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

Platelet-Rich Plasma: A Milieu of Bioactive Factors - Corrected Proof

2012-01-30

Abstract: Platelet concentrates such as platelet-rich plasma (PRP) have gained popularity in sports medicine and orthopaedics to promote accelerated physiologic healing and return to function. Each PRP product varies depending on patient factors and the system used to generate it. Blood from some patients may fail to make PRP, and most clinicians use PRP without performing cell counts on either the blood or the preparation to confirm that the solution is truly PRP. Components in this milieu have bioactive functions that affect musculoskeletal tissue regeneration and healing. Platelets are activated by collagen or other molecules and release growth factors from alpha granules. Additional substances are released from dense bodies and lysosomes. Soluble proteins also present in PRP function in hemostasis, whereas others serve as biomarkers of musculoskeletal injury. Electrolytes and soluble plasma hormones are required for cellular signaling and regulation. Leukocytes and erythrocytes are present in PRP and function in inflammation, immunity, and additional cellular signaling pathways. This article supports the emerging paradigm that more than just platelets are playing a role in clinical responses to PRP. Depending on the specific constituents of a PRP preparation, the clinical use can theoretically be matched to the pathology being treated in an effort to improve clinical efficacy.

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

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

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

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

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

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

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

2012-01-30

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

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.

In Vivo Graft Tension in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction During Active Leg-Raising Motion With the Knee Splinted - Corrected Proof

2012-01-27

Purpose: The purpose of this study was to measure the in vivo graft tension in anatomic 2-bundle anterior cruciate ligament (ACL) reconstruction during active leg-raising exercise with the knee immobilized. Methods: Anatomic double-bundle ACL reconstruction was performed with autogenous semitendinosus tendons in 7 patients while under general anesthesia. Two grafts were fixed with 2 EndoButton-CL devices (Smith & Nephew Endoscopy, Andover, MA) on the femur and were temporarily fixed to 2 tension-adjustable force gauges on the anterior tibial cortex. Then, a knee brace in semi-flexion was put around the knee, and 10 N of initial tension was applied to each graft at 20° of flexion. The tension on the anteromedial (AM) and posterolateral (PL) grafts was continuously measured during active leg-raising motion with the knee immobilized after patients had awoken from anesthesia. Then, the tension measurement was repeated during active leg-raising motion with the knee immobilized while a 2-kg weight was fitted around the ankle. Results: In situ graft tension during active leg-raising motion with a knee brace was 10.9 ± 4.0 N for the AM graft and 8.6 ± 5.1 N for the PL graft, whereas the tension with a 2-kg weight around the ankle was 10.9 ± 3.4 N for the AM graft and 9.9 ± 3.6 N for the PL graft. There was no significant difference between each graft in the 2 motions with a paired t test. Conclusions: Graft tension with the knee immobilized with a semi-flexed knee brace during active leg-raising motion was 19.5 N with no weight and 20.8 N with additional weight, both of which were almost equal to the initial graft tension at the time of fixation at 20°. Thus the leg-raising exercise can be recommended as safe when a semi-flexed knee brace is worn after ACL reconstruction. Clinical Relevance: These findings will help to plan postoperative rehabilitation programs with security.

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

2012-01-27

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

Histopathology of Residual Tendon in High-Grade Articular-Sided Partial-Thickness Rotator Cuff Tears (PASTA Lesions) - Corrected Proof

Kotaro Yamakado — 2012-01-27

Purpose: The purpose of this study was to examine the histopathologic features of the residual intact tissue of a partial articular surface tendon avulsion (PASTA) tear. Methods: In 30 consecutive patients with PASTA lesions, biopsy specimens of the residual tendon were taken. The mean age was 60.4 years (range, 28 to 78 years). All tears were converted to full-thickness tears and arthroscopically repaired. None of the patients were overhead athletes. Samples were histopathologically examined and graded by use of a modified semiquantitative scale (between 0, normal appearance, and 21, most abnormal appearance). Data were analyzed by multiple regression analysis to estimate the effect of aging, smoking status, duration of pain, and steroid injections. Results: Degenerative changes were evident in 28 of 30 cases (93%). The mean score on the modified semiquantitative grading scale was 10.5 (range, 3 to 16; SD, 2.6). Multiple regression analysis failed to show a statistically significant correlation between the score on the modified semiquantitative grading scale and aging, smoking status, duration of pain, or steroid injections. Conclusions: Over 90% of the macroscopically intact residual tendon tissues of the PASTA lesions showed moderate histopathologic degeneration. Level of Evidence: Level IV, therapeutic case series.

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

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

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

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

2012-01-27

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

Biceps Tenotomy Versus Tenodesis: Clinical Outcomes - Corrected Proof

2012-01-27

Purpose: We present a systematic review of the current literature regarding the use of the 2 most common surgical treatments for lesions of the long head of the biceps brachii, tenotomy or tenodesis. Currently, there is no consensus management in the literature because most studies lack high levels of evidence. Methods: PubMed was systematically reviewed for eligible articles relating to biceps tenotomy or tenodesis. Level I to IV evidence and English-language studies reporting on the clinical outcomes of these 2 procedures were included. The primary clinical outcome measurements for each study were determined and were normalized and reported as the percentage of “excellent/good” versus “poor” results based on criteria laid out in each study. Results: Sixteen studies met the inclusion criteria. All articles reviewed were of Level IV evidence, except for one Level II prospective cohort study. All studies, a total of 433 tenodesis procedures resulted in an excellent/good outcome in 74% of patients, with an 8% rate of cosmetic deformity. A total of 699 tenotomy procedures resulted in an excellent/good outcome in 77% of patients, with a 43% occurrence of cosmetic deformity. Postoperative bicipital pain was found in 43 of 226 cases (19%) of tenotomy and 18 of 74 cases (24%) of tenodesis. The 4 studies that compared the procedures directly did not show any significant clinical differences between the groups other than a cosmetic deformity being present more frequently after tenotomy. Conclusions: Tenotomy and tenodesis have comparably favorable results in the literature, with the only major difference being a higher incidence of cosmetic deformity with biceps tenotomy. However, there is currently no consensus regarding the use of tenotomy versus tenodesis for the treatment of lesions of the long head of the biceps brachii. The lack of prospective, randomized trials limits our ability to recommend 1 technique over the other. There is a great need for controlled trials to investigate the differences between these 2 procedures. Individual patient factors and needs should guide the surgeon on which procedure to use. Level of Evidence: Level IV, systematic review of Level IV studies.

Surgical Decision Making for Arthroscopic Partial Meniscectomy in Patients Aged Over 40 Years - Corrected Proof

2012-01-24

Purpose: To identify clinical variables that affect a surgeon's decision to recommend arthroscopic partial meniscectomy (APM). Methods: Members of 2 orthopaedic specialty societies were invited to participate in an online survey by e-mail. The survey consisted of surgeon demographics and case scenarios to evaluate clinical decision making for APM. Posterior probabilities were calculated to determine the effect of clinical factors on the likelihood of recommending APM. Results: Of the respondents with valid e-mail addresses, 733 (19.3%) returned a completed survey, but only 533 (14.1%) met the eligibility criteria (treated or referred an APM candidate within the past year). Respondents were aged 46.7 ± 9.4 and had performed a mean of 115 APMs in the previous year. Posterior probabilities for a combination of 6 clinical indicators identified 3 factors that most influenced a surgeon's decision to recommend APM: radiographic findings, McMurray test, and failure of nonoperative management. Conclusions: Significant variation exists among practicing orthopaedic surgeons with regard to decision making for APM. The 3 clinical factors that most influenced a surgeon's decision to recommend APM were normal radiographic findings, failed nonoperative treatment, and the presence of positive physical examination findings (i.e., positive McMurray test, joint line tenderness, and effusion). Level of Evidence: Level III, decision analysis.

Long-Term Outcome After Arthroscopic Repair of Type II SLAP Lesions: Results According to Age and Workers' Compensation Status - Corrected Proof

Patrick J. Denard, Alexandre Lädermann, Stephen S. Burkhart — 2012-01-24

Purpose: The purpose of this study was to determine the long-term functional outcome of anatomic arthroscopic repair of type II SLAP lesions with suture anchors. Methods: We examined all arthroscopic repairs of isolated type II SLAP lesions from January 2002 through December 2007. Fifty-five patients were available for long-term follow-up at a mean of 77 months. The mean patient age at the time of surgery was 39.7 years (range, 17 to 65 years); 23 patients were aged younger than 40 years, and 32 patients were aged 40 years or older. Fourteen cases involved Workers' Compensation claims. Results: Overall, functional outcome was improved from baseline compared with final follow-up for both American Shoulder and Elbow Surgeons scores (44.1 points v 86.2 points, P < .001) and University of California, Los Angeles scores (19.1 points v 31.2 points, P < .001). According to the University of California, Los Angeles grading system, 87% of cases had good or excellent results. Although the percentage of good and excellent results among patients aged 40 years or older (81%) was lower than that among patients aged younger than 40 years (97%), this difference did not reach statistical significance (P = .219). The percentage of good and excellent results among the non–Workers' Compensation cases (95%) was significantly higher than that in Workers' Compensation cases (65%) (P = .009). Overall, patient satisfaction was reported in 91% of cases, and return to normal sport or activity was reported in 82% of cases. Conclusions: In 87% of cases, a good or excellent functional outcome can be anticipated after arthroscopic repair of type II SLAP lesions with the described techniques. Variables associated with a poor outcome include Workers' Compensation cases and possibly older age (≥40 years). Level of Evidence: Level IV, therapeutic case series.

Characteristic Retear Patterns Assessed by Magnetic Resonance Imaging After Arthroscopic Double-Row Rotator Cuff Repair - Corrected Proof

Kenji Hayashida, Makoto Tanaka, Kota Koizumi, Masaaki Kakiuchi — 2012-01-24

Purpose: The purpose of this study was to examine magnetic resonance imaging (MRI) findings and elucidate retear pattern and its characteristics after surgical repair of the rotator cuff using an arthroscopic double-row suture anchor (DRSA) method. Methods: Forty-seven patients with complete rotator cuff tears treated by the DRSA method under arthroscopy whose repair condition was assessed by MRI approximately 12 months after the procedure were included in the study. The mean age at treatment was 65 years (range, 42 to 82 years). The mean follow-up period was 26 months (range, 24 to 32 months). Result: The repair integrity was classified into 5 groups according to MRI findings. A well-repaired tendon was seen in 34 shoulders. Partial retearing of the deep layer was observed in 2. Partial retearing of the superficial layer around the medial anchors was observed in 3. Complete retearing of the tendon around the medial anchors with a well-preserved footprint was observed in 4. Complete retearing of the tendon from the footprint was observed in 4. The retear patterns involving superficial retearing and complete retearing around the medial anchors were unexpected and unique. These types of retears seem to be characteristic of the DRSA method and were seen in cases with medium-sized tears. The incidence of characteristic retearing was 7 of 47. Conclusions: Superficial-side partial tearing and complete tearing around the medial-row anchors with a well-repaired tendon on the footprint could be characteristics of the DRSA method. These retear patterns were observed in 7 of 13 retear cases and 7 of 47 cases overall. The retear rate by the characteristic retear was high. Exploring the causes of this retear and preventing it could lead to better clinical results with the DRSA method. Level of Evidence: Level IV, therapeutic case series.

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

2012-01-24

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

Femoral Tunnel Length: Accessory Anteromedial Portal Drilling Versus Transtibial Drilling - Corrected Proof

Omer A. Ilahi, N. Janet Ventura, Amad A. Qadeer — 2012-01-24

Purpose: To determine whether drilling using an anteromedial portal technique during single-bundle anterior cruciate ligament (ACL) reconstruction risks creating femoral tunnels less than 25 mm long in the clinical setting. Methods: Intraoperative measurements of femoral tunnel length in a group of 35 consecutive patients undergoing single-bundle primary ACL reconstruction with transtibial (TT) femoral drilling were compared with a subsequent group of 80 consecutive patients undergoing the same procedure with accessory anteromedial portal (AAMP) femoral drilling. The length of femoral tunnels created through the AAMP in male patients was compared with that in female patients, and the expected likelihood of obtaining tunnels shorter than 25 mm was determined for either gender. Results: The mean femoral tunnel length in the AAMP group was significantly shorter than that in the TT group (35.6 mm and 40.7 mm, respectively; P < .0001). In male patients in the AAMP group, the femoral tunnel length was significantly greater on average than that in female patients in the same group (36.8 mm and 33.5 mm, respectively; P = .0001). The shortest measured femoral tunnel was 28 mm long. The statistical likelihood of femoral tunnels created by AAMP drilling being less than 25 mm in length was 0.47% for female patients and 0.1% for male patients. Conclusions: Although femoral tunnel length with AAMP drilling is, on average, approximately 5 mm (12.5%) shorter than with TT drilling, the likelihood of the tunnel being too short to allow for suspensory fixation with adequate graft placed within the femoral tunnel is very low. Female patients undergoing single-bundle ACL reconstruction with AAMP drilling have a femoral tunnel length that is approximately 3 mm (9%) shorter than that in male patients on average, but the expected likelihood of obtaining a tunnel shorter than 25 mm in female patients is still less than 1:200, compared with 1:1,000 for male patients. Level of Evidence: Level III, retrospective comparative study.

Magnetic Resonance Imaging and Arthroscopic Findings of the Popliteomeniscal Fascicles With and Without Recurrent Subluxation of the Lateral Meniscus - Corrected Proof

2012-01-20

Purpose: The aim of this study was to examine the posterosuperior popliteomeniscal fascicle (sPMF) and anteroinferior popliteomeniscal fascicle (iPMF) by use of magnetic resonance imaging in control knee joints and joints with recurrent subluxation of the lateral meniscus (RSLM) to determine the incidence of abnormal popliteomeniscal fascicles (PMFs) in these groups. Methods: Knee joints were diagnosed with RSLM when there was a history of mechanical locking episodes and when subluxation of the lateral meniscus was recognized on arthroscopy. In this study 238 knee joints were evaluated. The joints were classified into a control group (215 joints), RSLM group (16 joints), and contralateral RSLM group (7 joints). Classification of the sPMF (iPMF) on magnetic resonance imaging was as follows: type I, a tense, low-intensity band ran from the superior (inferior) border of the lateral meniscus to the popliteus tendon; type II, an unclear band ran from the superior (inferior) border of the lateral meniscus; and type III, no band was observed. Types II and III were thought to exhibit abnormal PMFs. The distribution of knee joints among the 3 groups and PMF types was examined. Results: Percentages of abnormal sPMFs and iPMFs were 40% and 26%, respectively, in the control group; 100% and 29%, respectively, in the contralateral RSLM group; and 100% and 100%, respectively, in the RSLM group. A significant difference in the distribution of knee joints by classification of sPMFs was recognized between the control and contralateral RSLM groups (P < .0001). A significant difference in iPMFs was also recognized between the contralateral RSLM and RSLM groups (P = .0005). Conclusions: A significantly high incidence of abnormal sPMFs was found in RSLM and contralateral knees. Thus abnormal sPMFs existed in both knee joints before patients had locking symptoms, suggesting that abnormal sPMFs may be required for locking symptoms. A significantly high incidence of abnormal iPMFs was found only in the knee joints with RSLM. An abnormal iPMF is thus the essential lesion to allow the at-risk lateral meniscus to become unstable beyond the rate of control knees. Level of Evidence: Level III, case-control study.

The 25 Most Cited Articles in Arthroscopic Orthopaedic Surgery - Corrected Proof

2012-01-20

Purpose: The purpose of this study was to use Web of Knowledge to determine which published arthroscopic surgery–related articles have been cited most frequently by other authors by ranking the 25 most cited articles. We furthermore wished to determine whether there is any difference between a categorical “journal-by-journal” analysis and an “all-database” analysis in arthroscopic surgery and whether such a search methodology would alter the results of previously published lists of “citation classics” in the field. We analyzed the characteristics of these articles to determine what qualities make an article important to this subspecialty of orthopaedic surgery. Methods: Web of Knowledge was searched on March 7, 2011, using the term “arthroscopy” for citations to articles related to arthroscopy in 61 orthopaedic journals and using the all-database function. Each of the 61 orthopaedic journals was searched separately for arthroscopy-related articles to determine the 25 most cited articles. An all-database search for arthroscopy-related articles was carried out and compared with a journal-by-journal search. Each article was reviewed for basic information including the type of article, authorship, institution, country, publishing journal, and year published. Results: The number of citations ranged from 189 to 567 in a journal-by-journal search and from 214 to 1,869 in an all-database search. The 25 most cited articles on arthroscopic surgery were published in 11 journals: 8 orthopaedic journals and 3 journals from other specialties. The most cited article in arthroscopic orthopaedic surgery was published in The New England Journal of Medicine, which was not previously identified by a journal-by-journal search. Conclusions: An all-database search in Web of Knowledge gives a more in-depth methodology of determining the true citation ranking of articles. Among the top 25 most cited articles, autologous chondrocyte implantation/transplantation is currently the most cited and most popular topic in arthroscopic orthopaedic surgery and research. Clinical Relevance: Analysis of the 25 most cited articles allows us to identify the most popular field of research in arthroscopic orthopaedic surgery and gives us insight into the quality and characteristics that are required for an article to become highly cited.

Effects of Arm Position on Maximizing Intra-Articular Visualization of the Biceps Tendon: A Cadaveric Study - Corrected Proof

Nathan D. Hart, S. Raymond Golish, Jason L. Dragoo — 2012-01-20

Purpose: The purpose of this study was to assess the intra-articular length of the biceps tendon in various shoulder and arm positions and identify the position in which the extra-articular portion of the tendon is maximally visualized within the glenohumeral joint. Methods: We measured 18 positions in 4 fresh-frozen cadaveric shoulders for a total of 72 measurements. In each measurement the position of the proximal biceps tendon was measured relative to a baseline measurement in neutral position (0° shoulder flexion, 0° shoulder abduction, 0° elbow flexion, 0° shoulder rotation). Positions measured ranged between the following: 0° and 30° shoulder flexion; 0° and 40° shoulder abduction; 0° and 90° elbow flexion; and 0° neutral, 30° internal, and 30° external shoulder rotation. Results: The position creating the greatest increase in intra-articular biceps tendon length from baseline was 30° shoulder flexion, 40° shoulder abduction, 90° elbow flexion, and 0° rotation. On average, 56% of the tendon within the bicipital groove is brought into view by the maximal position relative to baseline. In maximizing intra-articular biceps tendon length, the effect of elbow flexion was highly significant (P < .001) and the combined effect of shoulder flexion-abduction was significant (P = .016). Conclusions: The position of 30° shoulder flexion, 40° shoulder abduction, and 90° elbow flexion significantly increases the excursion of the proximal biceps tendon relative to a neutral position. Over 50% of the tendon within the bicipital groove at baseline can be pulled out of the groove by placing the extremity in the maximal position and using an arthroscopic probe. Rotation of the humerus does not improve intra-articular excursion. Clinical Relevance: Maximizing the intra-articular tendon length by arm positional change is likely to be useful for arthroscopic examination of the biceps tendon.

Relation Between Mucoid Degeneration of the Anterior Cruciate Ligament and Posterior Tibial Slope - Corrected Proof

Kwang-Hwan Jung, Sung-Do Cho, Ki-Bong Park, Yoon-Seok Youm — 2012-01-20

Purpose: The purpose was to analyze the association between posterior tibial slope (PTS) and mucoid degeneration of the anterior cruciate ligament (ACL). Methods: From October 1999 to May 2010, 84 arthroscopies were performed in 82 patients (18 men and 64 women) with mucoid degeneration of the ACL. The mean patient age was 53 years (range, 25 to 75 years). In addition to this patient group (group I), the study included a control group without mucoid degeneration of the ACL that was randomly matched for age, sex, body mass index, left or right side, and associated lesions (group II). For each group, the diagnosis was made by use of magnetic resonance imaging and arthroscopy, and a plain lateral radiograph was used to measure the PTS. Results: The mean PTS was 13.5° ± 2.6° (range, 8.2° to 19.5°) in group I and 9.4° ± 2.5° (range, 4.8° to 15.5°) in group II. The mean PTS in group I was significantly greater than that in group II (P < .001). For group I, the mean PTS of the involved knee was significantly greater than that of the uninvolved contralateral knee (P = .044). There were no differences according to age, sex, left or right side, body weight, and body mass index (P > .05). Conclusions: Mucoid degeneration of the ACL was found to be associated with an increased PTS. The patients with mucoid degeneration of the ACL had a greater mean PTS than matched control patients (13.5° v 9.4°, P < .001). Level of Evidence: Level III, diagnostic study of nonconsecutive patients without consistently applied gold standard.

Allograft Versus Autograft Decision for Anterior Cruciate Ligament Reconstruction: An Expected-Value Decision Analysis Evaluating Hypothetical Patients - Corrected Proof

Robert S. Rice, Brian R. Waterman, James H. Lubowitz — 2012-01-20

Purpose: The purpose of this study was to determine the optimal decision between autograft and allograft for patients undergoing anterior cruciate ligament (ACL) reconstruction. Methods: An expected-value decision analysis with sensitivity analysis was performed to systematically quantify the clinical decision. We evaluated 100 randomly selected individuals aged 16 to 70 years with regard to the following variables: age, sex, activity level (International Knee Documentation Committee form), and visual analog scale regarding potential outcome preferences. Patients with prior ACL injury were excluded. A decision tree was constructed (allograft v autograft potential outcomes), and a literature review determined probabilities of potential outcomes. Statistical fold-back analysis calculated optimal treatment. Sensitivity analysis determined the effect of changing the outcome probabilities on the decision. Results: Of the subjects, 88 met the study inclusion criteria. The mean age was 44 years (range, 16 to 66 years), 67% of subjects were female, and the mean activity level was moderate. The expected value for autograft reconstruction was 11.22 versus 8.42 for allograft. Increasing the probability of complications associated with autograft (sensitivity analysis) decreased the expected value of autograft reconstruction. Significant limitations include that (1) decision analysis does not investigate actual patients in whom discussion of graft options between doctor and patient highly influences the decision and (2) patient decision largely depends on the information provided. Conclusions: Decision analysis shows that autograft is preferred over allograft for ACL surgical reconstruction. Clinical Relevance: Patients' aversion to allograft tissue in general, and specific aversion to risk of disease transmission, results in a decision for ACL autograft, independent of expected outcomes.

Follow-up Computed Tomography Arthrographic Evaluation of Bony Bankart Lesions After Arthroscopic Repair - Corrected Proof

Jin-Young Park, Seung-Jun Lee, Sang-Hoon Lhee, Suk-Ha Lee — 2012-01-20

Purpose: The follow-up results of bony union after an arthroscopic bony Bankart repair have not been reported. We studied follow-up computed tomography (CT) arthrograms to evaluate radiographic healing of bony Bankart fragments. Methods: Among 41 patients who underwent arthroscopy for a bony Bankart lesion between July 2006 and May 2009, 31 cases in 30 patients who had undergone sequential follow-up CT arthrography preoperatively, at 3 months postoperatively, and at 1 year postoperatively were enrolled. Radiologic patterns of fracture healing were classified into bony healing and fibrous healing. The mean age was 23.4 years, and the mean follow-up was 30.5 months. The mean interval from the first trauma to surgery was 32.5 months, and the mean preoperative dislocation number was 12.1. Results: The mean preoperative glenoid defect was 14.1%. The fracture healing patterns included 26 bony and 5 fibrous unions. There was a significant positive relation between the total dislocation number and the preoperative glenoid defect (P = .003). The proportion of the mean fragment dimension to a circle drawn through the outer cortex of the inferior glenoid was 8.4% preoperatively, 6.6% at 3 months postoperatively, and 6.2% at 1 year postoperatively. The fragment size decreased from that measured preoperatively to the size measured 3 months after surgery (P < .05). However, the fragment size was maintained between 3 months and 1 year postoperatively (P > .05). The mean Rowe score at 1 year postoperatively was 97.2. Conclusions: Follow-up CT arthrographic evaluation showed that small bony Bankart fragments survived without resorption until 1 year postoperatively, even with fibrous union, and that reattached bone fragment fixation to the anatomic position with the labrum could survive. Level of Evidence: Level IV, therapeutic case series.

No Increased Occurrence of Osteoarthritis After Anterior Cruciate Ligament Reconstruction After Isolated Anterior Cruciate Ligament Injury in Athletes - Corrected Proof

2012-01-20

Purpose: To evaluate the long-term radiographic and clinical results of anterior cruciate ligament (ACL) reconstruction by comparing the injured knee with the contralateral knee in athletes with isolated ACL tear returning to preinjury sports. Methods: Twenty-eight patients with isolated ACL tears without concomitant injuries at baseline returning to previous sports were selected. ACL reconstruction was performed with patella or hamstring tendon graft. Conventional radiographs and a 3-T magnetic resonance imaging study of both knees were obtained at a mean follow-up of 10 years after ACL reconstruction and were compared with each other. The International Knee Documentation Committee score and Tegner activity index were used for clinical evaluation and the Knee Injury and Osteoarthritis Outcome Score for evaluating self-reported knee function. Results: The 3-T magnetic resonance imaging study showed positive signs of osteoarthritis in 33% of operated knees and 39% of nonoperated knees (P = .64). Conventional radiographs showed ongoing signs of radiographic osteoarthritis in 14% of uninjured knees according to Kellgren and Lawrence, in comparison with 21% of injured knees (P = .73). The functional outcomes between the injured knee and uninjured knee did not show any statistical differences. The mean postoperative International Knee Documentation Committee score was 89.2 ± 9.3 points, and the total Knee Injury and Osteoarthritis Outcome Score was 92.7 ± 7.8. The median preinjury Tegner score was 8 ± 2, corresponding to 7 ± 2 at follow-up. In 68% of patients, the Tegner score was unchanged from preinjury to follow-up. Conclusions: Athletes with an isolated ACL rupture showed no increased risk of the development of post-traumatic osteoarthritis in the long-term after ACL replacement when compared with the uninjured contralateral knee. Our findings support the evidence to perform ACL replacement in athletes. Level of Evidence: Level IV, therapeutic case series.

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

2012-01-20

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

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

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

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

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

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

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

Supraphysiologic Temperature Enhances Cytotoxic Effects of Bupivacaine on Bovine Articular Chondrocytes in an In Vitro Study - Corrected Proof

2011-12-15

Purpose: The purpose of this study was to determine the effects of temperature or 0.25% bupivacaine treatment in combination with supraphysiologic temperatures on chondrocyte viability. Methods: Bovine articular chondrocytes in suspension culture were treated with phosphate-buffered saline solution at 20°C, 37°C, 40°C, 42°C, 45°C, 47°C, and 50°C for 15, 30, and 60 minutes or with phosphate-buffered saline solution at 37°C, 45°C, and 50°C for 30 and 60 minutes followed by 0.25% bupivacaine at 20°C for 60 minutes. Chondrocyte viability was analyzed by flow cytometry with the LIVE/DEAD Viability/Cytotoxicity Kit (Molecular Probes, Eugene, OR). Annexin V and ethidium double staining determined whether apoptosis or necrosis occurred. Results: Temperatures from 20°C to 42°C did not cause chondrocyte death. Temperatures at or above 45°C caused significant chondrocyte death, particularly at 50°C for 60 minutes, compared with 37°C at 60 minutes (P < .01). When the chondrocytes were incubated at 50°C, subsequent exposure to bupivacaine significantly increased chondrocyte death compared with the saline solution–treated control group (P < .001). There were additive cytotoxic effects when bupivacaine was combined with supraphysiologic temperatures. It was also found that bupivacaine at supraphysiologic temperatures caused necrosis of articular chondrocytes. Conclusions: Temperatures at or above 45°C caused significant chondrocyte death. Bupivacaine treatment in the presence of 45°C and 50°C temperatures significantly increased necrosis of bovine articular chondrocytes in this in vitro study. Clinical Relevance: Immediate intra-articular injection of bupivacaine after heat-generating procedures may cause damage to the cartilage because of the additive cytotoxic effects of bupivacaine and elevated temperature.

Lateral Femoral Cortical Breach During Anterior Cruciate Ligament Reconstruction: A Biomechanical Analysis - Corrected Proof

2011-12-15

Purpose: The purpose of our study was to determine whether secondary fixation is needed when lateral femoral wall breach occurs and whether the diameter of the femoral tunnel affects the cyclical and ultimate load to failure of 3 different suspensory fixation devices. Methods: Sixty fresh-frozen porcine femora were dissected to isolate the anterior cruciate ligament (ACL) footprint. Femoral ACL tunnels were then drilled at diameters of 7, 8, 9, and 10 mm. We conducted 5 separate cyclical and ultimate load testing trials, at each tunnel diameter, for 3 different cortical suspension devices. Results: The mean load to failure decreased as the tunnel size enlarged for all 3 devices. In 7-mm tunnels, mean failure load ranged from 1,163.7 to 1,455.0 N across the 3 devices; in 8-mm tunnels, 1,154.7 to 1,643.2 N; in 9-mm tunnels, 820.8 to 1,125.21 N; and in 10-mm tunnels, 314.7 to 917.8 N. Modes of failure also varied as the tunnel sizes enlarged. The ultimate load was not different among the 3 manufacturers (P = .08), but there was a difference in the ultimate load across the 4 tunnel diameters (P < .05), except when we compared the 7-mm tunnel with the 8-mm tunnel (P = .91). Conclusions: With 7- and 8-mm-diameter tunnels, failure loads with each of the suspensory devices tested exceeded the documented interference screw load to failure. Clinical Relevance: Our findings suggest that, for soft-tissue ACL grafts, femoral tunnels of 8 mm or less can be drilled through the lateral femoral cortex while still using a suspensory device for graft fixation. With pediatric, double-bundle, and anatomic ACL reconstructions, smaller and shorter tunnels are routinely used. Thus, breaching the lateral cortex when using suspensory fixation may increase tunnel length while still achieving stable fixation.

Prospective Outcomes of Young and Middle-Aged Adults With Medial Compartment Osteoarthritis Treated With a Proximal Tibial Opening Wedge Osteotomy - Corrected Proof

Robert F. LaPrade, Stanislav I. Spiridonov, Lukas M. Nystrom, Kyle S. Jansson — 2011-12-15

Purpose: The purpose of this study was to conduct a prospective outcome analysis of proximal tibial opening wedge osteotomies performed in young and middle-aged patients (aged <55 years) for the treatment of symptomatic medial compartment osteoarthritis of the knee. Methods: A consecutive series of young and middle-aged adults who underwent proximal tibial opening wedge osteotomies for symptomatic medial compartment osteoarthritis and genu varus alignment were prospectively followed up. Patients were evaluated with preoperative and postoperative modified Cincinnati Knee Scores and International Knee Documentation Committee objective knee subscores for knee effusions and the single-leg hop. Calculations were made of the preoperative and postoperative long-leg radiographic mechanical weight-bearing axis, patellar height (Insall-Salvati index), and tibial slope. A separate cohort of asymptomatic patients was used to quantify tibial plateau anatomy to provide an objective description of the lower extremity mechanical axis. Results: There were 47 patients, with a mean age of 40.5 years, with a minimum of 2 years' follow-up, who formed this patient cohort. Modified Cincinnati Knee Scores improved significantly from 42.9 preoperatively to 65.1 at a mean of 3.6 years of follow-up. Radiographic analysis of a separate cohort showed the medial tibial eminence to be located at the 41% point along the tibial plateau from medial (0%) to lateral (100%). There was a significant improvement in malalignment: the mean mechanical axis passed through the tibial plateau at 23% of the distance along the proximal tibia preoperatively versus 54% postoperatively. The Insall-Salvati index decreased from 1.03 to 0.95 (P < .05), and posterior tibial slope increased from 9.4° to 11.7° (P < .05). Of the osteotomies, 3 (6%) were considered failures, defined by revision of the osteotomy or conversion to total knee arthroplasty. Conclusions: Performing proximal tibial opening wedge osteotomies to treat symptomatic medial compartment osteoarthritis in carefully selected patients leads to a significant improvement in subjective and objective clinical outcome scores with correction of malalignment at a mean of 3.6 years postoperatively. Level of Evidence: Level IV, therapeutic case series.

Biologic Enhancement of a Common Arthroscopic Suture - Corrected Proof

2011-12-12

Purpose: The purpose of this study was to investigate the in vitro effects of an arginine–glycine–aspartic acid (RGD) coating on a high-strength nonabsorbable polyester/polyethylene (PE/PEE) suture material commonly used in orthopaedic procedures. Methods: Human bone and tendon specimens were isolated and cultured. The cells were then plated in known densities in the presence of RGD-coated and uncoated PE/PEE suture and allowed to adhere for predetermined time periods. The RGD-coated and uncoated control sutures were then removed and assayed for cell osteoblast and tenocyte adhesion and proliferation. Results: The RGD-modified suture showed a statistically significant increase in both adhesion and proliferation of human tenocytes when compared with uncoated controls (P < .05). Conclusions: The RGD peptide sequence can be effectively coupled with commercially available PE/PEE suture. RGD-coated suture is able to stimulate the adhesion and proliferation of human tenocyte cells in vitro, as well as withstand standard sterilization and storage conditions. Furthermore, the acid hydrolysis process did not affect the strength of the suture material. Clinical Relevance: RGD-modified suture materials have the potential to create favorable biologic responses when used in common orthopaedic procedures.

Injury of the Suprascapular Nerve During Latarjet Procedure: An Anatomic Study - Corrected Proof

Alexandre Lädermann, Patrick J. Denard, Stephen S. Burkhart — 2011-12-12

Purpose: The purpose of this study was to evaluate the relation between the specific exit point of the screws securing the coracoid graft and the suprascapular nerve during the Latarjet procedure. Methods: Ten fresh-frozen shoulder specimens were dissected after having undergone an open Latarjet procedure. Results: The mean distance from the posterior exit site of the superior screw to the suprascapular nerve at the base of the scapular spine was only 4 mm. Two of the superior screws were directly in contact with the major branch of the suprascapular nerve, and 2 screws were also in contact with minor branches of the suprascapular nerve. As for the inferior screw, there was contact with the major branch in 1 case and with minor branches of the suprascapular nerve in 6 cases. In the axial plane, the screws were not in contact with the suprascapular nerve if the angle relative to the glenoid was less than or equal to 10°. Conclusions: The proximity of the suprascapular nerve to the posterior glenoid rim puts this nerve at risk during insertion of the screws used for the Latarjet procedure. Placement of screws within 10° of the face of the glenoid in the axial plane is safe and will avoid the potential for suprascapular nerve injury. Clinical Relevance: This study quantifies the relative risk of injury to the suprascapular nerve during the Latarjet procedure.

A Pilot Study of Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction With Ligament Remnant Tissue Preservation - Corrected Proof

2011-12-09

Purpose: The purpose of this pilot study was to evaluate the preliminary results of an anatomic double-bundle anterior cruciate ligament (ACL) reconstruction procedure with ligament remnant tissue preservation. Methods: By use of the transtibial technique, 2 doubled semitendinosus tendons were grafted into 4 tunnels created at the center of each bundle attachment, penetrating the ACL remnant tissue. In total, 44 patients (27 male and 17 female patients) with an isolated ACL injury underwent ACL reconstruction with this procedure. The mean age of the patients was 29 years (range, 17 to 58 years). Postoperative clinical evaluations were performed at 16.6 months on average (range, 12 to 23 months). Radiologic evaluations were also performed to evaluate the tunnel location in the femur and the tibia. Results: The mean operation time was 86 minutes (range, 72 to 96 minutes) in the cases with ACL reconstruction only. Postoperatively, the mean anterior laxity was 0.7 mm. The postoperative pivot-shift test was negative in 81.8% of the patients, whereas there were no patients evaluated as ++. No patients showed any extension or flexion deficit. There were no patients evaluated as “nearly abnormal” or “abnormal” according to the International Knee Documentation Committee evaluation. The tunnel angles of the 4 tunnels were identical to those reported in a previous study. Conclusions: The minimal 1-year clinical results of anatomic double-bundle ACL reconstruction with ligament remnant tissue preservation were comparable to previously reported results of anatomic double-bundle reconstruction without remnant tissue preservation. Level of Evidence: Level IV, therapeutic case series.

Arthroscopic Treatment of Hip Chondral Defects: Autologous Chondrocyte Transplantation Versus Simple Debridement—A Pilot Study - Corrected Proof

2011-12-06

Purpose: To compare the effectiveness of simple arthroscopic debridement versus arthroscopic autologous chondrocyte transplantation (ACT) for the treatment of hip chondral lesions.Methods: We carried out a controlled retrospective study of 30 patients affected by a post-traumatic hip chondropathy of the third or fourth degree, according to the Outerbridge classification, measuring 2 cm2 in area or more. Of these patients, 15 underwent arthroscopic ACT, whereas the other 15 underwent arthroscopic debridement. The 2 groups were similar in age, sex, degree, and location of the pathology. All the patients were assessed before and after the procedure with the Harris Hip Score (HHS).Results: In both groups the mean follow-up was approximately 74 months (range, 72 to 76 months). The mean size of the defect was 2.6 cm2. The patients who underwent ACT (group A) improved after the procedure compared with the group that underwent debridement alone (group B). The mean HHS preoperatively was 48.3 (95% confidence interval [CI], 45.4 to 51.2) in group A and 46 (95% CI, 42.7 to 49.3) in group B (P = .428 [no significant difference]). The final HHS was 87.4 (95% CI, 84.3 to 90.5) in group A and 56.3 (95% CI, 54.4 to 58.7) in group B (P < .001 [significant difference]).Conclusions: This study indicates that an ACT procedure can be used in the hip for acetabular chondral defects.Level of Evidence: Level III, retrospective comparative study.

Meniscal Morphologic Changes on Magnetic Resonance Imaging Are Associated With Symptomatic Discoid Lateral Meniscal Tear in Children - Corrected Proof

2011-12-01

Purpose: To determine whether meniscal deformation and displacement on magnetic resonance imaging (MRI) are associated with tears by use of arthroscopic findings as a standard of reference in children with discoid lateral meniscus (DLM).Methods: We reviewed MRI scans and intraoperative videos of 69 consecutive patients (79 knees) treated arthroscopically for suspicious DLM tears. The mean age at surgery was 10.9 years (range, 4.3 to 17.6 years). Signal changes and morphologic changes (deformation or displacement) of DLM on magnetic resonance (MR) images were graded by 2 independent observers using our modifications of previously described classification schemes, and then the grades were determined by consensus of the observers. Meniscal tears were assessed by an observer, blinded to the MRI studies, based on arthroscopic findings. Signal changes and morphologic changes of DLM on MR images were correlated with tears.Results: Tears were found more frequently in menisci showing morphologic changes on MR images (P = .001). Of the 25 menisci with a grade 3 signal change (linear or band-like signal intensity extending to the superior or inferior meniscal surface), 24 had tears, and a horizontal cleavage was the most commonly associated tear type. Of the 50 menisci with a grade 1 (dot-like intrameniscal signal change), grade 2 (linear or band-like intrameniscal signal change), or diffuse signal change, 34 were morphologically changed on MR images, and 29 of these (85%) were torn, whereas 9 of the 16 menisci (56%) not morphologically changed were torn (P = .036).Conclusions: Preoperative MRI evaluations based on signal intensities do not accurately predict the presence of a DLM tear in children, except when a DLM shows a grade 3 signal change. Meniscal deformation or displacement observed on preoperative MR images suggests a higher risk of meniscal tears, even in menisci with signal changes other than grade 3 changes.Level of Evidence: Level IV, therapeutic case series.

Arthroscopic Stabilization of the Shoulder in Adolescent Athletes Participating in Overhead or Contact Sports - Corrected Proof

2011-12-01

Purpose: To investigate the outcome of arthroscopic capsular repair for shoulder instability in an active adolescent population participating in overhead or contact sports.Methods: We identified 67 patients (aged 13 to 18 years) with post-traumatic recurrent shoulder instability for inclusion in the study from our computer database. Of these patients, 65 (96%) were available for clinical review. There were 44 male and 21 female patients, with a mean age of 16 years at the time of surgery. All patients participated in overhead or contact sports at a competitive level. Arthroscopic capsulolabral repair was performed after at least 6 months of failed nonoperative treatment. The mean follow-up was 63 months. Shoulder range of motion and functional outcomes were measured preoperatively and postoperatively with Single Assessment Numeric Evaluation (SANE), Rowe, and American Shoulder and Elbow Surgeons (ASES) scores. Furthermore, type of sport, time until surgery, and number of dislocations were analyzed from our database to find any correlation with the recurrence rate.Results: At final follow-up, the mean SANE score was 87.23% (range, 30% to 100%) (preoperative mean, 46.15% [range, 20% to 50%]); the mean Rowe score was 85 (range, 30 to 100) (preoperative mean, 35.9 [range, 30 to 50]); and the mean ASES score was 84.12 (range, 30 to 100) (preoperative mean, 36.92 [range, 30 to 48]). The mean forward flexion and external rotation with the arm at 90° abduction did not change from preoperative values; 81% of the patients returned to their preinjury level of sport, and the rate of failure was 21%. The recurrence rate was not related to the postoperative scores (P = .556 for SANE score, P = .753 for Rowe score, and P = .478 for ASES score), the number of preoperative episodes of instability (P = .59), or the time from the first instability episode to the time of surgery (P = .43). There was a statistically significant relation (P = .0021) between recurrence and the type of sport practiced. Recurrence rate was related to the type of sport practiced.Conclusions: Arthroscopic stabilization is a reasonable surgical option even in an adolescent population performing sports activities. However, it must be emphasized to the patients and their relatives that the recurrence rate that could be expected after an arthroscopic procedure is higher than in the adult population.Level of Evidence: Level IV, therapeutic case series.

Current Concepts in Clinical Research: Web-Based, Automated, Arthroscopic Surgery Prospective Database Registry - Corrected Proof

James H. Lubowitz, Patrick A. Smith — 2011-11-24

Abstract: In 2011, postsurgical patient outcome data may be compiled in a research registry, allowing comparative-effectiveness research and cost-effectiveness analysis by use of Health Insurance Portability and Accountability Act–compliant, institutional review board–approved, Food and Drug Administration–approved, remote, Web-based data collection systems. Computerized automation minimizes cost and minimizes surgeon time demand. A research registry can be a powerful tool to observe and understand variations in treatment and outcomes, to examine factors that influence prognosis and quality of life, to describe care patterns, to assess effectiveness, to monitor safety, and to change provider practice through feedback of data. Registry of validated, prospective outcome data is required for arthroscopic and related researchers and the public to advocate with governments and health payers. The goal is to develop evidence-based data to determine the best methods for treating patients.

A Surgical Technique Using Presoaked Vancomycin Hamstring Grafts to Decrease the Risk of Infection After Anterior Cruciate Ligament Reconstruction - Corrected Proof

Christopher J. Vertullo, Mark Quick, Andrew Jones, Jane E. Grayson — 2011-11-24

Purpose: The purpose of this study was to investigate whether presoaking hamstring graft with a dilute antibiotic solution provides a potential new tool to improve measures to prevent joint infection.Methods: This is a retrospective analysis of data that were prospectively collected for 1,135 consecutive patients who underwent anterior cruciate ligament reconstruction (ACLR) during a 7-year period. In the initial 3-year period, 285 patients (group 1) underwent ACLR with a hamstring autograft with preoperative intravenous (IV) antibiotics. In the subsequent 4-year period, 870 patients underwent ACLR with a vancomycin-presoaked hamstring autograft (group 2) with preoperative IV antibiotics. Presoaking involved wrapping hamstring tendon autografts in a sterile gauze swab, which had been previously saturated with 5-mg/mL vancomycin solution.Results: In group 1 a total of 4 postoperative joint infections were documented (1.4%). Each case showed increasing pain and effusion, as well as a high intra-articular white blood cell count and increased C-reactive protein level. Of the 4 infected cases, 3 cultured coagulase-negative Staphylococcus (Staphylococcus epidermidis). The fourth case was treated as a postoperative infection despite a negative culture and responded to arthroscopic washout and IV antibiotics. In group 2 no infections (0%) were recorded, and no investigatory washouts occurred. The difference was statistically significant. Known failures were similar in each group.Conclusions: Prophylactic vancomycin presoaking of hamstring autografts statistically reduced the infection rate in this series compared with IV antibiotics alone.Level of Evidence: Level IV, therapeutic case series.

Dynamic Contact Mechanics of Radial Tears of the Lateral Meniscus: Implications for Treatment - Corrected Proof

2011-11-11

Purpose: To characterize the effect of radial tears (RTs) of the lateral meniscus and their subsequent treatment (inside-out repair, partial meniscectomy) on joint contact mechanics during simulated gait.Methods: Six human cadaveric knees were mounted on a simulator programmed to mimic human gait. A sensor was inserted below the lateral meniscus to measure peak joint contact pressure location, magnitude, and contact area. The following conditions were compared: intact meniscus, 30% RT (at the popliteal hiatus), 60% RT, 90% RT, repair, and partial meniscectomy. Data were analyzed in the midstance phase of gait (14% and 45%) when axial force was at its highest (2,100 N).Results: Intact knees had peak contact pressures of 5.9 ± 0.9 MPa and 6.4 ± 1.1 MPa at 14% and 45% of gait, respectively. RTs of up to and including 60% had no effect on pressure magnitude or location. RTs of 90% resulted in significantly increased peak pressure (8.4 ± 1.1 MPa) in the postero-peripheral aspect of the tibial plateau and reduced contact area versus the intact knee, at 45% of gait. Repair resulted in a significant decrease in peak pressure (7.7 ± 1.0 MPa) relative to 90% RT but had no effect on contact area. Partial lateral meniscectomy resulted in areas and pressures that were not significantly different from 90% tears (8.7 ± 1.5 MPa).Conclusions: Simulated large RTs of the lateral meniscus in the region of the popliteal hiatus show unfavorable dynamic contact mechanics that are not significantly different from those resulting from a partial lateral meniscectomy. Pressure was significantly reduced with inside-out repair but was not affected by partial meniscectomy; contact area was not restored to that of the intact condition for either procedure.Clinical Relevance: Large RTs in the region of the popliteal hiatus show unfavorable dynamic contact mechanics.