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        Arthroscopic Notchplasty and Debridement for the Treatment of Osteoarthritis of the Knee: 2- and 5-Year Results

        Leigh Brezenoff, Sohail Ahmad, Robert P. Nirschl, David Gonzalez Arlington, Virginia, U.S.A.
        Introduction: Numerous studies have evaluated the efficacy of knee arthroscopy in the treatment of osteoarthritis. Treatments have varied from simple lavage to extensive debridements, with mixed results. Our purpose is to evaluate the effect of arthroscopic notchplasty and removal of impinging lesions with the goal of regaining lost knee extension, thereby reducing contact forces in the patellofemoral joint. Methods: 64 patients with arthritic symptoms in the knee refractory to conservative treatment underwent knee arthroscopy. Treatment included debridement of meniscal lesions, thermal or mechanical stabilization of chondral defects, removal of impinging osteophytes, and notchplasty. The primary goal of surgery was to regain knee extension. Subchondral stimulation of fibrocartilage with drilling or microfractures was not performed. Age, duration & severity of symptoms, pre & post surgical HSS scores (52 total), compartments involved, motion, impinging lesions, & level of satisfaction were evaluated. Patients with less than 5 years of follow up were excluded. Results: 36 patients (mean age 64.8) were available for a minimum 5 year follow up. At 2 years, 32/36 were satisfied. Mean HSS scores improved from 29.2 to 48.0. All four early failures had tricompartment disease, mean pre-op HSS scores = 21.5, and mean pre-op flexion contractures = 15.6 degrees. At 2 years, all had reformed their flexion contractures. All four underwent knee replacements at a mean 4.5 years. At 5 years, mean HSS score improvement was from 29.2 to 43.2. 25/36 were satisfied with good to excellent results. 3/36 had some deterioration and were rated fair. The 8/36 failures underwent 7 TKA and 1 HTO. The 25/36 with satisfactory results had a mean pre-op flexion contracture of 7.3 degrees and average HSS scores of 33.2, whereas the other 11/36 had mean contractures of 15.0 degrees and average HSS scores of 20.1. Poor results were associated with contractures greater than 10 degrees (P = .05) and lower pre-op HSS scores (P = .05 Wilcoxon Rank Sum). Discussion and Conclusion: In our study, regaining and maintaining knee extension and thereby unloading the knee joint was prognostic of improved outcomes. Arthroscopy notchplasty and removal of impinging tibialosteophytes to regain knee extension increased the longevity and efficacy of our treatment of the osteoarthritic knee.

        Nonarthritic Hip Pain in Young Patients: Evaluation and Treatment Algorithm

        Christian P. Christensen, Joseph C. McCarthy, Jo-ann Lee Bethesda, Maryland, U.S.A.
        An algorithm has been developed that focuses on the evaluation of younger patients with hip pain without an obvious plain x-ray diagnosis. Most hip pain in skeletally mature patients without a positive radiographic diagnosis is due to musculotendinous injury and resolves with conservative treatment. An accurate history and physical is the first step in management and must allow the physician to identify the source of pain as either an acute or repetitive (overuse) injury. If necessary, this is followed by a standard radiographic series and occasionally laboratory studies. Patients with new hip pain and negative radiographs who cannot bear weight following trauma generally require a MRI to rule out a non-displaced fracture, avascular necrosis, or synovitis. Patients with new anterior hip pain without obvious injury should be queried and closely examined to rule out general surgical, gynecological, urological, or vascular sources. Patients with posterior thigh and buttock pain should be evaluated closely to rule out spine etiologies. Patients with chronic lateral hip and thigh pain should be divided into those with radiating symptoms, mechanical symptoms, and patients having tenderness over the lateral aspect of the hip. Patients with lateral hip and thigh pain generally have symptoms associated with the greater trochanter or iliotibial band and generally respond to conservative measures. In all it is important to carefully evaluate younger patients with hip pain and negative radiographs initially and to re-evaluate them if they are not better within 2 to 3 weeks. Acute injuries are notable for tenderness or mechanical symptoms. Mechanical symptoms around the hip like locking, popping, snapping, or giving way should be examined carefully in order to delineate whether the source is intra-articular or extra-articular. Patients with mechanical symptoms should be referred to an orthopedic surgeon. Mechanical symptoms are often due to intra-articular lesions though extra-articular causes such as a snapping iliopsoas or iliotibial band should be ruled out. Intra-articular etiologies often require an MRI with gadolinium or high contrast technique. Positive intra-articular findings demonstrated on MRI are often successfully managed using hip arthroscopy. It is important to follow a step-wise progression in the management of these complicated patients to better utilize healthcare dollars and to prevent excessive long-term disability and pain.

        Acute ACL Tears in Skiers: Associated Injuries

        Mark Rekant, Orrin Sherman, John Bonamo, Nick Bavaro New York, New York, U.S.A.
        Purpose: It has generally been accepted that acute ACL tears in skiers result from a different mechanism of injury than those that occur in other high-load athletic activities. Therefore, it has been reported that the incidence and pattern of associated intra-articular and extra-articular injuries are different than those associated with other athletic activities requiring contact or deceleration and directional change. However, over the last several years this has not been our experience. As a result, the purpose of this study was to determine if the acute ACL injured knee in skiers is more traumatic than previously documented. Materials and Methods: The medical records of 91 patients who had sustained complete ACL tears while skiing between January 1993 and December 1998 were retrospectively reviewed. The mean age was 31.6 (range 16-54). None of the patients were professional skiers nor had any history of a prior knee injury. The diagnosis of an ACL tear was made initially by history and physical exam and subsequently supported by MRI findings. Arthroscopic assisted ACL reconstruction was performed when the patient was functionally optimized. At the time of surgery, any associated intra-articular abnormalities were documented (meniscal, osteochondral, or ligamentous) in addition to reconfirming any associated extra-articular findings (MCL, LCL tears). Results: An associated meniscal tear was detected in 57 of the 91 patients (63%) evaluated. In total, there were 71 meniscal tears (31 lateral meniscal, 40 medial meniscal) in 57 skiers. Fourteen of the 71 (20%) tears were amenable to surgical repair. Of patients over 40 years of age, 94% (17 of 18) were documented to have coexisting meniscal tears of which 4 were repaired. Overall, of the 57 skiers with a meniscal tear, 26 (45%) had an isolated medial meniscal tear, 17 (30%) had an isolated lateral meniscal tear, and 14 (25%) had both lateral and medial meniscal tears. Additional intra-articular knee injuries noted at the time of surgery included osteochondral changes of at least Outerbridge grade II in nature in 31 (34%) of the patients. Extra-articularly, 14 (15%) sustained MCL tears; and 1 of the 91 patients sustained a concomitant PCL tear. Conclusion: Anterior cruciate ligament tears sustained while skiing generate greater intra-articular damage than once believed. This investigation encountered a sixty-three percent rate of concurrent meniscal tears, and osteochondral injuries in as many as a third of all the injured skiers. Older skiers were noted to have a remarkably higher percentage of accompanying meniscal tears. Realization that the “isolated” ACL injury in skiers is less frequent than previously thought, a more diligent approach in which a more aggressive surgical strategy to these injured patients may be warranted.

        Arthroscopically Assisted Patella Revision

        Arturo Corces, Virgilia Gonzales, Felix Stanziola Miami, Florida, U.S.A.
        The efficacy of arthroscopy has been well documented for both the diagnosis and treatment of the numerous conditions that can arise after a total knee arthroplasty. Release of the PCL, lateral release, excision of the prepatellar fibrosis for the patella “clunk” syndrome, release of fibrous bands for patellar tracking problems have all been well documented as complications of total knee replacement that can be effectively treated with the aid of the arthroscope. Complications related to the patella button are among the most common in total knee replacement. Revision of a failed patella component necessitates an open incision and a formal medial patella incision. There is a significant morbidity that is associated with an open procedure of this nature. Two patients are presented that underwent an arthroscopically assisted patellar revision after having complications arising from their patella after having had a total knee arthroplasty. Both patients had had failure of the patella button and would have needed to undergo an open procedure in order to revise the loose patella. The arthroscope was used to aid in diagnosing the failure of the patellar component and then to prepare and assist in the insertion of a new component through a minimal incision. The technique utilized is described. This procedure resulted in a decrease in the morbidity that would have resulted from a formal open procedure. Minimum follow-up is now 18 months and both patients have had marked improvement in their knee scores. Arthroscopically assisted patella revision is a viable alternative to a formal open procedure and will result in a decrease in morbidity, rapid mobilization and a smaller surgical incision as is often seen with other arthroscopic procedures.

        A Prospective Analysis of the Accuracy of Knee MRI Interpretation by Orthopaedic Surgeons and Musculoskeletal Radiologists

        Suken A. Shah, Michael G. Ciccotti, Venkat Sethurman, Mark E. Schweitzer Chadds Ford, Pennsylvania, U.S.A.
        Purpose: To compare, prospectively, the accuracy of knee MRI interpretation by orthopaedic sports medicine surgeons and musculoskeletal radiologists compared to the “gold standard” of arthroscopy; is there added value, in terms of clinical decision-making, with a radiologist's interpretation? Materials and Methods: An orthopaedic sports medicine surgeon (ORS) and a musculoskeletal radiologist (RAD) evaluated MRI scans of the knee joint of fifty (50) patients prospectively and independently. Their interpretations were recorded and compared to the findings at the time of arthroscopy. The ORS did have the opportunity to examine the patients prior to reviewing the MRI scans, and had access to the RAD's reading prior to surgery. Any changes to the preoperative surgical plan were noted based on the RAD's reading. Results: With regard to medical meniscal pathology, no tears went undiagnosed by the ORS (sensitivity = 100%), whereas the RAD missed 2 tears (sensitivity = 91%). They shared a false positive rate of 60%. In the lateral compartment, 4 tears of the lateral meniscus went undiagnosed by the ORS (sensitivity = 70%), whereas the RAD did not appreciate 6 tears (sensitivity = 46%). Furthermore, the false positive rate of the ORS was 47% and the RAD's was 6%. The overall accuracy in interpreting meniscal pathology was identical for both interpreters: 90%. In the areas of ligamentous lesions and other intraarticular pathology, both were similar with high degrees of accuracy (ORS = 100%, RAD = 93%). However, both interpreters were not as adept in identifying areas of chondral lesions in the knee joint (ORS sensitivity = 53% vs. RAD sensitivity = 61%). The ORS had a high degree of correlation to the RAD when diagnosing extra-articular pathology such as cysts and tendon abnormalities. However, the RAD was more sensitive to bone marrow abnormalities. Discussion and Conclusion: Due to current economic pressures in healthcare, there is some debate for the need of a radiologist's interpretation of certain orthopaedic imaging studies. Orthopaedic sports medicine specialists evaluate MRI scans of the knee joint routinely as part of their clinical practice, and are adept at utilizing this diagnostic test. This study demonstrates, in a prospective fashion, that an experienced orthopaedic surgeon, with a history and physical exam, can accurately interpret MRI scans of the knee joint. The orthopaedic surgeon and radiologist both had an accuracy of 90% when interpreting the menisci of the knee joint; the accuracy in other areas was similar. Additionally, the radiologist's interpretation did not cause a change in the clinical management prescribed by the orthopaedic surgeon for any patients in this study.

        Arthroscopy of the Painful Total Knee Replacement

        Arturo Corces, Virgilia Gonzalez, Felix Stanziola Miami, Florida, U.S.A.
        Eleven procedures were performed in ten patients who had had a previous total knee replacement performed for osteoarthritis. The presenting complaint was a painful total knee replacement in all the patients, however two patients also had patellar problems that necessitated a revision of the patella performed arthroscopically and four patients had marked stiffness secondary to the initial procedure. All the patients were available for follow-up at an average of 18 months with a range of four years to three months. Ten of the eleven procedures resulted in an improvement in the patient's knee score. The four procedures that were performed for stiffness resulted in an average 35 degree increase in the range of motion. One patient who was treated for pain and noted to have marked fibrosis had initial relief and over a two-year period had recurrence of the fibrosis with concurrent loss of motion. The patient underwent a second arthroscopy two years after the index procedure and had a marked improvement in both pain relief as well as stiffness. Two arthroscopic revisions of the patella were performed in patients who had loosening of the patella component. One patient continued with severe and chronic pain after the arthroscopy. There were no complications associated with the arthroscopic procedure. Arthroscopy of the total knee replacement is a safe, reliable, and effective procedure with minimal complications.

        Arthroscopy of the Hip: A Follow-up Study

        Armin Tenrany, Michael M. Alexiades, Jose A. Rodriguez, Stephen J. Nicholas Staten Island, New York, U.S.A.
        Introduction: Our objective was to evaluate the results of hip arthroscopy and to determine whether a correlation exists between physical findings or unenhanced MRI alone with intraoperative findings. Methods: We retrospectively reviewed all of the hip arthroscopy procedures performed at our institution. Indications for hip arthroscopy were hip pain with physical signs or MRI-confirmed pathology amenable to arthroscopic treatment. Twenty-eight hips (twenty-seven patients) underwent arthroscopic evaluation and treatment by one of two surgeons using similar technique. There were seventeen women and ten men, with a mean age of 34.6 years. Twenty-five patients were available for complete follow-up evaluation. The average length of follow-up was 13.2 months. Overall hip condition was rated by the patient on a 0 to 10 scale, where 10 indicated a normal hip and 0 indicated a poor hip with major limitations in activities of daily living. Results: Intraoperative findings included: 16 pts (64%) had an isolated labral tear, 3 pts (12%) had dysplasia with an associated labral tear, 1 pt (4%) had dysplasia without an associated labral tear, 2 pts (8%) had synovial chondromatosis, and 1 pt (4%) had loose bodies. Overall hip condition increased from an average preoperative score of 3.4 out of 10 to an average postoperative score of 7.3. In patients with hip dysplasia, overall hip condition increased from 3.6 to 7.3. Three patients with underlying hip dysplasia experienced some relief, yet ultimately underwent a hip and/or pelvic osteotomy. One patient with no improvement later had an iliopsoas release with relief. Twenty-six% of patients had postoperative numbness in either the perineal area or lateral femoral cutaneous nerve distribution, which completely resolved. There was a positive correlation between preoperative symptoms of hip click and acetabular labral injury in 74% of patients. MRI evidence of labral tears correlated with intraoperative findings in 92% of patients. The average C-E angle was 31.7 degrees. Patient satisfaction was 96%. Conclusion: Hip arthroscopy should be considered a valuable method of diagnosis and treatment of various forms of hip pathology. In patients with a suspected acetabular labrum tear, unenhanced MRI imaging may serve as a useful diagnostic tool in the orthopaedic surgeon's evaluation.

        Optimization of Soft Tissue as a Graft Source for Ligament Reconstruction

        David N.M. Caborn, Pete Hester, Kevin Sumida, Jeff Selby Lexington, Kentucky, U.S.A.
        This scientific exhibit will review the use of both autograft and allograft tissues and their indications in knee ligament reconstruction. Procurement, Preparation, Biomechanical properties, Sizing, Surgical Technique, Fixation and Rehabilitation will be reviewed. The goal being to demonstrate practical techniques, to optimize surgical outcome for both the single and combined ligamentously compromised knee.

        Quality of Life Analysis of Arthroscopic Meniscal Repair With Bioabsorbable Arrows in the Setting of HS ACL Reconstruction

        Ronald A. Navarro, Brian Wiley Harbor City, California, U.S.A.
        Objectives: Bioabsorbable all-inside techniques of arthroscopic meniscal repair have occasionally been criticized due to inferior strength of repair. The combination of bioabsorbable arthroscopic meniscal repair in the setting of anterior cruciate ligament (ACL) reconstruction with hamstrings tendons and bioabsorbable screws combines two potentially less stable fixation methods. The purpose of this study was to determine how this technique and setting of meniscal repair affected the patient's satisfaction or quality of life. Materials: A single surgeon's consecutive series of 23 arthroscopically repaired meniscal tears with bioabsorbable arrows in 18 patients who underwent ACL reconstruction with autogenous hamstrings fixed by bioabsorbable screws was the basis for the study. In eleven cases, the medial meniscus only was repaired, in 2 the lateral meniscus was only repaired, and in five both were repaired. Three arrows were used on average in each meniscus. A modified Health Status Questionnaire was used to evaluate the patients' overall quality of life. Criteria for successful meniscal repair were the following: 1) knee pain or mechanical symptoms, 2) stable knee exam, 3) level of vigorous activity, 4) no subsequent re-surgery anterior cruciate reconstruction or repair of meniscus. Results and Conclusions: At 12 months average follow-up, patients routinely denied or had minimal pain, with the average being 2.75 out of a scale of 10. Joint line tenderness was virtually nonexistent and the patients all reported good knee stability. Fifteen of eighteen patients have resumed vigorous cutting sports at high school to intercollegiate levels. All health status responses in the areas of physical function, daily activity and emotional, social and mental health averaged greater than 90, out of 100. Only two patients required repeat surgery for failure of meniscus repair. In one, the ACL reconstruction was intact and repeat meniscal repair with arrows and fibrin clot led to eventual meniscal healing. The patient is now assymptomatic. In the other, a degenerative tear required debridement and symptom abatement. Significance: The study demonstrated the arthroscopic meniscal repair with bioabsorbable arrows in the setting of ACL reconstruction with hamstrings tendons and bioabsorbable screws has successfully improved patients' quality of life and stabilized the knee in over 95% of the menisci (22/23). At early follow-up, arthroscopic meniscal repair with bioabsorbable arrows in the setting of ACL reconstruction remains a viable alternative in the armamentarium of techniques for meniscal repair.

        Another Look at O'Donoghue's Triad

        Jonathan J. Paul, Kurt Spindler, Jack T. Andrish, John A. Bergfeld, Richard D. Parker Concord, North Carolina, U.S.A.
        Introduction: Combined ACL and MCL injuries have been associated with increased medial meniscus tear (O'Donoghue) and lateral meniscus tear (Shelbourne) incidence respectively. Neither of these previous reports included a control group. Purpose: To compare extent and type of intra-articular pathology in combined anterior cruciate deficient knees with grade 2 or 3 MCL injuries to a control group of ACL deficient knees with no MCL injury. Methods: This is a prospective, consecutive study involving ACL reconstructions. Pre-operatively, patients documented a detailed history of their knee. At surgery, the intra-articular pathology was documented on an ACL Registry Form based on the patient's examination under anesthesia and arthroscopic examination. A database was developed on ORACLETM. The database allowed an analysis of the relationship between the pathology between the control group and the group with a combined ACL/MCL injury. Patient's with any previous history of surgery on the involved knee, any re-injuries or any giving way episodes were excluded. Only complete ACL tears were included. Chi-squared and Fisher's Exact test were used for data analysis. Results: (See Table)
        Tabled 1
        Isolated ACL Injury Group (n = 335)Combined ACL/MCL Injury Group (n = 71)P
        Time injury to surgery (yr)0.89 (SD 2.9)0.26 (SD .94).12
        Medial meniscus tear
        Incidence40% (n = 135)36% (n = 42).55
        Tear Length (mm)14.1 (SD 8.1)11.5 (SD 7.5).14
        Lateral meniscus tear
        Incidence49% (n = 164)59% (n = 42).12
        Tear Length (mm)10.2 (SD 6.0)11.8 (SD 6.5).1
        LFC Lesion Incidence20% (n = 68)36% (n = 26).003
        MFC Lesion Incidence18% (n = 59)23% (n = 16).3
        Lachman (mm difference)7.3 (SD 3.7)9.1 (SD 5.1)<.0001
        Discussion and Conclusion: Knees with combined ACL, MCL injuries had a significantly increased incidence of chondromalacia of the lateral femoral condyle when compared to a control group of isolated ACL deficient knees. This finding may help account for the increased incidence of arthritis seen on long term follow-up studies in combined ACL, MCL injury. No statistically significant association was observed for either medial or lateral meniscus tears, although a trend was seen for increased lateral meniscus tears in the combined ACL, MCL group. In our patient population, a triad of ACL tear, MCL tear and a lateral femoral condyle lesion was seen.

        Arthroscopic Bankart Reconstruction Using the Bio-anchor

        F. Alan Barber, Stephen J. Snyder, Jeffrey S. Abrams, Gregory C. Fanelli, Felix H. Savoie III Plano, Texas, U.S.A.
        Purpose: To compare a poly L-lactic acid (PLLA) biodegradable anchor (Bio-Anchor, Linvatec) with a standard metal anchor (Mitek G2) for arthroscopic Bankart reconstruction. Methods: This was a prospective, multicenter, randomized study of consecutive arthroscopic Bankart procedures begun in 1994. Inclusion criteria were recurrent anterior glenohumeral instability and a minimum age of 16. Exclusion criteria were significant glenoid bone deficiency, large Hill Sachs lesion, rotator cuff tears, posterior labrum tears, or biceps ruptures. Altogether 56 patients followed an average of 20 months (range 12 to 48) were randomized to either Group 1 (Bio-Anchor) or Group 2 (Mitek G2). Group 1 held 43 patients (32 males and 11 females) with an average age of 27. Group 2 held 13 males with an average age of 27.89% of the patients were recreational athletes, and 68% listed their injury as sports related. 96% had a positive apprehension test before surgery. 87% reported pain with ADLs and 29% reported the pain as constant. 18% were workers compensation cases. Results: At follow up, no pain with ADLs was reported by 98% of both groups. 4 reported pain with heavy activity. 93% of those with positive apprehension tests were negative after surgery. Motion was comparable in both groups improving from 155° preop to an average 175° postop. An average of 2.8 Bio-Anchors and 3.0 G2 anchors were used in each case. Subjectively, 86% of the Bio-Anchor and 92% of the G2 patients reported they felt “much better.” The rest reported feeling “better.” No operative complications were reported. One Bio-Anchor and one Mitek G2 patient developed recurrent dislocations in the post operative period (3.5%). No lytic or resorptive postoperative bone changes were seen in the radiographs of either group. Synovitis was not observed. No anchor problems were reported. Discussion: No differences in radiographic, objective, subjective findings exist between the Bio-Anchor or G2 anchor groups. The PLLA biodegradable material in the Bio-Anchor caused no adverse events. The biodegradable anchor offers advantages in postoperative imaging, “revisability,” ability to accommodate a selection of sutures, and a softer eyelet unlikely to fray or damage a suture. We feel the keys to the 96% success rate are: 1) using three anchors, 2) anchor placement on the articular surface, 3) using nonabsorbable sutures, and 4) at least three weeks of postoperative immobilization. Significance: The Bio-Anchor is safe and effective for arthroscopic procedures.

        Osteochondral Lesions of the Talus: A Correlation Between Operative Treatment and Clinical Outcome Using a New Cartilage Grading System

        Struan H. Coleman, Hollis G. Potter, Jonathan T. Deland, Martin J. O'Malley New York, New York, U.S.A.
        Osteochondritis dessicans (OCD) of the talus is a well documented entity that goes by several names. While a number of studies have attempted to correlate treatment of OCD of the talus with clinical outcome, the results are erratic. This is largely due to an inconsistency in grading the lesions. The purpose of our study was to correlate operative technique with clinical outcome for a series of OCD lesions of the talus treated at our institution. Most importantly, we employ a novel system to grade cartilage overlying an OCD lesion, both as seen with magnetic resonance (MR) imaging and arthroscopically. Methods: Forty-two osteochondral lesions of the talar dome were treated in forty-one patients between 1993 and 1997. All of the lesions were treated arthroscopically in one of three ways: 1) the lesion was shaved, 2) the lesion was drilled, or 3) an osteochondral fragment was secured into a defect with absorbable pins. The articular cartilage overlying each osteochondral lesion was evaluated on MR and arthroscopically and graded 0 through 5 using the following classification: 0—normal cartilage, 1—intact cartilage surface, but ballutable, 2—fibrillation/fissures not extending to subchondral bone, 3—flap present or bone exposed, 4—loose undisplaced fragment, 5—displaced fragment. The Ankle-Hindfoot clinical rating scale (0 to 100 points) was used to assess the functional status of each patient treated for an OCD lesion of the talus; average follow-up was 27 months. Results: The average age of the forty-five patients was 38 years. 58% of the patients were male. The cartilage overlying the OCD lesion was graded a ‘1’ in 3 cases, a ‘2’ in 14 cases, a ‘3’ in 20 cases, a ‘4’ in 6 of the cases and 3 of the cases received a grade of ‘5’. 26 of the 46 lesions were drilled, 14 lesions were shaved. An osteochondral fragment was pinned into the defect in 6 cases. For the 19 OCD lesions graded a ‘1’ or a ‘2’ by MR and at the time of surgery, all of these patients had a good or excellent result regardless of the treatment method. For the 18 cases graded a ‘3’ by MR, the patients treated by drilling (12) all had good or excellent outcomes, while those treated by shaving alone (8) only half (4) had a good or excellent result, while the other half (4) had a poor result. For the 6 OCD lesions graded a ‘4’, 4 of the lesions were treated by securing the fragment; three of these patients had a good result while one patient had a poor outcome. The 2 patients treated by drilling a grade ‘4’ lesion both had a fair outcome. All 3 of the patients receiving a grade of ‘5’ on MR had a poor clinical outcome, regardless of the treatment modality. Conclusion: By using a grading system for the cartilage overlying an OCD lesion of the talus, it is possible to predict clinical outcome based on the type of operative treatment. For cartilage receiving grades of ‘3’ and ‘4’, drilling the lesion and securing the fragment when possible improves the clinical outcome of the patient. There appears to be no correlation between the type of operative treatment and the clinical outcome for OCD lesions graded a ‘1’, ‘2’ or ‘5’ by our system.

        Avoiding Graft Tunnel Mismatch in Endoscopic Anterior Cruciate Reconstruction: A New Technique and Early Clinical Results

        Domenick Sisto, Greg Hartman, Mark Nikkel Sherman Oaks, California, U.S.A.
        A common problem encountered in endoscopic anterior cruciate ligament reconstruction is graft-tunnel mismatch. A new technique provides direct measurement of the tibial tunnel length plus the intraarticular distance. This allows direct calculation of the length of the femoral tunnel necessary to avoid a graft-tunnel mismatch. Between June 15, 1998 and July 31, 1999, we performed eighty-six anterior cruciate ligament reconstructions (eighty-six patients) utilizing an autologous bone-patellar-bone graft. The length of the tibial tunnel is determined by adding the average intraarticular distance (25 mm) and the average femoral tunnel length (25 mm) and subtracting it from the total graft length (TTL = TGL − (IAD + FTL)). After reaming the tibial tunnel, a seven millimeter over-the-top guide is then used to place the femoral guide pin. The calibrated markings are read at the entrance to the tibial tunnel on the anterior aspect of the tibia. The length read here is the combined length of the tibial tunnel length plus the intraarticular distance (TTL + IAD). A simple formula can then be used to determine the femoral tunnel length (FTL) needed to avoid any graft–tunnel mismatch. The formula is FTL = TGL − (TTL + IAD). The femoral tunnel is then drilled to the appropriate length. The average graft-tunnel mismatch for the eighty-six anterior cruciate ligament reconstruction was about one millimeter (1.07 mm; range, −5 mm to +2 mm). Of the eighty-six patients, 58 percent (N = 50) had a zero reading implying no graft-tunnel mismatch. In summary, we believe that a method that eliminates the problem of graft-tunnel-mismatch has been described. It is simple, reproducible, and early clinical data suggests that it is very effective.

        Two-Year Follow-up of Meniscal Repair With the Bioabsorbable Fixation Device

        Mark J. Lemos, Robert Gutierrez, Richard M. Wilk, Paul M. Smiley, Anthony A. Schepsis, Hugh P. Jones Burlington, Massachusetts, U.S.A.
        Introduction: The value of meniscal repair is well established. Several all-inside arthroscopic techniques have become available to achieve this. One such technique involves the use of a biodegradable polylactic acid tack, which has made repair technically easier to perform. This study evaluates the 2-years results of arthroscopic meniscal repair using this device. Methods: We reviewed 36 patients who had undergone meniscal repair with the bioabsorbable Arrow, (Bionx, Warsaw, Indiana). All procedures were performed by one of four fellowship-trained sports medicine orthopaedic surgeons in one of two affiliated hospitals with a minimum follow-up of two years. Review consisted of evaluation of patient records, interview and clinical examination by an independent examiner. Lysholm and Tegener knee scores were recorded. Complications and clinical failure, defined as re-operation were noted. Results: The average age of the patients were 30.6 years. The ratio of medial to lateral meniscal repairs was 5:1. Twenty-one patients underwent concurrent ACL reconstruction and in this subgroup there were no clinical failures. In the remaining group, isolated meniscal repairs in stable knees, the clinical failure rate was 14% (2 re-operations). Local soft tissue complications occurred in 20% of patients, including a single case of arrow migration through the skin. These symptoms typically resolved over several months. Conclusion: The availability of sutureless all inside absorbable techniques for meniscal repair has made the operation technically easier to perform arthroscopically. In our patients local complications related to device migration, device prominence, and soft tissue inflammation associated with absorption of the device was common (20%). These were usually transient, we emphasize the importance of selection of the correct device length to minimize these effects. As with other meniscal repair techniques, a higher success rate was found in knees undergoing concurrent ACL reconstruction. Our results demonstrates a clinical success rate utilizing absorbable all inside technique comparable with reported results using established inside out techniques.

        ACL Reconstruction Performed Under 3-in-1 Nerve Block: Results Utilizing Newer Generation Surgical Techniques

        Wayne K. Augé II, Joseph Griffin Santa Fe, New Mexico, U.S.A.
        Introduction: ACL reconstruction has evolved dramatically during the last three decades. Newer generation surgical techniques now allow completion of this procedure solely under 3-in-1 femoral nerve block with local infiltration. The purpose of this study is to report our experience performing primary ACL reconstruction solely under 3-in-1 nerve block with local infiltration, evaluating intra-operative and post-operative conditions, patient costs, and patient satisfaction when compared to spinal and general anesthesia. Methods: Fifty sequential patients were randomized prospectively into three anesthesia protocols: Group I a single dose of propofol followed by a 3-in-1 nerve block; Group II general anesthesia; and Group III spinal anesthesia. Subjects underwent ACL reconstruction utilizing central third patellar tendon with interference screw fixation. All procedures were performed without placement of a tourniquet, under gravity inflow without an arthroscopic pump, and utilizing a one incision technique. All subjects received local anesthetic infiltration before the operative procedure; and, joint infiltration at completion. Intraoperative and post-operative conditions and patient cost were evaluated and compared. Results: No difference was noted in either intra-operative pain or operating conditions. Group I exhibited no requirement for post-operative opiates, no complications such as nausea/urinary retention, a marked decrease in time to achieve discharge criteria, and high patient satisfaction. Both Group II and Group III subjects required opiates during the intra- and post-operative period with 3% nausea in Group II and 2% urinary retention in Group III. The intra- and post-operative patient cost for Group I subjects was 58.9% less than spinal anesthesia and 78.7% less than general anesthesia. Discussion: The evolution of ACL reconstruction has brought significant advances in repair techniques and treatment protocols. The advantages of the 3-in-1 nerve block augmented with local infiltration include simplicity, safety, high patient satisfaction, low cost, decreased requirement for intra- and post-operative opiates, decreased time to achieve discharge criteria, and lack of complications. We recommend use of the 3-in-1 nerve block to assist in the operative treatment of the ACL deficient patient since the combination of newer generation surgical techniques and anesthetic protocols can translate to improvements in patient satisfaction and operative costs.

        Revision ACL Reconstruction in the Setting of Rural Managed Care

        Wayne K. Augé II Santa Fe, New Mexico, U.S.A.
        Introduction: The development of managed care has increased health care access and the penetration of elective orthopaedic procedures in rural communities. Recently, the “ruralization of sports medicine” due to physician surplus has brought newer techniques into these communities providing the opportunity to observe changing trends in orthopaedic care—particularly to examine elements relative to surgical failure that when defined can augment patient outcome in the primary setting and decrease total treatment cost for specific injuries. The socio-economic phenomenon of ACL reconstruction provides a unique opportunity to evaluate these issues and assist in practice management and development of health policy. Methods: Twenty-two patients were referred to our regional rural orthopaedic center over a two year period for treatment of failed ACL reconstruction. Patients were reviewed retrospectively as to the etiology of failure and the total cost of treatment (including index and subsequent procedures). Only patients undergoing primary reconstruction within the last five years were included for study as surgical techniques evolve. Number of procedures were correlated to etiology of failure and total cost of treatment. Results: Group I (59.1%) failed due to surgical error (92.3% tunnel placement; 7.7% fixation failure); Group II (18.2%) failed due to repeat traumatic episodes; Group III (18.2%) failed due to laxity without rupture after reconstruction; and Group IV (4.5%) failed due to other causes (i.e., infection). Total cost of care after successful revision exceeded that of the index procedure by an average of 260.8% (time adjusted) for all cases. No correlation existed between etiology of failure and number of procedures per patient. The total cost of treatment was greatest for Group I and Group IV with statistical differences from Group II and Group III (P < .05). Discussion: ACL reconstruction has provided a largely predictable outcome for the ACL deficient patient by achieving stability and return to sport. Although reports indicate a limited decrease in early osteoarthritis in patients successfully reconstructed, the indications for reconstruction have widened to include additional patient groups. Due to this interest in the ACL, more physicians offer treatment and a large number of ACL reconstructions are being performed today. Although the absolute failure rate has not been determined, an inordinate number of failures due to surgical error was observed. Socio-economic pressures associated with treatment of the primary ACL deficient patient warrant examination.

        Radiographic Analysis of Tunnel Morphology After Single-Bundle PCL Reconstruction

        John Klimkiewicz, Russell Petrie, Jason Lowenstein, Christopher Harner Washington, DC, U.S.A.
        Purpose: To evaluate and measure post-operative bone tunnel morphology for the presence of tunnel expansion in patients undergoing single bundle posterior cruciate ligament (PCL) reconstruction for isolated and combined PCL injuries of the knee. Methods: Sixteen patients underwent isolated or combined single bundle arthroscopic PCL reconstruction with Achilles allograft between 1994-96. There were 13 males and 3 females with an average age of 26.5 years. PCL graft fixation consisted of a femoral metallic interference screw in conjunction with a tibial bi-cortical screw and ligamentous washer in all cases. Lateral and 45° postero-anterior weightbearing radiographs were analyzed at an average of 19.2 months (9-49 months), post-operatively. Comparison of the measurements of the sclerotic margins of the bone tunnels at their widest dimension was made by a single observer with a digital caliper, and compared to the initially drilled tunnel size obtained from the operative reports after correction for radiographic magnification. Accuracy and reliability analysis of the measurement technique was performed and confirmed by a second observer. Statistical analysis was performed with a student's t test (P = .05). Results: The operatively drilled tibial tunnel sizes measured 10.8 ± 0.4 mm, as compared to the sclerotic margins of the tibial tunnels that measured 13.05 ± 2.9 mm, post-operatively. The mean percentage increase in tunnel dimension was 20.9 ± 28.1%. This difference was statistically significant at the 5% confidence interval (P = .0094). On the femoral side, the bone plus appeared incorporated at the roof of the inter-condylar notch such that no tunnel measurement or meaningful comparison could be made. Conclusion: As has previously been reported in ACL reconstruction with indirect methods of fixation, tunnel expansion appears to likewise exist following PCL reconstruction on the tibial side using similar methods of graft fixation. Further study is required to compare more direct methods of fixation as well as the clinical significance of this phenomenon.

        Rotator Cuff Repair With a New Implant: ADHOC® Claw

        Charles A. Hugues Lille, France.
        Introduction: The bone is often the “weak link” that explains the failure of the rotator cuff repair. A new implant is located on the external cortex one inch below the greater tuberosity, which is the strongest part of the bone. Purpose: The purpose is to present this new technique and the preliminary results of the 21 first patients (Jan 98 to Dec 98) with a follow up of 13 months (21 to 9 m). The Implant: ADHOC® CLAW is a stainless steel claw with an open eyelet where can pass through 2 sutures. The Procedure: In a beach chair or a lateral decubitus position, a gleno humeral and a sub acromial arthroscopy allows to perform a Neer acromioplasty and to make clear the edges of the tear. Through a mini open approach a bone trough is created. A double needled threaded n°2 suture is passed through the cuff from below to above. An ancillary hook with a slot, perforates the cortical bone one inch below the top of the greater tuberosity and catches the suture at the bottom of the trough. The suture is pulled back of the cortical bone, and passed through the open eyelet of the claw. Then we pull on the 2 threads and the ADHOC® CLAW is fixed firmly against the external cortex, we tie the knot at the top of the cuff partially in the trough. Two sutures can be used. Results: 21 patients: 13 females, 8 males, mean age: 55 years old (41 to 68). Mean follow-up 13 months (21 to 9). Simple Shoulder Test (F. Matsen/12 pts): pre-op: 3 pts post-op: 10.14 pts. Pain (ASSES score/10 pts): pre-op: 7.14 pts., post-op: 1.33 pts. Constant score ponderate: pre-op: 40.42 pts. post-op: 94.4 pts. Activity of daily living: pre-op: 6.9 pts, post-op: 18.9 pts/20. Range of motion: pre-op: 25 pts, post-op: 35.14 pts/40. Straight: pre-op: 4 pts, post-op: 8.38 pts/25. Complications: 2 Re-ruptures. We note no migration of the implant. One after injury, a second repair gives a good result. One with a previous surgery and a very large and degenerative cuff (grade II fatty degeneration), we perform a inverse total shoulder prosthesis with a good result. Conclusion: For rotator cuff repair, we use a new implant that permits a strong bone fixation with 2 sutures in the eyelet. ADHOC® CLAW has a good pull out strength and is easily visible by X-rays. Mini open approach is recommended. The preliminary results are very encouraging with this short follow up.

        Debridement Arthroscopy 10-Year Follow-up

        Fred D. Cushner, Brian J. McGinley, W. Norman Scott New York, New York, U.S.A.
        The treatment of osteoarthritis of the knee is a difficult problem. In the senior author's opinion nonaggressive arthroscopic debridement of the knee joint is an effective procedure to relieve pain and restore function in patients with osteoarthritis of the knee. A subjective telephone interview of patients 10 or more years after arthroscopic debridement evaluated the long term results of this treatment in patients with osteoarthritis of the knee. The patients were all candidates for total knee replacement who selected arthroscopy as a temporizing procedure. Of the 191 knees undergoing arthroscopic 91 knees in 77 patients were contacted for followup. Sixty-seven percent of the 91 knees did not go on to total knee arthroplasty at an average of 13.2 years followup. The Tegner activity score averaged 3.5 and patient satisfaction averaged 8.6 on a 0 to 10 scale. Twenty-one patients (30 knees) or (33%) went on to total knee arthroplasty at an average of 6.7 years. Seven of these knees had Outerbridge Grade 4 articular cartilage changes and clinically significant meniscus tears. Seven of the 19 knees (37%) with Outerbridge Grade 4 changes in 80% of one knee compartment did not require total knee arthroplasty after greater than 10 year followup. The difficulties in long term followup in this patient population is evident, yet the number of patients who had a functional lifestyle after arthroscopic debridement was notable.

        An Arthroscopic Staging System of the Rotator Cuff and Coracoacromial Arch: A Systematic Approach to Treatment

        Leigh S. Brezenoff, Robert P. Nirschl, Eric J. Guidi Arlington, Virginia, U.S.A.
        Introduction: The term impingement syndrome has been used to describe symptoms related to the rotator cuff in the absence of a full-thickness tear. To date accepted etiology of this disorder has been extrinsic impingement of the rotator cuff between the humeral head and the acromion. Recommended treatment has been to address this space issue with acromioplasty. In contradistinction, growing evidence now suggests that a spectrum of histopathology of cuff tendinosis occurs intrinsically, with subsequent reactive changes within the coracoacromial arch. Method: 100 consecutive shoulder arthroscopies performed by the senior author for the diagnosis of rotator cuff disease, without full thickness tears were reviewed. These patients all failed a course of conservative treatment consisting of NSAIDS, physical therapy and other modalities. A retrospective review of the operative reports and photographs was performed. A staging system was developed to describe the pathoanatomy observed during arthroscopy. We are proposing a treatment protocol that addresses each of these findings. Four areas within the shoulder were reviewed. Each was staged according to findings documented during arthroscopy. Each stage is a progression of worsening disease. The rotator cuff was examined and challenged with a shaver from the glenohumeral side as well as the arch/bursal side. The undersurface of the acromion, and coracoacromial ligament were examined and staged. Finally, the acromioclavicular joint was examined and staged, including the presence or absence of preoperative symptoms. Results: The glenohumeral side of the rotator cuff was addressed first. All abnormal appearing cuffs were staged based on the depth of diseased tissue. There were no normal cuffs in this series, 18% of the cuffs had damage less than 2 mm deep, 52% demonstrated damage in the range of 2-4 mm deep, the remaining 28% had greater than 4 mm of damage. The bursal side of the cuff was then examined both visually and by feel with a meniscal hook. We noted a normal appearance in 69% of the cuffs, with 36% of these felt thin to probing. The coracoacromial arch was staged based upon presence of bursitis, soft tissue thickening of the underside of the acromion, an acromial traction spur of the CA ligament attachment area, or the presence of a true acromial variant (Type III). Traction spurs were noted in 30% of the cases with only 2% having true variants. In the remaining 68%, the underside of the acromion had no bony changes. Finally, the AC joint was examined for evidence of osteoarthritis or presence of bony exostosis. Discussion and Conclusion: No published description of the combined pathologic findings within the rotator cuff and the coracoacromial arch is available in the literature. This study identifies a spectrum of pathology and presents a staging system that allows identification of the specific pathoanatomy. Proper treatment of rotator cuff disorders requires a directed approach, addressing only the pathoanatomy, leaving normal tissue intact.

        Internal Derangement of the Knee After Ipsilateral Femoral Shaft Fractures: MR Imaging Findings Versus Arthroscopic Findings

        Raúl Roura, Edgardo Colón, Antonio H. Soler-Salas, Yamil Rivera Río Piedras, Puerto Rico.
        Introduction: In recent literature various reports have been published focusing on associated ipsilateral knee ligament and meniscal injury with a femoral shaft fracture. Only three reports in the literature have used arthroscopy to evaluate knee injury. De Campos et al have demonstrated a high incidence of partial and complete cruciate ligaments tears, as well as meniscal injuries in the knees of patients with ipsilateral diaphyseal fractures. The reported incidence of knee injury ranges from as little as 5% to as high as 62% in patients who have sustained femur fractures. A recent study by Blacksin and Levy used Magnetic Resonance Imaging to delineate the types and frequencies of injuries seen in the knee after ipsilateral femoral shaft fractures. One limitation of this study was the lack of arthroscopic confirmation of these findings. At present no previous study has compared MRI findings vs. an arthroscopic evaluation of the knee pathology. The purpose of the present study is to document the extent of ipsilateral knee injuries initially occurring with femoral fractures by examination under anesthesia and arthroscopic evaluation of the knee and compare them with MRI findings. Methods: A total of 30 patients, ages 17 through 45 (or squeletally mature) with unilateral closed femoral shaft fractures treated in the emergency room and hospitalized at the University Hospital of the University of Puerto Rico, and treated with IM nailing were included. Patients with open knees, intraarticular fractures, patellar fractures, gunshot wound, previous knee injuries, pathologic fractures or injury to the contralateral leg were excluded. A complete history physical exam and plain radiographs were taken to every patient. The history was focused on mechanism of trauma and the physical exam and radiograph will be focused on describing the type of fracture. A diagnostic MRI of the ipsilateral knee was performed prior to the arthroscopy. Results were kept blind until after the arthroscopy was done. Then a diagnostic arthroscopy of the ipsilateral knee was performed with a physical exam under anesthesia performed at the same day of the arthroscopy. All patients with positive findings during the arthroscopy were treated accordingly. Results: A higher incidence of soft tissue knee damage was found associated with ipsilateral femur fractures. Of the 30 patients included about half were found with some soft tissue damage. In order of occurrence they were ligamentous injuries, meniscal injuries and cartilaginous injuries. The arthroscopic evaluation resulted in a more precise diagnosis and a higher number of injuries were identified using this method and provided a treatment tool at the moment of diagnosis. In contrast physical examination under anesthesia alone and MRI resulted in a poor diagnostic method as a lower number of lesions were identified even in patients that later resulted with lesions under arthroscopic evaluation. Discussion and Conclusion: Our results show that the incidence of soft tissue damage associated with ipsilateral femur fractures is high enough to deserve a protocol of evaluation and treatment before secondary damage occurs. Arthroscopic evaluation resulted in a more reliable tool for identifying the lesions and at the time provided a treatment option.

        Opening Wedge Tibial Osteotomy: Load Changes With and Without Fibular Osteotomy

        Matthew Messina, John D. Kelly, IV, Edward J. Stolarski, Raymond A. Moyer Bangor, Maine, U.S.A.
        Introduction: Closing wedge tibial osteotomy has become an effective treatment for unicompartmental varus gonarthrosis. Proponents of this technique state that the proximal tibiofibular joint will prevent valgus correction unless the fibula is shortened or the tibiofibular ligaments are removed. Recently opening wedge tibial osteotomy utilizing hemicallotasis has been described to achieve a valgus tibia. This technique involves placing a single frame dynamic external fixator medially and gradually distracting (1 mm/day) until the appropriate degree of valgus is attained. One of the cited advantages of this technique is that no proximal fibular disruption or osteotomy is required to effect correction. The authors conducted an in vitro analysis of opening wedge tibial osteotomy to measure load changes during opening with and without fibular osteotomy. The purpose of the study was to determine if significant load changes occurred at a specific distance of opening with the addition of a fibular osteotomy. Materials and Methods: Load changes during opening wedge tibial osteotomy, with and without fibular osteotomy, were evaluated in ten fresh frozen cadaveric specimens. A tension/compression load cell was incorporated into a single frame dynamic external fixator. The fixator was then applied to the medial aspect of the specimen and a corticotomy was performed using a standard technique. Load changes were recorded at opening distances of 1, 1.5, 2, 2.5 cm. An oblique fibular osteotomy was then performed and load changes were recorded in similar fashion. Results: Data was analyzed utilizing an independent two sample t-test. Statistical significance was set at a p-value of less than 0.01. A statistically significant decrease in load was shown at each of the opening distances measured with the addition of a fibular osteotomy. Discussion: The addition of a fibular osteotomy was found to significantly decrease the load transmitted during opening wedge tibial osteotomy at each of the four opening distances measured. A fibular osteotomy should therefore be considered when performing this technique. Future clinical studies should test the applicability of this data in reference to pin tract infection, patient tolerance to the external frame during the opening phase and maintenance of correction over time.

        Femoral Nerve Block for Analgesia in ACL Reconstruction: Efficacy Before and After Surgery

        Bradley M. Thomas, I. Martin Levy, Bernadette DeJesus, Alexander Bastin New York, New York, U.S.A.
        Loss of knee extension is the most common complication following anterior cruciate ligament reconstruction (ACLR). Successful quadriceps contraction enables patients to gain full knee extension after ACLR. Postoperative pain following ACLR delays quadriceps contraction, which directly influences loss of knee extension. Femoral nerve block (FNB) has been demonstrated to decrease postoperative pain following ACLR. The objective of our study was to assess quadriceps function and pain relief after anterior cruciate ligament reconstruction in knees in which a FNB was placed either before or after surgery. In a prospective randomized study, 23 consecutive patients were evaluated who underwent a primary arthroscopically assisted ACLR performed by a single surgeon from December 1998 to May 1999. The patients were randomized to either Group 1, who received a preoperative femoral nerve block, or Group 2, who received a postoperative femoral nerve block. For 3 consecutive days postoperative pain was assessed using a visual analog scale and quadriceps function was assessed by the patient's ability to straight leg raise (SLR). The patients receiving the FNB prior to surgery (Group 1) were able to SLR 82% for all the times tested and 91% of the time for postoperative days 2 and 3, compared to 68% overall for Group 2. In addition, the pain scores for group 1 were significantly lower in all time periods tested, with postoperative days 1 and 3 statistically significant (P < .05). We conclude that a femoral nerve block allows for early quadriceps contraction and that a FNB placed prior to surgery achieves better postoperative pain control and allows earlier straight leg raising than when a FNB is placed after surgery. By achieving early straight leg raising patients receiving a FNB prior to ACLR will have earlier return of quadriceps function and fewer complications with loss of knee extension.

        Modified Technique of Morgan's All-Inside Repair of Posterior Horn of Medical Meniscus: Using 2 Posteromedial Portals to Ease the Technical Difficulties

        Chul Won Ha, Jin Hwan Ahn Seoul, Korea.
        Introduction: The repair of the torn posterior horn of the medial menisci at the most periphery or at the meniscocapsular junction by suture appears to have some advantages over repair by other methods using arrows or tacks. However, the original technique of all-inside repair of the peripheral tears introduced by Morgan seems to be a quite demanding procedure. The authors introduce a modified technique of all-inside repair of the peripheral or meniscocapsular junctional tears of the posterior horn of the medial menisci using 2 posteromedial portals. The authors technique appears to ease the technical difficulties of Morgan's technique of all-inside repair. Technique of Repair: The routine arthroscopic examination of the knee joint is done with standard anterolateral & anteromedial portals. The arthroscope inserted through the anterolateral portal is advanced to the posteromedial compartment with the transnotch technique. The first posteromedial portal is established 5 mm above the level of the upper surface of the posterior horn of the medial meniscus under arthroscopic visualization. Thorough examination and probing of the peripheral portion of the posterior horn of the medial meniscus is accomplished. The second posteromedial portal is established 10 mm above the previously-made posteromedial portal carefully avoiding injury of the saphenous nerve using transillumination technique. A 5.5 mm diameter universal cannula with a diaphragmed lumen is inserted through the upper posteromedial portal. A suture hook is inserted through the lower posteromedial portal and meniscal suture is performed passing the suture hook through the torn portion in posterior to anterior direction. While passing the suture hook through the meniscal tissue, a probe is inserted through the upper posteromedial portal via the universal cannula, and stabilizes the inner portion the meniscus by pulling posteriorly. This greatly facilitates the passage of the suture hook. The PDS suture is inserted long enough into the posteromedial compartment through the lumen of the suture hook inserted via the lower posteromedial portal. A suture retriever is inserted through the upper posteromedial portal via the universal cannula, and both ends of the suture material is retrieved one by one from each side of the tear. The repair is secured with sliding knots. The knots are made outside the universal cannula, and then advanced into the repair site and tightened with knot pusher. The knot pusher passes through the universal cannula inserted via the upper posteromedial portal. Once the knot is completely secured, a cutter is inserted through the lower posteromedial portal and makes the cut of the PDS suture over the knot. Usually 3-4 sutures are made for the posterior horn tears with the repetition of the above technique. Discussion and Conclusion: The authors' modified technique using 2 posteromedial portals has the advantage of greatly increasing the working space of suture hook. The suture hook works through the lower posteromedial portal rather than working through the cannula. This greatly helps the arthroscopic surgeon handle the suture hook more easily and more widely. The probe inserted through the upper posteromedial portal can also help the suture hook inserted through the lower posteromedial portal pass through the torn portion of the meniscus & avoid damage to the articular cartilage of the femoral condyle by the sharp tip of the suture hook. Working through the two posteromedial portals appeared to ease greatly the technical difficulties of Morgan's original technique of working through the one large-bore cannula. The small portals and the cannula with smaller diameter & diaphragmed lumen rather than the large-bore cannula keep the posteromedial compartment distended, which also help ease the work of sutures in the posteromedial compartment. We have done more than 50 repairs with this technique, which greatly eased the technical difficulties of all inside repair in our hands. The authors' modification of the technique of all inside repair appears quite versatile and seems to help the arthroscopic surgeon get the most advantages of Morgan's technique.

        Failure of PLLA Screw Incorporation as a Mode of ACL Hamstring Autograft Failure

        Vladimir Martinek, Thomas Muzzougro, Kerin Armstrong, Dalip Pelinkovic, Freddie H. Fu Pittsburgh, Pennsylvania, U.S.A.
        Introduction: Graft fixation is an important factor in successful anterior cruciate ligament reconstruction. While BPTB grafts allow solid fixation following bone-to-bone healing within the osseous tunnels, the integration of soft tissue tendon grafts (hamstrings) in the bone tunnels is still critical in both direct and indirect fixation methods. Although the outcome following ACL reconstructions with hamstring grafts has shown satisfactory clinical results, BPTB seems to demonstrate greater AP stability. However, there have been no reports to date about larger series of soft tissue graft fixation failures. Case Report: We report three cases of ACL hamstring autograft failures associated with a failed PLLA interference screw incorporation. In the three patients, a revision ACL reconstruction was performed 7, 15 and 30 months following ACL reconstruction with autologous quadruple Semitendinosus-Gracilis graft (fixation with bioabsorbable PLLA screw). The patients (16 and 18 y. old females, 17 y. old male) were compliant with standard postoperative rehabilitation, and did not return to active sports until 6 months after the initial ACL surgery. All patients reached full range of motion and had good postoperative results at 6 months period. All three patients reported a minor trauma, which may have caused the ACL injury. At revision arthroscopy, the ACL graft was insufficient due to an elongation in 2 cases and torn in the proximal third in one case. In all three cases, the bioabsorbable interference screw was found intact in the femoral tunnel and could be removed entirely or in large pieces. After the removal of the interference screw, the graft could be removed easily from the femoral tunnel. In all cases, there was no significant ingrowth of soft tissue into the walls of the bone tunnel. In all three patients, the original femoral tunnel was used for the placement of the revision ACL graft using metal interference screws for fixation. Discussion: Three years ago we began to use bioabsorbable interference screw for bilateral fixation of the doubled Semitendinosus-Gracilis graft, after seeing 8-10% primary failures of the endobutton fixation of these grafts. We have used this technique in lower level athletes or women for over three years now and have seen good early results until today. However, our report demonstrates that in some cases there is a lack of screw and tendon incorporation in the bone tunnel up to 2.5 years following implantation. We cannot exclude that this phenomenon is caused by the presence of the inert degradable screw. Conclusion: One should be aware that the failure of incorporation of the PLLA interference screw could cause proximal graft failure.

        Endoscopic Retrocalcaneal Decompression

        Mauricio Gutierrez, German Salcedo Cali, Colombia.
        In insertion achilles tendinopathy, the retrocalcaneal bursa is often the source of inflammation and pain. An anatomic study in cadavers was performed. Retrocalcaneal endoscopy was performed in 10 ankles (7 patients) with signs and symptoms of retrocalcaneal bursitis for at least six months refractary to conservative treatment. MRI confirmed the increase of size of the bursa. The operations were performed as an outpatient procedure by a two portal technique. The inflamed bursa and the posterior part of the calcaneus were removed. Motion was stimulated from the first day and early weight bearing was permitted as tolerated. In two patients, localized peritendinitis was found. At 3 months we found good results in 7 ankles and there were tenderness at the insertion of the Achilles in 2 ankles and no pain or swelling in the retrocalcaneal area. At 12 and 15 months there were mild pain in 2 ankles (at the Achilles insertion) and normal ROM was recovered. There were no wound problems nor sensory alterations. One patient presented, at 6 months with signs of noninsertional tendinopathy. Endoscopic retrocalcaneal decompression gives satisfactory early results.

        Arthroscopy for Diagnosis and Therapy of Early Osteoarthritis of the Hip: 1-Year Results

        Michael Dienst, Romain Seil, Stefan Gödde, Dieter Kohn Homburg/Saar, Germany.
        Introduction: Failure to conservative treatment in patients with less advanced radiographic signs of osteoarthritis of the hip confronts with the decision of further treatment. Various authors have described difficulties in the assessment of cartilage degeneration or identification of loose bodies and labral tears which may be responsible for exacerbation of pain. The aim of this prospective study is to analyze the use of Hip Arthroscopy (HA) for assessment of cartilage degeneration and concomitant intraarticular pathology and its therapeutic effect. Methods: From October 1997 to August 1999 24 HA have been performed in osteoarthritic hips graded Danielsson 1 to 5 (∅3.2). Patients' ages ranged from 21 to 77 (∅47). Preop- and F/U-exams consisted of a physical exam following a standard protocol and a questionnaire for the patient including evaluation of pain by a visual analogue scale (VAS). The preoperative X-rays was always completed by MR imaging. HA was performed in supine position, the superficial and the deep compartments of the hip were scoped. Results: There were no vascular or permanent neurological complications, but a damage to the cartilage of the femoral head in 3 patients, the labrum was scratched twice and perforated in 1 case. In 1 patient HA had to be terminated abnormally because of development of a severe soft tissue edema. In 1 patient, an hypesthesia of the lateral femoral cutaneous nerve was present for a few days. In addition to cartilage degeneration, concomitant loose bodies and osteochondral flakes, impinging osteophytes, degeneration of the labrum and synovial disease were found. Arthroscopic findings were exceeding preoperative imaging, concomitant pathology was mostly not imaged preoperatively. Removal of loose bodies and osteophytes, partial resection of labral tears and partial synovectomy was performed. Preoperatively (n = 24), Harris-Hip-Score (HHS) was ∅57. 1-3 months after HA (n = 20), HHS was improved to ∅69, VAS demonstrated a reduction of pain by ∅40%. 1 year after HA, HHS was ∅71, pain reduced by ∅30%. All values were significant (P < .05) due to the t-test for matched pairs (HHS) and the Wilcoxon-signed-rank test (VAS). Conclusions: HA is superior to noninvasive preoperative imaging for the assessment of cartilage degeneration and identification of concomitant intraarticular pathology such as loose bodies and labral tears. If therapy cannot be performed during arthroscopy further therapy can be planned. In addition, there is a significant, at least temporary therapeutic benefit of HA but a risk of damage to cartilage and labrum has to be considered.

        Dislocation of the Femoral Head by Distension Alone: An Experimental Study in Cadavers

        Michael Dienst, Michael Brang, Stefan Gödde, Dieter Kohn Homburg/Saar, Germany.
        Introduction: Even under fluoroscopy and distraction, puncture and portal placement into the deep compartment between the weight-bearing part of the femoral head and the acetabulum hold the risk of damage to labrum and cartilage when no lens is within the joint. The aim of this cadaver study was to quantify the effect of distension alone, when the hip joint is punctured far away from the labrum and cartilage at the femoral neck and no traction is applied. Methods: 6 hip joints were studied in 6 fresh cadavers. After rigor mortis was broken, the cadavers were placed supine on a traction table without any traction force. An 8 mm twist drill was introduced centrally within the femoral head and the hip joint punctured from the anterolateral portal anteriorly at the junction between the femoral head and the neck. Digital images were obtained by fluoroscopy with distension of 0, 10, 20, 30 and 40 ml of saline and transferred to a PC. Points of reference on the acetabulum were selected on each radiograph. 5 distances between the femoral and acetabular subchondral bone were measured in standardized angles to the reference points. In addition, the center of the femoral head was marked and the displacement measured. Projection error was corrected by measurement of the twist drill. Results: The puncture was easily performed in all cases. After distension with 10 ml of saline, the center of the femoral head was displaced laterally by ∅2.5 mm and distally by ∅1.6 mm. For every further distension with 10 ml, the center was displaced laterally by ∅2.2 mm/0.8 mm/0.2 mm and distally by ∅0.6 mm/0.3 mm/0 mm. After 40 ml of saline, total lateral displacement was 5.7 mm ±2.5 mm and total distal displacement 2.6 mm ±1 mm. Displacement was best seen at the cranial margin of the acetabular fossa and the weight-bearing zone and less clear close to the tear drop. Conclusions: Introduction of a cannula into the joint from an anterolateral portal at the junction between the femoral head and the neck can be verified under fluoroscopy by lateral and distal displacement of the femoral head. Using a guide wire and a cannulated trocar, further portal placement to the superficial compartment of the hip is safe at this side. In addition, breakage of the joint seal can be performed at this side without the risk of damage to cartilage and labrum before entering the weight-bearing part of the joint.

        Endoscopic Release for Stenosing Tenosynovitis of the Digits

        Juan C. Molero, J.R. Cayarillo-Morillo, Luis Vargas-Ortiz Zulia, Venezuela.
        Stenosing tenosynovitis of the digits is one of the most frequent causes of pain and functional limitations of the hand. From an economic and public health point of view it is greatly relevant because in the majority of the cases affect the female population in the age of greatest productivity. The purpose of the study is to demonstrate the use of endoscopic technique in the liberation of stenosing tenosynovitis of the digits. In addition, to understand the frequency of the disease as well as to reduce rehabilitation time. And to establish a surgical protocol with the necessary longitudinal incision for the application of this technique. We have developed a new technique for endoscopic release of the stenosing tenosynovitis of the digits. It's advantages include: 1. minimal incision, 2. less morbidity, 3. local anesthesia, 4. ambulatory procedure, 5. rapid recuperation and 6. accessible cost. We therefore add this new viable surgical alternative for the hand surgeon, who has experience in endoscopic procedures, to positively and efficiently resolve a frequent problem encountered daily in the practice of the specialist. Between May 1, 1995 and 1999, 32 patients were operated with endoscopic techniques for stenosing tenosynovitis of the digits. The technique consisted in the longitudinal incision of the A-1 pulley of the flexor tendons under endoscopic vision, throughout a distal approach at the MCP flexor crease. The method showed to be effective in 100% of the cases, with 87.50% excellent results and 12.50% good results. There were no complications nor signs of repetition of symptoms. Therefore, we recommend the technique, as an alternative surgical method, because it offers a direct view while cutting the pulley in an easy and less traumatic way.