Bailout Options for Intra-operative Implant and Instrumentation Related Incidents and Complications During Arthroscopic Knee Surgery-A Retrospective Study.

Background: Arthroscopic knee procedures are one amongst the common surgical interventions for problems in the knee. It is technically more demanding than an open procedure and is associated with several potential complications. During arthroscopy procedures, several technical challenges may arise, and even experienced surgeons may encounter new issues. However, careful attention to the surgical technique can help prevent or resolve them. Methodology: The study was conducted on all patients who underwent knee arthroscopy procedure during study period. We recorded details of the implants used and any unexpected situations related to them, as well as how they were managed. Instrumentation-related parameters such as screwdriver issues, radiofrequency ablator issues, scope damages, shaver complications, probe complications, and meniscus suture passing devices were also assessed. Results: In total, there were 12 (3.73%) implant and instrument-related incidents and complications, of which 5 (1.55%) were implant-related and 7 (2.17%) were instrument related. Among the instrumentation-related incidents and complications, two (0.62%) were screwdriver breakage incidents, two (0.62%) were radiofrequency ablator-related incidents, one was arthroscopic probe (0.31%) related incident, one (0.31%) was meniscus suture passing device related complication and one (0.31%) was arthroscope related incident. Conclusion: Surgeons must be ready to anticipate and effectively manage any technical difficulties that may arise during the procedure, maintaining composure in the face of unexpected challenges and guiding the team. In most cases, incidents can be addressed intra operatively and may not have long-term effects on patient outcomes. It is crucial to have multiple implant and instrument backup options available for successful surgery.

Periosteum-Augmented Soft-Tissue Graft for Anterior Cruciate Ligament Reconstruction.

Soft-tissue grafts are an option for anterior cruciate ligament reconstruction. One of the major drawbacks of soft-tissue grafts is the delay in the osteointegration and ligamentization of the implanted graft. Enveloping the ends of the graft with periosteum sleeves can hasten the osteointegration process and help in quicker rehabilitation of the patient. This article describes a simple and unique way to augment the soft-tissue graft with periosteum for anterior cruciate ligament reconstruction.

A Novel Technique of Resecting Localized Pigmented Villonodular Synovitis of the Knee Joint.

Introduction: Pigmented villonodular synovitis is an uncommon benign proliferation of the synovium. In the knee joint, it can present as a localized or a diffuse form and can mimic numerous conditions. Case Report: We present a case report of a 54-year-old male with localized form of this condition. The diagnosis is not often made clinically but usually made with the help of magnetic resonance imaging and histopathology. We used a novel technique for resecting the tumor by arthroscopy. Conclusion: A high index of suspicion is required for the diagnosis of the condition and arthroscopic excision results in lower morbidity and lesser recurrence rates.

Revision of Failed Medial Meniscus Posterior Root Repair: A Case Report.

Introduction: Meniscal root tear decreases the ability of the meniscus to convert the axial load to radially directed hoop stress. This leads to a decreased contact area and increased contact pressures, leading to early osteoarthrosis of the knee and eventually higher chances of undergoing total knee replacement. Meniscal root repair helps to restore normal knee kinematics; however, non-anatomical repair results in increased strain in the repair and causes early failure of the repair, leading to abnormal knee kinematics. Case Report: A 45-year-old female with a body mass index of 40.6, hypothyroid, and type II diabetes mellitus presented to the outpatient department with the complaints of left knee pain and difficulty in walking. She had undergone an arthroscopic medial meniscus posterior root repair 1 year back. Clinical and radiological examinations helped to diagnose a re-tear of the medial meniscus root with a non-anatomic tibial tunnel. She then underwent arthroscopic revision root repair surgery. Currently, the patient is at a 1-year follow-up and has resumed her activities of daily living. Conclusion: Anatomical repair of the posterior horn of the medial meniscus is important in restoring normal knee kinematics and for the ability of the meniscus to maintain the hoop stress. Non-anatomic repair leads to early failure and progression to rapid cartilage degeneration, resulting in early osteoarthritis and eventual knee replacement. Any revision surgery presents its own different set of challenges. The basic principles must be adhered to while addressing any failure of the primary surgery.

Anatomical Landmark Technique for Femoral Tunnel Placement of Lateral Extra-Articular Tenodesis.

The anterolateral ligament is a crucial part of the anterolateral complex of the knee, providing rotator stability to the knee and being a primary restraint to tibial internal rotation. Lateral extra-articular tenodesis added to anterior cruciate ligament reconstruction can reduce pivot shift without sacrificing the range of motion or increasing the risk of osteoarthritis. A 7- to 8-cm longitudinal skin incision is made and a 9.5- to 10-cm × 1- cm wide iliotibial band graft is dissected, leaving the distal attachment intact. The free end is whip stitched. One of the most important steps during the procedure is the identification of the site of attachment of the iliotibial band graft. The leash of vessels, fat pad, lateral supracondylar ridge, and fibular collateral ligament serve as important landmarks. The tunnel is drilled from the lateral femoral cortex with a guide pin and reamer pointing 20 to 30° anteriorly and proximally while the arthroscope visualizes the femoral anterior cruciate ligament tunnel. The graft is routed under the fibular collateral ligament. The graft is fixed with a bioscrew while the knee is kept in 30° flexion and the tibia is kept in neutral rotation. We believe that lateral extra-articular tenodesis gives the anterior cruciate ligament graft a good chance for faster healing along with addressing anterolateral rotatory instability. Choosing a correct fixation point is very important to restore normal knee biomechanics.

The Proximity of the Axillary Nerve During Keyhole Tenodesis of the Long Head of the Biceps Tendon: A Cadaveric Study.

Background: Over time, surgical management for conditions involving the long head of the biceps tendon (LHBT) has evolved. Some techniques, such as keyhole tenodesis proposes bicortical drilling, however, carries an axillary nerve injury risk. The goal of our cadaveric study was to see if we could keep a safe zone between the point of exit of keyhole tenodesis of biceps and axillary nerve. Methodology: The study was performed on ten shoulders from five fresh frozen cadavers. Between the lower border of the transverse humeral ligament (THL) and the superior margin of the pectoralis major insertion at the lowest limit of the bicipital groove, a beath pin was driven through with the help of the modified tip aimer tibial jig procured from the anterior cruciate ligament reconstruction (ACL) set, which was fixed at an arc of 45°. The distance between the axillary nerve and beath pin at the exit point was measured. Results: The biceps tendon musculotendinous junction was followed all the way to the inferiorly and biceps tendon was found in the groove. The average distance from the axillary nerve to the exit point of the beath pin was 17.7 mm (range 14.4-20.9 mm, 95% CI). Conclusion: The axillary nerve is not injured during bicortical drilling when keyhole tenodesis of biceps is performed at the distal limit of the groove of biceps. The area in the biciptal groove between inferior margin of THL and superior border of pectoralis major insertion is safe area for biceps tenodesis.

Fibrin Clot Augmented Repair of Longitudinal Tear of Medial Meniscus.

Repair of meniscus injuries always posed a significant problem, especially in relatively avascular zones. Several methods to augment the repair were devised, but only a few had convincing results. Fibrin clot augmentation is one of the augmentation procedures that shows good promise in this premise. The major hurdle to it is difficulty in delivering into the meniscus tear under constant irrigation during arthroscopic procedures. This article presents a simple and unique way to prepare and transfer a fibrin clot into a meniscal tear in a step-by-step manner.

Arthroscopically-Assisted Latissimus Dorsi Transfer for Irreparable Rotator Cuff Insufficiency: Modes of Failure and Clinical Correlation.

PURPOSE: The main objective of this retrospective study was to analyze the rate and modes of failure of latissimus dorsi transfer (LDT). The secondary objective was to evaluate whether a rupture of the transfer was associated with a worse outcome. METHODS: During a 2-year period, we performed consecutive LDTs either for irreparable posterior-superior rotator cuff tears (RCTs) or for failed prior repair. All the LDTs were performed by a single surgeon. All transfers were arthroscopically assisted and fixed as a tubularized LD tendon in a bone tunnel inside the humeral head. Three metal clips were placed systematically intraoperatively in the tubularized tendon at a fixed distance of 2, 4, and 6 cm from the tip of the tendon. Immediate postoperative standard anteroposterior radiographs were performed and the position of the metal clips was compared with their position on radiographs performed at 6 weeks and 3 and 24 months postoperatively. Constant, Subjective Shoulder Value (SSV), Simple Shoulder Test (SST), Activities of daily living requiring active external rotation (ADLER), visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) scores and patient's subjective satisfaction (assessed by self-questionnaire) at last follow-up were compared between patients who had a rupture of the transfer and those who did not. RESULTS: Sixty-six patients were included. Six of 66 patients (9%) were lost to follow-up. There were 11 complications (18.3%) in the global series (10 hematoma and 1 subscapularis retear). At a mean 35.2 months (range 24-50 months), there were 23/60 cases of rupture (38%). The 7 scores and the satisfaction reported were significantly lower for patients who had a rupture of the transfer versus those who had an intact transfer: Constant score, 42.8 versus 68.7 (P = .001); SSV, 48.9 versus 71.6 (P = .001); SST, 4.8 versus 8.4 (P = .012); ADLER, 19.7 versus 26.7 (P = .005); VAS, 3.7 versus 2.3 (P = .082); ASES, 55.4 versus 74.8 (P = .056); and 13% of either satisfied or very satisfied patients versus 78% (P < .001). CONCLUSIONS: The rate of rupture of LDT is high (38%). With complete healing of LDT, the outcome is significantly lower in those with rupture compared with those without rupture, showing that LDT can efficiently treat massive and irreparable RCT. LEVEL OF EVIDENCE: Level IV, case series treatment study.

The main cause of instability after unconstrained shoulder prosthesis is soft tissue deficiency.

BACKGROUND: Instability is one of the major causes of failures in unconstrained anatomic total shoulder arthroplasty (TSA). This study reviewed the instabilities that may occur in an anatomic shoulder platform system to identify its potential predictors. We hypothesized that soft tissue deficiency was the main cause of instability and that the best treatment option would be conversion to a reverse shoulder arthroplasty (RSA). MATERIALS AND METHODS: Between 2003 and 2013, we reviewed 27 patients who experienced postoperative instability, and the overall incidence was 5.07%. There were 8 hemiarthroplasties (HAs), 14 TSAs with metal-backed glenoid components, and 5 TSAs with cemented glenoid components. RESULTS: We reported 10 isolated subscapularis tears, 6 massive rotator cuff tears, 8 component malpositions, 2 component dissociations or loosening, and 1 humeral shortening. These dislocations occurred early, within the first 6 months postoperatively, in 20 patients and later in 7. Specific procedures were performed in 8 patients, 17 were converted successfully to a RSA, and no surgery was done in 2 patients. At the last follow-up (mean, 36.96 months) Constant scores, Subjective Shoulder Value, and Simple Shoulder Test scores improved significantly to 49.9, 56.4%, and 6.9 of 12, respectively (P < .05). None of the 25 patients who were revised were categorized as failures. Patients who underwent conversion had a better outcome than those who had other specific procedures (P = .001). CONCLUSION: The major cause of instability in our series was soft tissue deficiency. Most of the patients required conversion, and the platform system we used made conversions easier.

Functional and computed tomography correlation of femoral and tibial tunnels in single-bundle anterior cruciate ligament reconstruction: Use of accessory anteromedial portal.

BACKGROUND: An accessory anteromedial portal (AAMP) has been shown to be effective in placing an anatomically ideal femoral tunnel. It is well known that this is due to the independent femoral drilling which is possible with the AAMP. However very little is known regarding the significance of this reconstruction technique in influencing the functional outcomes of anatomic anterior cruciate ligament reconstruction (ACLR). This study documents the influence of tibial and femoral tunnel positions on functional outcomes of anatomic ACLR using the AAMP. MATERIALS AND METHODS: 41 patients who underwent anatomic ACLR between 2011 and 2013 were included in this prospective cohort study. The primary outcome involved the documentation of femoral and tibial tunnel positions with volume rendering imaging using a three-dimensional computed tomography (3D-CT) done at the end of 1 year. The tunnel position evaluations from the CT images were performed by an independent observer specializing in radiodiagnosis. Functional outcome measures included preoperative and postoperative Lysholm and International Knee Documentation Committee (IKDC) scores (subjective) documented by an independent investigator who was not involved with the surgical procedure, at the end of 1 year. RESULTS: The minimum followup was 1 year. All patients achieved good clinical and functional outcomes postoperatively with no reported complications. Tunnel position evaluations with 3D-CT revealed the average tibial tunnel distance to be 15.5 mm (standard deviation [SD] =2.52) from the anterior border of the tibial plateau and the average femoral tunnel distance to be 14.33 mm (SD = 2.6) from the inferior margin of the medial surface of lateral femoral condyle and 13.72 mm (SD = 2.8) from the posterior margin of the medial surface of lateral femoral condyle. The average tunnel diameters were found to be 7.9 mm (SD = 0.72) for the tibial tunnels and 8.6 mm (SD = 1.07) for the femoral tunnels. Statistically significant correlation between the tibial tunnel distance and the IKDC scores with anterior placement of tibial tunnel were found; however, no such statistical relationship were found between the femoral tunnel positions and the functional outcome measures. CONCLUSION: AAMP gives an ideal approach to drill the femoral tunnel independently. However, the influence of this tunnel placement on long term functional outcomes of ACLR needs to be assessed on larger cohort of patients.

A subscapularis-preserving arthroscopic release of capsule in the treatment of internal rotation contracture of shoulder in Erb's palsy (SPARC procedure).

The purpose of this study was to evaluate a minimally invasive subscapularis-preserving arthroscopic release of capsule in the treatment of internal rotation contracture of the shoulder due to Erb's palsy. We performed our procedure (subscapularis-preserving arthroscopic release of capsule) in 10 paediatric shoulders with an average age of 20.2 months and followed them for an average period of 41.5 months. All the patients were assessed clinically and radiologically preoperatively and postoperatively at regular intervals. The Mallet scoring system was used for analysing the results. The average gain in passive external rotation was 50°. The active internal rotation was preserved in all the cases. With the mid-term follow-up, there was no loss of the gained external rotation or the recurrence of internal rotation contracture of the shoulder. Our hypothesis has achieved its goal in preserving subscapularis, active internal rotation and treatment of internal rotation contracture of the shoulder. The success of this procedure lies in the early identification of starting of internal rotation contracture and early surgical intervention to prevent progressive permanent glenohumeral osseocartilaginous deformity.

Arthroscopic keyhole proximal biceps tenodesis: a technical note.

We describe an arthroscopic keyhole technique for proximal biceps tenodesis. The technique is safe, easy to reproduce, cost-effective, and less time consuming. It does not need any special instrumentation and is suitable especially for use in the developing countries. It enables examination of the biceps sheath and distal biceps tendon for unidentified tears, synovitis, and fibrosis.