Medial Tears Research Articles

A Pilot Study to Assess Fatty Infiltration of the Supraspinatus in Patients with Rotator Cuff Tears: Comparison with Magnetic Resonance Imaging

The aim of this study was to quantitatively assess the echo intensity of the supraspinatus muscle and compare magnetic resonance imaging and ultrasound findings for 27 patients (12 women, 15 men, 65.8 ± 11.5 y). Tear size and fatty infiltration were determined by magnetic resonance imaging; five stages were assigned based on Goutallier's classification. Gray-scale histogram analysis was used for ultrasound assessment, which was performed in both subcutaneous fat and supraspinatus muscle in three different regions; the echo intensity ratio was the ratio of echo intensity in subcutaneous fat to that in the supraspinatus muscle. Sonograms of 27 shoulders revealed 3 shoulders with a partial tear, and 4 with a small tear, 6 with a medium tear, 6 with a large tear and 4 with a massive tear; 4 shoulders had no tear. Supraspinatus muscle echo intensity and echo intensity ratio were significantly lower in the stage 0 and 1 than in stages 2–4. Our study suggests that ultrasound can quantitatively and objectively assess fatty infiltration in the rotator cuff muscle.

Sex-Specific Predictors of Intra-articular Injuries Observed During Anterior Cruciate Ligament Reconstruction.

Background:Male patients tend to have more meniscal and chondral injuries at the time of anterior cruciate ligament (ACL) reconstruction than females. No studies have examined sex-specific predictors of meniscal and chondral lesions in ACL-injured patients.Purpose:To identify sex-specific predictors of meniscal and chondral lesions, as well as meniscal tear management, in patients undergoing ACL reconstruction.Study Design:Cohort study; Level of evidence, 3.Methods:Data were collected prospectively from 689 patients (56.2% males) undergoing ACL reconstruction between 2005 and 2014. Predictors of meniscal tears, meniscal tear management, and chondral injuries were determined using multivariate logistic regression models stratified by sex. Predictors were age, body mass index (BMI; 25-29.99 and ≥30 vs ≤24.99 kg/m2), mechanism (contact vs noncontact) and type (high-impact sports [basketball, football, soccer, and skiing] and other sports vs not sports-related) of injury, interval from injury to surgery (≤6 vs >6 weeks), and instability episodes (vs none). Odds ratios and 95% CIs were reported.Results:Males had more lateral (46% vs 27.8%; P < .0001) and medial (40.2% vs 31.5%; P = .01) meniscal tears, as well as more lateral (72.1% vs 27.9%; P < .0001) and medial (61.4% vs 38.6%; P = .01) meniscectomies than females. For males, age predicted chondral injuries and medial meniscectomy; BMI ≥30 kg/m2 predicted medial meniscal tears; high-impact and other sports predicted medial meniscal tears, medial meniscectomies, and medial meniscal repairs; injuries ≤6 weeks from surgery predicted lateral meniscal repairs; and instability episodes predicted medial meniscal tears, medial tears left in situ, medial meniscectomies, and medial meniscal repairs. For females, age predicted chondral injuries, BMI ≥30 kg/m2 predicted lateral meniscectomies and repairs, and instability episodes predicted medial meniscectomies.Conclusion:Sex differences were observed. For males, predictors included age, BMI, sports-related injuries, injuries ≤6 weeks from surgery, and instability episodes. For females, predictors included age, BMI, and instability episodes.

Arthroscopic Changes of the Biceps Pulley in Rotator Cuff Tear and Its Clinical Significance in Relation to Treatment

BackgroundIn the case of rotator cuff tears, the biceps pulley can be stressed by the unstable biceps tendon, and this can subsequently affect the stability of the subscapularis tendon. Therefore, it is important to distinguish between normal variations and lesions of the biceps pulley that affect anterosuperior lesions in cases of rotator cuff tears.MethodsFrom January 2002 through November 2010, we observed biceps pulley and associated anterosuperior lesions in 589 of 634 cases (93%) of arthroscopic rotator cuff repair, including 72 cases (12.2%) of small tears, 219 cases (37.2%) of medium tears, 134 cases (22.8%) of large tears, and 164 cases (27.8%) of massive tears. We classified normal stretched biceps pulleys as type I, stretched biceps pulleys with mild changes as type II, those with a partial tear as type III, and torn pulleys as type IV.ResultsWe were able to classify 589 cases of biceps pulleys as type I, II, III, or IV associated lesions in rotator cuff tears. Type I was seen in 91 cases (15.4%), type II in 216 cases (36.7%), type III in 157 cases (26.7%), and type IV in 101 cases (17.1%); unidentified cases numbered 24 (4.1%). Nearly three-quarters, 73.3%, of the cases (432/589) had associated anterosuperior lesions, and combined treatment for the associated lesions was administered in 29.2% (172/589) of cases.ConclusionsBiceps pulley lesions with more than partial tears were identified in 48% of rotator cuff tear cases. The incidence and severity of pulley lesions were related to the rotator cuff tear size, the status of the long head of the biceps tendon and subscapularis tendon lesion, and the treatment methods.

Correlation of Meniscal and Articular Cartilage Injuries in Children and Adolescents With Timing of Anterior Cruciate Ligament Reconstruction

Background: In pediatric patients, anterior cruciate ligament (ACL) reconstruction is controversial; however, delaying surgery until skeletal maturity is complete may increase the risk of secondary meniscal and articular cartilage injury. Purpose: To assess the risk of meniscal and chondral injuries with delay of ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Records were reviewed in patients younger than 17 years (median age, 14 years) who had ACL reconstruction. Patients were consecutively enrolled and assigned to 1 of 3 surgical groups based on timing of surgery: acute (<6 weeks after surgery), subacute (6-12 weeks), or chronic (>3 months). The type and grade of meniscal injuries was documented according to the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine (ISAKOS) meniscal classification criteria. International Cartilage Repair Society (ICRS) criteria were used to document location and grade of chondral injuries. Associations between patient characteristics and meniscal injury were tested using rank sum and chi-square tests. Regression analyses were conducted to model incidence and severity of lateral and medial meniscal tears. There were 130 patients who had 135 ACL reconstructions between the years of 2000 and 2012. Results: Sixty-two ACL injuries were treated acutely, 37 were subacute, and 36 were chronic. Meniscal injuries (n = 112) included 70 lateral and 42 medial tears. Time to surgery had bivariate association with lateral and medial meniscal tears (P = .016 and .007, respectively). Independent risk factors for incidence of lateral meniscal tears were younger age (P = .028) and return to sports activities before surgery (P = .007). Patients with 1 episode of instability had 3-fold higher odds of higher grade lateral meniscal tear (95% CI, 1.30-7.60). Compared with acute reconstruction, subacute and chronic reconstruction patients had 1.45 and 2.82 times higher odds, respectively, of lateral meniscal tear severity (P = .12). Independent risk factors for incidence of medial meniscal tears were female sex (P = .03), older age (P = .01), and any episode of instability (P = .01). Adjusted odds ratio for medial meniscal tear was 4.7 for an instability episode (vs no episode; P = .01). Adjusted odds ratio for increased severity of medial meniscal tears included any instability episode, 5.6 (P < .01); playing sports before reconstruction, 15.2 (P < .01); and time to surgery greater than 3 months, 4.3 (P = .046). Seventeen patients had 23 chondral injuries. The risk factors for chondral injury included increased time to surgery (P = .005) and any instability episode (P = .001). For increased grade of chondral injury, risk factors were time to surgery (P ≤ .001) and any instability episode (P = .003). Conclusion: Delayed ACL reconstruction increased the risks of secondary meniscal and chondral injuries in this population of pediatric patients.

Bone marrow stimulation at the footprint of arthroscopic surface-holding repair advances cuff repair integrity

Bone marrow stimulation (BMS) at the footprint of arthroscopic rotator cuff repair has not been fully evaluated according to the preoperative tear size and surgical technique. In this study, we investigated the effect of BMS on cuff repair integrity after an arthroscopic surface-holding (ASH) repair. A total of 111 patients (mean age, 64.5 years) with chronic rotator cuff tears who underwent treatment by the ASH method with BMS by drilling of multiple holes at the footprint (67 shoulders) or without BMS (44 shoulders) were studied, and all patients were observed prospectively. Sugaya's classification was used to evaluate cuff integrity by postoperative magnetic resonance imaging, with types IV and V classified as rotator cuff retears. The mean scores for cuff integrity were 2.2 ± 0.2 and 1.7 ± 0.2 in the non-BMS and BMS groups, respectively. The mean scores were similar between the 2 groups for medium tears; however, scores for large-massive tears were significantly lower in the BMS group. The overall retear rate was 23.9% in the non-BMS group and 9.1% in the BMS group, and the distribution of repair types differed significantly. For large-massive tears, the retear rate was much higher in the non-BMS group (28.6%) than in the BMS group (4.5%), although the rates for medium tears were comparable between the 2 groups. These findings demonstrate that applying BMS to the footprint during ASH repair results in improved cuff repair integrity, particularly in large-massive tears, and suggest the importance of biologic treatment for rotator cuff healing after arthroscopic rotator cuff repair.

Diagnostic accuracy of 3.0 T magnetic resonance imaging for the detection of meniscus posterior root pathology.

The purpose of this study was to determine the diagnostic accuracy of 3 T MRI, including sensitivity, specificity, negative and positive predictive values, for detection of posterior medial and lateral meniscus root tears and avulsions. All patients who had a 3 T MRI of the knee, followed by arthroscopic surgery, were included in this study. Arthroscopy was considered the gold standard. Meniscus root tears diagnosed at arthroscopy and on MRI were defined as a complete meniscus root detachment within 9 mm of the root. All surgical data were collected prospectively and stored in a data registry. MRI exams were reported prospectively by a musculoskeletal radiologist and reviewed retrospectively. There were 287 consecutive patients (156 males, 131 females; mean age 41.7 years) in this study. Prevalence of meniscus posterior root tears identified at arthroscopy was 9.1, 5.9% for medial and 3.5% for lateral root tears (one patient had both). Sensitivity was 0.770 (95% CI 0.570, 0.901), specificity was 0.729 (95% CI 0.708, 0.741), positive predictive value was 0.220 (95% CI 0.163, 0.257) and negative predictive value was 0.970 (95% CI 0.943, 0.987). For medial root tears, sensitivity was 0.824 (95% CI 0.569, 0.953), specificity was 0.800 (95% CI 0.784, 0.808), positive predictive value was 0.206 (95% CI 0.142, 0.238) and negative predictive value was 0.986 (95% CI 0.967, 0.996). For lateral meniscus posterior root tears, sensitivity was 0.600 (95% CI 0.281, 0.860), specificity was 0.903 (95% CI 0.891, 0.912), positive predictive value was 0.181 (95% CI 0.085, 0.261) and negative predictive value was 0.984 (95% CI 0.972, 0.994). This study demonstrated moderate sensitivity and specificity of 3 T MRI to detect posterior meniscus root tears. The negative predictive value of 3 T MRI to detect posterior meniscus root tears was high; however, the positive predictive value was low. Sensitivity was higher for medial root tears, indicating a higher risk of missing lateral root tears on MRI. Imaging has an important role in identifying meniscus posterior horn root tears; however, some root tears may not be identified until arthroscopy. Prognostic study (diagnostic), Level II.

WHAT RESULTS IN TENDON AND MUSCLE TISSUES OF THE ROTATOR CUFF FROM FULL-THICKNESS TEARS: DATA OF MRI, ARTHROSCOPY AND HISTOLOGY

Full-thickness rotator cuff tears - is abundant injury which leads to the expressed pain syndrome and functional violation of the top extremity. At making decision about necessary of surgery, MRI is the important source of information about the injury The purpose: to determine the qualitative and quantitative indicators of degenerative-dystrophic changes in muscular and tendinous parts of the rotator cuff. based on a combined MRI, arthroscopic and histological diagnostics of full-thickness rupture of shoulder cuff Methods: We have examined 28 patients with full-thickness rotator cuff tears. MRI of damaged joint to all patients before an operation was performed. Thereafter an arthroscopy was performed and intraoperative biopsy of the muscular and tendinous parts of the rotator cuff, with following histological examination. Results: It was found that at small full-thickness rotator cuff tears the intensity of degenerative changes in muscular and tendinous tissue was lower, so these tears are the most promising for all kinds of treatment. At medium and big tears intensity of degenerative changes in the tissues begins to prevail over productive inflammation and it limits to the ability of conservative treatment and increases the risk of unsuccessful outcomes of arthroscopic reconstruction. Conclusions: In this regard, it is necessary to search biological decisions, which complement the stage of arthroscopic reconstruction of the rotator cuff.

Transtendon rotator-cuff repair of partial-thickness articular surface tears can lead to medial rotator-cuff failure.

PurposeThe purpose of this study was to evaluate clinical and anatomic outcomes of patients following transtendon rotator-cuff repair of partial articular supraspinatus tendon avulsion (PASTA) lesions.Patients and methodsPatients in the senior author’s practice who had isolated PASTA lesions treated by transtendon rotator-cuff repair were included (n=8) and retrospectively reviewed. All patients were evaluated preoperatively and at a mean of 21.2 months (±9.7 months) postoperatively using standardized clinical evaluation (physical exam, American Shoulder and Elbow Surgeons, and Simple Shoulder Test). All patients underwent postoperative imaging with a magnetic resonance imaging arthrogram.ResultsThere was a significant improvement in American Shoulder and Elbow Surgeons (42.7±17.5 to 86.9±25.2) and Simple Shoulder Test (4.6±3.2 to 10.1±3.8) scores from pre- to postoperative, respectively. Postoperative imaging demonstrated full-thickness medial cuff tearing in seven patients, and one patient with a persistent partial articular surface defect.ConclusionTranstendon repair of PASTA lesions may lead to improvements in clinical outcome. However, postoperative imaging demonstrated a high incidence of full-thickness rotator-cuff defects following repair.

Early Passive Motion Versus Immobilization After Arthroscopic Rotator Cuff Repair

To provide a synthesis of the highest-quality literature available comparing early passive motion (EPM) with strict sling immobilization during the first 4 to 6 weeks after surgery. The Medline, Cochrane, and Embase databases were searched for eligible studies. We reviewed 886 citations, and 5 randomized clinical trials (RCTs) (Level II) met the inclusion criteria for meta-analysis. Four RCTs contributed to the analysis of range of motion, and 5 contributed to the analysis of retear rates. A single Level IV study was available for qualitative review. Random-effects models were used for meta-analysis, computing mean differences for continuous variables and risk ratios for dichotomous variables. EPM resulted in improved shoulder forward flexion at 3 months (mean difference, 14.70°; 95% confidence interval [CI], 5.52° to 23.87°; P= .002), 6 months (mean difference, 4.31°; 95% CI, 0.17° to 8.45°; P= .04), and 12 months (mean difference, 4.18°; 95% CI, 0.36° to 8.00°; P= .03). External rotation at the side was only superior with EPM at 3 months (mean difference, 10.43°; 95% CI, 4.51° to 16.34°; P= .0006). Rotator cuff retear rates (16.3% for immobilization v 21.1% for EPM; risk ratio, 0.82; 95% CI, 0.57 to 1.20; P= .31) were not significantly different between EPM and immobilization at a minimum of 1 year of follow-up. A small number of RCTs with low to moderate risks of bias are currently available. Meta-analysis suggests that after primary arthroscopic rotator cuff repair of small to medium tears, EPM results in 15° of improved forward flexion at 3 months and approximately 5° at 6 and 12 months. External rotation is improved by 10° with EPM at 3 months only. The clinical importance of these differences has yet to be determined. Retear rates at a minimum of 1 year of follow-up are not clearly affected by type of rehabilitation. Level II, meta-analysis of Level II studies and qualitative review of Level IV study.

Causes of Early Stent Thrombosis in Patients Presenting With Acute Coronary Syndrome: An Ex Vivo Human Autopsy Study

The study interrogated an autopsy registry to investigate the histopathologic features of early stent thrombosis (ST) in patients presenting with acute coronary syndrome (ACS). The occurrence of early ST following percutaneous coronary intervention (PCI) for ACS remains a clinical problem despite advances in stent technology in both bare-metal and drug-eluting stents. Sixty-seven stented coronary lesions from 59 patients who presented with ACS and died within 30 days were included. Stented segments were cross sectioned at 3 to 4 mm intervals and evaluated by light microscopy, andmorphometric analysis was performed. Early ST (<30 days of PCI) was identified in 34 (58%) of the 59 patients. Early ST was dependent on the underlying plaque morphology and underlying thrombus burden: presence of necrotic core prolapse was more frequent in thrombosed lesions compared with patent lesions (70% vs. 43%, p= 0.045) and maximal underlying thrombus thickness was significantly greater in thrombosed versus patent lesions. All 3 patients with false lumen stenting hadST. Detailed analysis revealed that the percent of necrotic core prolapse, medial tear, or incomplete apposition was significantly greater in the early ST compared with patent group (28% vs.11%, p< 0.001; 27% vs.15% p=0.004; and 34% vs. 18% p= 0.008, respectively). Multivariate analysis revealed that maximal depthof strutpenetration, % strut with medial tear, and % struts with incomplete apposition were the primary indicators ofearly ST. The current autopsy study highlights the impact of thrombus burden and suboptimal stent implantation in unstable lesions as a trigger of early ST, suggesting that improvement in implantation technique and refinement of stent design may improve clinical outcomes of ACS patients.

Reverse Segond Fracture Variant Without Posterior Cruciate Ligament Injury

Objectives:Reverse Segond fracture, which was described as the association of an avulsion of deep capsular portion of medial collateral ligament and tears of both posterior cruciate ligament (PCL) and medial meniscus, is an extremely rare injury, unlike Segond fracture. The aim is to report successful surgical treatment of a case with “Reverse Segond Fracture” with intact PCL.Methods:The patient was a 16 years old male, who admitted to emergency department of our Level I trauma center after a pedestrian traffic accident. The main complaint was pain on left knee and shoulder. Physical examination revealed mainly limitation in range of motion (ROM) of relevant joints. Radiology revealed Reverse Segond fracture in the left knee and associated left clavicula mid-shaft fracture. Imaging with MRI and CT revealed neither PCL injury or additional ligamentous pathologies of knee. MRI only revealed medial meniscus tear.Results:In surgery, avulsed bony portion of Reverse Segond fracture was fixed to tibia with a suture anchor and a cannulated screw securely under medial meniscus. Peripheral longitudinal medial meniscus tear was fixed with a 2-0 absorbable suture. Clavicle was internally fixed meanwhile. Knee range of motion (ROM) was started early on postoperative first day, then augmented progressively. The patient was mobilized partially-weight bearing after 1.5 months and returned to his active daily life after 2.5 months. He was without any residual complaints after a final follow-up period of 26 months.Conclusion:This case report would be evaluated as a Reverse Segond Fracture variant, as no injury to PCL was noted, in contrast to its original definition in the relevant literature, which is also scarse. To the best of knowledge, this is the first report of successful surgical treatment of a case with Reverse Segond Fracture variant without PCL tear in the relevant literature.

Traitement des luxations récentes du coude : à propos de 30 cas

Elbow dislocations are encountered in contact sports and other extreme sports. This retrospective study included 30 cases of elbow dislocations, treated between 2007 and 2012. The average age of our patients was 36 years, all male and victims of violent trauma in local equestrian competitions. The dislocation was posterolateral in 23 cases and direct posterior in the other seven. This involvement was associated to a fracture of the radial head in six cases and a medial epicondyle tear in a patient. All subjects had a reduction under sedation or general anesthesia. Fractures of the radial head were treated by screwing in four cases and resection in two cases. We also made screwing for the epicondyle fracture. The treatment was completed by analgesic immobilization for about 10 days followed by active mobilization in 22 patients, in whom the elbow was considered perfectly stable. In eight patients, mobilization in the area of stability, protected by an articulated orthosis, was established for a minimum of 45 days. After a mean follow-up of 22 months, a range of motion for flexion-extension greater than 100° was achieved in 80% of patients and only two cases have kept a severe stiffness. The overall results, as assessed using the Mayo Elbow Performance Score, were good to very good in 25 patients, fair in three patients and poor in only two cases. The sport recovery was gradual and the return to competition was not allowed before the sixth month.

Unusual Appearance of an Osteochondral Lesion Accompanying Medial Meniscus Injury

An osteochondral lesion in the knee joint is caused by a focal traumatic osteochondral defect, osteochondritis dissecans, an isolated degenerative lesion, or diffuse degenerative disease. An osteochondral lesion with a cleft-like appearance accompanying medial meniscus injury is rare without trauma. We report the case of a 13-year-old boy who complained of right knee pain and swelling, with radiographic findings of an osteochondral defect. Arthroscopic inspection showed an osteochondral lesion in the medial condyle of the femur and tibial plateau accompanying a partial medial meniscus discoid tear. Partial meniscectomy was performed, and a microfracture procedure was carried out on the osteochondral defect. The patient was asymptomatic at 2 years' follow-up. This technique is a relatively easy, completely arthroscopic procedure that spares the bone and cartilage and has yielded a good clinical outcome in a skeletally immature patient who had an osteochondral lesion with a cleft-like appearance.

Patterns of Meniscal Damage Associated with Acute ACL Rupture

Patterns of Meniscal Damage Associated with Acute ACL Rupture

Bilateral, simultaneous medial meniscus bucket handle tears in a 23-year-old female.

Traumatic tears of the meniscus are well reported in the literature. Rarely, bilateral meniscal tears occur. A PubMed search found that only three cases of bilateral medial meniscus bucket handle type tears have been reported. Treatment options range from partial meniscectomy to repair of the meniscal tear. Repair is reported to be more successful in the vascular red-red or red-white zones. We present the case of a 23-year-old female who sustained simultaneous bilateral medial meniscus bucket handle type tears in an automobile accident. She was treated in a staged fashion with knee arthroscopy. Her meniscus tears were both found to be in the vascularized zone and meniscal tear repair was conducted. At two weeks postoperatively, she had excellent resolution of her symptoms and has returned to pain-free weight-bearing. She has remained pain-free at six-month follow-up.

The Tortoise Versus the Hare—It’s a Photo Finish

There are a number of known factors that can affect clinical outcomes and structural healing after rotator cuff repair. Some of these are fixed variables, such as patient age and comorbidities, tear size, and tissue quality, while others, such as patient-related factors like smoking, repair construct, and postoperative management, are modifiable and may allow for improvement in patient outcomes. The traditional school of thought regarding the initiation of postoperative rehabilitation following rotator cuff repair has favored early passive shoulder motion to prevent stiffness. Until recently, this approach has been largely uniform. However, over time, data suggesting poorer tendon healing in certain subsets of patients have accumulated, leading some surgeons to advocate a delayed rehabilitation protocol with an initial phase of strict immobilization. The theoretical “trade-off” of this approach would be to improve the likelihood of tendon healing at the potential expense of an increased risk of postoperative stiffness and a delayed recovery timeline. The current study by Keener and coauthors from Washington University analyzes this question and does so in a superb fashion. In this Level-I, prospective, randomized trial, the authors identified and enrolled 124 patients under the age of sixty-five years who underwent arthroscopic repair of a small or medium tear (<30 mm in anterior-to-posterior …

Segmental arterial mediolysis, reparative phase: An analysis and case report showing conversion to fibromuscular dysplasia with renal infarction

Segmental arterial mediolysis (SAM), an uncommon arteriopathy putatively caused by norepinephrine released by alpha-1 adrenergic agonists or some Beta-2 agonists capable of releasing norepinephrine from the peripheral sympathetic nervous system potentially can present ischemic and organ injury symptoms caused by sequelae created in its reparative phase in lieu of catastrophic hemorrhages announced in its injurious phase. The case documents this presentation—the patient presenting renal infarcts and ischemic lesions causing abdominal angina, hypertension and a nephrectomy event developing 10 years after prolonged ritodrine treatment for premature labor. This agent may have directly caused SAM or sensitized the patient to agonists causing SAM encountered at a latter date. A variety of lesions derived from injurious phase arterial injuries characterize reparative phase SAM. All were encountered in a hilar branch of the resected renal artery. These included side-by-side sequela aneurysms grossly forming a large fusiform aneurysm, granulation tissue filling adventitial medial tear spaces in which a dissecting hematomas developed, medial muscle loss centered to the outer media repaired with fibrous tissue, arterial stenosis created by reparative intimal plaques, and arterial thrombo-embolism. These lesions were mirrored in accompanying radiologic studies. The accompanying renal vein exhibited changes consistent with repair of the spastic venous angiopathy that often accompanies abdominal SAM. This angiopathy, putatively induced by Endothelin-1, suggested that this agent played a role in the genesis of the arterial lesions. Angiographic resolution of non-treated sequelae occurred in 5 months either spontaneously or due to treatment with bosentem. Conclusions: The histologic and angiographic changes demonstrate that the clinical onset of reparative SAM may be significantly delayed to produce ischemic lesions, renal infarction and in this case report, medial fibromuscular dysplasia in the hilar branch of the renal artery.

Biomechanical Validation of Load-Sharing Rip-Stop Fixation for the Repair of Tissue-Deficient Rotator Cuff Tears

Background: Poor-quality tendon is one of the most difficult problems the surgeon must overcome in achieving secure fixation during rotator cuff repair. A load-sharing rip-stop construct (LSRS) has recently been proposed as a method for improving fixation strength, but the biomechanical properties of this construct have not yet been examined. Purpose: To compare the strength of the LSRS construct to that of single-row fixation for rotator cuff repair. Study Design: Controlled laboratory study. Methods: Rotator cuff tears were created in 6 cadaveric matched-pair specimens and repaired with a single row or an LSRS. In the LSRS repair, a 2-mm suture tape was placed as an inverted mattress stitch in the rotator cuff, and sutures from 2 anchors were placed as simple stitches that passed medial to the suture tape. The suture tape limbs were secured with knotless anchors laterally before sutures were tied from the medial anchors. Displacement was observed with video tracking after cyclic loading, and specimens were loaded to failure. Results: The mean load to failure was 371 ± 102 N in single-row repairs compared with 616 ± 185 N in LSRS repairs (P = .031). There was no difference in displacement with cyclic loading between the groups (3.3 ± 0.8 mm vs 3.5 ± 1.1 mm; P = .561). In the single-row group, 4 of 6 failures occurred at the suture-tendon interface. In the LSRS group, only 1 failure occurred at the suture-tendon interface. Conclusion: The ultimate failure load of the LSRS construct for rotator cuff repair was 1.7 times that of a single-row construct in a cadaveric model. Clinical Relevance: The LSRS rotator cuff repair construct may be useful in the repair of difficult tears such as massive tears, medial tears, and tears with tendon loss.

Posterior root tear of the medial and lateral meniscus

An avulsion of the tibial insertion of the meniscus or a radial tear close to the meniscal insertion is defined as a root tear. In clinical practice, the incidence of these lesions is often underestimated. However, several biomechanical studies have shown that the effect of a root tear is comparable to a total meniscectomy. Clinical studies documented progredient arthritic changes following root tears, thereby supporting basic science studies. The clinical diagnosis is limited by unspecific symptoms. In addition to the diagnostic arthroscopy, MRI is considered to be the gold standard of diagnosis of a meniscal root tear. Three different direct MRI signs for the diagnosis of a meniscus root tear have been described: Radial linear defect in the axial plane, vertical linear defect (truncation sign) in the coronal plane, and the so-called ghost meniscus sign in the sagittal plane. Meniscal extrusion is also considered to be an indirect sign of a root tear, but is less common in lateral root tears. During arthroscopy, the function of the meniscus root must be assessed by probing. However, visualization of the meniscal insertions is challenging. Refixation of the meniscal root can be performed using a transtibial pull-out suture, suture anchors, or side-to-side repair. Several short-term studies reported good clinical results after medial or lateral root repair. Nevertheless, MRI and second-look arthroscopy revealed high rates of incomplete or absent healing, especially for medial root tears. To date, most studies are case series with short-term follow-up and level IV evidence. Outerbridge grade 3 or 4 chondral lesions and varus malalignment of >5° were found to predict an inferior clinical outcome after medial meniscus root repair. Further research is needed to evaluate long-term results and to define evident criteria for meniscal root repair.

The relationship between intra-articular meniscal, chondral, and ACL lesions: finding from 1,774 knee arthroscopy patients and evaluation by gender

Knowing the relationship between diagnoses is important in knee arthroscopy in terms of defining possible treatment modalities preoperatively. The purpose of our study was to define the diagnoses made intraoperatively through knee arthroscopy and the relationships between them. We evaluated the results of knee arthroscopies performed over a 10-year period. The sites and sizes of chondral lesions, the existence of anterior cruciate ligament (ACL) injury, and the sites of meniscal lesions were noted for a total of 1,774 patients. The relationships between these lesions were evaluated statistically. Chondral lesions and posterior medial meniscal tears were predominant in females, whereas complete ACL tears were predominant in males. ACL tears were commonly accompanied by medial and lateral meniscal bucket-handle tears. In cases with advanced chondral lesions, medial and lateral posterior meniscal and lateral anterior meniscal tears were more common. According to our results, posterior tears of the medial menisci, medial and lateral femoral condyles, lateral tibial plateau type 3 or 4 cartilage lesions, and the rate of diagnostic arthroscopy were higher in females, while middle substance and bucket-handle tears of medial menisci and total rupture of the ACL were more common in males. ACL injuries were seen to coexist with medial or lateral menisci bucket-handle tears, with no relationship between the site or size of the chondral lesions. A relationship between medial and lateral meniscal tears and the site of femoral and tibial chondral surface lesions was detected.