients with universally applied gold standard.

Arthroscopic Treatment of Femoral Acetabular Impingement in Patients With Preoperative Generalized Degenerative Changes - Corrected Proof

Monika Horisberger, Alexander Brunner, Richard F. Herzog — 2010-02-12

Purpose: The aim of this study was to evaluate the short-term results after arthroscopic femoroacetabular impingement (FAI) correction combined with additional procedures addressing labral and chondral damages in patients who showed generalized severe cartilage lesions intraoperatively.Methods: Between 2004 and 2007, 20 patients (16 men and 4 women) could be included in the study. Clinical parameters, the pain score on a visual analog scale, initial radiologic degenerative changes, the alpha angle, and the Nonarthritic Hip Score were prospectively documented. The study endpoint was the implantation of a total hip arthroscopy or the latest follow-up.Results: At a mean follow-up of 3.0 years, 10 patients (50%) had undergone, or planned to undergo, total hip replacement. The remaining patients showed a significant improvement in pain, Nonarthritic Hip Score, and hip flexion and internal rotation.Conclusions: In patients with already marked generalized chondral lesions, arthroscopy does not have any effect beyond the short-term pain relief resulting from debridement. The study underlines the fact that FAI with advanced osteoarthrosis, particularly Tönnis grade III, is not an indication for arthroscopic FAI correction.Level of Evidence: Level IV, therapeutic case series.

Hamstring Strength Recovery After Hamstring Tendon Harvest for Anterior Cruciate Ligament Reconstruction: A Comparison Between Graft Types - Corrected Proof

Clare L. Ardern, Kate E. Webster, Nicholas F. Taylor, Julian A. Feller — 2010-02-01

Purpose: The purpose of this study was to investigate hamstring strength after harvest of 1 or 2 hamstring tendons for anterior cruciate ligament reconstruction.Methods: We recruited 50 individuals who had returned to regular sporting activity to participate in a comparative study at a mean of 32.5 months after anterior cruciate ligament reconstructive surgery (30 in semitendinosus-gracilis group and 20 in semitendinosus group). Isokinetic hamstring strength (at 60°/s and 180°/s with the peak torque and torque produced at 60°, 90°, and 105° of knee flexion recorded) and isometric hamstring strength (at 30°, 90°, and 105° of knee flexion) were measured, and the standing knee flexion angle was used to evaluate functional hamstring strength recovery.Results: No significant differences between the groups were found in any of the isometric or isokinetic strength measures or in the standing knee flexion angle. No relation was found between the standing knee flexion angle and the isometric hamstring strength results obtained at 105° of knee flexion (r2 = 0.034).Conclusions: These findings show that the choice of hamstring tendon graft—that is, semitendinosus alone or semitendinosus and gracilis—is unlikely to significantly influence postoperative hamstring strength outcomes in athletes returning to sports postoperatively. Both graft choices showed strength deficits of between 3% and 27% compared with the nonoperated limb, indicating that hamstring strength deficits persist despite successful completion of rehabilitation. The results also show that the standing knee flexion angle should not be used as a surrogate clinical measure of hamstring strength.Level of Evidence: Level III, retrospective comparative study.

Arthroscopic Ganglionectomy Through an Intrafocal Cystic Portal for Wrist Ganglia - Corrected Proof

2010-02-01

Purpose: A retrospective study was conducted on arthroscopic ganglionectomy in wrists using a novel intrafocal cystic portal. The safety and efficacy of this technique were assessed by treatment of 15 wrists in 15 patients.Methods: Arthroscopic ganglionectomy was performed by the same surgeon with the patient under general anesthesia or regional block. Preoperative complaints, intraoperative findings, and postoperative results of all the patients were reported. The mean follow-up was 15.3 months. Functional assessment by use of modified Mayo wrist scores, patient satisfaction, and recurrence were included in the follow-up evaluation.Results: Two thirds of the patients acquired good to excellent results, whereas the results for the remaining third were fair. Complications included 1 recurrence and 1 case of transient paresthesia sensation. The most common arthroscopic findings were capsular and ligament lesions, rather than ganglionic stalks.Conclusions: Arthroscopic ganglionectomy through an intrafocal cystic portal is a safe and efficacious option for the treatment of painful wrist ganglia.Level of Evidence: Level IV, therapeutic case series.

False FHL: A Normal Variant Posing Risks in Posterior Hindfoot Endoscopy - Corrected Proof

Phinit Phisitkul, Annunziato Amendola — 2010-01-25

Abstract: Posterior hindfoot endoscopy has been more commonly used in the treatment of various pathologies by surgeons with different arthroscopic experience. The flexor hallucis longus is usually the initial and most important landmark serving as a medial boundary for the arthroscope and instruments to avoid inadvertent injury to the tibial nerve and vessels. We report 2 cases in which the presence of the peroneocalcaneus internus muscle, “false FHL,” imitated the flexor hallucis longus, risking imminent neurovascular injury during the initial endoscopic exposure. Awareness of this rare anatomic variation, preoperative magnetic resonance imaging studies, and intraoperative differentiation techniques were found helpful to avoid devastating complications.

The Outcome of Type II SLAP Repair: A Systematic Review - Corrected Proof

Kalyan Gorantla, Corey Gill, Rick W. Wright — 2010-01-25

Purpose: The purpose of this study was to systematically review the literature regarding the outcome of arthroscopic repair of type II SLAP lesions in order to assess the effectiveness of current methods of treatment.Methods: We performed a systematic review of the results of repair of type II SLAP lesions. Inclusion criteria included outcome studies of repair of type II SLAP lesions with minimum 2-year follow-up and Level IV evidence or higher published in the English language in peer-reviewed journals.Results: There is no Level I or II evidence for SLAP repair outcome. Regarding the general outcome after type II SLAP repair, the percentage of good and excellent results ranged from 40% to 94%. Return to previous level of play ranged from 20% to 94%. Overhead athletes are the most challenging to return to the previous level of performance for this diagnosis, and their return rate reflects this. Five studies reported these results, and the rate of return ranged from 22% to 64% for baseball players.Conclusions: Arthroscopic repair of type II SLAP tears results in overall excellent results for individuals not involved in throwing or overhead sports. The results of type II SLAP repair in throwing or overhead athletes are much less predictable. Future studies should be prospective in nature and at least use a longitudinal prospective cohort design to determine predictors of outcome.Level of Evidence: Level IV, systematic review of Level III and IV studies.

Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Allograft: An Age-Dependent Outcome Evaluation - Corrected Proof

F. Alan Barber, Jorge Aziz-Jacobo, Fernando Barrera Oro — 2010-01-25

Purpose: To compare the outcomes of a consecutive series of nonrevision bone–patellar tendon–bone (BPTB) allograft anterior cruciate ligament (ACL) reconstructions in patients aged 40 years or older and patients aged younger than 40 years.Methods: Prospectively collected data from consecutive BPTB allograft ACL reconstructions fixed with biodegradable interference screws and performed by a single surgeon were analyzed by use of established outcome measures. Preoperative and postoperative outcome assessments included Cincinnati, Lysholm, and Tegner scores and International Knee Documentation Committee (IKDC) activity scores. Lachman test, pivot-shift test, and KT arthrometer (MEDmetric, San Diego, CA) measurements were obtained at a minimum of 24 months after surgery.Results: In total, 32 patients met the inclusion criteria (21 men and 11 women). The mean follow-up was 35 months (range, 24 to 58 months). Of the patients, 21 were aged younger than 40 years (66%) and 11 were aged 40 years or older (34%). The mean age was 35 years (range, 18 to 55 years). In patients aged younger than 40 years, the mean postoperative Cincinnati score was 82.4 (39.1 preoperatively); Tegner score, 6.2 (3.9 preoperatively); Lysholm score, 89.5 (46.8 preoperatively); and IKDC activity score, 2.7 out of 4 (1.7 preoperatively). Five patients had a positive postoperative Lachman test, but none had a positive pivot-shift test. KT examinations showed a manual maximum difference of less than 3 mm in all but 1 patient (mean, 0.7 mm). In patients aged 40 years or older, the mean postoperative Cincinnati score was 83.8 (44.4 preoperatively); Tegner score, 6.6 (3.9 preoperatively); Lysholm score, 88.8 (50.1 preoperatively); and IKDC activity score, 2.7 out of 4 (2.1 preoperatively). One patient had a positive postoperative Lachman test, but none had a positive pivot-shift test. KT examinations showed a manual maximum difference of less than 3 mm in all but 1 patient (mean, 1.3 mm).Conclusions: The outcomes of BPTB allograft ACL reconstructions were not different both subjectively and objectively for patients aged 40 years or older and patients aged younger than 40 years. BPTB allograft ACL reconstruction provides consistent results for patients of all age groups.Level of Evidence: Level III, retrospective comparative study.

Ligamentization of Tendon Grafts Treated With an Endogenous Preparation Rich in Growth Factors: Gross Morphology and Histology - Corrected Proof

2010-01-18

Purpose: To investigate whether the application of a particular platelet-rich plasma preparation rich in growth factors (PRGF) during anterior cruciate ligament (ACL) surgery gives a potential advantage for better tendon graft ligamentization.Methods: This study included 37 volunteers who underwent either conventional (control group, n = 15) or PRGF-assisted (n = 22) ACL reconstruction with an autogenous hamstring and required second-look arthroscopy to remove hardware or loose bodies, treat meniscal tears or plica syndrome, or resect cyclops lesions at 6 to 24 months after ACL surgery. The gross morphologies of the grafts were evaluated on second-look arthroscopy by use of the full arthroscopic score (0 to 4 points) to evaluate graft thickness and apparent tension (0 to 2 points) plus synovial coverage (0 to 2 points). At the same time, biopsy specimens were harvested uniformly from the grafted tendons. In these specimens the histologic transformation of the tendon graft to ACL-like tissue was evaluated by use of the Ligament Tissue Maturity Index, and a score to assess the progression of new connective tissue enveloping the graft was created by use of 3 criteria previously used to characterize changes during ligament healing: cellularity, vascularity, and collagen properties.Results: The overall arthroscopic evaluation of PRGF-treated grafts showed an excellent rating in 57.1% of the knees (score of 4) and a fair rating in 42.9% (score of 2 or 3). In contrast, evaluation of untreated grafts showed an excellent rating in 33.3% of the knees, a fair rating in 46.7%, and a poor rating in 20% (score of 0 or 1). Overall, arthroscopic evaluations were not statistically different between PRGF and control groups (P = .051). PRGF treatment influenced the histologic characteristics of the tendon graft, resulting in tissue that was more mature than in controls (P = .024). Histologically evident newly formed connective tissue enveloping the graft was present in 77.3% of PRGF-treated grafts and 40% of controls. The appearance of the connective tissue envelope changed with increasing time from surgery. On the basis of the histologic findings, we suggest that the remodeling of PRGF-treated grafts involves the formation of synovial-like tissue enveloping the graft. This tissue is eventually integrated in the remodeled tendon graft, conferring a similar appearance to the normal ACL.Conclusions: The use of PRGF influenced the histologic characteristics of tendon grafts, resulting in more remodeling compared with untreated grafts. We have shown temporal histologic changes during the 6- to 24-month postoperative period of graft maturation, with newly formed connective tissue enveloping most grafts treated with PRGF.Level of Evidence: Level III, case-control study.

Avoiding Mismatch in Allograft Anterior Cruciate Ligament Reconstruction: Correlation Between Patient Height and Patellar Tendon Length - Corrected Proof

2009-12-28

Purpose: The purpose of this study was to evaluate whether a correlation exists between patient height and soft-tissue patellar tendon length.Methods: Magnetic resonance imaging (1.5 T) was performed for knee pathology on 403 patients. The patellar tendon length was measured in the midsagittal plane by a board-certified musculoskeletal radiologist. Patient height was recorded to the nearest inch. Patients were grouped into 6 subgroups with 4-inch range intervals based on height. The entire study group was analyzed. Subgroup analysis and gender analysis were performed to determine statistical significance.Results: The mean patellar tendon length was 45 ± 7 mm (range, 30 to 66 mm). Wide ranges were noted among each height subgroup irrespective of gender. Significant differences were noted between most height subgroups independent of gender.Conclusions: This study showed that a correlation exists between patient height, gender, and patellar tendon length. Although variation occurs among patients of the same height, significant differences in mean patellar tendon lengths do exist between patients in different height subgroups.Clinical Relevance: Parameters are provided using patient gender and height to reduce the potential for graft-construct mismatch when ordering bone–patellar tendon–bone allografts for anterior cruciate ligament reconstruction.