Arthroscopy Research Articles

Rehabilitation Protocol Variability Following Arthroscopic Bankart Repair and Remplissage for Management of Anterior Shoulder Instability: A Systematic Review.

Augmentation of an arthroscopic Bankart repair with the remplissage (ABR) procedure has shown to confer a decrease in recurrence rates, yet, at the expense of potentially compromising shoulder motion. The purpose was to examine clinical studies that described a post-operative rehabilitation protocol after an arthroscopic Bankart repair and remplissage procedure. It was hypothesized that a review of the literature would find variability among the studies and that, among comparative studies, there would be a limited distinction from protocols for isolated Bankart repairs. Systematic Review. A search was conducted using three databases (PubMed, EMBASE, and CINAHL) according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. The following terms were combined while utilizing Boolean operators: (Bankart lesion OR labral tear) AND (remplissage). Studies evaluating patients after arthroscopic stabilization for unidirectional anterior glenohumeral instability with the addition of the remplissage procedure and at least 1 year follow-up were included for analysis. A total of 41 studies (14 Level IV, 24 Level III, 2 Level II, and 1 Level I) were included with a total of 1,307 patients who underwent ABR. All patients had <30% glenoid bone loss and a range of 10-50% humeral head size Hill-Sachs lesion. Type and position of immobilization were the most reported outcomes (41/41) followed by time of immobilization (40/41). Moreover, 23/41 studies described their initial post-operative shoulder range of motion restrictions, while 17/41 specified any shoulder motion allowed during this restrictive phase. Time to return to sport was also described in 37/41 of the retrieved studies. Finally, only two of the 27 comparative studies tailored their rehabilitation protocol according to the specific procedure performed, underscoring the lack of an individualized approach (i.e.same rehabilitation protocol for different procedures). The results of the present systematic review expose the variability among rehabilitation protocols following ABR. This variability prompts consideration of the underlying factors influencing these disparities and underscores the need for future research to elucidate optimal rehabilitation. Based on the results of this systematic review and the senior authors´ clinical experience, a rehabilitation approach similar to an isolated Bankart repair appears warranted, with additional precautions being utilized regarding internal rotation range of motion and external rotation strengthening. Level 3.

Diaphragm-sparing efficacy of subparaneural upper trunk block for arthroscopic shoulder surgery: A randomised controlled trial.

Inter-scalene block (ISB) is associated with an inevitable risk of hemi-diaphragmatic paresis (HDP). To reduce the risk of HDP, an upper trunk block (UTB) has been proposed at the brachial plexus division level. We hypothesised that UTB would be associated with a lower incidence of HDP than ISB while providing sufficient analgesia following arthroscopic shoulder surgery. Randomised controlled trial. A tertiary teaching hospital. Seventy patients aged 20 to 80 years undergoing arthroscopic rotator cuff repair. Ultrasound-guided ISB or UTB was performed with 5 ml 0.75% ropivacaine. The primary outcome was the incidence of complete HDP, assessed by diaphragm excursion using ultrasound, defined as a decrease to 25% or less of baseline or occurrence of paradoxical movement. Postoperative pulmonary function change, pain scores, opioid consumption and pain-related outcomes were the secondary outcomes. The UTB group had a significantly lower incidence of complete HDP than the ISB group [5.9% (2/34) vs. 41.7% (15/36); absolute difference, 35.8%; 95% confidence interval (CI), 17.8 to 53.7%; P < 0.001]. The postblockade decline in pulmonary function was more pronounced in the ISB group than that in the UTB group. The pain score at 1 h postoperatively was not significantly different between the groups (ISB vs. UTB group: median 0 vs. 1; median difference, -1; 95% CI, -2 to 0.5). No significant difference was observed in any other secondary outcomes. UTB was associated with a lower incidence of HDP compared with ISB while providing excellent analgesia in arthroscopic shoulder surgery. Clinical Trial Registry of Korea ( https://cris.nih.go.kr ) identifier: KCT0007002. Chungnam National University Hospital Institutional Review Board No. 2021-12-069.

Evaluation of healing after arthroscopic repair of lateral meniscal tears around the popliteal hiatus

BackgroundThe popliteal hiatus stabilizes the lateral meniscus (LM). Variable failure rates for LM repairs have been reported in knees with lateral meniscal tears (LMTs), which may be attributable to low vascularity around the popliteal hiatus. An effective repair method is essential to enhance the biological healing and stability of LMTs around the popliteal hiatus. HypothesisArthroscopic repair of LMTs, including the popliteus tendon around the popliteal hiatus, is expected to produce a low reoperation rate and effective treatment, both clinically and radiographically. Material and methodsFrom June 2011 to August 2020, 93 patients (mean age 27.9 ± 13.5 years) who underwent arthroscopic repair of LMTs including the popliteus tendon around the popliteal hiatus were enrolled. Patients with LMTs were divided into three groups: isolated LMTs, discoid LMTs, and LMTs with ACL injury. Patients had a minimum clinical follow-up of 2 years (mean 37.9 ± 19.3 months) and Tegner activity, Lysholm knee, and Hospital for Special Surgery (HSS) scores were evaluated for all patients. The widths of the popliteal hiatus and LM extrusion were measured on the sagittal and coronal planes using preoperative and postoperative magnetic resonance imaging (MRI). ResultsThe Tegner activity (2.6 ± 1.2–4.5 ± 1.3), Lysholm (67.9 ± 14.2–88.1 ± 6.4), and HSS scores (79.8 ± 11.5–93.7 ± 5.1) were significantly improved in all knees (p < 0.001). The width of the popliteal hiatus measured on MRI was significantly decreased, when comparing the preoperative and postoperative MRI for all knees (sagittal plane, 2.9 ± 1.4–1.5 ± 0.5 mm; coronal plane, 3.8 ± 2.5 to 1.9 ± 1.0 mm) (p < 0.05). The LM extrusion measured on the sagittal plane of postoperative MRI was also significantly reduced after arthroscopic repair (24.8 ± 3.1–23.7 ± 2.8 mm) (p = 0.001). Five reoperations (5/93, 5.3%) were performed, suggesting a clinical failure. ConclusionArthroscopic repair of isolated, discoid and post-traumatic LMTs including the popliteus tendon around the popliteal hiatus, is an effective surgical treatment for LM stabilization. Level of evidenceLevel IV, retrospective series.

Clinicoradiological and Arthroscopic Correlation of Meniscal Injuries

Background: Menisci in knee joint serve very important functions of distributing joint stresses and stabilizing the joint. Meniscus tears are on the rise because of increased sports participation. Along with detailed history taking, the physical examination and special investigations such as magnetic resonance imaging (MRI) are required to diagnose meniscal injuries. A diagnostic arthroscopy is considered as the gold standard. Owing to heavy work duties, overdependence on MRI without due clinical examination is on the rise. The aim of our study was to correlate the findings of clinically diagnosed meniscal tears with its radiological and arthroscopic findings and to find out the reliability of clinical examination and MRI in meniscal injuries considering arthroscopy as the gold standard. Materials and Methods: It was a prospective, longitudinal study performed over 12 months. All patients fulfilling inclusion criteria underwent clinical examination and MRI scan; the data obtained were evaluated and correlated with arthroscopic findings. Using necessary equations sensitivity, specificity and accuracy were calculated. Results: The clinical examination showed sensitivity, specificity, and accuracy of 75%, 90.62%, and 83.33%, respectively, when correlated with arthroscopy. MRI scan showed sensitivity, specificity, and accuracy of 82.86%, 92%, and 86.67%, respectively, when correlated with arthroscopy. Conclusion: MRI and clinical examination are comparably sensitive, specific, and accurate for diagnosing meniscal injuries with a subtle preference toward MRI. Author recommends a thorough clinical examination should suffice, but having a MRI scan beforehand is always beneficial in the absence of other concerns to do MRI.

Low Socioeconomic Indicators Correlate with Critical Pre-Operative Glenoid Bone Loss and Care Delays

BackgroundChronic and recurrent shoulder dislocations prior to stabilization can increase the risk of glenoid bone loss. Glenoid bone loss exceeding critical levels can lead to further instability and decreased outcomes following arthroscopic labral repair. Indicators of low socioeconomic status (SES), such as high Area Deprivation Index (ADI) and non-commercial insurance, are related to generalized delays to orthopedic care, which can cause recurrent instability and increase glenoid bone loss. Hypothesis/PurposeHigher national ADI and non-commercial insurance would be associated with greater levels of radiographic glenoid bone loss after glenoid instability. MethodsA retrospective study was performed with patients who underwent anterior labral repair. Chart review included demographics, course of care data, preoperative instability data, national ADI, and insurance status. The Neighborhood Atlas Website and patients’ home addresses were used to obtain national ADI. Glenoid bone loss was measured using the Best-fit circle Pico method on three-dimensionally aligned magnetic resonance images (MRIs). Researchers were blinded to SES indicators during radiographic analysis. Glenoid bone loss was compared between SES indicators using one-way ANOVAs. Results146 patients met inclusion criteria and had complete datasets (23.3% female; 22.4±7.0-years-old; national ADI=16.1±15.3). Patients experienced on average 9.12±6.63% glenoid bone loss. A curve fitting tool determined a quadratic non-linear regression best characterized the association of glenoid bone loss and ADI (R2 = 0.392, p < 0.001). Individuals with commercial insurance experienced 8.58%±6.69% glenoid bone loss as compared to 11.78%±6.30% in individuals with Medicaid insurance (p=0.03). Critical bone loss at a threshold of 13.5% was more likely with higher national ADI (p<0.001) and Medicaid insurance (OR=2.49, CI=1.02-6.09). However, only national ADI was predictive of subcritical bone loss at a threshold of 10% (p<0.001). ConclusionPatients with greater national ADI and Medicaid insurance status had greater rates of critical preoperative glenoid bone loss at a threshold of 13.5%. Greater national ADI is also predictive of subcritical glenoid bone loss at a threshold of 10% and overall glenoid bone loss. Further study is needed to assess the postoperative implications of these findings in this population.

Comparison of Mediolateral (V-shaped) versus Anteroposterior Dominant Rotator Cuff Tears: The Anteroposterior Tear Width Contributes More to Postoperative Retears than Mediolateral Length when the Tear Size Area is Similar

Tear size is a significant prognostic factor following rotator cuff repair. However, no study has investigated which dimension of the tear, the mediolateral or anteroposterior, more significantly influences the outcome when the product of the two dimensions, the tear size area, is similar. A retrospective cohort study was conducted with patients who underwent arthroscopic FTRCT repair. Two contrasting groups were derived from preoperative tear dimensions. The mediolateral dominant (MLD) group consisted of 45 FTRCTs with the mediolateral tear dimension at least 1.5 times larger than the anteroposterior, and retraction exceeding the humeral head apex. The anteroposterior dominant (APD) group included 35 FTRCTs with an inverse proportion of the dimensions and retraction short of the humeral head apex. Demographic data, pre- and postoperative magnetic resonance imaging (MRI), clinical scores, and strength were compared between the groups. The mean follow-up was 26.7 and 32.2 months in the MLD and APD groups, respectively. The tear size in area (MLD vs. APD, 521.0 vs. 523.4 mm2, P=.960) and the discrepancy between ML and AP dimensions (2.0 vs. 1.9, P=.597) were similar. However, the MLD group demonstrated significant female predominance (P=.003), dominant arm involvement (P=.007), a higher incidence of pathologic subacromial spurs (P=.016), narrower acromiohumeral distance (P<.001), shorter residual tendon (P<.001), and advanced supraspinatus muscle atrophy (P=.005). Other baseline parameters were comparable between the groups. At the one-year postoperative MRI, the MLD group demonstrated a significantly lower retear rate (4.4% vs. 31.4%, P=.001). Nevertheless, clinical scores and strength at the last follow-up did not significantly differ. In a similar tear size area, the greater AP width contributes more than the ML length in causing a retear. Female predominance, dominant arm involvement, subacromial spurs, shorter residual tendon, and supraspinatus muscle atrophy were more demonstrated in MLD tears. Surgeons should be aware that healing may be poor in APD tears despite less retraction.

Knee

The October 2024 Knee Roundup360 looks at: Managing the unexpected: treatment of intraoperative medial collateral ligament injuries; Identifying subgroups of patients that may benefit from robotic arm-assisted total knee arthroplasty: secondary analysis of data from a randomized controlled trial; Cost-effectiveness of enoxaparin versus aspirin in the prevention of venous thromboembolism after total hip or knee arthroplasty: an analysis from the CRISTAL cluster-randomized trial; Cartilage regeneration and long-term survival in medial knee osteoarthritis patients treated with high tibial osteotomy and osteochondral autologous transfer system; Treatment of chronic and complex meniscal tears with arthroscopic meniscus repair augmented with collagen matrix wrapping: failure rate and functional outcomes; Long-term outcomes of multiligament knee injuries in American football players.

Forty-two Percent of Patients Undergoing Arthroscopic Shoulder Surgery are Using Psychotropic Medications

PurposeThe purposes of this study were to determine the prevalence of psychotropic medication use in patients undergoing shoulder arthroscopy at a single institution, and to identify the most common medications and classes of drugs being taken in this specific patient population. We hypothesized a large portion of patients undergoing shoulder arthroscopy are concomitantly taking prescription psychotropic medications. MethodsA retrospective chart review was conducted on patients treated by three fellowship trained orthopaedic sports medicine and shoulder surgeons between 2019-2021. All patients who underwent shoulder arthroscopy during this time period were included. The following data was collected: age, sex, laterality for surgery, prior surgeries on operated shoulder, specific surgery performed, and use of psychotropic medications. Drug categories included anticonvulsants, antidepressant/ anxiolytics, sedative hypnotics, stimulants, antipsychotics, and multiple psychotropic drugs. Psychotropic medications were included if they were listed as ‘taking’ at any point in time in the patient’s chart within a 6-month window prior to surgery. ResultsOf the 1,279 (828 males; 451females) patient charts that were reviewed, 534 (41.8%) were prescribed at least one psychotropic. In 2021, 201 (44.4%) of the 453 patients were taking at least one psychotropic. Similarly in 2020, 152 (38.2% of the 453 patients) and 2019, 181 (42.2% of the 429 patients) were found to be on at least one psychotropic. Of the 1,279 patients included, 282 (34.1%) of 828 males were prescribed psychotropic drugs, as compared to 252 (55.9%) of 451 females (p=0.001). From 2019-2021, 137 (25%) of the patients using psychotropic drugs, were prescribed anticonvulsant/mood stabilizers, 105 (19%) antidepressants, 75 (14%) sedative hypnotics, 23 (4%) stimulants, 4 (1%) antipsychotics, 190 (35%) were prescribed multiple psychotropics. From 2019-2021 the rate of antidepressant/ anxiolytic and or sedative hypnotic prescription psychotropic drug use increased from 28% to 30.5% (p=.42). ConclusionThis study demonstrated that a large portion of patients undergoing shoulder arthroscopy were taking psychotropic medication. Further, it was found that female patients had significantly higher utilization of these medications, as compared to males. Clinical RelevanceUnderstanding the prevalence of these medications in orthopaedic patients is essential for surgeons to take into consideration, in order to limit pre-, intra-, and post-operative complications, as well as optimize patient outcomes.

Graft Failure and Contralateral ACL Injuries After Primary ACL Reconstruction: An Analysis of Risk Factors Using Interpretable Machine Learning.

Anterior cruciate ligament (ACL) reconstruction (ACLR) can be successful in restoring knee stability. However, secondary ACL injury, either through graft failure or contralateral injury, is a known complication and can significantly impact the ability of a patient to return successfully to previous activities. To develop and internally validate an interpretable machine learning model to quantify the risk of graft failure and contralateral ACL injury in a longitudinal cohort treated with ACLR. Case-control study; Level of evidence, 3. An established geographic database of >600,000 patients was used to identify patients with a diagnosis of ACL rupture between 1990 and 2016 with a minimum 2-year follow-up. Medical records were reviewed for relevant patient information and 4 candidate machine learning algorithms were evaluated for prediction of graft failure and contralateral ACL injury in patients after ACLR as identified either on magnetic resonance imaging or via arthroscopy. Performance of the algorithms was assessed through discrimination, calibration, and decision curve analysis. Model interpretability was enhanced utilizing global variable importance plots and partial dependence curves. A total of 1497 patients met inclusion criteria. Among them, 140 (9.4%) had graft failure and 128 (8.6%) had a contralateral ACL injury after index surgery at a median follow-up of 140.7 months (interquartile range, 77.2-219.2 months). The best performing models achieved an area under the receiver operating characteristics curve of 0.70 for prediction of graft failure and 0.67 for prediction of contralateral ACL injury, outperforming a logistic regression fitted on the identical feature set. Notable predictors for increased risk of graft failure included younger age at injury, body mass index (BMI) <30, return to sports <13 months, initial time to surgery >75 days, utilization of allograft, femoral/tibial fixation with suspension/expansion devices, concomitant collateral ligament injury, and active or former smoking history. Predictors of contralateral ACL injury included greater preoperative pain, younger age at initial injury, BMI <30, active smoking history, initial time to surgery >75 days, history of contralateral knee arthroscopies, and involvement in contact sports. Less than 18% of all patients who undergo ACLR should be expected to sustain either a graft failure or contralateral ACL injury. Machine learning models outperformed logistic regression and identified greater preoperative pain, younger age, BMI <30, earlier return to higher activity, and time to surgical intervention >75 days as common risk factors for both graft failure as well as contralateral ACL injury after ACLR. Surgeon-modifiable risk factors for graft failure included allograft and femoral/tibial fixation with a suspension/expansion combination.

Approaching ramp lesions from the different world of posterior knee compartment: A review of evidence with a proposal of a new classification and treatment

AbstractRamp lesions (RLs) are peripheral lesions that occur in the posterior part of the medial meniscus or where it attaches to the joint capsule. The classification of the medial meniscus RLs has been the focus of numerous studies and publications. This review provides an overview of RL's current classification and treatment options in anterior cruciate ligament deficient knees. The study also aims to present a more practical classification system for RLs to assist in treatment decision‐making. For the first time, we also presented a new surgical treatment for incomplete inferior and double‐complete RL based on the posterior knee arthroscopy that provides direct access to the posterior meniscal borders, enabling effective treatment and stronger biomechanical repair.Level of EvidenceLevel V.

Management of Rotator Cuff Tears in Severely Osteoporotic Patients

Management of rotator cuff tears (RCT) in osteoporotic patients presents significant challenges for treating clinicians because of compromised bone quality. We present a case series of 2 patients with RCT and severe osteoporosis highlighting the complexities of operative and nonoperative management and underscoring the importance of preoperative optimization and careful surgical planning in this vulnerable population. Patient 1 experienced initial improvement postarthroscopic RCT repair but required revision surgery because of anchor pullout, with eventual conversion to reverse total shoulder arthroplasty. Patient 2 faced intraoperative challenges because of previously undiagnosed osteoporosis, leading to difficulties in securely placing suture anchors, and was referred to the fracture liaison service (FLS) for osteoporosis management postoperatively. A multifaceted approach integrating preoperative optimization, advanced surgical techniques, and postoperative management is advised to improve operative success. Extensive perioperative bone quality assessments and augmentation strategies are warranted, including medication comanagement through an FLS if available. Detailed surgical planning is crucial, focusing on arthroscopic repair technique while considering various anchor factors to mitigate failure including proper placement, design, and pullout analysis. Intraoperative bone augmentation with materials such as calcium phosphate, magnesium phosphate, and polymethyl methacrylate cements significantly improves anchor fixation strength in osteoporotic bone. Consideration of a transosseous approach and potential for conversion to an open procedure is also an option when necessary. This review highlights the unique challenges and potential options available to treating clinicians when managing RCT in osteoporotic patients. Continued research and refinement of emerging treatment strategies are essential to improve outcomes and quality of life in this patient population.

Arthroscopic Repair for Posterior Shoulder Instability is Associated with Favorable Outcomes and High Return to Sport or Work: A Systematic Review and Meta-Analysis

PurposeThe purposes of this systematic review and meta-analysis were to assess clinical outcomes of primary arthroscopic repair for unilateral PSI in all patients, to evaluate clinical outcomes in athletes, and to compare clinical outcomes between contact and overhead athletes. MethodsA systematic review was performed using PRISMA Guidelines. Included studies reported on primary arthroscopic treatment of PSI with at least 1 year of follow-up. Studies were excluded if they were not in English, included revisions/open procedures or anterior/multidirectional instability, had fewer than ten patients or no full text available, or were biomechanical analyses/descriptions of surgical technique. Primary outcomes were rates of return to sport (RTS), return to preinjury level (RTPL), recurrent instability, and revision surgery. Outcomes were evaluated in all patients and all athletes, with further subdivision for contact and overhead. ResultsOf the 1,504 screened studies, 30 met inclusion criteria (1,649 shoulders). Mean age at surgery was 23.3 years (range: 12.4-65 years), and mean follow-up was 35.5 months (range: 12-140.4 months). There were 1051 males and 196 females. RTS rates were 91.7% among all patients and 90.9% in all athletes, with no statistical difference between contact and overhead athletes (92.8% vs. 88.1%, P=.176). RTPL rates were 78.7% among all patients and 75.6% in all athletes, with no statistical difference between contact and overhead athletes (90.8% vs. 62.3%, P=.072). Recurrent instability rates were 7.0% among all patients and 8.0% in all athletes, with no statistical difference between contact and overhead athletes (7.3% vs. 7.4%, P=.981). Revision rates were 3.7% among all patients and 3.3% in all athletes, with no statistical difference between contact and overhead athletes (6.8% vs. 0%, P=1). ConclusionPrimary arthroscopic treatment of PSI is associated with favorable outcomes and high return to sport and work rates. Recurrent instability and pain were the most common reasons for revision. Level of EvidenceLevel IV: Systematic review and meta-analysis of Level II to IV studies

The Suprascapular Artery as a Reference for the Evaluation of Supraspinatus Fatty Infiltration on Magnetic Resonance Imaging.

Fatty infiltration (FI) of the supraspinatus is commonly seen in chronic large-to-massive rotator cuff tears. Evaluating FI in patients with severe muscle atrophy can be confusing. The purpose of this study was to investigate the anatomic relationship between the suprascapular artery and supraspinatus muscle on magnetic resonance imaging (MRI) to provide a method for defining the border of the supraspinatus muscle on Y-view MRI. It was hypothesized that the branches of the suprascapular artery would encircle the supraspinatus muscle on Y-view and adjacent MRI slices and could be used for defining the supraspinatus outline on oblique sagittal images. Cohort study (diagnosis); Level of evidence, 3. A total of 172 shoulders that had undergone arthroscopic repair for large-to-massive rotator cuff tears were retrospectively included. Two methods, one based on the supraspinous fossa and trapezius (SF method) and the other based on the region bounded by the branches of the suprascapular artery (SA method), were used for defining the supraspinatus outline on Y-view MRI for the assessment of FI. Preoperative supraspinatus FI grade and tangent sign and postoperative tendon integrity were evaluated. Shoulder function was assessed using the American Shoulder and Elbow Surgeons (ASES) score and active range of motion. The branches of the suprascapular artery encircled the supraspinatus in all shoulders, with the diameter of the branches ranging from 0.5 to 3 mm. The agreement in supraspinatus FI grading between the SF and SA methods was 65.12%. When limited to the 61 shoulders with a positive tangent sign, the agreement dropped to 22.95% (κ = 0.032). The group (FI grade 2 by SA method and ≥3 by SF method) showed no significant difference in postoperative outcomes compared with the 2-vs-2 group but had significantly better postoperative ASES scores (P = .001) and active range of motion in forward elevation (P = .020) compared with the ≥3-vs-≥3 group. The tangent sign was positive in 92.16% of the 2-vs-≥3 group. The suprascapular artery is a reliable reference for the evaluation of supraspinatus FI. When a positive tangent sign presents, supraspinatus FI is likely to be overestimated if the hyperintensity outside the region bounded by the branches of the suprascapular artery is mistaken as FI.

Arthroscopic Repair of the Medial Meniscal Root Tear: A Simple Surgical Technique

Medial meniscal root tears pose significant challenges in orthopaedic practice, disrupting knee biomechanics and predisposing to degenerative changes. This article introduces an arthroscopic repair technique tailored for posterior root tears of the medial meniscus. The procedure involves meticulous preoperative evaluation, arthroscopic identification, and suture anchor fixation to restore normal knee mechanics. Inclusion and exclusion criteria ensure suitability, whereas postoperative care emphasizes early rehabilitation. By elucidating the surgical technique and outlining clinical implications, this article aims to equip surgeons with effective strategies for managing this challenging orthopaedic condition.

An Innovative, Cost-Effective, and Flexible Traction Alternative for Shoulder Arthroscopy in Lateral Decubitus Position

During shoulder arthroscopic surgery in the lateral decubitus position, effective and stable continuous traction is a basic requirement for the smooth progression of the surgery. Herein, we describe a safe, reliable, and cost-effective lateral decubitus traction assembly.

Effect of a Preoperative Subacromial Epinephrine Injection on Visualization During Shoulder Arthroscopic Surgery: A Randomized Controlled Trial.

The addition of epinephrine to arthroscopic irrigation fluid has been shown to improve surgeon-rated visual clarity during shoulder arthroscopic surgery. Subacromial injections of epinephrine are also used for this purpose. To assess the influence of a preoperative subacromial epinephrine injection on surgeon visualization during subacromial shoulder arthroscopic surgery. It was hypothesized that the epinephrine injection would improve surgeon-rated visual clarity. Randomized controlled trial; Level of evidence, 1. A double-blind randomized controlled trial including adult patients undergoing shoulder arthroscopic surgery in the beach-chair position requiring visualization of the subacromial space was performed. Patients in the epinephrine group (n = 30) received a preoperative subacromial injection of bupivacaine and epinephrine, and those in the control group (n = 30) received a preoperative subacromial injection of bupivacaine. Epinephrine was added to the first 10 L of arthroscopic irrigation fluid in all patients. The primary outcome was surgeon-rated visual clarity throughout the procedure that was recorded at the end of the procedure using a visual analog scale (VAS) scored from 0 (worst) to 10 (best). Secondary outcomes included an increase in pump pressure during the procedure, total operative time, and the intraoperative use of blood pressure-modulating medications. Rotator cuff repair was performed in 88.3% of patients (25/30 epinephrine; 28/30 control), with multiple procedures performed in 85.0% of patients (23/30 epinephrine; 27/30 control). The VAS score for visual clarity was slightly better in the epinephrine group compared with the control group, although the difference was neither statistically nor clinically significant (8.3 ± 1.4 vs 7.5 ± 1.8, respectively; P = .09). There was no difference between the epinephrine and control groups in the need for an increase in pump pressure to improve visualization (8/30 [26.7%] vs 7/30 [23.3%], respectively; P > .99), total operative time (62.0 ± 19.4 vs 64.0 ± 30.1 minutes, respectively; P = .90), or the intraoperative use of blood pressure-modulating medications (20/30 [66.7%] vs 17/30 [56.7%], respectively; P = .60). There were no perioperative adverse events in either group. The addition of a subacromial epinephrine injection before shoulder arthroscopic surgery resulted in a small improvement in visual clarity that was neither statistically nor clinically significant, with no adverse effects reported in this study. NCT05244525 (ClinicalTrials.gov).

Characterization of articular lesions associated with glenohumeral instability using arthroscopy.

The prevalence of osteoarthritis (OA) associated with instability of the shoulder ranges between 4% and 60%. Articular cartilage is, however, routinely assessed in these patients using radiographs or scans (2D or 3D), with little opportunity to record early signs of cartilage damage. The aim of this study was to assess the prevalence and localization of chondral lesions and synovial damage in patients undergoing arthroscopic surgery for instablility of the shoulder, in order to classify them and to identify risk factors for the development of glenohumeral OA. A total of 140 shoulders in 140 patients with a mean age of 28.5 years (15 to 55), who underwent arthroscopic treatment for recurrent glenohumeral instability, were included. The prevalence and distribution of chondral lesions and synovial damage were analyzed and graded into stages according to the division of the humeral head and glenoid into quadrants. The following factors that might affect the prevalence and severity of chondral damage were recorded: sex, dominance, age, age at the time of the first dislocation, number of dislocations, time between the first dislocation and surgery, preoperative sporting activity, Beighton score, type of instability, and joint laxity. A total of 133 patients (95%) had synovial or chondral lesions. At the time of surgery, shoulders were graded as having mild, moderate, and severe OA in 55 (39.2%), 72 (51.4%), and six (4.2%) patients, respectively. A Hill-Sachs lesion and fibrillation affecting the anteroinferior glenoid cartilage were the most common findings. There was a significant positive correlation between the the severity of the development of glenohumeral OA and the patient's age, their age at the time of the first dislocation, and the number of dislocations (p = 0.004, p = 0.011, and p = 0.031, respectively). Synovial inflammation and chondral damage associated with instability of the shoulder are more prevalent than previously reported. The classification using quadrants gives surgeons more information about the chondral damage, and could explain the pattern of development of glenohumeral OA after stabilization of the shoulder. As the number of dislocations showed a positive correlation with the development of OA, this might be an argument for early stabilization.

Clinical Outcomes of the Arthroscopic Capsular Suture-Lifting Technique in the Treatment of Femoroacetabular Impingement in Patients With Borderline Developmental Dysplasia of the Hip

Background: Patients with femoroacetabular impingement (FAI) are likely to present with borderline developmental dysplasia of the hip (BDDH). Considering the prolonged risk of negative prognosis in these patients, the need for surgical management of the capsule has been emphasized. Although previous studies have advocated different techniques of capsular closure during surgery, no consensus has been achieved. Therefore, the aim of this study was to evaluate the clinical outcomes of a new arthroscopic capsular suture-lifting technique for the treatment of FAI combined with BDDH. Hypothesis: The arthroscopic capsular suture-lifting technique would achieve better anterior stability and show better clinical outcomes compared with routine capsular closure. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients diagnosed with FAI and BDDH and who underwent hip arthroscopy in our hospital between September 1, 2017, and April 30, 2021, were evaluated. Data were collected prospectively and analyzed retrospectively. Patients were divided into 2 groups according to the capsule closure methods used: capsular suture-lifting technique (lifting group) and routine capsular closure (control group). Anteroposterior hip radiography, Dunn view radiography, and computed tomography imaging were carried out for all patients preoperatively and postoperatively. Patient-reported outcomes, including the modified Harris Hip Score (mHHS) and visual analog scale (VAS) for pain, were collected preoperatively and at least 1 year after surgery and compared between the 2 groups. The Wilcoxon signed-rank test was used to evaluate changes in preoperative to postoperative mHHS scores and VAS. Mann-Whitney U test was used to evaluate significant differences in postoperative mHHS and VAS scores in the 2 groups. Results: In all, 144 patients were included in this study, of whom 77 (53.5%) underwent the arthroscopic capsular suture-lifting technique and 67 (46.5%) underwent routine arthroscopic surgery. The patients in both groups had significant improvement in postoperative mHHS and VAS compared with the preoperative assessment ( P &lt; .05). The postoperative VAS score of patients in the suture-lifting group was significantly lower (2.6 vs 3.8; P &lt; .05) and the mHHS score was significantly higher (75.2 vs 68.5; P &lt; .05) than those of patients in the control group. Of the 77 patients in the suture-lifting group, 68 (88.3%) surpassed the minimal clinically important difference (MCID) and 49 (63.6%) achieved the Patient Acceptable Symptom State (PASS). Of the 67 patients in the control group, 26 (38.8%) surpassed MCID and 32 (47.8%) achieved PASS. The percentage of patients achieving MCID and PASS in the suture-lifting group was significantly greater than that in the control group ( P = .007 for MCID; P = .03 for PASS). Conclusion: The study demonstrated that the arthroscopic capsular suture-lifting technique provided good clinical outcomes in the treatment of patients with FAI combined with BDDH. This technique showed better improvement of postoperative clinical outcomes than routine capsular closure.

Clinical significance of posterior talofibular ligament injury in chronic lateral ankle instability.

Although arthroscopic repair of the anterior talofibular ligament (ATFL) is widely performed, the effect of posterior talofibular ligament (PTFL) injury on clinical outcomes remains unclear. This study aimed to evaluate the magnetic resonance imaging (MRI) findings of the PTFL in chronic lateral ankle instability (CLAI) and determine whether the presence or absence of PTFL injury affected the postoperative outcomes of arthroscopic ATFL repair. Forty ankles of 35 patients who underwent arthroscopic repair for CLAI were included in this study as the experimental group, together with 25 ankles of 24 patients without CLAI as the control group. The PTFL thickness (PTFLT) and PTFL cross-sectional area (PTFLCSA) were measured using MRI and compared between the control and CLAI groups. The clinical outcomes of arthroscopic repair were compared between ankles with and without PTFL injuries. The mean PTFLT and PTFLCSA values were significantly higher in the CLAI group than in the control group. The PTFLT and PTFLCSA in the PTFL injury group were significantly larger than those in the non-injury group in the CLAI group. Postoperatively, there were no significant differences in clinical scores and talar tilt angles on stress radiographs between ankles with and without PTFL injury; however, instability recurrence was frequently observed in ankles with PTFL injury (32.1%) compared to the ankles without PTFL injury (16.7%). Poor-quality ATFL remnant, ATFL inferior fascicle, and calcaneofibular ligament injuries were frequently observed in ankles with PTFL injuries. Our findings indicate that PTFL injury is highly associated with CLAI but it does not affect postoperative clinical scores. However, postoperative instability recurrence was more often observed in ankles with PTFL injuries, given that they frequently have poor-quality ATFL remnants and CFL injuries. Level III.

Arthroscopic Debridement and Proximal Fibular Osteotomy in the management of knee Osteoarthritis: A Descriptive Longtudinal Study

Introduction: Knee osteoarthritis commonly occurs in the medial compartment. Arthroscopic debridement eases pain by irrigating debris and inflammatory cytokines. Proximal fibular osteotomy shifts the loading force more laterally from the medial compartment, eliminating pain and delaying degenerative progression. This study aims to evaluate pain relief by combining both procedures in knee osteoarthritis of the medial compartment. Methods: The study was conducted in Nepal Medical College Teaching Hospital from November 2021 to December 2022 after the ethical approval from institutional review committee (IRC Ref. No. 025-078/079). The outcome was assessed by visual analog score and knee society scores, who underwent a combined procedure of arthroscopic debridement and proximal fibular osteotomy during a study period of 12 months.Results: Diagnostic arthroscopy was done in 32 patients, out of which, 27 patients underwent combined procedure with arthroscopic debridement and proximal fibular osteotomy. The mean visual analog score in combined procedure was 6.89 ± 0.93 initially and 3.11 ± 0.69 at 12 months follow up. The mean knee society score in combined procedure was 46.85 ± 6.1 preoperatively and 84.26 ± 8.27 postoperatively at 12 months follow up. Common peroneal nerve neuropraxia was observed in 8 (29.62%) patients, which resolved spontaneously during 6 months of time period. Conclusions: Combined arthroscopic debridement and proximal fibular osteotomy procedure is effective in treating knee osteoarthritis of the medial compartment, as it decreases pain and improves knee society score.