Arthroscopic Methods Research Articles

Arthroscopic Treatment of Multidirectional Shoulder Instability in Athletes

Background There are few reports in the literature detailing the arthroscopic treatment of multidirectional instability of the shoulder. Hypothesis Arthroscopic management of symptomatic multidirectional instability in an athletic population can successfully return athletes to sports with a high rate of success as determined by patient-reported outcome measures. Study Design Case series; Level of evidence, 4. Methods Forty patients (43 shoulders) with multidirectional instability of the shoulder were treated via arthroscopic means and were evaluated at a mean of 33.5 months postoperatively. The mean patient age was 19.1 years (range, 14-39). There were 24 male patients and 16 female patients. Patients were evaluated with the American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability scoring systems. Stability, strength, and range of motion were also evaluated with patient-reported scales. Results The mean American Shoulder and Elbow Surgeons score postoperatively was 91.4 of 100 (range, 59.9-100). The mean Western Ontario Shoulder Instability postoperative percentage score was 91.1 of 100 (range, 72.9-100). Ninety-one percent of patients had full or satisfactory range of motion, 98% had normal or slightly decreased strength, and 86% were able to return to their sport with little or no limitation. Conclusion Arthroscopic methods can provide an effective treatment for symptomatic multidirectional instability in an athletic population.

A Biomechanical Comparison of Transosseous–Suture Anchor and Suture Bridge Rotator Cuff Repairs in Cadavers

Background Several biomechanical studies comparing open and arthroscopic rotator cuff repair methods have shown inferior performance of arthroscopic repairs. Suture anchor–augmented transosseous repairs and suture bridge repairs have shown superior biomechanical performance when compared with other methods, but these 2 repair methods have not been directly compared. Hypothesis There will be no difference in the biomechanical performance of the transosseous–suture anchor and suture bridge techniques. Study Design Controlled laboratory study. Methods Eight paired cadaveric shoulder specimens (16 specimens) had creation followed by repair of a complete tear of the supraspinatus, with the first member of each pair undergoing repair by a transosseous–suture anchor technique and the second member undergoing repair by the suture bridge technique. Specimens were then cycled from 10 to 180 N for 200 cycles, followed by testing to failure at 33 mm/s. Elongation was measured during cyclic testing, and failure load and stiffness were obtained during load-to-failure testing. Failure method was recorded. Results There was no significant difference between transosseous–suture anchor repairs and suture bridge repairs for elongation (4.0 ± 1.60 mm vs 3.5 ± 1.1 mm, P = .31), failure load (408 ± 93 N vs 419 ± 62 N, P = .70), or stiffness (58 ± 10 N/mm vs 58 ± 14 N/mm, P = .94). The most common mode of failure with each method was suture cutting through tendon. Conclusion The suture bridge repair exhibited similar biomechanical performance during cyclic and load-to-failure testing as a transosseous–suture anchor repair, which historically has been performed in open or mini-open fashion. Clinical Relevance Arthroscopic rotator cuff repairs can be performed that are as strong as open or mini-open repairs.

Comparison of Arthroscopic and Open Treatment of Septic Arthritis of the Wrist

Open irrigation and débridement is the standard of treatment for septic arthritis of the wrist. Although isolated cases of arthroscopic irrigation and débridement have been reported, a comparison of arthroscopic and open techniques has not been performed, to our knowledge. The purpose of this study was to compare the two methods of management. A retrospective comparison of patients with septic arthritis of the wrist initially treated, over an eleven-year period, with open or arthroscopic irrigation and débridement was undertaken at a single institution. The clinical presentation, laboratory and microbiological findings, hospital course, complications, and outcomes were compared between the two groups. Between 1997 and 2007, thirty-six patients with septic arthritis involving a total of forty wrists were identified. Nineteen wrists (seventeen patients) were initially treated with open irrigation and débridement, and twenty-one wrists (nineteen patients) were initially treated arthroscopically. Eleven wrists in the open-treatment cohort required repeat irrigation and débridement, and eight wrists in the arthroscopy cohort required a repeat procedure. If a repeat irrigation and débridement was required, it was performed in an open fashion in all but two cases. When the comparison included all of the patients in the series, no difference between the two cohorts was found with regard to the number of irrigation and débridement procedures required or the length of the hospital stay. However, when the comparison was limited to the patients with isolated septic arthritis of the wrist, it was found that only one of seven wrists in the open-treatment cohort but all eight wrists in the arthroscopy cohort had been successfully managed with a single irrigation and débridement procedure (p = 0.001). No patient in whom isolated septic arthritis of the wrist had been treated with arthroscopic irrigation and débridement required a second operation. The patients in whom isolated septic arthritis of the wrist was treated with the open method stayed in the hospital for an average of sixteen days compared with a six-day stay for those in whom isolated septic arthritis of the wrist was treated with the arthroscopic method (p = 0.04). The ninety-day perioperative mortality rate in the series was substantial (18% [three patients] in the open-treatment cohort and 21% [four patients] in the arthroscopy cohort). Arthroscopic irrigation and débridement is an effective treatment for patients with isolated septic arthritis of the wrist; these patients had fewer operations and a shorter hospital stay than did patients who had received open treatment. However, these benefits were not seen in patients with multiple sites of infection. Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Comparison of Medial Knot versus Trans-Tendon Suture Pass on the Mechanical Stability of Double Row Rotator Cuff Repair (SS-02)

Several arthroscopic double row methods involve trans-tendon passage of suture which is 'bridged' to a lateral anchor. Although this is relatively simple and quick, we were concerned about the potential for decreased construct stability at the medial margin of the repair. The purpose of this study was to compare the effects of medial knot tying versus simple trans-tendon suture passage upon construct stability with double row repair.

Combined Arthroscopic and Modified Open Approach for Cam Femoroacetabular Impingement: A Preliminary Experience

We report our case series of patients undergoing surgical treatment (femoral osteoplasty) for symptomatic cam femoroacetabular impingement (FAI). Clinical results using a modified Heuter anterior approach combined with adjunctive hip arthroscopy are presented. A chart review of 16 hips (14 consecutive patients) was conducted. Radiographic parameters (alpha angle, head-neck offset, and Tönnis grade) were compared preoperatively and postoperatively. Clinical features (range of motion, provocative testing, and Harris hip score) were assessed. At 2.0 years, mean hip flexion improved from 94.1 degrees to 110.0 degrees (P < .01) and internal rotation from 7.1 degrees to 12.3 degrees (P = .02). The mean alpha angle improved from 64.5 degrees to 43.3 degrees (P < .01), whereas the mean femoral head-neck offset improved from 1.9 to 9.6 mm (P < .01). The mean Harris hip score improved from 63.8 to 76.1 (P = .01). No deterioration in overall radiographic Tönnis grades was present at last follow-up. The combination of hip arthroscopy with a limited anterior approach (Heuter) is a useful technique for patients with cam or cam-dominant FAI lesions. We believe the limited anterior approach with open osteoplasty presents a reasonable alternative to arthroscopic methods of osteoplasty with minimal drawbacks in the event that total hip arthroplasty is indicated in the future. Level IV, therapeutic case series.

Arthroscopic Repair of Chronic Lateral Ankle Instability

The current "gold standard'' for treatment of chronic lateral ankle instability is the Broström-Gould procedure. Most authors recommend this type of operation even after an arthroscopic inspection of the joint. We review our results with an arthroscopic method of lateral ankle ligament repair. A method of arthroscopic lateral ligament repair with an anchor placed in the fibula is described. We used this technique on 31 consecutive patients (28 were available for followup). Twenty-one patients had work or traffic accidents, four suffered casual falls. and three had sport-related lesions. The patients were evaluated after 24.5 month average followup. The average postoperative AOFAS score was 85.3 (82.3 in the workers-compensation group and 94.4 in the others) and average satisfaction was 3.8 (3.5 to workers-compensation and 4.6 for the others). Complications occurred in nine patients (29%), but only three cases had ongoing problems. We had two recurrences (another sprain without instability on the stress radiograph). Three patients had some wound healing problems and three had injuries of the superficial peroneal nerve, one of which is persistent. One patient developed a deep venous thrombosis postoperatively. With this method, we achieved good clinical results. We had several complications but most of them were minor. It was a simple procedure with less morbidity to most patients. We believe it produced an anatomical repair of the lateral ligament with clinical and functional results similar to other techniques.

肩関節鏡視下手術の現状

Recently, arthroscopic operation for shoulder disease has shown excellent outcomes. In traditional shoulder surgery, with a wide incision, postoperative contracture is a serious concern for both patients and surgeons. Arthroscopic operation makes it possible for patients to return to their pre-injury daily activity level with minimal adverse functional effects to the surrounding shoulder joint. This is of particular importance especially for athletes. In general, traumatic shoulder dislocation and torn rotator cuff are treated with arthroscopic operation. The avulsion of the antero-inferior portion of the glenoid rim causes recurrent anterior instability of the shoulder, and surgeons should restore it to the anatomical position to prevent shoulder dislocation. Torn rotator cuff is the most common source of shoulder pain. Once, the rotator cuff is torn, in addåtion to shoulder pain, the decrease of range of motion causes distress to the patients. Therefore, suturing of the rotator cuff is performed. Using arthroscopy, surgeons can treat these traumas with minimal side effects. To perform arthroscopy for shoulder disease, well-established anatomical knowledge and technical training are necessary for surgeons. Although the long-term results of arthroscopic operation have not been investigated, the short-term results of arthroscopic repair in shoulder dislocation and torn rotator cuff have been satisfactory. This is because the reported benefits included less postoperative pain, decreased risk of deltoid dehiscence, and possible accelerated recovery and rehabilitation. Arthroscopic repair may arguably not be the most appropriate procedure for a younger person with a massive tear in whom long-term strength is more important, and a strong argument can be made for minimal-incision or open repair in this particular population. Future studies on arthroscopic repair methods and basic-science studies to improve the biological healing of the shoulder joint are needed before further recommendations can be made.

Verletzungen und Erkrankungen des Akromioklavikulargelenkes

Osteoarthritis or instability of the acromioclavicular (AC) joint may cause significant impairment or pain in the shoulder. If symptoms of osteoarthritis persist despite conservative treatment, distal clavicular resection is usually curative. Injuries and instability are classified according to Rockwood. Treatment of mild instability due to trauma is nonoperative. An underestimated acute injury to the AC joint may result in chronic instability. Different techniques are presented for operative treatment of significant acute or chronic instability. Arthroscopic methods are now available for treating both acute and chronic instability.

Long-Term Independent Evaluation After Arthroscopic Extra-Articular Bankart Repair with Absorbable Tacks

Several arthroscopic methods have been developed to treat posttraumatic recurrent anterior shoulder instability in an attempt to match the results that can be achieved with open repair. The aim of this study was to perform an independent long-term clinical and radiographic evaluation after extra-articular arthroscopic Bankart repair with use of absorbable tacks (Suretac fixators). Eighty-one consecutive patients with posttraumatic recurrent anterior shoulder instability underwent an extra-articular arthroscopic Bankart procedure. Seventy-one (88%) of the patients were reexamined physically after a median duration of follow-up of 107 months by two independent examiners and constituted the study group. Their clinical and radiographic outcomes were documented. At the time of follow-up, twenty-seven (38%) of the seventy-one patients had experienced some kind of shoulder instability, although fifteen of them had had a new, clinically relevant shoulder injury. Eleven patients had had subluxation only, and sixteen had had redislocation. Fourteen of the twenty-seven patients had had a single episode of instability. Seven patients had undergone additional surgery to treat shoulder instability. The instability episodes occurred less than two years postoperatively in nine patients, between two and five years postoperatively in twelve, and more than five years postoperatively in six. At the time of final follow-up, the median external rotation in abduction was 90 degrees (range, 0 degrees to 120 degrees ) compared with 95 degrees (range, 70 degrees to 125 degrees ) for the contralateral, uninjured shoulders (p < 0.001). Before the injury, fifty-two patients (73%) participated in overhead or contact sports, whereas thirty-four patients (45%) participated in such activities at the time of follow-up. At the time of follow-up, the drill holes used to implant the absorbable tacks were invisible or hardly visible in fifty-eight (91%) of sixty-four patients for whom radiographs had been made. A marked increase in degenerative changes was noted when follow-up radiographs were compared with the preoperative radiographs. This long-term follow-up study of arthroscopic extra-articular Bankart repairs revealed an unexpectedly high number of patients with new episodes of instability. This finding led to a slight modification of the technique. Since most instability episodes occurred after two years, it is important to follow patients for a longer period of time after surgical treatment of recurrent anterior shoulder instability to identify the true recurrence rate.

The Outcome and Structural Integrity of Arthroscopic Rotator Cuff Repair with Use of the Double-Row Suture Anchor Technique

The reported rate of failure after arthroscopic rotator cuff repair has varied widely. The influence of the repair technique on the failure rates and functional outcomes after open or arthroscopic rotator cuff repair remains controversial. The purpose of the present study was to evaluate the functional and anatomic results of arthroscopic rotator cuff repairs performed with the double-row suture anchor technique on the basis of computed tomography or magnetic resonance imaging arthrography in order to determine the postoperative integrity of the repairs. A prospective series of 105 consecutive shoulders undergoing arthroscopic double-row rotator cuff repair of the supraspinatus or a combination of the supraspinatus and infraspinatus were evaluated at a minimum of two years after surgery. The evaluation included a routine history and physical examination as well as determination of the preoperative and postoperative strength, pain, range of motion, and Constant scores. All shoulders had a preoperative and postoperative computed tomography arthrogram (103 shoulders) or magnetic resonance imaging arthrogram (two shoulders). There were thirty-six small rotator cuff tears, forty-seven large isolated supraspinatus or combined supraspinatus and infraspinatus tendon tears, and twenty-two massive rotator cuff tears. The mean Constant score (and standard deviation) was 43.2 +/- 15.1 points (range, 8 to 83 points) preoperatively and 80.1 +/- 11.1 points (range, 46 to 100 points) postoperatively. Twelve of the 105 repairs failed. Intact rotator cuff repairs were associated with significantly increased strength and active range of motion. Arthroscopic repair of a rotator cuff tear with use of the double-row suture anchor technique results in a much lower rate of failure than has previously been reported in association with either open or arthroscopic repair methods. Patients with an intact rotator cuff repair have better pain relief than those with a failed repair. After repair, large and massive rotator cuff tears result in more postoperative weakness than small tears do.

Correlation between arthroscopic and histopathological grading systems of articular cartilage lesions in knee osteoarthritis

Arthroscopic and particularly histopathological assessments have been used to evaluate alterations of knee cartilage in osteoarthritis (OA). The aim of this study was to examine the correlation between an arthroscopic method to grade the severity of chondropathies and the histological/histochemical grading system (HHGS) applied to the corresponding articular cartilage areas in knee OA. The articular cartilage surface was examined by chondroscopy using the Beguin and Locker severity criteria, analysing the lesions in 72 chondroscopic areas. Afterwards, samples were obtained by dividing the cartilage surface of the medial tibiofemoral compartment of three OA knee joints into equal squares and they were evaluated histologically using the HHGS. The correlation between both grading methods was assessed using the weighted Kappa coefficient (K(w)). The results obtained with both scores showed good agreement (K(w): mean+/-standard deviation, 0.619+/-0.071). While the average HHGS scores of the chondral samples showed a better agreement with arthroscopic grades 0, I and II, the arthroscopic evaluation has a tendency to overestimate chondral lesions for histological grades III and IV. The intra- and inter-observer reliability of the HHGS evaluation of chondral lesions was excellent (Intraclass Correlation Coefficient: 0.909 and 0.941, respectively). In this study, we found a good quantitative correlation between established arthroscopic severity and histopathological scoring systems, particularly in less advanced lesions. Our results suggest that the arthroscopic method is a valuable tool in clinical research to score chondropathies in the medial femorotibial compartment of the OA knee, although some limitations should not be overlooked.

An arthroscopic bone graft procedure for treating anterior–inferior glenohumeral instability

The purpose of this study is twofold: to present an arthroscopic method for treating anterior-inferior glenohumeral instability, and to evaluate its feasibility in a cadaveric model. This arthroscopic technique was performed in ten fresh frozen cadaver shoulder specimens. Quality of the results following the procedure were evaluated subjectively by assessing how the bone block graft was placed respect glenoid rim. We also evaluated adjacent axillary nerve and the neuro-vascular structures medial to the coracoid. We had six 'good' results, two 'fair' results, and two 'poor' results. The present study indicates that an anterior bone graft procedure for treating anterior bone defects of the glenoid in anterior inferior shoulder instability can be successfully performed. The worst results occurred during our first five procedures, suggesting a learning curve. However, the learning curve doesn't appear to be steep, as the good results gained in the last five procedures confirm.

Traitement chirurgical des instabilités antérieures de l’épaule chez les joueurs de rugby : résultats cliniques et radiographiques au recul minimum de cinq ans

In rugby players, 9 to 11% of injuries involve shoulder trauma. Anterior dislocation is one of the most severe accidents affecting the upper limb; recurrent dislocation, observed in more than 60%, appears to be related to the characteristic mechanism of injury in this sport (tackling). Surgical treatment for this instability is a bone block or capsulolabral repair. The purpose of this work was to evaluate outcome with minimum five-years follow-up after treatment by selective capsule repair in a homogeneous series of rugby players. Between 1995 and 2001, 31 rugby players were reviewed at mean 82 months (range: 60 to 120 months) follow-up. Sixty-one percent were regional-level players. A tackle was involved in the instability accidents for half of the players. Age at surgery was 21 years (range: 16 to 34), on average 4.44 years (range: 2 to 20) after the instability accident. Signs of capsule hyperlaxity were noted in 16 shoulders (46%). Dislocation was noted in 27 shoulders, subluxation in five. Chronic pain and instability were noted for three shoulders. Disinsertion of the anteroinferior labrum was noted in 23 shoulders (65%) and was repaired with two, three or four anchors. Isolated capsule distension was observed in twelve shoulders. Neer capsuloplasty was performed on 33 shoulders, with complementary labral reinsertion for 21 of them. Ninety-seven percent of the patients were playing rugby again after surgery, the longest delay being one year after the operation. A new episode of instability after major trauma was observed in six shoulders (17%), on average 3.8 years (range: 0.5 to 6) after the operation. Isolated capsule repair had the poorest prognosis (p=0.04). Compared with the contralateral side, external rotation decreased on average 6.2 degrees (elbow to chest) and 3.4 degrees at 90 degrees abduction. Subscapular muscle force decreased on average 2.05 kg. The Rowe and Duplay-Walch scores were good or excellent for 86% and 80% of shoulders, respectively. Patient satisfaction was 88%. According to Samilson, radiographic degeneration was noted in 32% of shoulders, with stage 1 osteoarthritis in 45% and stage 2 in 23%. Young age appears to be a major factor, predictive of recurrence after a first instability accident; the type of sport would only be indirectly involved. Nevertheless, for patients playing this type of contact sports, the appropriateness of surgical stabilization can be debated; arthroscopic anatomic methods have not yet yielded results equivalent to open surgery. The results in this series are similar to those found elsewhere in the literature, but with a follow-up longer than generally reported. Anatomic reconstruction of anterior stability elements enables these patients to resume their contact sport at an equivalent level with restored joint motion.

Decreased Range of Motion Following Arthroscopic Remplissage

The Hill-Sachs lesion is an impression fracture of the posterolateral margin of the humeral head that commonly results from impaction with the anterior glenoid rim during subluxation or dislocation of the shoulder. This bony defect has been implicated as an etiology of recurrent instability of the shoulder. The "remplissage" technique described by Wolf is an arthroscopic method of filling the Hill-Sachs defect via infraspinatus tenodesis and posterior capsulodesis. The purpose of this technique is to prevent recurrent instability by making the Hill-Sachs lesion extra-articular thereby eliminating engagement of the defect with the anterior glenoid rim. In addition, the infraspinatus tenodesis acts as a checkrein by preventing anterior translation of the humeral head. We report a complication of this recently described technique. A 28-year-old man who failed conservative management underwent an arthroscopic Bankart repair with a concomitant remplissage procedure. Two years postoperatively, the patient continued to struggle with the loss of external rotation. Conservative management with physical therapy and range of motion exercises failed. The patient was treated with an arthroscopic release of the tenodesed infraspinatus, which improved external rotation by 202 in circle intraoperatively. At 6 months postoperatively, the patient has maintained a significant increase external rotation. We hypothesize that the loss in external rotation occurred as a result of the tenodesis of the infraspinatus and posterior capsule into the Hill-Sachs defect. The tenodesed cuff and capsular tissue acted as a mechanical block to external rotation of the shoulder.

Arthrolyse antérieure de l’épaule sous arthroscopie dans les séquelles de paralysie obstétricale du plexus brachial. Résultats préliminaires

Retraction of the shoulder in internal rotation is observed in 25% of children with brachial plexus birth palsy (C5, C6 +/- C7). Early bone and joint deformities affecting the glenohumeral joint are the consequences. The stiff internal rotation requires surgical release which can involve the capsule and ligaments, muscles, or both. Internal release can be combined with muscle transfer to improve active external rotation. We report the results obtained with arthroscopic anterior capsular release combined with latissimus dorsi transfer. From 1999 through 2006, fourteen children with a stiff shoulder in internal rotation secondary to brachial plexus birth palsy were managed in our unit. All had recovered biceps function six months after surgery. The glenohumeral dysplasia was analyzed on the preoperative magnetic resonance imaging. Pre- and postoperative passive external rotation (RE) were measured with the arm along the body and at 90 degrees elbow flexion. Internal rotation was measured using the Mallet score (hand-back test). Combined active abduction antepulsion was measured when the child was playing. Mean age at surgery was three years six months. Arthroscopic internal release was performed for eight children. All had an associated latissimus dorsi transfer. Among the 14 children managed in the unit, arthrolysis was not be performed in six, either because of the lack of an adequate electrode (two patients) or because the child presented posterior glenohumeral dislocation making it impossible to introduce the optic channel (four patients). Arthroscopic anterior release was performed for the eight other patients. These eight patients were reviewed at a mean three-year follow-up. Passive external rotation was improved, with a mean gain of 60 degrees with no recovery of passive internal rotation. The abduction antepulsion movement was also improved, mean gain 90 degrees . A stiff shoulder in internal rotation can develop during the first two years of life. Several techniques have been proposed for internal release. The origin of the progressive limitation of passive external rotation remains a subject of debate. Is it due to retraction of the internal rotators, or to capsule-ligament retraction, or both? In 1992, Harryman et al. demonstrated the role of the capsule and the coracohumeral ligament in limiting external rotation. Consequently, we have opted for early release (less than two years of age) using an arthroscopic method limited to the capsule and ligaments. Our results for passive external rotation are comparable to those reported by others. However, this technique enables preserved mobility for internal rotation. Arthroscopic anterior release limited to the capsule and the ligaments is an effective, minimally invasive technique. Leaving the internal rotator muscles intact preserves internal rotation of the shoulder and reduces the risk of anterior instability.

Measurement of Glenoid Bone Loss

Background Osteotomies at an angle of 45° to the long axis of the glenoid were originally used in a cadaveric model to simulate the bone loss that can occur clinically in anterior instability of the shoulder. However, this type of glenoid defect is not consistent with the usual clinical scenario, in which bone loss occurs nearly parallel (at 0°) to the long axis of the glenoid. Purpose Our objectives were to compare the amount of glenoid bone loss measured after a 45° glenoid osteotomy with that after a 0° osteotomy and to determine differences in bone loss measurement from 2 different posterior shoulder portals. Study Design Controlled laboratory study. Methods Glenoids of 14 embalmed cadaveric shoulders (mean age, 81 years; range, 56–90) were mounted in a custom shoulder holder, and 2 posterior portals (2 and 3 o'clock) were fixed into place. The area of a best-fit circle of the inferior portion of the glenoid was digitally calculated, and 2 sequential osteotomies of 12.5% and 25% of anteroinferior glenoid bone loss area were created. Two different types of osteotomies were created: group 1, “inverted-pear” bone loss (45° to the long axis of the glenoid); and group 2, “clinical” bone loss osteotomy (0° to the long axis of the glenoid). Measurements of bone loss were performed based on the bare spot method from 2 simulated posterior portals at 2 and 3 o'clock using a calibrated probe and digital calipers. The osteotomy was measured in 3 different locations (upper, middle, and lower thirds). Results In the 12.5% bone loss model, bone loss measurements for both groups were significantly higher than expected (22.2%–23.1 % in group 1,17.4%–17.9% in group 2; P = .031-.049). In the 25% bone loss model, the mean measured bone loss was 27.8% in group 1 and 27.5% in group 2; however, bone loss measurements varied significantly in group 1 based on measurement location along the osteotomy (upper third, 12.3%; middle third, 31.5%; lower third, 39.8% loss) (P = .01-.0001). In group 2, the bone loss measurements were less varied (23.5%–0.3%). There were no differences between the location of the posterior portal (2 vs 3 o'clock) in determination of glenoid bone loss for both the 12.5% and 25% osteotomies. Conclusion Glenoid bone loss determination in a 45° osteotomy model significantly overestimates the amount of true glenoid bone loss. However, in a 0° clinical bone loss simulation model, the arthroscopic bare spot method of bone loss determination was sufficiently accurate at all 3 areas (upper, middle, and lower third) of bone loss. Both the 2-o'clock and 3-o'clock posterior portals were accurate to determine the amount of glenoid bone loss as referenced from the bare spot. Clinical Relevance Arthroscopic determination of glenoid bone loss is more accurate than what has been previously described with the 45° simulation model. Measurement of glenoid bone loss from either the 2-o'clock or 3-o'clock posterior portal is accurate in a clinical bone loss model.

Artroscopia do joelho de ovinos

O trabalho teve por objetivo avaliar artroscopicamente a articulação do joelho de ovinos hígidos em diferentes idades, com o intuito de determinar, de acordo com os portais estabelecidos, a capacidade de observação das estruturas. Utilizaram-se 18 animais da raça Santa Inês, divididos em três grupos experimentais eqüitativos, conforme a idade cronológica, sendo: Grupo I, 6-8 meses (peso médio de 25 kg); Grupo II, 2 anos (peso médio de 50 kg); e Grupo III, 3,5-5 anos (peso médio de 55 kg). Foram estabelecidos três portais: (1) portal artroscópico primário, craniolateral; (2) portal para fluxo de drenagem; e (3) portal instrumental, craniomedial. Identificaram-se com facilidade a patela, sulco e bordas trocleares, côndilos medial e lateral do fêmur, e tendão do músculo extensor longo dos dedos. Após a remoção da maior parte do coxim gorduroso infrapatelar com emprego do "shaver" foram visibilizados, ainda com dificuldade, os ligamentos cruzados e os meniscos. Para a identificação dos primeiros foram necessárias movimentos de flexão e extensão e para os meniscos manobras de varo e valgo. O grau de dificuldade foi inversamente proporcional ao tamanho da articulação. Sendo assim, foi possível concluir que os portais artroscópicos utilizados possibilitaram a identificação das principais estruturas articulares, independente da idade, e o método em si teve por vantagem a rápida recuperação pós-operatória dos animais.

Comparison of a Double Bundle Arthroscopic Inlay and Open Inlay Posterior Cruciate Ligament Reconstruction Using Clinically Relevant Tools: A Cadaveric Study

The ideal surgical management of isolated and combined posterior cruciate ligament (PCL) injuries is controversial. One active debate concerns the advantages of an open tibial inlay technique versus an arthroscopic transtibial tunnel technique. Therefore, the goal of this study is to biomechanically compare arthroscopic and open double-bundle PCL tibial inlay procedure with and without posterolateral corner (PLC) deficiency. Ten matched pairs of cadaveric knees were randomly assigned to undergo PCL sectioning and reconstruction using either the open inlay or arthroscopic inlay approach. Clinical testing consisted of posterior drawer, TELOS stress testing, and dial testing at both 30 degrees and 90 degrees . The knee conditions tested were intact, after PCL sectioning, after PLC release, and following PCL reconstruction, with and without the PLC repair. Both 1-way repeated measures and 2-way mixed design analyses of variance were used to determine differences between the knee conditions, with significance set at P < .05. After PCL and PLC reconstruction, 10 of 10 open specimens and 9 of 10 arthroscopic specimens were a grade 0 posterior drawer. The remaining arthroscopic specimen was grade I. The average radiographic posterior displacement for arthroscopic and open reconstructions (PCL+/PLC+) was 3.9 and 2.7 mm, respectively, with no significant difference. However, if the PLC was deficient (PCL+/PLC-), the translation for arthroscopic and open specimens increased to 8.5 and 6.5 mm, respectively, and was statistically different from the intact state but not from each other. At 30 degrees of knee flexion, both the open and arthroscopic specimen averaged 8.4 degrees of external rotation. At 90 degrees of knee flexion, the external rotation measurements increased to 9.6 degrees and 9.3 degrees in the arthroscopic and open groups, respectively. Additionally, there was no significant difference in external rotation between intact and reconstructed knees with either group. The arthroscopic method of double-bundle inlay PCL reconstruction provides comparable stability to the open inlay using clinically relevant measurement tools both in the PLC intact or deficient state. This novel arthroscopic double-bundle PCL inlay reconstruction provides comparable stability to the open approach with a potential for lower operative morbidity.

A Review of Femoroacetabular Impingement in Athletes

There are a multitude of well recognized hip and groin injuries that commonly affect athletes; however, a more recently recognized and possibly often overlooked cause of hip pain is that of femoroacetabular impingement (FAI). FAI is characterized by abutment of the femoral neck against the acetabular rim, which may occur by two mechanisms known as 'CAM' or 'pincer' impingement, although most commonly by a mixture of both. CAM impingement is characterized by abutment of the femoral neck against the acetabulum due to a morphological abnormality of the femoral head-neck junction. Pincer impingement occurs where an abnormality of the acetabulum results in impingement against an often normal femoral neck. Both CAM and pincer impingement are known to result in pathological consequences of cartilage delamination and labral lesions, leading to significant pain and disruption to athletic performance and activities of daily living in athletes. There are currently several methods of assessing the degree of impingement by use of CT and magnetic resonance imaging scans, which can be used in conjunction with magnetic resonance arthrography and arthroscopy to assess the damage caused to the underlying structures of the hip. Both open and arthroscopic surgical methods are used, with recent reports in athletes showing excellent results for lifestyle improvement and frequency of returning to sport. In cases of hip and groin pain in athletes, it is important to remember to look for typical history, and examination and imaging findings that may suggest a diagnosis of hip impingement. This article goes some way to explaining the principles, consequences and management of FAI.

Basics of Arthroscopic Rotator Cuff Repair

Traditional methods of open and mini-open rotator cuff repairs have shown excellent results in shortand medium-term follow-up and remain viable methods of treating rotator cuff pathology. A trend toward the arthroscopic repair of rotator cuff tears continues, however, and will probably accelerate as the next generation of surgeons is trained in arthroscopic treatment methods. The purpose of this article is to provide an overview of the arthroscopic treatment of rotator cuff repair with an emphasis on technique. An understanding of the principles of rotator cuff repair and arthroscopy serves as a basis for a step-by-step approach to arthroscopic rotator cuff repair.