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

Magnetic Resonance Imaging Evaluation of the Integration and Maturation of Semitendinosus-Gracilis Graft in Anterior Cruciate Ligament Reconstruction Using Autologous Platelet Concentrate - Corrected Proof

2010-08-30

Purpose: To evaluate integration and maturation of semitendinosus-gracilis (STG) grafts in anterior cruciate ligament (ACL) reconstruction with magnetic resonance imaging (MRI) in patients who underwent ACL reconstruction with STG with and without autologous platelet concentrate (APC).Methods: A randomized single–blinded evaluator prospective study was performed in 2 consecutive series of patients who underwent reconstruction over a 14-month period: 30 with APC use (group A) and 20 as control subjects (group B). At 6 months, an MRI evaluation was performed, with observation of the graft's maturation and presence or absence of synovial fluid at the tunnel-graft interface. To facilitate interpretation, a scoring scale was designed to evaluate graft integration and maturation. Results: Regarding the presence of synovial fluid at the bone-graft interface, the test was negative in 86.84% of patients in group A and 94.74% in group B. A disorganized autograft signal pattern was found in 2.63% in group A and 5.26% in group B. Signal intensity was considered hypointense in 63.16% in group A and 42.11% in group B, isointense in 34.21% in group A and 52.63% in group B, and hyperintense in 0% in both groups. The final mean score was 4.45 points in group A and 4.2 points in group B (P ≥ .05). Poor integration was found in 2.63% in group A and 5.26% in group B (P = .214). Good integration was found in 97.37% in group A and 94.74% in group B (P = .784).Conclusions: In our consecutive series of patients who underwent ACL reconstruction with STG grafts, 1 group with intraoperative APC use versus a control group, followed up by MRI at 6 months after reconstruction, we did not find any statistically significant benefit in the APC group in terms of integration assessment and graft maturation (ligamentization).Level of Evidence: Level III, case-control study.

Outcomes of Arthroscopic Rotator Cuff Repair in Patients Aged 70 Years or Older - Corrected Proof

2010-08-23

Purpose: To evaluate outcomes of arthroscopic rotator cuff repair in patients aged 70 years or older.Methods: We identified 44 consecutive patients aged 70 years or older undergoing primary all-arthroscopic repair of symptomatic full-thickness tears of the rotator cuff. A minimum 2-year follow-up was performed by an independent examiner including range of motion and dynamometer strength testing, and shoulder functional outcome scores including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and pain score on a visual analog scale were determined. Paired t tests were performed to compare preoperative and postoperative measures. Postoperative Constant-Murley scores were normalized with scores from age- and sex-matched healthy individuals.Results: Of the patients, 39 (88.6%) were available for follow-up evaluation, with a mean age of 75.3 ± 4.2 years (range, 70.1 to 89.8 years) and a mean follow-up of 36.1 ± 9.9 months (range, 24.3 to 59.4 months). The American Shoulder and Elbow Surgeons score improved from 45.8 ± 16.6 (mean ± SD) to 87.5 ± 14.4 at final follow-up (P < .0001). The Simple Shoulder Test score improved from 3.9 ± 2.3 to 9.8 ± 2.5 (P < .0001). The pain score on the visual analog scale improved from 4.6 ± 2.2 to 0.5 ± 0.9 (P < .0001), and forward elevation increased from 114.8° ± 42.0° to 146.2° ± 33.2° (P = .0012). Mean age- and sex-matched normalized Constant-Murley scores ranged from 88.3% to 97.2% of normal in men and 81.7% to 88.8% of normal in women.Conclusions: Arthroscopic rotator cuff repair provides significant improvement in pain and function in carefully selected patients aged 70 years or older with symptomatic full-thickness rotator cuff tears and has a low complication rate.Level of Evidence: Level IV, therapeutic case series.

Bilateral Discoid Lateral Meniscus in Knees: Evaluation of the Contralateral Knee in Patients With Symptomatic Discoid Lateral Meniscus - Corrected Proof

Jin Hwan Ahn, Sang Hak Lee, Jae Chul Yoo, Han-Jun Lee, Jae Sung Lee — 2010-08-23

Purpose: The aim of this study was to analyze, by use of magnetic resonance imaging (MRI), the contralateral discoid lateral meniscus (DLM) status of 33 patients who underwent an operation for a symptomatic DLM.Methods: This diagnostic study included 33 consecutive patients who underwent arthroscopic surgery for a unilaterally symptomatic DLM. All patients' contralateral knees were checked with simple radiographs and MRI scans. Knees were also evaluated through physical examinations and a clinical scoring system. On the basis of the MRI findings, DLM was categorized into 3 types: normal type, incomplete discoid type, and complete discoid type. The tear patterns of the lateral menisci as imaged by radiographs and the associated chondral lesions imaged by MRI were analyzed by consensus in the bilateral knees.Results: All but 1 of the contralateral, asymptomatic knees (97%) were diagnosed by MRI to have complete or incomplete DLM. DLMs with tears were found in the contralateral knees in 11 cases (33%), and chondral lesions were found in 4 (12%) of the complete discoid type cases. On radiography, 23 (70%) of the 33 contralateral knees showed characteristic findings of DLM. We found that 29 pairs of knees (88%) had the same lateral meniscus shape on MRI. A κ analysis showed significant and good agreement between the radiographic findings, the tear pattern of the lateral menisci, and the associated chondral lesions on MRI scans in bilateral knees.Conclusions: DLM commonly occurs bilaterally in patients with symptomatic, unilateral surgical DLM, although this finding was applicable only to young, Asian male patients. Characteristic radiographic findings and the MRI findings of symptomatic DLM patients were significantly correlated between both knees. Level of Evidence: Level I, testing of previously developed diagnostic criteria in a series of consecutive patients with universally applied reference gold standard.

The Effect of Recombinant Human Platelet-Derived Growth Factor BB–Coated Sutures on Rotator Cuff Healing in a Sheep Model - Corrected Proof

2010-08-23

Purpose: The purpose of this study was to determine whether suture could be coated with recombinant human platelet-derived growth factor BB (rhPDGF-BB) and whether the coated suture would improve histologic scores and biomechanical strength of sheep rotator cuff repairs.Methods: FiberWire sutures (Arthrex, Naples, FL) were dip coated in a collagen–rhPDGF-BB solution. Coating was confirmed by use of enzyme-linked immunosorbent assay. Rotator cuff tears were created in 18 sheep. The tendons were wrapped in Gortex (Gore Medical, Flagstaff, AZ) and allowed to scar for 2 weeks. Tendons were then repaired to bone by use of standard anchors loaded with either rhPDGF-BB–coated sutures or uncoated sutures. Gross examination, histologic analysis, and biomechanical testing were performed 6 weeks after repair.Results: Enzyme-linked immunosorbent assay confirmed successful loading of the growth factor onto the sutures. Gross examination showed well-healed tendon-to-bone interfaces in both rhPDGF-BB–augmented repairs and controls. Histologic analysis using a semiquantitative rating scale showed improved tendon-to-bone healing in the rhPDGF-BB–augmented repairs. There was no significant difference in the ultimate load to failure of rhPDGF-BB–augmented rotator cuff repairs compared with standard suture repairs at 6 weeks after repair.Conclusions: We were able to coat No. 2 FiberWire with rhPDGF-BB. At short-term follow-up, rhPDGF-BB–coated sutures enhanced histologic scores of sheep rotator cuff repairs; however, ultimate load to failure was equivalent to standard suture repairs. Clinical Relevance: rhPDGF-BB–coated sutures seem to produce a more histologically normal tendon insertion.

Arthroscopic Repair of Anterosuperior Rotator Cuff Tears Combined With Open Biceps Tenodesis - Corrected Proof

2010-08-23

Purpose: The purpose of this study was to look at the functional outcomes of arthroscopic repair of anterosuperior rotator cuff tears with open biceps tenodesis when indicated.Methods: We retrospectively reviewed the cases of 17 patients (17 shoulders) who underwent arthroscopic repair of anterosuperior tears with concurrent open biceps tenodesis. At final follow-up, an independent examiner collected shoulder functional outcome scores including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog pain scale. Objective information including range of motion and strength was also collected.Results: Of the 17 patients, 13 (77%) were available for evaluation with a mean age of 52.7 ± 7.0 years at the time of surgery (range, 32 to 65 years) and a mean follow-up of 34.6 ± 10.5 months (range, 14 to 52 months). The mean American Shoulder and Elbow Surgeons score improved from 50.6 ± 18.9 (range, 13 to 75) preoperatively to 89.6 ± 7.5 (range, 50 to 100) postoperatively (P < .001). There was a significant increase in the mean Simple Shoulder Test score from 6.1 ± 3.2 preoperatively (range, 0 to 10) to 10.7 ± 1.2 (range, 9 to 12) postoperatively (P < .001). Of the 13 patients, 11 (85%) patients were “delighted” with the surgical outcome and the other 2 patients (15%) were “pleased.”Conclusions: Arthroscopic repair of anterosuperior rotator cuff tears with open biceps tenodesis provides a significant improvement in pain relief and shoulder function. Level of Evidence: Level IV, therapeutic case series.

Biomechanical Comparison of 4 Double-Row Suture-Bridging Rotator Cuff Repair Techniques Using Different Medial-Row Configurations - Corrected Proof

2010-06-14

Purpose: Biomechanical comparison of different suture-bridge configurations of the medial row with respect to initial construct stability (time 0, porcine model).Methods: In 40 porcine fresh-frozen shoulders, the infraspinatus tendons were dissected from their insertions. All specimens were operated on by use of the suture-bridge technique, only differing in terms of the medial-row suture-grasping configuration, and randomized into 4 groups: (1) single-mattress (SM) technique, (2) double-mattress (DM) technique, (3) cross-stitch (CS) technique, and (4) double-pulley (DP) technique. Identical suture anchors were used for all specimens (medial: Bio-Corkscrew FT 5.5 [Arthrex, Naples, FL]; lateral: Bio-PushLock 3.5 [Arthrex]). All repairs were cyclically loaded from 10 to 60 N until 10 to 200 N (20-N stepwise increase after 50 cycles each) with a material testing machine. Forces at 3 and 5 mm of gap formation, mode of failure, and maximum load to failure were recorded.Results: The DM technique had the highest ultimate tensile strength (368.6 ± 99.5 N) compared with the DP (248.4 ± 122.7 N), SM (204.3 ± 90 N), and CS (184.9 ± 63.8 N) techniques (P = .004). The DM technique provided maximal force resistance until 3 and 5 mm of gap formation (90.0 ± 18.1 N and 128.0 ± 32.3 N, respectively) compared with the CS (72 ± 8.9 N and 108 ± 20.2 N, respectively), SM (66.0 ± 8.9 N and 90.0 ± 26.9 N, respectively), and DP (62.2 ± 6.2 N and 71 ± 13.2 N, respectively) techniques (P < .05 for each 3 and 5 mm of gap formation). The main failure mode was suture cutting through the tendon.Conclusions: Comparing the 4 different suture-bridge techniques, we found that modified application of suture-bridge repair with double medial mattress stitches significantly enhanced biomechanical construct stability at time 0 in this porcine ex vivo model. Clinical Relevance: This technique increases initial stability and resistance to suture cutting through the rotator cuff tendon after arthroscopic suture-bridge repair.

An Analysis of the Posterior Cruciate Ligament Isometric Position Using an In Vivo 3-Dimensional Computed Tomography–Based Knee Joint Model - Corrected Proof

2010-05-17

Purpose: This study aimed to review the isometric point of the posterior cruciate ligament (PCL) based on insertional locations identified in recent anatomic studies by use of a 3-dimensional knee model.Methods: Ten living subjects with healthy knees were evaluated. High-resolution computed tomography scans were performed at 3 positions of 0°, 90°, and 135°, and 3-dimensional knee images were constructed. Customized software was used to define tibial and femoral insertion points of the PCL, based on recently described anatomy. The femoral attachment site of the PCL was divided into 4 sectors (labeled A through D), and the tibial attachment site was divided into 6 sectors (labeled 1 through 6). Twenty-four virtual PCL bundles were created between these sectors, and their length was measured in the 3 knee flexion positions.Results: In 0° and 90° of knee flexion, the virtual bundle showing the least amount of length change (1.10 ± 0.66 mm) was at sector D-6, that is, a posteromedial bundle inserting into the most posterior femoral sector (sector D) and the most distal tibial sector (sector 6). This change was not significantly different compared with all other virtual bundles with tibial points connected to femoral sector D (P > .05). An isometric position for the PCL (length change <2 mm) could not be found in 135° of knee flexion because of lengthening of all virtual bundles.Conclusions: Our data suggest that the femoral attachment point is more important than the tibial attachment point: any of the 6 tibial bundles attached to the most posterior femoral sector had similar isometric properties.Clinical Relevance: Reproducing normal tibial and femoral anatomy underpins PCL surgical reconstruction. These findings suggest that to perform an isometrically accurate PCL reconstruction, particular attention should be paid to the location of the femoral attachment site, once the tibial footprint has been established. There were no isometric points in any virtual PCL bundle in the fully flexed knee because of excessive lengthening. Therefore, to avoid lengthening of the reconstructed graft, we recommend that fixation is performed at knee flexion angles between 0° and 90° and that patients avoid high flexion during postoperative rehabilitation.

Unfavorable Results of Partial Meniscectomy for Complete Posterior Medial Meniscus Root Tear With Early Osteoarthritis: A 5- to 8-Year Follow-Up Study - Corrected Proof

2010-05-10

Purpose: The aim of this retrospective study was to evaluate the clinical and radiographic outcomes of arthroscopic partial meniscectomy for complete posterior medial meniscus root tear (PMMRT) in patients with early radiographic evidence of knee osteoarthritis at a minimum follow-up of 5 years.Methods: Forty-six cases had complete PMMRT with follow-up of at least 5 years and were treated with arthroscopic partial meniscectomy. On the basis of medical records, we reviewed the arthroscopic findings of joint degeneration (Outerbridge grading), clinical results using the modified Lysholm (ML) knee score and a patient questionnaire, and radiographic evaluation of degeneration using Kellgren-Lawrence (KL) grading.Results: The incidence of complete PMMRT in the study population was 15%. At a mean follow-up of 78 months (range, 60 to 103 months), the mean ML score significantly improved from 72 (range, 62 to 78) preoperatively to 77 (range, 70 to 98) at final follow-up (P < .01), 16 patients (35%) showed progression of degeneration from KL grade 0 to 2 preoperatively to KL grade 2 to 4, 56% of patients indicated improvement in pain, 67% of patients were satisfied with the results of the procedure, and 19% of patients underwent reoperation. There was a significant negative correlation between chondral wear during arthroscopy (ρ = −0.516, P = .002) and preoperative KL grade (ρ = −0.429, P = .004) with ML score at final follow-up.Conclusions: Although arthroscopic partial meniscectomy for complete PMMRT significantly improved ML scores postoperatively, only 56% of patients had improvement in pain, 67% were satisfied with the outcome of the procedure, and 35% showed radiographic progression of osteoarthritis at a mean follow-up of 77 months. Level of Evidence: Level IV, therapeutic study.