Arthroscopy The Journal of Arthroscopic and Related Surgery

Published by WB Saunders
Online ISSN: 1526-3231
Print ISSN: 0749-8063
Intra-articular use of 0.5% bupivacaine is common in arthroscopic surgery. This study was conducted to test the hypotheses that (1) 0.5% bupivacaine is toxic to articular chondrocytes, and (2) the intact articular surface protects chondrocytes from the effects of short-term exposure to 0.5% bupivacaine. Freshly isolated bovine articular chondrocytes were prepared into alginate bead cultures and were treated with 0.5% bupivacaine solution or 0.9% saline for 15, 30 or 60 minutes, washed, and returned to growth media. Chondrocytes were recovered from alginate 1 hour, 1 day, and 1 week after bupivacaine exposure; they were fluorescently labeled to identify apoptotic and dead cells and were analyzed by flow cytometry. Twelve osteochondral cores were harvested from bovine knees. The superficial 1 mm of cartilage was removed from 6 cores (top-off). Intact and top-off cores were submerged in 0.9% saline or 0.5% bupivacaine solution for 30 minutes and then maintained in chondrocyte growth media for 24 hours. Live-cell/dead-cell fluorescent imaging was assessed using confocal microscopy. Greater than 99% chondrocyte death/apoptosis was observed in all bupivacaine-exposed alginate bead cultures compared with 20% cell death in saline-treated controls (P < .05). Osteochondral cores with intact surfaces treated with 0.5% bupivacaine showed 42% dead chondrocytes. When the articular surface was removed, 0.5% bupivacaine resulted in increased cell death, with 75% dead chondrocytes (P < .05). Results show that 0.5% bupivacaine solution is cytotoxic to bovine articular chondrocytes and articular cartilage in vitro after only 15 to 30 minutes' exposure. The intact bovine articular surface has some chondroprotective effects. Because healthy chondrocytes are important for maintenance of the cartilage matrix, chondrocyte loss may contribute to cartilage degeneration. This study shows a cytotoxic effect of 0.5% bupivacaine solution on bovine articular chondrocytes in vitro. Although these results cannot be directly extrapolated to the clinical setting, the data suggest that caution should be exercised in the intra-articular use of 0.5% bupivacaine.
Intra-articular administration of local anesthetic solution provides analgesia after arthroscopic knee surgery. Bupivacaine is considered the gold standard local anesthetic in this indication, but ropivacaine, which is less toxic than bupivacaine, can consequently be administered in higher doses, potentially increasing the duration of analgesia. We compared the analgesic effect of intra-articular injection of ropivacaine 225 mg and bupivacaine 150 mg in patients undergoing arthroscopic surgery. Double-blind, randomized prospective clinical study. The study included 45 patients scheduled for knee meniscus repair under arthroscopy, who were allocated randomly into 3 groups to receive, intra-articularly, 30 mL of isotonic saline, bupivacaine 0.5%, or ropivacaine 0.75% solutions at the end of surgery. Postoperatively, pain was measured using a visual analog scale (VAS) at rest and on mobilization. Propacetamol was given when patients complained of pain. VAS scores at rest and on mobilization were higher in the saline group compared with the ropivacaine group (P = .006 and P = .01, respectively). No difference in VAS scores was documented between bupivacaine and the saline groups. The median delay between the intra-articular administration and propacetamol administration was shorter in the saline group (15 minutes; range, 15 to 120 minutes) compared with the ropivacaine group (240 minutes; range 15 to 720 minutes) but no difference was documented between the bupivacaine group (30 minutes; range, 15 to 360 minutes) and the other 2 groups. This level I study documents that intra-articular ropivacaine 0.75% provides better analgesia than bupivacaine 0.5% after knee arthroscopic surgery. Level I.
PURPOSE: The purpose of this study was to establish whether suture anchor capsulorrhaphy (SAC) is biomechanically superior to suture capsulorrhaphy (SC) in the management of recurrent anterior shoulder instability without a labral avulsion. METHODS: Twelve matched pairs of shoulders were randomized to either SC or SAC. Specimens were mounted in 60° of abduction and 90° of external rotation. Testing was conducted on an MTS servohydraulic load testing device (MTS, Eden Prairie, MN). A compressive load of 22 N was applied, followed by a 2-N anterior and posterior force to establish a 0 point. Translation with 10-N anterior and posterior loads was recorded for baseline laxity measurement. Arthroscopic capsulorrhaphy was performed with either 3 solitary sutures or 3 suture anchors. Specimens were remounted and returned to the 0 point. Translation was measured with 10-N anterior and posterior loads to determine reduction in translation. Specimens were then loaded to failure to the 0 point at a rate of 0.1 mm/s. RESULTS: Load to failure was significantly greater (P = .02) in the SC group (13.6 ± 1.0 N) versus the SAC group (20.5 ± 2.8 N). No differences were found between SC (2.7 ± 0.7 mm) and SAC (2.3 ± 0.6 mm) when we compared reduction of anterior translation with a 10-N load. The percent reduction of anterior displacement with a 10-N load was similar for the SC (49.9%) and SAC (49.6%) groups. The dominant mode of failure in the study was suture pull-through of the capsular tissue. CONCLUSIONS: Our study indicates that labral-based SC and SAC similarly reduce anterior glenohumeral translation at low loading conditions. Load-to-failure studies indicate that SAC exhibits significantly greater resistance to translation at higher loading conditions. Our study suggests that the use of a suture anchor when one is performing a capsulorrhaphy may provide biomechanical advantage at high loading conditions. CLINICAL RELEVANCE: Our study suggests that when one is performing capsulorrhaphy, the use of a suture anchor may provide biomechanical advantages at high loading conditions.
The purpose of this study was to investigate intra-articular hip joint pathologies in professional athletes who sustained dislocation and were treated with hip arthroscopy. Between August 23, 2000, and September 15, 2006, 14 professional athletes (12 male and 2 female) sustained a nonfracture traumatic hip dislocation during active competition and were treated by a single surgeon. A retrospective chart review of this cohort was done to report the intra-articular hip pathologies identified at the time of arthroscopy. The average time from dislocation to relocation was 3.56 hours. The mean time from dislocation to surgery was 125 days (range, 0 to 556 days). The average age at the time of arthroscopy was 30.5 years (range, 16 to 46 years). All patients had labral tears. All patients had chondral defects. Two had isolated femoral head chondral defects, 6 had isolated acetabular chondral defects, and 6 had chondral defects on both surfaces. Eleven patients had loose osteochondral fragments. Eleven patients had partial or complete tears of the ligamentum teres. Nine patients had evidence of femoroacetabular impingement; 4 had isolated cam lesions, 1 had an isolated pincer lesion on the acetabular rim, and 4 patients had mixed type pathology. Two patients had capsulolabral adhesions. Two patients had a capsular tear. Additionally, 3 patients underwent intraoperative evaluation of the lateral epiphyseal vessels with Doppler imaging to confirm good blood flow to the femoral head with consistent pulse. The results of this study show that traumatic dislocation is accompanied by a variety of intra-articular hip joint pathologies, the most common being labral, chondral, intra-articular loose fragments, and disruption of the ligamentum teres.
The purposes of this study were to examine the morphologic features of the axillary nerve and its relation to the glenoid under an arthroscopic setup, and to determine the changes in nerve position according to different arm positions. Twenty-three fresh-frozen fore-quarter cadaveric shoulder specimens were used for evaluations in an arthroscopic setup with the lateral decubitus position. The main trunk of the axillary nerve with or without some of its branches was exposed after careful arthroscopic dissection. Morphologic features and the course of the axillary nerve from the anterior and posterior portals were documented. The closest distances from the glenoid rim were measured with a probe by use of a distance range system. The changes in nerve position were determined in 4 different arm positions. At the end of arthroscopic examination, the nerves were marked and verified by open dissections. The axillary nerve appeared in the joint near the inferior edge of the subscapularis muscle. With reference to the inferior glenoid rim horizontally, the nerve had a mean running angle of 23 degrees (range, 14 degrees to 41 degrees; SD, 8 degrees ). The closest points from the glenoid were between the 5:30- and 6:00-o'clock position (right) or 6:00- and 6:30-o'clock position (left). The closest distance range varied from 10 to 25 mm in the neutral arm position. The abduction-neutral position resulted in the greatest distance between the inferior glenoid and the nerve. The abduction-neutral rotation position was the optimal position for minimizing axillary nerve injuries, because it resulted in the greatest distance between the inferior glenoid and the nerve. Knowledge of the anatomy of the axillary nerve aids the shoulder surgeon in avoiding nerve injury during arthroscopic procedures. Abduction-neutral rotation may be more helpful for arthroscopic surgeons performing procedures in the anteroinferior glenoid with the nerve being farther away from the working field.
Results after arthroscopic treatment of anterior glenohumeral instability continue to improve as advancements are made in instrumentation and techniques. We present 71 cases of anterior glenohumeral instability treated with arthroscopic anterior stabilization and posterior capsular plication. Case series. Arthroscopic anterior reconstruction and posterior inferior "pinch-tuck" capsular plication was performed in 71 shoulders (67 patients) with anterior glenohumeral instability. The average follow-up was 33.3 months (range, 20 to 24 months). Outcomes were assessed by completion of the Simple Shoulder Test (SST), Western Ontario Shoulder Instability (WOSI) Index, a Rowe score, and a subjective self-assessment shoulder instability form. Postoperative dislocation occurred in 5 patients (7%). The average SST score was 11.2 (12 maximum) and the average WOSI Index was 85.6% (range, 30.6% to 100%). The average Rowe score was 85. Ninety-seven percent of patients reported they were able to return to their normal activity level, and 90% of patients reported that they were able to return to their previous level of athletics; 100% of patients reported that they were doing better than before surgery and were satisfied with their result; 100% of patients reported that they would undergo the procedure again. Arthroscopic anterior stabilization using suture anchors, combined with posterior capsular suture plication, is a reliable treatment option for anterior glenohumeral instability. Level IV.
To evaluate the short-term results of 2 different techniques of endoscopic iliopsoas tendon release for the treatment of internal snapping hip syndrome. Between January 2005 and January 2007, a consecutive series of patients with the diagnosis of internal snapping hip syndrome was treated with endoscopic release of the iliopsoas tendon. The patients were randomized into 2 different groups. Patients in group 1 were treated with endoscopic iliopsoas tendon release at the lesser trochanter, and patients in group 2 were treated with endoscopic transcapsular psoas release from the peripheral compartment. Hip arthroscopy of both the central and peripheral compartments was performed in both groups using the lateral approach. Associated injuries were identified and treated arthroscopically. Postoperative physical therapy was the same for both series, and each patient received 400 mg of celecoxib daily for 21 days after surgery. Preoperative and postoperative Western Ontario MacMaster (WOMAC) scores and imaging studies were evaluated. Nineteen patients were included in the study: 10 in group 1 (5 male and 5 female; average age, 29.5 years) and 9 in group 2 (8 female and 1 male; average age, 32.6 years). No statistical difference was found in group composition. Associated injuries were found and treated in 8 patients in group 1 and 7 patients in group 2. No statistical difference was found between groups in preoperative WOMAC scores, and every patient in both groups had an improvement in the WOMAC score. Improvements in WOMAC scores were statistically significant in both groups, and no difference was found in postoperative WOMAC results between groups. No complications were seen. Iliopsoas tendon release at the level of the lesser trochanter or at the level of the hip joint using a transcapsular technique is effective and reproducible. We found no clinical difference in the results of both techniques.
The purpose of this study was to determine if three-dimensional computed tomography (3-D CT) scans of the glenoid can be used to accurately quantify, by means of a glenoid index, bone loss in patients with anterior glenohumeral instability, and to compare the results with arthroscopic measurements to determine if the 3-D CT scan can preoperatively predict which patients with anterior glenohumeral instability will benefit from a bone grafting procedure. From 2003 to 2006, 188 patients with anterior glenohumeral instability underwent arthroscopic evaluation and treatment by the senior author (S.S.B.). Of 188 total patients, there were 25 patients ranging in age from 15 to 43 years (median, 19 years) who underwent 3-D CT evaluations of both shoulders followed by arthroscopy of the unstable shoulder. For an arthroscopically measured bone loss of less than 25% of the inferior glenoid diameter, an arthroscopic Bankart repair was performed; for a glenoid bone loss of greater than or equal to 25%, an open Latarjet reconstruction was performed. We defined the glenoid index as the ratio of the maximum inferior diameter of the injured glenoid compared to the maximum inferior diameter of the uninjured contralateral glenoid as calculated from the 3-D CT scans. If the glenoid index was greater than 0.75, the patient was predicted to benefit from an arthroscopic Bankart repair (the need for surgery and the type of surgery having been determined on the basis of arthroscopic measurements). However, if the glenoid index was less than or equal to 0.75, the patient was predicted to benefit from an open Latarjet procedure. The results of each patient's glenoid index were compared with the arthroscopic decision to perform either an arthroscopic Bankart repair or an open Latarjet procedure. Of the 25 patients included in this study, 13 patients underwent an open Latarjet procedure and 12 patients underwent an arthroscopic Bankart repair. The 3-D CT scans accurately predicted the arthroscopic decisions to perform an arthroscopic Bankart repair or open Latarjet in 24 (96%) of 25 cases (Fisher exact test; P < .001). The glenoid index as calculated from the 3-D CT scan accurately predicted the requirement of a bone grafting procedure for 24 (96%) of 25 patients when the benchmark value of 0.75 was used. The 3-D CT scan can therefore be used by surgeons as an additional diagnostic tool for preoperative planning and patient counseling. Level III, development of diagnostic criteria with universally applied reference (nonconsecutive patients).
Focal chondral or osteochondral defects can be painful and disabling, have a poor capacity for repair, and may predispose patients for osteoarthritis. New surgical procedures that aim to reestablish hyaline cartilage have been introduced and the results seem promising. The purpose of this study is to provide reliable data on chondral and osteochondral defects in patients with symptomatic knees requiring arthroscopy and to calculate the prevalence of patients who might benefit from cartilage repair surgery. Prospective study. One thousand consecutive knee arthroscopies were included in this study. Immediately after each arthroscopy, the surgeon completed a questionnaire providing detailed information about the findings. Chondral and osteochondral lesions were classified in accordance with the system recommended by the International Cartilage Repair Society (ICRS). Chondral or osteochondral lesions (of any type) were found in 61% of the patients. Focal chondral or osteochondral defects were found in 19% of the patients. In these patients, 61% related their current knee problem to a previous trauma, and a concomitant meniscal or anterior cruciate ligament injury was found in 42% (n = 81) and 26% (n = 50), respectively. The mean chondral or osteochondral total defect area was 2.1 cm(2) (range, 0.5 to 12; standard deviation [SD], 1.5). The main focal chondral or osteochondral defect was found on the medial femoral condyle in 58%, patella in 11%, lateral tibia in 11%, lateral femoral condyle in 9%, trochlea in 6%, and medial tibia in 5%. It has been suggested that cartilage repair surgery may be most suitable in patients younger than 40 to 50 years old. A single, well-defined ICRS grade III or IV defect with an area of at least 1 cm(2) in a patient younger than 40, 45, or 50 years accounted for 5.3%, 6.1%, and 7.1% of all arthroscopies, respectively. Our study supports the contention that articular cartilage defects are common. It has the advantages of a prospective design and use of a new classification system recommended by the ICRS. This modern system focuses on objectively measurable parameters of the lesion's extent and not its surface appearance.
Between September 1992 and December 1996 we reviewed three transverse displaced fractures of the patella occuring in 1,320 ACL reconstructions using bone-patellar tendon-bone autograft. All the patients suffered local injury to the donor knee between 8 and 12 weeks postoperatively. Immediate rigid fixation using single or double anterior tension band allowed early mobilization and full weight bearing. Between 6 and 9 months after fracture, the screws and the wire were removed and the grafts tested. Results of the pivot shift and Lachman test under anesthesia were negative and arthroscopic visualisation showed the graft to be intact. Postoperative assessment included the Lysholm and Tegner scales, the International Knee Documentation Committee Evaluation form (IKDC), KT-1000 arthrometer, and isokinetic dynamometer strength testing. No significant differences in the final outcome were noted between reconstructions complicated by patellar fracture and normal ACL reconstructions.
The purpose of this study was to evaluate the sensitivity, specificity, and accuracy of routine 1.0-Tesla magnetic resonance imaging (MRI) versus arthroscopy in detecting fresh traumatic chondral lesions of the knee. Over a period of 6 years, 578 consecutive military personnel underwent MRI before arthroscopy of the knee. Of these, 32 patients with arthroscopically proven fresh traumatic chondral lesions of the knee were chosen for further analysis. A supplementary condition was that arthroscopy was performed no later than 6 weeks after the onset of trauma. The original MRIs and hospital records were re-evaluated and the chondral lesions were graded and compared with arthroscopic findings. The arthroscopic results served as the gold standard when the sensitivity, specificity, and accuracy of MRI were calculated. The age of the patients ranged from 19 to 21 years (mean, 19.6 years). MRI detected cartilage defects with a sensitivity of 36% (95% confidence interval [CI], 23% to 50%), specificity of 91% (95% CI, 85% to 95%), and diagnostic accuracy of 78% (95% CI, 72% to 83%). MRI results were affected by the grade of the chondral lesions. This study shows that routine 1.0-T MRI is not sensitive but is specific and somewhat accurate in detecting fresh traumatic articular cartilage lesions. The hypothesis of this study was that 1.0-T MRI could replace diagnostic arthroscopy in the diagnosis of fresh traumatic chondral lesions. Our results fail to support this hypothesis because of the poor sensitivity obtained with MRI. Level II, development of diagnostic criteria.
Sixty-five surgical cases were studied to determine whether 1.5% glycine, used as an irrigation solution during electrosurgery to the knee, had any histological effect on the synovial cells or the articular cartilage. Histologic specimens of the articular cartilage were stained with Safranin-O to assess proteoglycans-enhanced chrondrocyte function, and the synovium was stained with pentachrome. The results indicated that there were no adverse effects, either short term or long term, when viewing both the synovium and the articular cartilage histopathologically after glycine irrigation subsequent to the electrothermal procedure.
We reviewed 28 patients who underwent anterior cruciate ligament reconstruction with immediate, 1-, 2-, and 3-year postreconstruction KT-1000 manual maximum testing. Arthrometer measurements were correlated with functional knee criteria to evaluate the ability of the KT-1000 to predict postreconstruction functional results. Despite a range of immediate postreconstruction arthrometer injured-minus-normal (I - N) differences, there was no association with I - N difference at last follow-up. Patients followed-up for 1 year were not different from those who were followed-up for longer with respect to intraoperative or 1-year I - N difference or functional performance scores. Furthermore, excellent functional knee scores were the norm at all stages of follow-up despite a wide range of arthrometric laxity changes. The results suggest that functional knee criteria, although partially subjective, are more useful indicators of outcome than intrareconstruction and postreconstruction arthrometric measures.
To evaluate meniscal damage and the midterm clinical outcome, we performed a retrospective review of 105 lateral meniscal cysts that were treated arthroscopically at our institution. Retrospective review. From a series of 8,100 knee arthroscopies, 122 patients (1.5%) with 124 lateral meniscal cysts were selected. Eight of the patients were lost to follow-up and 11 patients had associated pathology; therefore, 105 lateral meniscal cysts on stable knees were included in this study. Average follow-up was 5 years (range, 1 to 12.5 years). The mean age was 33 years (range, 12 to 69 years). All patients had presented with tenderness over the joint line with a palpable mass. All cases were treated arthroscopically and all patients underwent a complete physical examination before surgery and at last follow-up. Radiographic evaluation was available at final follow-up for 68 cases. All patients had a meniscal tear at the time of surgery and 60 (57%) had a horizontal cleavage component. For meniscal tears, arthroscopic partial lateral meniscectomy was performed in 104 cases and meniscal repair in 1 case. For cysts, intra-articular debridement was performed in 91 cases and open cystectomy in 14. Eleven cysts recurred and a second arthroscopy was required. The clinical results, including those cases with recurrent cysts, were excellent or good in 87% of cases. Osteoarthritis following treatment for meniscal cysts occurred in 9% of cases. When there was a cyst and no other intra-articular damage, the prognosis was excellent. For lateral meniscal cysts, arthroscopic partial meniscectomy with intra-articular debridement yields predictable results. Level IV.
The purpose of this study was to identify outcomes and outcome predictors of arthroscopic debridement with osteochondral bone stimulation (microfracture) for osteochondral lesions of the ankle. One hundred five consecutive patients with osteochondral lesions of the ankle who underwent ankle arthroscopy with microfracture were prospectively followed up for a mean of 31.6 +/- 12.1 months. Study patients were evaluated at 6 weeks, 3 months, 6 months, 12 months, and annually after surgery. Assessments via a visual analog scale for pain during daily activities and sport activity, the Roles and Maudsley score, and the American Orthopaedic Foot & Ankle Society ankle and hindfoot scoring system were obtained at each visit. Outcome predictors were analyzed by logistic regression model. There were no failures of treatment with lesions smaller than 15 mm. In contrast, only 1 patient met the criteria for success in the group of lesions greater than 15 mm. Statistical analysis revealed that increasing age, higher body mass index, history of trauma, and presence of osteophytes negatively affected outcome. The presence of instability and the presence of anterolateral soft-tissue scar were correlated with a successful outcome. This study found a strong correlation between lesion size and success across its entire population. For lesions smaller than 15 mm, regardless of location, excellent results were obtained. In addition, increasing age, higher body mass index, history of trauma, and presence of osteophytes negatively affect outcome. The presence of instability and anterolateral soft-tissue scar correlated with a successful outcome. Level IV, prognostic case series, prognostic study.
Several reports have shown the progression of degenerative osteoarthritis after anterior cruciate ligament (ACL) reconstruction. No report has been published about early cartilage change after ACL reconstruction. The purpose of this study was to evaluate the articular cartilage after ACL reconstruction in a short postoperative period by arthroscopy. Case series. We examined the status of articular cartilage of 105 patients who received ACL reconstruction and second-look arthroscopy. Cartilage lesion was evaluated arthroscopically in the 6 articular surfaces independently, and these features were classified by modified Outerbridge's classification. We compared the articular cartilage at reconstruction and at second-look arthroscopy. A significant worsening of the status of the articular cartilage was seen after ACL reconstruction. This worsening was seen at all articular surfaces except the lateral femoral condyle. Most of the change involved softening or fibrillation. Anterior laxity and meniscal lesion had no correlation with a progression of degenerative change of articular cartilage. Patient's age influenced the progression of articular cartilage damage after reconstruction significantly in our cases. The status of articular cartilage was significantly worsened after ACL reconstruction. Potent risk factors causing articular cartilage damage include female gender and age of 30 years or older. Level IV.
Purpose: The aims of this prospective cohort study were to assess the long-term results after isolated superior labral repair and to determine whether the results were associated with age. Methods: One hundred seven patients underwent repair of isolated SLAP tears. There were 36 women and 71 men with a mean age of 43.8 years (range, 20 to 68 years). Mean follow-up was 5.3 years (range, 4 to 8 years). Of the patients, 62 (57.9%) were aged 40 years or older. Follow-up examinations were performed by an independent examiner; 102 patients (95.3%) had a 5-year follow-up. Results: The Rowe score improved from 62.8 (SD, 11.4) preoperatively to 92.1 (SD, 13.5) at follow-up (P < .001). Satisfaction was rated excellent/good for 90 patients (88%) at 5 years. There was no significant difference in the results for patients aged 40 years or older and those aged under 40 years. Difficulty with postoperative stiffness and pain was reported by 14 patients (13.1%). Conclusions: Our results suggest that long-term outcomes after isolated labral repair for SLAP lesions are good and independent of age. Postoperative stiffness was registered in 13.1% of the patients. Level of evidence: Level IV, therapeutic case series.
The purpose of this study was to determine the optimal knot configuration that maximized both knot and loop security when tied with 2 different types of nonabsorbable, braided suture. In vitro biomechanical study. Six commonly used arthroscopic sliding knots (Duncan loop, Nicky's knot, Tennessee slider, Roeder knot, SMC knot, Weston knot) with and without a series of 3 reversing half-hitches on alternating posts (RHAPs) as well as a static surgeon's knot were tied. Two different nonabsorbable, braided sutures were used, and a total of 7 knots were tied for each possible combination of knots and sutures, for a total of 182 knots. Each knot was tied around a 30-mm circumference post to assure a consistent loop circumference of 30 mm before "locking" the complex sliding knots by tensioning the wrapping limb of the suture. Each loop was mounted on a Material Testing System machine, and its circumference was measured at a 5-N preload to assess each knot's ability to maintain a tight suture loop without slippage (loop security). Knot security was measured as the maximum force to failure at 3 mm of crosshead displacement or suture breakage during single-pull load testing. The surgeon's knot provided the highest force to failure and the tightest loop circumference whether tied with No. 2 Ethibond (Ethicon, Somerville, NJ) or No. 2 Fiberwire (Arthrex, Naples, FL) suture. Among the sliding knots, the Roeder knot with 3 RHAPs showed the best balance of loop security and knot security when tied with No. 2 Ethibond or No. 2 Fiberwire. Sliding knots tied without RHAPs showed low force to failure and loose suture loops whether tied with Ethibond or Fiberwire. The addition of 3 RHAPs improved knot security and, in most cases, loop security of all the sliding knots. When tying a static surgeon's knot or a sliding knot with RHAPs, using No. 2 Fiberwire increased the force to failure over comparable knots tied with No. 2 Ethibond. All knots failed by a combination of knot slippage and suture stretch. When using No. 2 Ethibond, securing most sliding knots with 3 RHAPs or tying a surgeon's knot changed the failure mechanism from knot slippage to suture stretch, suggesting that the maximum knot holding capacity of No. 2 Ethibond had been achieved when tying these knot configurations. However, even at failure forces twice that achieved with No. 2 Ethibond, suture slippage continued to occur with sliding knots with 3 RHAPs using No. 2 Fiberwire. This indicates that the maximum knot-holding capacity of No. 2 Fiberwire had not been achieved, and that further knot configurations should be tested. (1) A static surgeon's knot provides the best balance of loop security and knot security within the knot configurations tested in this study. (2) A sliding knot without RHAPs has both poor loop security and knot security and should not be tied. (3) The addition of 3 RHAPs improves knot security of all sliding knots tested and improves loop security of most of the sliding knots tested. (4) The addition of 3 RHAPs improves the knot security of all sliding knots to adequately resist predicted in vivo loads. (5) The Roeder knot with 3 RHAPs provides the best balance of loop security and knot security within the sliding knot configurations tested in this study regardless of suture type. (6) Tying a surgeon's knot or a sliding knot with 3 RHAPS using No. 2 Fiberwire increases knot security over the same knot tied with No. 2 Ethibond. This study identifies the static and sliding configurations of commonly used arthroscopic knots in order to aid the surgeon in choosing the most biomechanically effective knot for use in arthroscopic surgery.
In this study, we measured functional outcomes of patients treated arthroscopically with microfracture for full-thickness traumatic defects of the knee. A case series of patients with 7 to 17 years' follow-up. Between 1981 and 1991, a total of 72 patients (75 knees) met the following inclusion criteria: (1) traumatic full-thickness chondral defect, (2) no meniscus or ligament injury, and (3) age 45 years and younger (range, 13 to 45 years). Seventy-one knees (95%) were available for final follow-up (range, 7 to 17 years). All patients completed self-administered questionnaires preoperatively and postoperatively. The following results were significant at the P <.05 level. Significant improvement was recorded for both Lysholm (scale 1 to 100; preoperative, 59; final follow-up, 89) and Tegner (1 to 10; preoperative, 3; final follow-up, 6) scores. At final follow-up, the SF-36 and WOMAC scores showed good to excellent results. At 7 years after surgery, 80% of the patients rated themselves as "improved." Multivariate analysis revealed that age was a predictor of functional improvement. Over the 7- to 17-year follow-up period (average, 11.3 years), patients 45 years and younger who underwent the microfracture procedure for full-thickness chondral defects, without associated meniscus or ligament pathology, showed statistically significant improvement in function and indicated that they had less pain.
To determine whether compensatory neuromuscular and biomechanical adaptations exist after successful anterior cruciate ligament reconstruction and rehabilitation. Seventy subjects, 5.3 +/- 3 years after surgery, participated in this study. Sagittal-plane lower extremity kinematic, gluteus maximus, vastus medialis, medial hamstring, and gastrocnemius electromyography (EMG) and vertical ground reaction force data were collected during single-leg countermovement jump (CMJ) performance. Women had lower propulsive and landing forces, lower CMJ heights, less hip and knee flexion, and greater angular hip, knee, and ankle velocities than men (P < or = .014). The involved lower extremity of men and women had decreased landing forces (P = .008). During propulsion, men and women had increased involved-lower extremity gluteus maximus (P < .0001) and decreased vastus medialis (P = .013) EMG amplitudes, whereas women had bilaterally increased gastrocnemius EMG amplitudes compared with men (P = .003). During propulsion, men had longer gluteus maximus and vastus medialis EMG durations than women (P < .0001). During landing, both men and women had increased gluteus maximus EMG amplitudes at the involved lower extremity (P < .0001). Women had increased vastus medialis (P = .01) and gastrocnemius (P < .0001) EMG amplitudes compared with men. During landing, men had longer gluteus maximus (P = .004), vastus medialis (P = .012), and gastrocnemius (P = .007) EMG durations than women and the involved-lower extremity vastus medialis EMG durations of both men and women were shorter than at the noninvolved lower extremity (P = .011). Decreased involved-lower extremity landing forces, decreased vastus medialis activation, and increased gluteus maximus and gastrocnemius activation suggest a protective mechanism to minimize knee loads that increase anterior translatory knee forces during single-leg jumping. Women showed more balanced gluteus maximus, vastus medialis, and gastrocnemius contributions to dynamic knee stability than men during CMJ landings but used shorter activation durations. Level IV, therapeutic case series.
A retrospective analysis of 68 knees from 65 patients older than 40 years, who had undergone a partial medial meniscectomy, was carried out. The average age of the patients was 49.7 years (range, 40 to 74), and the mean follow-up period was 7.8 years (range, 5 to 11). The patients were divided into two groups based on the degree of articular cartilage degeneration. Group I consisted of 53 knees that did not have any significant articular cartilage damage beyond grade I or II. Group II consisted of 15 knees that had grade III or IV cartilage damage. Overall, excellent results were obtained in 44 patients (47 knees), good results in 10 patients, fair results in six patients, and poor results in five patients. In group I, 46 knees (87%) had an excellent outcome, and only one patient had a poor result. In contrast, patients in group II had significantly worse results, with only one knee (7%) having excellent outcome, and four knees had a poor result. A specific history of trauma did not affect the clinical outcome. Forty-two patients (64%) were able to resume normal athletic activities without any restrictions. Arthroscopic partial medial meniscectomy in patients older than 40 years is an acceptable and effective long-term treatment, particularly in patients without significant articular cartilage damage.
Posterior superior glenoid impingement is a recently recognized mechanism of injury producing rotator cuff injury in athletes. Usually the mechanism is repetitive overhand activity such as throwing. A survey of the author's practice was undertaken to show a wider spectrum of this mechanism both in the activity that caused it and the number of structures at risk of injury from this mechanism. The survey revealed 11 patients who had a clear recollection of their mechanism of injury and an objective documentation of the injury by arthroscopy or imaging studies. The majority of shoulders had damage to more than one of the five structures at risk from this mechanism of injury. Six cases were not sports related. Glenoid impingement may injure one or more of the following: (1) superior labrum, (2) rotator cuff tendon, (3) greater tuberosity, (4) inferior glenohumeral ligament or labrum, and (5) superior glenoid bone. Injury to more than one structure may be the rule and injury to one structure may indicate investigation of the other four.
To study how well an anterior cruciate ligament (ACL) graft fixed at the 10 and 11 o'clock positions can restore knee function in response to both externally applied anterior tibial and combined rotatory loads by comparing the biomechanical results with each other and with the intact knee. Type of Study: Biomechanical experiment using human cadaveric specimens. Ten human cadaveric knees (age, 41+/-13 years) were reconstructed by placing a bone-patellar tendon-bone graft at the 10 and 11 o'clock positions, in a randomized order, and then tested using a robotic/universal force-moment sensor testing system. Two external loading conditions were applied: (1) 134 N anterior tibial load with the knee at full extension, 15 degrees, 30 degrees, 60 degrees, and 90 degrees of flexion, and (2) a combined rotatory load of 10 N-m valgus and 5 N-m internal tibial torque with the knee at 15 degrees and 30 degrees of flexion. The resulting kinematics of the reconstructed knee and in situ forces in the ACL graft were determined for each femoral tunnel position. In response to a 134-N anterior tibial load, anterior tibial translation (ATT) for both femoral tunnel positions was not significantly different from the intact knee except at 90 degrees of knee flexion as well as at 60 degrees of knee flexion for the 10 o'clock position. There was no significant difference in the ATT between the 10 and 11 o'clock positions, except at 90 degrees of knee flexion. Under a combined rotatory load, however, the coupled ATT for the 11 o'clock position was approximately 130% of that for the intact knee at 15 degrees and 30 degrees of flexion. For the 10 o'clock position, the coupled ATT was not significantly different from the intact knee at 15 degrees of flexion and approximately 120% of that for the intact knee at 30 degrees of flexion. Coupled ATT for the 10 o'clock position was significantly smaller than for the 11 o'clock position at 15 degrees and 30 degrees of flexion. The in situ force in the ACL graft was also significantly higher for the 10 o'clock position than the 11 o'clock position at 30 degrees of flexion in response to the same loading condition (70 +/- 18 N v 60 +/- 15 N, respectively). The 10 o'clock position more effectively resists rotatory loads when compared with the 11 o'clock position as evidenced by smaller ATT and higher in situ force in the graft. Despite the fact that ACL grafts placed at the 10 or 11 o'clock positions are equally effective under an anterior tibial load, neither femoral tunnel position was able to fully restore knee stability to the level of the intact knee.
A clinical trial was carried out to investigate the long-term outcome of Meniscus Arrow (Bionx Implants, Blue Bell, PA) repair. In a case series 113 consecutive patients with an arthroscopic all-inside Meniscus Arrow repair were evaluated. The mean age was 30 years, and the mean length of follow-up was 6 years. Of the patients, 84% were available for follow-up. Repairs were performed in either the medial (81%) or lateral (19%) posterior horn in only the red-red or red-white meniscal zone. Concomitant anterior cruciate ligament reconstruction was performed in 66% of patients. Of the patients, 28% showed a retear of the meniscus and had to undergo arthroscopic revision with partial meniscectomy. Simultaneous anterior cruciate ligament reconstruction had no significant influence on the revision rate. In patients who did not undergo revision, the mean Lysholm score was 91 points and the mean Cincinnati knee score was 93 points. The International Knee Documentation Committee classification was A or B in 90% of patients and C in 10%. At revision surgery, 2 patients showed distinct femoral cartilage damage caused by the head of the Meniscus Arrow. The Meniscus Arrow shows a high clinical failure rate of 28.4%, especially given that the use of the device was restricted to tears in the red-red and red-white zone of the meniscus, which would be expected to have a good healing potential. More than 80% of all failures occurred during the first 3 postoperative years, suggesting that the initial refixation potential of the Meniscus Arrow is low. Device-specific complications required additional operative treatment. Level IV, therapeutic case series.
The objective of this study was to review the results of arthroscopic resection of dorsal wrist ganglion (DWG), as well as to describe the senior author's technique and technical details to minimize potential complications. Between September 1999 and May 2004, 114 patients underwent arthroscopic resection of DWG with a minimum follow-up of 24 months. We describe the surgical technique and discuss our results and complications. A total of 114 patients (87 female patients and 27 male patients) with a mean age of 33.1 years were treated with our operative technique. The symptoms at presentation were unsightly appearance in 63 (55.2%), pain in 33 (28.9%), and both unsightly appearance and pain in 18 (15.8%). The patients presented between 1 and 96 months before surgery (mean, 17.81 months). Of the patients, 66 (57.9%) had been treated previously with nonsurgical modalities (aspiration) and 1 had undergone open surgery. The origin of the DWG was more commonly related to the midcarpal joint (85 patients [74.6%]). Our surgery brought about a significant improvement in flexion and extension after surgery (P < .005). Similarly, our surgery brought about a significant improvement in grip strength (P < .005). In patients with preoperative pain, treatment also showed a significant impact. At 2 years' follow-up, there were 14 recurrences (12.3%), diagnosed at a mean of 16.86 months after surgery (range, 2 to 25 months). Complications were identified in 6 patients (5.26%), and the mean time off work was 11 days, with a majority of patients returning in less than 1 week. Arthroscopic DWG resection showed an improvement in functional measurements in addition to relief of pain in a significant proportion of patients. Complications related to the operative technique did not cause any significant long-term functional deficit. The recurrence rate was 12.3%, and patient satisfaction was high. Arthroscopic technique allows patients to use their hand immediately. The results of this study support the use of arthroscopy as primary treatment for DWG resection. Level IV, therapeutic case series.
Arthroscopy is an indispensable tool in the diagnosis, treatment, and postoperative follow-up of pigmented villonodular synovitis (PVNS) and enables classification of PVNS into three forms: diffuse, localized, and mixed. A series of 13 cases of PVNS of the knee is presented; 12 patients underwent surgery. According to the anatomic type of PVNS found, the authors used extensive classic surgery or endoscopy. Follow-up averaged 4.2 years (range, 1-10 years). The best results were obtained in cases of localized PVNS. Overall, nine patients were totally asymptomatic at follow-up. Four patients experienced some pain when fatigued or with changes in the weather. There was no recurrence of symptoms.
Clinical research has become a major influencing factor in the determination of treatment choice in our society. Outcome data have been requested by third-party payers, patients, and administrators alike. Currently, there are over 10 different scoring systems that have been used to evaluate the efficacy of treatment for shoulder instability. Some of these scoring systems are based on the specific condition of shoulder instability; however, other systems are broadly based to incorporate a spectrum of shoulder conditions. This review summarizes the process of proper development and testing of the scoring systems, discusses their role in clinical research with respect to shoulder instability, and explains the dichotomy of postoperative recurrence of instability and high shoulder scores. The Shoulder Rating Questionnaire (SRQ), Melbourne Instability Shoulder Score (MISS), Western Ontario Shoulder Instability Index (WOSI), Oxford Instability Score (OIS), and Simple Shoulder Test were shown to be reliable for patients with instability. The SRQ, MISS, WOSI, OIS, and American Shoulder and Elbow Surgeons score have all been shown to be largely responsive. There are 2 shoulder scoring systems, the WOSI and the MISS, that we recommend be used to evaluate shoulder instability. The SRQ and OIS were found to be less responsive for patients with instability compared with patients with other shoulder dysfunctions. Other scoring systems lack inter-rater reliability, validity, and/or responsiveness for patients in the instability population. The optimal scoring system for patients with upper extremity problems other than those with shoulder instability has yet to be determined; however, the American Shoulder and Elbow Surgeons score may be considered, because this instrument has been proven to be valid, reliable, and responsive.
This study was performed to evaluate 2 arthroscopic techniques for rotator cuff repair used by 1 surgeon for more than 12 years. The main objective of this study was to test the reliability of these arthroscopic repair techniques not only using clinical assessment during the follow-up, but through observation of the healing process of the tendons during the arthroscopic removal of the staples in our first group of patients. Type of Study: This study was a before/after trial. We present the results of arthroscopic repair of full-thickness rotator cuff tears in 100 patients. In group I, 35 patients had staple fixation, and in group II, 65 patients had side-to-side suture and anchor repair. Follow-up ranged from 2 to 14 years. All shoulders were evaluated using the UCLA rating scale. Shoulders repaired with staples (group I) were evaluated arthroscopically at staple removal. Arthroscopic subacromial decompression was performed in 26 of the 35 patients in group I and in 65 of the 65 patients in group II; 58 patients in group II had concomitant resection of distal clavicle. In group I, 22 patients (63%) had excellent results (UCLA scores, 34-35), 7 (20%) had good results (UCLA scores, 28-33), 4 (11%) had fair results (UCLA scores, 21-27), and 2 (6%) of the patients had poor results (UCLA scores, 0-20). In group II, 47 patients (72%) had excellent results (UCLA scores, 34-35), 12 (19%) had good results (UCLA scores, 28-33), 2 (3%) had fair results (UCLA scores, 21-27), and 4 (6%) of the patients had poor results (UCLA scores, 0-20). Patients with well-healed rotator cuff tendons had satisfactory postoperative results and better overall functional results. The arthroscopic techniques for rotator cuff repair achieve results comparable to the results of traditional open repair. However, these technically demanding arthroscopic procedures require advanced arthroscopic skills and have a steep learning curve.
PURPOSE: The purpose of this study was to evaluate the overall long-term improvement of autologous chondrocyte implantation (ACI) treatment in terms of patient satisfaction, clinical assessment, and magnetic resonance imaging (MRI) evaluation. Furthermore, we aimed to assess the impact of independent variables on clinical outcomes and patient satisfaction. METHODS: We evaluated 23 patients (mean age, 30.5 ± 8.2 years) with full-thickness chondral lesions of the distal femur who underwent first-generation ACI with periosteum between 1997 and 2004. The Lysholm score, Tegner activity score, subjective International Knee Documentation Committee score, numeric rating scale score, and Short Form 36 score were used for clinical assessment preoperatively, at 1 year postoperatively, and at 7 to 14 years (mean, 9.9 years) after surgery. MRI was performed to evaluate the cartilage preoperatively and at final follow-up, by use of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. RESULTS: ACI resulted in a substantial improvement in all clinical outcome parameters, even as much as 14 years after implantation, although a small deterioration was noticed between intermediate and final evaluations in some outcome parameters. Of the patients, 73.1% stated that they would undergo the operation again. Younger patients with a shorter duration of preoperative symptoms and smaller defect sizes benefited most. MRI findings confirmed complete defect filling in 52.3% of the patients at final follow-up. CONCLUSIONS: Our long-term results confirm that first-generation ACI is an effective treatment for large full-thickness chondral and osteochondral lesions of the knee joint. Younger patients with a shorter duration of preoperative symptoms and smaller defect size benefited most in our study. LEVEL OF EVIDENCE: Level IV, therapeutic case series.
To investigate the long-term outcome of combined arthroscopic and radiation synovectomy of the knee joint in early cases of rheumatoid arthritis (RA) with regard to knee function and the need for surgical re-interventions. Between 1993 and 1997, a consecutive series of 38 RA patients with therapy-refractory synovitis of the knee joint and only mild cartilage lesions (not exceeding Outerbridge grade II at surgery) were treated with combined arthroscopic and radiation synovectomy. Knee function was assessed preoperatively; at 6 months, 1 year, and 5 years; and finally, at a mean of 14 years with 4 different functional scores. A Kaplan-Meier survival curve was calculated with "any re-intervention" and "total knee arthroplasty" as endpoints. Of 38 knees, 32 were available for the final 14-year follow-up with a total of 22 re-interventions: intra-articular steroid injection (n = 3), arthroscopic (n = 2) or radiation (n = 1) re-synovectomy, and total knee arthroplasty (n = 16). The remaining 10 patients with no re-intervention showed knee function not significantly different from the postoperative state. With any surgical re-intervention as the endpoint, the survival rate was 84% at 5 years (95% confidence interval [CI], 67.0% to 86.7%), 44% at 10 years (95% CI, 26.7% to 60.0%), and 32% at the 14-year assessment (95% CI, 16.0% to 49.3%). With total knee arthroplasty as the endpoint, the joint survival rate was 88.5% at 5 years (95% CI, 68.5% to 96.2%), 53.9% at 10 years (95% CI, 33.3% to 71.6%), and 39.6% at 14 years (95% CI, 18.9% to 48.6%). Combined arthroscopic and radiation synovectomy leads to a stable improvement of knee function for a minimum of 5 years, but surgical re-interventions were frequently observed at the 14-year assessment and challenge the long-term benefit of the procedure. Patients with no interventions had a significantly shorter history of disease (7 v 11 years). Level IV, therapeutic case series.
Forty-eight patients were enrolled in a study to determine the time interval for maturity and remodeling following arthroscopically assisted autogenous anterior cruciate ligament reconstruction (ACLR). Two biopsy specimens, one superficial and one deep, at the same level in the midsubstance of the ACL were obtained. Graft age, time from ACL reconstruction to biopsy, ranged from 3 months to 120 months. The patients were placed into four groups, (1) 3 to 6 months, (2) 7 to 12 months, (3) more than 12 months, and (4) control, in accordance with the time following ACL reconstruction. Each specimen was independently evaluated using light microscopy by two different observers in a blinded design. The biopsy specimens were evaluated for vascularity, cellularity, fiber pattern, and metaplasia when compared with the normal ACL. None of the patients was protected from activity as a result of ligament biopsy and no adverse outcomes were reported as a result of biopsy. Our study showed that fiber pattern, cellularity, vascularity, and degree of metaplasia obtained gross histological similarity with a normal ACL by 12 months after autogenous reconstruction. Unexpectedly, no significant statistical differences were noted for all grafts more than 6 months after ACLR, for two of the histological features studied, vascularity and fiber pattern, P=.05. We conclude that by 12 months after autogenous ACLR, graft maturity resembles a normal ACL. Additionally, because no statistical differences were noted in vascularity and fiber pattern after 6 months following autogenous ACLR, significant graft maturity may occur before 12 months. This may allow early postoperative return to full activity and support proponents of accelerated rehabilitation programs following autogenous ACLR.
One hundred fifty-six arthroscopic transglenoid multiple suture repairs were performed for chronic anterior shoulder instability. In 150 shoulders (96% follow-up), the outcome with respect to recurrence of instability and the Bankart Score was determined a minimum of 2 years and a mean of 4.1 years after surgery (range, 2 to 8.2 years). During the follow-up interval, 11 shoulders (7.3%) redislocated. Fourteen other shoulders (9.3%) had at least one episode that we interpreted as recurrent subluxation. Shoulders with a Bankart lesion and younger patients had a higher probability of recurrent instability (P < .05). We concluded that this method is most effective in shoulders without a Bankart lesion and in patients older than 25 years of age (regardless of pathology).
The purpose of this study was to evaluate the early outcomes of arthroscopic management of femoroacetabular impingement (FAI). Ninety-six consecutive patients (100 hips) with radiographically documented FAI were treated with hip arthroscopy, labral debridement or repair/refixation, proximal femoral osteoplasty, or acetabular rim trimming (or some combination thereof). Outcomes were measured with the impingement test, modified Harris Hip Score, Short Form 12, and pain score on a visual analog scale preoperatively and postoperatively at 6 weeks, 3 months, and 6 months, as well as yearly thereafter. Preoperative and postoperative radiographic alpha angles were measured to evaluate the adequacy of proximal femoral osteoplasty. There were 54 male and 42 female patients with up to 3 years' follow-up (mean, 9.9 months). The mean age was 34.7 years. Isolated cam impingement was identified in 17 hips, pincer impingement was found in 28, and both types were noted in 55. Thirty hips underwent labral repair/refixation. A comparison of preoperative scores with those obtained at most recent follow-up revealed a significant improvement (P < .001) for all outcomes measured: Harris Hip Score (60.8 v 82.7), Short Form 12 (60.2 v 77.7), visual analog score for pain (6.74 v 1.88 cm), and positive impingement test (100% v 14%). The alpha angle was also significantly improved after resection osteoplasty. Complications included heterotopic bone formation (6 hips) and a 24-hour partial sciatic nerve neurapraxia (1 hip). No hip went on to undergo repeat arthroscopy, and three hips have subsequently undergone total hip arthroplasty. Arthroscopic management of patients with FAI results in significant improvement in outcomes measures, with good to excellent results being observed in 75% of hips at a minimum 1-year follow-up. Alteration in the natural progression to osteoarthritis and sustained pain relief as a result of arthroscopic management of FAI remain to be seen. Level IV, therapeutic case series.
Although the clinical outcome of arthroscopic resection for a torn discoid lateral meniscus is known to be successful in the short term, long-term successful results are necessary. We reviewed the clinical results of arthroscopic meniscectomy for a torn discoid lateral meniscus in 29 knees, with an average follow-up of 16 years. Subjective symptoms were evaluated with the use of a questionnaire developed by the International Knee Documentation Committee (IKDC). The trends of IKDC scores and patient age at the time of surgery were statistically evaluated through a stepwise piecewise linear regression analysis. Radiographic examination was performed in 15 knees. The average IKDC score was 87 points. Statistical analysis conducted with the use of a regression model of scores revealed that the regression line declined from 90 to 72 points at ages between 25 and 30 years at the time of surgery. Radiographic examination revealed that patients with degenerative changes at the lateral joint compartment, such as joint space narrowing and subchondral sclerosis, were of greater average age at the time of surgery than did patients who did not develop these changes. Results suggest that clinical outcomes associated with this method are successful for longer than 10 years for patients younger than 25 years of age; however, older patients may develop problems caused by degenerative changes that may result from increased stress on the affected joint compartment. Level IV, therapeutic case series.
The purpose of this study was to (1) evaluate the long-term functional outcome of arthroscopic rotator cuff repair of massive rotator cuff tears (RCTs) and (2) compare double-row (DR) and single-row (SR) repairs. This was a retrospective review of massive RCTs treated with an arthroscopic rotator cuff repair over an 8-year period. Minimum 5-year follow-up was available for 126 repairs at a mean of 99 months. Among 107 complete repairs, there were 62 SR and 45 DR repairs. Functional outcome was determined by University of California, Los Angeles (UCLA) and American Shoulder and Elbow Surgeons scores. A multivariate analysis was performed to examine the role of a DR repair. For all repairs combined, improvements were observed in forward flexion (132° v 168°), pain (6.3 v 1.3), UCLA score (15.7 v 30.7), and American Shoulder and Elbow Surgeons score (41.7 v 85.7) (P < .001). A good or excellent outcome, obtained in 78% of cases, was associated with a complete repair (P = .035) and a DR repair (P = .008). When we excluded partial repairs, postoperative UCLA gain was greater after a DR repair (P = .007). Patients reported their shoulder as feeling closer to normal after a DR repair compared with an SR repair (93.5% v 84.4%, P = .006). A DR repair was 4.9 times more likely to lead to a good or excellent outcome (P = .021). When a DR repair of a massive RCT is possible, on the basis of the ability to mobilize the tendons, a better long-term functional outcome can be expected compared with an SR repair. Given the known high risk of recurrence after repair of massive RCTs and the knowledge that functional outcome is related to recurrence, a DR repair of massive RCTs should be performed when there is sufficient tendon mobility.
To compare 2 techniques for optimizing joint congruency for miniature osteochondral autografting in the knee: intrinsic postoperative forces acting on overdrilled autografts protruding from the femur versus alignment by a surgeon at the time of grafting. Controlled animal model experiment. A full-thickness cartilage defect was created on the weight-bearing surface of the medial femoral condyle of 13 mature sheep. Three 4.5 x 10 mm cylindrical autografts were inserted into 14-mm deep recipient holes such that the grafts were held in place by side-wall friction alone. One treatment group received grafts that were delivered flush with the surrounding cartilage and the second group received grafts that were left 2-mm proud of the joint surface. Three months postoperatively, the proud grafts had been repositioned by weight bearing but perigraft fissuring and fibroplasia, and subchondral cavitations were serious complications. It is suspected that these complications were caused by excessive motion between the graft and recipient site in the proud grafts. Grafts should be delivered flush with the joint surface when performing osteochondral transfers to avoid graft micromotion and the consequent interference with graft integration and function.
We present the case of an 18-year-old horse rider with an avulsion fracture of the ligamentum teres causing persistent hip pain and locking for 2 years. The patient had no history of major trauma; however, repeated minor hyperabduction injuries occurred. We were able to successfully treat this patient by arthroscopic removal of the bony fragments and two loose bodies and partial resection of the ligamentum teres.
The purpose of this study was to evaluate the outcomes and identify predictors of success for arthroscopic posterior Bankart reconstruction with modern suture anchor repair and anterior capsulolabral plication in a well-defined patient population-recurrent, traumatic, involuntary, unidirectional posterior shoulder instability. Patients with recurrent, traumatic, involuntary, unidirectional posterior shoulder instability who underwent arthroscopic repair with a minimum of 2 years' follow-up were identified and evaluated retrospectively with outcome measures in the form of objective and subjective scores. Statistical analysis was performed to identify predictors of success with significance set at .05. Twenty-nine consecutive patients with a mean age of 26.3 years underwent posterior reconstruction and anterior balancing capsulolabral plication as needed with a mean follow-up of 5.5 years. Outcome scores averaged as follows: American Shoulder and Elbow Surgeons, 90.7; University of California, Los Angeles, 32.6; Simple Shoulder Test, 11.7; and Western Ontario Shoulder Instability, 82.9% of normal. Recurrent instability occurred in 3.4% of patients, 84.6% returned to sports, and 96.6% of patients believed surgery was successful and worthwhile. Patients who were younger (<30 years) or patients with more extensive pathology who required additional surgical procedures or received supplemental anterior plication sutures had less reliable or worse outcomes (P < or = .041). In a traumatic patient population with involuntary, unidirectional posterior shoulder instability, modern suture anchor repair of posterior labral lesions is effective and provides reliable outcomes. Younger patients and patients with worse pathology who required additional procedures had less reliable outcomes. Patients with supplemental anterior plication had more postoperative pain, and this adjunctive procedure may not be necessary for traumatic posterior labral tear surgery. Level IV, therapeutic case series.
We report a case of detachment of an Endobutton (Acufex Microsurgical, Mansfield MA) used for femoral fixation of a reconstructed anterior cruciate ligament. The Endobutton, which was confirmed to be in place on the suprapatellar space of the femur by radiograph 18 months postoperatively, was found in the popliteal space by radiograph 25 months after surgery. This is a rare complication, but our case suggests that the Endobutton should not be fixed too distal close to the femoral groove.
PURPOSE: The purpose of this study was to compare revision rates and outcomes after anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) autografts versus BPTB allografts in patients aged 18 years or younger with closed physes. METHODS: Institutional review board approval was obtained for this study. This study included 90 consecutive patients aged 18 years or younger with closed physes who underwent primary ACL reconstruction by a single surgeon between 1998 and 2009, with either BPTB autograft (n = 70) or BPTB allograft (n = 20). Patients who had concomitant ligament injuries were excluded. Outcome measures included the Lysholm score, Tegner activity scale, and patient satisfaction (0, very unsatisfied; 10, very satisfied). Failures were defined as cases requiring ACL revision surgery. RESULTS: Of the 90 patients, 79 (88%) were contacted (20 of 20 with allografts and 59 of 70 with autografts). Of these 79 patients, 9 (11%) required revision ACL reconstruction. In the autograft group, 3% (2 of 59) required revision ACL reconstruction at a mean of 15.4 months (range, 13.0 to 17.7 months) after the index procedure. In the allograft group, 35% (7 of 20) required revision ACL reconstruction at a mean of 9.1 months (range, 5.3 to 12.0 months) after the index procedure. The allograft group was 15 (95% confidence interval [CI], 2 to 123) times more likely to require revision reconstruction than the autograft group (P = .001). The mean Lysholm score at follow-up was 85 (95% CI, 80.4 to 90.3) for the autograft group and 91 (95% CI, 88.1 to 97.3) for the allograft group (P = .46). The median Tegner activity scale was 7.0 (95% CI, 6.9 to 8.0) for autograft group and 6.5 (95% CI, 4.9 to 8.4) for the allograft group (P = .27). Median patient satisfaction score was 10 of 10 in both cohorts. No failures were seen in either group at 2 years postoperatively. Five of seven allograft failures occurred because of a premature return to sports. CONCLUSIONS: No significant differences in function, activity, or satisfaction were found between allograft and autograft reconstructions in this patient population. The allograft group had a failure rate 15 times greater than that in the autograft group, with all failures occurring within the first year after reconstruction. LEVEL OF EVIDENCE: Level III, retrospective comparative study.
The purpose of this study was to determine whether a relationship existed between primary adhesive capsulitis and acromial morphology. Case control series. Between January 1999 and June 2002, a total of 100 patients (104 shoulders) were diagnosed with adhesive capsulitis. A retrospective chart review was performed of all of these patients. A total of 67 patients (69 shoulders) met the inclusion criteria of primary adhesive capsulitis. The patients' range of motion and signs of impingement were documented. The supraspinatus outlet radiographs were assessed, and each patient's acromial morphology was graded as type I, II, or III. A case control group of 53 patients (58 shoulders) was assessed to determine the validity of our results. This group consisted of a series of new patients that were referred to the clinic during February 2003 for assessment of their shoulders. The average age of the patients in the adhesive capsulitis group was 52.5 +/- 7.6 years, with 34 women (50.7%) and 33 men (49.3%). The control group had an average age of 51.1 +/- 16.9 years in a series of 19 (35.8%) women and 34 (64.2%) men. The average range of motion was 98.0 degrees +/- 23.5 degrees of forward elevation, and 91.9 degrees +/- 24.3 degrees of abduction. The forward elevation was 165.5 degrees +/- 15.3 degrees and the abduction was 162.4 degrees +/- 18.4 degrees. The predominant acromial morphology in both groups in this study was a type II acromion (75.4% in the adhesive capsulitis group and 74.1% in the control group). The chi-square analysis within the specific groups showed statistically significant differences in the number of type II compared with type I acromions, and type II compared with type III acromions in both series. However, statistical analysis showed no significant difference between the various acromial types when comparing the adhesive capsulitis group with the control group. Our results show a significant number of patients with both adhesive capsulitis and, in the control group, type II acromions. We found no statistical difference between these 2 groups. Based on our results, the intrinsic trauma that occurs from subacromial space narrowing caused by the anterior acromial shape, cannot be implicated as the cause of primary adhesive capsulitis. Level III, case control study.
To report on our experience of patients who received infusion of bupivacaine with epinephrine after arthroscopic glenoid labral repair surgery and in whom glenohumeral joint chondrolysis subsequently developed, as well as to determine the incidence of such chondrolysis in our surgeons' patient populations. A retrospective chart review of 18 patients diagnosed with chondrolysis was carried out. All patients were from 2 experienced orthopaedic surgeons' practices. Details of their clinical course were obtained and summarized. These data were compared with all other arthroscopies completed by the 2 surgeons to determine the incidence of chondrolysis. All 18 patients diagnosed with glenohumeral joint chondrolysis received postoperative infusion of bupivacaine with epinephrine through an intra-articular pain pump catheter (IAPPC). None of the patients received thermal energy as part of their procedure. None of the patients had evidence of glenohumeral joint infection, although an extensive workup was frequently undertaken. Clinically, patients presented with a stiff, painful shoulder. Examination showed decreased range of motion of the affected shoulder. Radiographs and magnetic resonance imaging showed joint space narrowing, as well as subchondral sclerosis and cyst formation. Of the 18 patients, 14 have since undergone repeat arthroscopic procedures, and 5 have received a humeral head-resurfacing operation. Within the same time period, there were 113 arthroscopies, with 45 pain pumps used. Chondrolysis developed in 16 of 32 patients with high-flow IAPPCs and 2 of 12 patients with low-flow IAPPCs (1 patient's IAPPC flow rate was not documented). Although we cannot establish a causal link, the development of glenohumeral chondrolysis may be related to the intra-articular infusion of bupivacaine with epinephrine postoperatively. We thus caution against the use of IAPPCs. Level IV, therapeutic case series.
Eugen Bircher was a strong advocate of diagnostic arthroscopy as shown in several papers on the topic of internal derangements of the knee published between 1921 and 1926. During that time, he performed about 60 endoscopic procedures, which usually preceded a meniscectomy. We believe that this was the first time arthroscopy was used in a large scale for clinical purposes. Bircher was the head surgeon of the busy provincial Aarau General Hospital, a right-wing politician, and a highly ranked army officer. His interest in knee surgery was supported by his friend Fritz Steinmann, who was the "man of the pin" and an early promoter of skeletal traction for fracture treatment. Bircher believed in the early surgical treatment of meniscal lesions and, later, in the reconstruction of cruciate ligament lesions. He used the Jacobaeus thoracolaparoscope for arthroscopy, but it had poor endoscopic qualities. The electric lamp at the tip of the optical device was not mechanically protected and was therefore endangered by every manipulation within the joint space. Also, the 90 degrees optical system delivered a dark image. By the late 1920s, Bircher had developed the technique of double-contrast arthrography, and he gave up endoscopy by 1930. In 1935, he left surgery and took a military command in the Swiss army; later he was a representative of the Farmers Party in the National Parliament until his death.
Purpose: The purpose of this study was to test the hypothesis that double-bundle anterior cruciate ligament reconstruction yields better improvement in stability and functional recovery than the single-bundle technique. Methods: An Internet search was performed of the Pubmed, Embase, AMED, Cochrane Library, CNKI, Wanfang and VIP databases to find all published randomized controlled trials of anterior cruciate ligament reconstruction treated with the double-bundle versus single-bundle technique. Outcomes of stability improvement and functional recovery were meta-analyzed. Results: One thousand six hundred sixty-seven patients in 19 randomized controlled trials were involved in the meta-analysis. The overall relative risk (with 95% confidence interval) calculated with the random effects model in the pivot shift test and the International Knee Documentation Committee (IKDC) objective score for single-bundle versus double-bundle ACL reconstruction were 0.77 (0.67, 0.89) and 0.80 (0.68, 0.93), respectively. The overall relative risk calculated with the fixed effects model in the Lachman test was 0.84 (0.78 to 0.92). The overall standard mean differences (with 95% confidence interval) calculated with the random effects model were 0.26 (0.05, 0.46) for anterior side-to-side difference; -0.08 (-0.28,0.12) for Lysholm score; Tegner activity scale, -0.41 (-0.85, 0.03) for Tegner activity score; and -0.08 (-0.32, 0.15) for IKDC subjective score. Conclusions: Meta-analysis of random controlled trials revealed that double-bundle anterior cruciate ligament reconstruction resulted in significantly better anterior and rotational stability and higher IKDC objective scores compared with single-bundle reconstruction. However, the meta-analysis did not detect any significant differences in subjective outcome measures between double-bundle and single-bundle reconstruction, as evidenced by the Lysholm score, Tegner activity scale, and IKDC subjective score. Level of evidence: Level II, meta-analysis of Level I and II studies.
Endoscopic carpal tunnel release using Menon's technique has been shown to reduce recovery time, although previous studies have shown that there is still a considerable risk of nerve complications. The purpose of this study was to evaluate data from 227 hands of 191 patients who underwent releases with Menon's technique. Prospective study. Endoscopic releases were performed as an outpatient intervention by one surgeon. Follow-up evaluations included were analysis of satisfaction, quantitative measurements of grip strength, return to work time, and complications. After the surgery on the first 50 hands in 41 consecutive cases, the technique was modified. Prospectively, changes in the technique are due to difficulties maintaining the knife within the center of the cannula's slot and a relatively high complication rate. In the modified technique, a 2.7-mm 25 degrees endoscope and a triangular diamond-tipped knife were used to allow for more room for the instruments and a more safe procedure. During the first month after the surgery, 91% of the patients had better subjective satisfaction scores and by 12 weeks, 81% obtained 75% to 100% or greater grip strength. Within 3 weeks, 70% of the patients had returned to work. Twelve of 50 hands operated on using the original technique had nerve disturbance diagnosed at follow-up. Three of these 12 patients developed reflex sympathetic dystrophy. One patient had partial median nerve injury that was repaired at the time of the index operation. There was no serious complication observed in 177 hands of 150 cases operated on using the modified Menon's technique, except one postoperative hypoesthesia along the long and ring fingers that improved with time. The procedure is suitable for outpatient surgery and the risk of inadvertent damage to the neurovascular structures can be dramatically reduced with the modifications to the technique. LEVEL OF Evidence: Level IV.
The purpose of this study was to prospectively assess the outcome of hamstring autograft anterior cruciate ligament (ACL) reconstruction by use of identically shaped bioabsorbable and titanium interference screws in a randomized trial. One hundred patients were randomized to have either bioabsorbable or titanium interference screws used for graft tunnel fixation in hamstring autograft ACL reconstruction. Patients were objectively and subjectively assessed preoperatively and 3, 6, 12, and 24 months postoperatively. Radiographs at 12 months postoperatively were also assessed for tunnel width. Results: There were no differences in clinical outcome by use of Lysholm and International Knee Documentation Committee scores between the 2 groups at any stage of follow-up to 2 years. Tibial tunnel widths were the same between the 2 groups. There was slightly more tunnel widening in the femur when bioabsorbable interference screws were used. Identically shaped bioabsorbable interference screws and titanium interference screws used for hamstring autograft ACL reconstruction are equally successful up to 2 years postoperatively. Level I, prospective randomized trial with more than 80% follow-up.
In the decade from 1965 to 1975, arthroscopy advanced from a medical curiosity to a useful adjunct in the treatment of joint disease. The International Arthroscopy Association was established in 1974, with the prime purpose of teaching arthroscopy and disseminating information regarding the technique. Rapid advances were made in the field of instrumentation, courses were organized, and regular meetings were held as a forum for the exchange of information. Hence, in only 10 years, the technique became an established part of knee joint surgery, and the door was opened for the exploration of other joints. Dr. Masaki Watanabe deserves full credit for his contribution, which medical historians will undoubtedly establish as one of the great advances in orthopaedic surgery in the twentieth century.
Top-cited authors
Marc J Philippon
  • Steadman Philippon Research Institute
Anthony Romeo
Nikhil Verma
  • VIT University
Bryan T. Kelly
  • Hospital for Special Surgery
Augustus Mazzocca
  • UConn Health Center