Periosteal Sleeve Research Articles

Assessing the Role of Minimal Medial Tissue Release during Navigation-Assisted Varus Total Knee Arthroplasty Based on the Degree of Preoperative Varus Deformity.

We assessed the impact of a minimal medial soft-tissue release with complete peripheral osteophyte removal on the ability to attain manual preresection deformity correction during navigation-assisted total knee arthroplasty (TKA) for varus osteoarthritis. We included 131 TKAs for 109 patients with medial compartment predominant osteoarthritis. The steps for achieving minimal medial soft-tissue release were performed as follows: (1) elevation of a periosteal sleeve to 5-mm distal to the joint line and (2) complete removal of peripheral osteophytes. The evaluation criteria of this study were as follows: (1) age, (2) height, (3) weight, (4) body mass index (BMI), (5) sex, (6) the preoperative femorotibial mechanical angle in the neutral position before medial release and (7) the mechanical angle in maximum manual valgus stress after the two-step medial-release procedure (measured on the navigation screens). Multiple regression analysis of the criteria was performed to determine the degree of varus deformity that allowed neutral alignment but required extensive medial release. The femorotibial mechanical angle in the neutral position before medial release and sex correlated with the mechanical angle in maximum manual valgus stress on the navigation screen after medial release (r = 0.72, p < 0.001). Based on the regression formula, the maximum degree of preoperative varus deformity that allowed neutral alignment by the minimum medial-release procedure was 5.3 degrees for males and 9.1 degrees for females. The magnitude of deformity which has an impact on the ability to correct varus deformity (by minimal soft-tissue release and complete osteophyte removal) was clarified. If the preoperative degree of varus deformity was within 5.3 degrees for males and 9.1 degrees for females, an extensive medial release was not required to obtain neutral alignment.

Reduction of Neglected Displaced Fractures of the Distal Femoral Physis.

We performed open osteoclasis, soft-tissue release, and fracture fragment reduction and fixation to treat 10 cases of neglected physeal fractures of the distal aspect of the femur with severe deformity. To our knowledge, no specific surgical procedure for this problem has been reported in the literature. The procedure is typically performed through an extensile anterolateral approach. With use of an osteotome, the typically abundant fracture callus is disrupted and partially removed to recreate the original fracture line. Through periosteal dissection, an extensive musculoperiosteal detachment and release is achieved to facilitate fracture reduction while protecting the physis from further injury. Knee rehabilitation in closed, nondisplaced or minimally displaced fractures1.Open callus osteoclasis in combination with a Z-shaped quadriceps tenoplasty, reduction, and plaster cast immobilization2.Open subperiosteal osteoclasis, reduction, and tibial traction3.Open callus osteoclasis, reduction, and condylar plating4.Sequestrectomy with preservation of a periosteal sleeve to treat osteomyelitis complicating an open fracture1.Transfemoral amputation to treat gas gangrene or vascular injury following severe open injury1,5-7. This procedure was developed in remote medical facilities where patients are often first seen >21 days after the original injury. By that time, closed reduction or standard open reduction and internal fixation techniques are no longer possible. After 6 months of fracture age, the procedure is inefficient. This procedure allows correction of limb malalignment and shortening while preserving the growth plate1. In some cases, hypertrophic fracture callus might be mistaken for the femoral diaphysis.An extensive musculoperiosteal release will facilitate reduction of the fracture fragments.The adequacy of reduction must be assessed in all 3 planes intraoperatively.The adequacy of reduction must be assessed in all 3 planes intraoperatively.The adequacy of reduction must be assessed in all 3 planes intraoperatively.

Posterior Humeral Avulsion of the Glenohumeral Ligament: A Rare and Nonspecific Injury

Posterior Humeral Avulsion of the Glenohumeral Ligament: A Rare and Nonspecific Injury

Arthroscopic management of anterior labrum periosteal sleeve avulsion (ALPSA) lesions: A case series with improved clinical outcomes using a modified technique

IntroductionAnterior labrum periosteal sleeve avulsion (ALPSA) is the avulsion of the labrum and of the non-disrupted periosteum with the subsequent healing of the labrum in a medialized nonfunctional position on the glenoid neck. ObejctiveIn this study, a modified technique for arthroscopic repair of ALPSA lesions is presented, along with post operative clinical results and follow up. Method72 patients who underwent this procedure were included in this study. Patients with multidirectional instability, more than 20% of glenoid bone loss, and bony Bankart lesions were excluded. Results and conclusionIt was concluded that with this modified technique, a lower recurrence rate post arthroscopic repair of ALPSA lesions was seen with only 4 patients having postoperative recurrence of glenohumeral dislocation which amounts to 5.6%. Moreover, the data also showed a statistically significant improvement of 35.23% between the pre- and postoperative ASES scores.

Anterior Shoulder Instability Management: Indications, Techniques, and Outcomes

AbstractAnterior shoulder instability is common in young athletes. Male individuals younger than 20 years who are involved in contact sports are at particular risk of injury and recurrence. Essential imaging includes radiography and magnetic resonance imaging in all patients, with 3-dimensional computed tomography being helpful to evaluate glenoid bone loss and Hill-Sachs lesions. Evaluation of the glenoid track is essential to help determine appropriate treatment because off-track scenarios in which the Hill-Sachs width is greater than the glenoid width impart a risk of failure with isolated arthroscopic treatment. Associated injuries also must be evaluated, including bone loss, Hill-Sachs lesions, humeral avulsion of the glenohumeral ligament (HAGL), glenolabral articular disruption (GLAD), anterior labroligamentous periosteal sleeve avulsion (ALPSA), rotator cuff injury, other fractures, and axillary nerve injury. Optimal treatment continues to be debated. Conservative management with physical therapy for rotator cuff and periscapular strengthening can be attempted, with the addition of bracing if continued play is desired until the season’s conclusion. Surgical intervention is considered in patients with recurrent dislocations, glenoid bone loss, or large Hill-Sachs lesions or in young athletes involved in contact or high-risk sports. Treatment options include arthroscopic capsulolabral repair with at least 4 anchors if good tissue quality and no bone loss exist. Remplissage has been recommended by some surgeons if a large Hill-Sachs exists. Open repair is suggested in patients with a high number of recurrent dislocations without bone loss or in those who participate in high-risk sports. Coracoid transfer or the Latarjet procedure is suggested in patients with bone loss greater than 20%. Bone grafting for glenoid bone loss using autograft or allograft, such as distal tibial allograft, is recommended in patients with a failed Latarjet procedure or those with significant bone loss. Hill-Sachs lesion grafting may also be beneficial in those with large lesions that engage.

Suture anchor fixation of comminuted inferior pole patella fracture-novel technique: suture bridge anchor fixation technique.

Comminuted inferior pole fractures of the patella are notorious fractures where it is difficult to obtain rigid internal fixation by conventional tension band wiring. The purpose of this study is to evaluate the clinical and radiological outcomes of the suture bridge anchor fixation for these comminuted inferior pole fractures of the patella. From March 2012 to December 2018, suture bridge anchor fixation for the inferior pole comminuted fracture of the patella was performed in 22 patients. There were 21 patients of inferior pole comminuted fracture and 1 patient of lower periosteal sleeve avulsion fracture. Clinical outcomes including SF-36 score, Knee injury and osteoarthritis outcome score (KOOS) and post-operative range of motion were evaluated. In all patients, suture bridge anchor fixation was performed and, tension band wiring with K wire was added for large fragment fixation in two patients. We evaluated bony union, the patellar height using Insall-Salvati ratio and its complications. Mean age was 46 ± 20 (15-82)years. Mean follow-up period was 25 ± 18 (11-74)months. In all patients, bony union was achieved at postoperative 4months. At final follow-up, mean SF-36 score was 72 ± 15 (30-91) points and KOOS score was 66.7 ± 16 (43-97). The average range of motion was 134 ± 5 (125-140) degrees. As a complication, one patient developed a wound infection and subsequent osteomyelitis of inferior pole fracture fragment.Compared to the normal knee, the Insall-Salvati ratio of the injured knee averages 0.73 and this smaller ratio less than 0.8 meant patella baja. In the comminuted inferior pole fractures of the patella, suture bridge anchor fixation showed good bony union and satisfactory clinical outcomes at the short-term follow-up and could be a satisfactory alternative treatment option. Even though suture bridge anchor fixation in these fractures caused decreased Insall-Salvati ratio (patella height), any patellofemoral pain and limited range of motion was not developed. Level IV.

Accuracy of Magnetic Resonance Arthrography in the Detection and Classification of Chronic Anteroinferior Labrum Lesions

INTRODUCTION: Bankart, and Bankart variant labrum lesions such as Perthes lesion and anterior labrum periosteal sleeve avulsion are different types of surgically treatable anterioinferior labral lesions contributing to shoulder instability. Successful outcome following arthroscopic surgery requires accurate lesion diagnosis, pre operative planning and deployment of accordant surgical technique. The purpose of our study was to retrospectively evaluate the accuracy of Magnetic Resonance Arthrography not only in the detection but also the classification of chronic antero-inferior labrum injuries by using arthroscopy as the reference standard. STUDY DESIGN & METHODS: This study included 80 consecutive patients, 12 female with mean age of 28 year (range 17-46) presenting with recurrent shoulder instability who underwent Magnetic Resonance Arthrography in neutral and abduction external rotation positions prior to arthroscopic stabilisation. The findings of a single dedicated musculoskeletal radiologist were compared with the arthroscopic findings of a single experienced shoulder surgeon. RESULTS: Arthroscopic findings revealed 40 Bankart, 18 anterior labrum periosteal sleeve avulsion and 15 Perthes anteroinferior labrum lesions. Magnetic Resonance Arthrography detected 95.8% of overall labrum lesions with a sensitivity of 94% (0.86 to 0.98 ) and specificity 85.7% (0.46 to 0.99 ) and correctly classified 90% of labrum lesions with an accuracy of 93.8% (0.86-0.97) for Bankart lesions, 95% (0.88-0.98) for anterior labrum periosteal sleeve avulsion lesions and 95.5% (0.91-0.99) for Perthes lesions. CONCLUSION: Our study demonstrates that Magnetic Resonance Arthrography in neutral and abduction and external rotation position can achieve high levels of accuracy in detecting and correctly classifying chronic anteroinferior labrum lesions. It emphasises its value in alerting the surgeon to the presence and the type of labrum lesion. This allows forward-planning the surgical technique to be employed for intra-operative detection, correct dissection and optimal fixation.

An Unexpected Smile

Question: A 79-year-old man with a history of diabetes and dyslipidemia experienced painful swelling in the left knee after falling onto the ground. He noticed that his dentures were missing after the fall; however, he could not recall whether he swallowed the dentures. Consequently, he was sent to the emergency department and diagnosed with a quadriceps tendon rupture and periosteal sleeve avulsion fracture of the left patella. A lateral view of the neck did not reveal any radiopaque lesion, and the prevertebral soft tissue thickness remained normal (Figure A).

Arthroscopic Fixation of an Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) of the Shoulder

Anterior labroligamentous periosteal sleeve avulsions represent a diagnostic and treatment challenge. They are associated with a higher number of preoperative dislocations, as well as longer chronicity, and commonly result in a scarred and medialized labrum and periosteal sleeve complex. Anterior labroligamentous periosteal sleeve avulsion lesions therefore may be commonly overlooked. The complexity of the injury pattern has been associated with double the failure rate of standard Bankart lesions after arthroscopic repair. The purpose of this article is to describe our preferred arthroscopic technique for achieving full mobilization of the labral-periosteal complex and restore it to its anatomic location using a knotless, all-suture anchor construct.

Risk Factors for Postoperative Opioid Use in Arthroscopic Shoulder Labral Surgery

To determine the correlation between preoperative and postoperative opioid use in patients undergoing arthroscopic shoulder labral repair, as well as patient risk factors associated with increased postoperative opioid use after the procedure. A retrospective review of all patients undergoing arthroscopic shoulder labral surgery at a single institution between August 2013 and November 2017 was performed. Patients were stratified as opioid nonusers, acute users, or chronic users based on preoperative consumption. Patient demographic characteristics, injury characteristics, surgical interventions, and postoperative opioid use for the first 12 months after surgery were then analyzed. A total of 340 patients were included in this study. The average age was 26.3 years (range, 13-68 years), and the average body mass index was 27.5 (range, 18.4-45.0). Preoperative opioid users (acute and chronic) were found to continue to receive opioid medications at extended time points beyond 2 months postoperatively compared with nonusers (P < .001). Patients with intraoperatively identified SLAP tears experienced more preoperative pain and required more postoperative opioid prescriptions (P = .018). On stratification for other common shoulder instability injury patterns, no differences were found between the number of postoperative opioid prescriptions filled and the presence of Bankart lesion, Hill-Sachs lesion, reverse Hill-Sachs lesion, anterior labroligamentous periosteal sleeve avulsion, glenolabral articular disruption, or humeral avulsion of the glenohumeral ligament (P > .05). In patients undergoing arthroscopic labral surgery, the chronicity of preoperative opioid use, number of concomitant procedures at the time of initial surgery, and presence of biceps tenodesis were found to significantly increase postoperative opioid demand. Orthopaedic surgeons should recognize risk factors for increased opioid use postoperatively and adapt treatment strategies and patient counseling accordingly. Level III, retrospective cohort study.

Preoperative imaging of traumatic anterior shoulder instability: Diagnostic effectiveness of magnetic resonance arthrography and comparison with conventional magnetic resonance imaging and arthroscopy

Background: Associated injuries of traumatic anterior shoulder dislocations play an important role in predicting recurrent instability. MRI has proved popular for imaging of suspected abnormalities. MR arthrography (MRA) has been suggested to be more sensitive than MRI in the detection of labral tears and other capsular lesions. In this study, we aimed to assess prospectively the diagnostic effectiveness of MRA in the preoperative planning of traumatic anterior shoulder instability compared with conventional MRI and arthroscopy. Methods: Shoulder MRI and MRA in 100 patients (73 men and 27 women; mean age, 27 yr) with shoulder dislocations were evaluated by two musculoskeletal radiologists who were blinded to arthroscopic findings, which represented the reference standard. An arthroscopic surgeon blinded to the imaging findings evaluated the osseous abnormalities involving the humeral head and glenoid, anterior labroligamentous lesions, and capsular lesions. Sensitivity, specificity, accuracy, and positive and negative predictive values of each imaging study were calculated for each elemental lesion and compared using a paired McNemar test. Results: When comparing the sensitivity and accuracy values of the MRA and MRI for the detection of these elemental lesions, all values of MRA were higher than those of MRI (P&lt;0.01). However, when comparing the specificity values, both MRI and MRA were highly specific (100%) in diagnosing bony Bankart lesions and anterior labroligamentous periosteal sleeve avulsions. MRI missed Perthes lesions, humeral avulsions of the anterior glenohumeral ligament, and glenoid avulsions of the anterior glenohumeral ligament. Conclusions: Despite being invasive, MRA is considerably more useful in the identification and categorization of different elemental lesions of traumatic chronic anterior shoulder instability.

Imaging of the Shoulder Bankart Lesion and its Variants

The glenoid labrum is an important soft tissue structure that provides stability to the shoulder joint. When the labrum is injured, affected patients may present with chronic shoulder instability and future recurrent dislocation. The Bankart lesion is the most common labral injury, and is often accompanied by a Hill-Sachs lesion of the humerus. Various imaging techniques are available for detection of the Bankart lesion and its variants, such as anterior labroligamentous periosteal sleeve avulsion and Perthes lesion. Direct magnetic resonance (MR) arthrography is currently the imaging modality of choice for evaluation of the various types of labral tears. As normal anatomical variants of glenoid labrum are not uncommonly encountered, familiarity with appearances of this potential pitfall helps avoid misdiagnosis.

Multiple Subscapularis Tendon Sign: A New Risk Factor for Recurrence After Arthroscopic Anterior Shoulder Instability Surgery.

Background:Being able to predict recurrence after the treatment of shoulder instability would be helpful in planning the appropriate treatment.Purpose:To define the multiple subscapularis tendon sign (MSTS) as a novel anatomic variant and a possible risk factor for the recurrence of shoulder instability after anterior stabilization and to evaluate it, together with the other risk factors as described in the literature.Study Design:Case-control study; Level of evidence, 3.Methods:A total of 87 patients met the study criteria and underwent arthroscopic stabilization for anterior shoulder instability. The MSTS was evaluated in this study group. Age, sex, hand dominance, number of preoperative shoulder dislocations, history of overhead or contact sports participation, type of labral lesion, number of anchors used in surgery, presence of the drive-through sign, presence of the MSTS, Oxford Shoulder Score results, and the association of these parameters with recurrence were assessed. The mean follow-up time was 81.0 ± 27.9 months (range, 48-139 months).Results:Nine (10.3%) patients experienced recurrent instability. The presence of the MSTS (P = .009), existence of an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion (P = .04), and history of overhead or contact sports participation (P = .04) were significant risk factors for recurrence. The recurrence rates were as follows: 30.7% with the MSTS; 40% with the MSTS and an ALPSA lesion; and 75% with the MSTS, an ALPSA lesion, and a history of overhead or contact sports participation.Conclusion:The MSTS is a variation of the anterior shoulder joint capsule. It is a sign of capsular insufficiency or thinning, which may be a risk factor for recurrence after anterior stabilization. Considering the low success rates of anterior capsulolabral repair in patients participating in overhead or contact sports, especially when an ALPSA lesion is present, encountering the MSTS during surgery in this at-risk group may be an indicator for the surgeon to choose the surgical procedure more carefully.

An Ancillary Sign in the Diagnosis of Bankart and Bankart Variants in Patients With Glenohumeral Instability on Nonarthrographic Magnetic Resonance Imaging: Preglenoid Fat Thickness.

We investigated whether preglenoid fat thickness can be used as an ancillary sign for preliminary diagnosis of Bankart and its variants on nonarthrographic magnetic resonance imaging. Sixty-eight anterior dislocation patients were included in this retrospective study. Forty-eight patients with Bankart and its variants, as detected by arthroscopy and magnetic resonance arthrography, were included in the study group. The study group was divided into osseous Bankart, labral Bankart, Perthes, and anterior labroligamentous periosteal sleeve avulsion subgroups. Twenty patients with no detected labral pathologies by arthroscopy and magnetic resonance arthrography were included in the control group. In these patients, preglenoid fat tissue thickness at the anteroinferior portion was measured at the level of the glenoid tubercle. Thickness of preglenoid fat tissue was compared between groups with different labral pathologies and those with normal labrum. The preglenoid fat tissue thickness was 2.65 ± 1.05 mm in the control group and 0.90 ± 0.59 mm in the study group (P < 0.0001). Patients with preglenoid fat tissue thinner than 1.6 mm showed a significantly increased likelihood of having Bankart and its variants in receiver operating characteristic analysis (sensitivity of 95.8% and specificity of 85%). There was no significant difference in preglenoid fat tissue thickness between the subgroups of the study group (osseous Bankart, labral Bankart, Perthes, and anterior labroligamentous periosteal sleeve avulsion). Preglenoid fat tissue measurement can be used as an ancillary sign in the diagnosis of Bankart and Bankart variants in glenohumeral instability patients.

The Operative Outcomes of Displaced Distal Clavicle Fractures in Adolescents

Distal clavicle fractures in skeletally immature patients are rare injuries, accounting for 3.8% of all clavicle fractures in this population. Optimal management of significantly displaced fractures is not clear from the literature. Some authors favor nonoperative treatment, despite significant displacement, citing the osteogenic nature of the periosteal sleeve providing significant potential for remodeling. Others have advocated operative treatment, especially in athletes. This study investigates the functional outcomes of patients undergoing operative fixation of these fractures. We present our preferred surgical technique, which is reproducible and does not require a routine second operation to remove hardware. We investigated 36 skeletally immature patients with significantly displaced distal third clavicle fractures. All were treated surgically using the same operative technique. Outcomes included time to union and Disabilities of the Arm, Shoulder and Hand (DASH) score at 12 months. Mean age at time of injury was 14.2 years. Most injuries were sustained while playing a contact sport. Mean time to union was 6.7 weeks. The mean DASH score at 12 months was 3.9. There was 1 complication relating to an adverse reaction to suture material. There were no cases of clavicular shortening or duplication. Operative fixation of displaced distal third clavicle fractures using the technique presented here results in excellent clinical and radiographic outcomes in this age group. Level of Evidence: Level IV—case series.

The diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail

BackgroundThe nonunion of open and closed tibial shaft fractures continues to be a common complication of fractures. Tibial nonunions constitute the majority of long bone nonunions seen by orthopaedic surgeons. In this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions. MethodsBetween 2008 and 2014, 33 patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. The initial fracture management consisted of external fixation (27 patients), plate fixation (2 patients) and cast treatment (4 patients). All patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. There were 13 hypertrophic, 16 oligotrophic (atrophic) and 4 defect nonunions registered in our material. The primary goal was to perform a closed intramedullary nailing on antegrade manner. An open procedure was only unavoidable when implants had to be removed or an osteotomy had to be performed to improve the alignment. Functional rehabilitation was encouraged with the assistance of a physiotherapist early postoperative. Patients were examined regularly during followed-up for a minimum of 12 months period for clinical and radiological signs of union, infection, malunion, malalignment, limb shortening, and implant failure. ResultsThe time that elapsed from injury to intramedullary nailing ranged from 9 months to 48 months (mean 17 months).Open intramedullary nailing was unavoidable in 25 cases (75,75%), while closed nailing was performed in 8 patients (24,25%). Osteotomy or resection of the fibula was performed in 78,8% of the cases. All patients were followed up in average period of 2 years postoperative (range 1–4 years), and 31(93,9%) patients achieved a solid union within the first 8 months. Mean union time was 5±0.8 months. Complications included 2 (6,06%) patients, one with deep infection and another case with absence of bone healing. Anatomical alignment has been achieved in the majority of patients, 28 patients (84,8%). The additionally autogenous bone chips were added in 4 patients (12,1%) where cortical defect was greater than 50% of the bone circumference. ConclusionIn conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. Reaming of the medullary canal with preservation of periosteal sleeve create the "breeding ground" for sound healing of tibial shaft nonunions. Additionally cancellous bone grafting is recommended only in the case of defect nonunion.

The role of the periosteal sleeve in the reconstruction of bone defects using a non-vascularised fibula graft in the pediatric population

BackgroundFollowing resection of large benign bone tumors surgeons are confronted with bone defects severely affecting the stability of a limb. To restore the mechanical continuity of the bone different treatment methods using bone grafts have been described. In pediatric patients the thick periosteal sleeve is thought to contribute to bone formation. HypothesisAn intact periosteal sleeve is crucial in bone remodelling around a non-vascularised fibular graft used to bridge large bone defects. MethodsWe present a treatment technique applied in 6 cases comprising of subperiosteal tumor resection at the diaphyseal or metaphyseal level of long bones followed by defect bridging with a non-vascularised fibula graft inserted into the periosteal sleeve of the resection zone. Elastic intramedullary nails or plates were used for stabilisation. ResultsDue to the intact periosteum at the resection site bone integration occurred quickly and full remodelling was seen in all but one case. Tumor location in this case was at the metaphyseal level resulting in tumor resection at the growth plate. Although bone healing at the distal resection site was seen after a few weeks proximal consolidation was only partial. Full reconstitution of the fibula in the remaining periosteal sleeve was seen in 5 cases, partial reconstitution in 1 case. DiscussionIn the pediatric patient, the described technique is an effective and reliable treatment method for large benign bone tumors requiring resection. However, great diameter discrepancy of the donor and recipient site and a thin periosteum can be a limiting factor for its application. Level of evidenceLevel IV clinical study.

Anterior and Posterior Capsule- Periosteal sleeve avulsion as an unusual cause of Shoulder Instability

Traumatic anterior shoulder instability is a typical condition in young people and athletes. There are many different injuries that may be present, producing or coexisting with shoulder instability, in addition to classic Bankart lesion.

Arthroscopic Findings in Anterior Shoulder Instability.

Background: In the last years, basic research and arthroscopic surgery, have improved our understanding of shoulder anatomy and pathology. It is a fact that arthroscopic treatment of shoulder instability has evolved considerably over the past decades. The aim of this paper is to present the variety of pathologies that should be identified and treated during shoulder arthroscopy when dealing with anterior shoulder instability cases.Methods: A review of the current literature regarding arthroscopic shoulder anatomy, anatomic variants, and arthroscopic findings in anterior shoulder instability, is presented. In addition, correlation of arthroscopic findings with physical examination and advanced imaging (CT and MRI) in order to improve our understanding in anterior shoulder instability pathology is discussed.Results: Shoulder instability represents a broad spectrum of disease and a thorough understanding of the pathoanatomy is the key for a successful treatment of the unstable shoulder. Patients can have a variety of pathologies concomitant with a traditional Bankart lesion, such as injuries of the glenoid (bony Bankart), injuries of the glenoid labrum, superiorly (SLAP) or anteroinferiorly (e.g. anterior labroligamentous periosteal sleeve avulsion, and Perthes), capsular lesions (humeral avulsion of the glenohumeral ligament), and accompanying osseous-cartilage lesions (Hill-Sachs, glenolabral articular disruption). Shoulder arthroscopy allows for a detailed visualization and a dynamic examination of all anatomic structures, identification of pathologic findings, and treatment of all concomitant lesions.Conclusion: Surgeons must be well prepared and understanding the normal anatomy of the glenohumeral joint, including its anatomic variants to seek for the possible pathologic lesions in anterior shoulder instability during shoulder arthroscopy. Patient selection criteria, improved surgical techniques, and implants available have contributed to the enhancement of clinical and functional outcomes to the point that arthroscopic treatment is considered nowadays the standard of care.

Periosteal Sleeve Avulsion Fracture of the Quadriceps Tendon

AbstractSleeve fractures at the superior pole of the patella have been previously described in the literature. We present the case of a 15-year-old girl who sustained a patellar sleeve avulsion of the quadriceps tendon 1 month following patellar dislocation without surgical treatment. Open repair of quadriceps tendon was performed with subsequent union. Arthrofibrosis of the knee was noted; two subsequent manipulations and adhesiolysis were performed. At 18-month postinjury, normal motion and strength were present. Special attention to postoperative recovery of range of motion is imperative for good clinical outcome after periosteal sleeve avulsion fractures of the patella.