Arthroscopic knot typing techniques.

The development of arthroscopic shoulder reconstructive procedures has required the passage of sutures and tying of knots down a cannula. Successful accomplishment of this goal requires an understanding of both suture handling and knot tying techniques, in order to avoid tangles in the cannula, premature locking of knots, and inadequate knot seating. This article presents an overview of arthroscopic knot tying techniques. It explains a variety of knots by diagram, and will provide an understanding of the application and use of slip and nonsliding knots in arthroscopic surgery.

Laser-assisted shoulder surgery.

The application of laser/thermal energy in arthroscopic shoulder surgery remains controversial. Laser proponents tout the benefits of coagulation and vaporization of tissue, whereas opponents cite costs, complications, and the fact that the laser has not yet shown results superior to presently available mechanical techniques. A lack of basic science studies and the aversion of many physicians to the marketing aspects of laser technology have undermined the widespread orthopaedic acceptance of laser techniques. Newer applications, such as capsular shrinkage are just now being evaluated as to effect and efficacy. Orthopaedists should be assured that, at present, they are not compromising patient care by not using laser techniques.

Tissue fixation security in transosseous rotator cuff repairs: a mechanical comparison of simple versus mattress sutures.

The primary purpose of this investigation was to compare tissue fixation security by simple sutures versus mattress sutures in transosseous rotator cuff repair. These two repair techniques were each performed in 17 human cadaver shoulders, with two bone tunnels being used for the repair by two simple sutures and two other bone tunnels being used for the repair by one mattress suture. The repairs were loaded to failure in a servohydraulic materials test system. Rotator cuff repair by simple sutures was found to be significantly stronger than repair by mattress sutures (P = .0007). The average ultimate load to failure for the simple suture construct (189.62 N) was 39.72% greater than that for the mattress suture construct (135.71 N). Most of the failures occurred by suture breakage at the knot. Load-sharing by multiple suture tails and multiple knots in the simple suture configuration likely contributed to its superior strength characteristics compared with the mattress suture configuration.

Management of complete traumatic anterior cruciate ligament tears in the skeletally immature patient: current concepts and review of the literature.

Once considered extremely rare, complete traumatic tears of the anterior cruciate ligament (ACL) in skeletally immature patients with open physes are now being diagnosed with increasing frequency. Concomitant subsequent meniscal injuries develop in a significant number of these patients. Nonoperative treatment, primary surgical repair of the torn ACL, or extraarticular stabilization procedures have not been reported to restore dynamic knee stability or prevent further meniscal damage. Transphyseal bone plugs from a patellar tendon graft fixed with suture or interference screws have not been reported in patients with significant growth potential and cannot be recommended. Soft-tissue autografts placed through transphyseal tunnels have been reported to give good functional results and minimize potential for growth disturbance.

Partial repair of irreparable rotator cuff tears.

This study analyzes the results of a previously unreported technique of reconstruction for the massive irreparable rotator cuff tear. The technique involves repair of the margins of the tear to restore the force couples and "suspension bridge" system of force transmission in the shoulder. Complete coverage of the defect was not considered to be essential as long as the normal mechanics of the shoulder were restored and the rotator cuff tear was converted to a "functional cuff tear." This procedure was performed on 14 patients. Improvement in function was dramatic. Active elevation (elevation denotes the plane of motion midway between the planes of shoulder abduction and shoulder flexion; elevation is reported because it is the most functional plane in which to raise the arm) improved by 90.8 degrees: from a preoperative average of 59.6 degrees to a postoperative average of 150.4 degrees. Strength improved an average of 2.3 grades on a 0-to-5-point scale. The average score on the UCLA Shoulder Rating Scale improved from a preoperative value of 9.8 to a postoperative value of 27.6. All but one patient was very satisfied with his or her result. The authors are of the opinion that this technique is preferable to other reconstructive techniques, such as tendon transposition, that emphasize coverage of the defect at the expense of destroying the normal mechanics of the shoulder. The authors suggest that partial repair of massive irreparable rotator cuff tears should supplant tendon transposition as the procedure of choice for this condition.

Saline magnetic resonance arthrography in the evaluation of glenohumeral instability.

Sixty-five patients underwent magnetic resonance (MR) shoulder arthrography. Forty-eight of these patients underwent examination under anesthesia (EUA). MR images were retrospectively evaluated for signs felt to be imaging indicators of shoulder instability, including evaluation of various capsular measurements and the presence of glenoid labral tears, as well as Hill-Sachs fractures. Statistical analysis of the results showed that no correlation between capsular indicators with EUA-documented instability was found. However, there was a statistically significant correlation between the presence of a Bankart cartilaginous deformity (p = 0.000) and Hill-Sachs fractures (p = 0.022) with EUA-documented instability. Sensitivity to labral tears was 89% and specificity was 98%, whereas Hill-Sachs fracture detection was 69% and 87%, respectively. We believe that MR saline arthrography is of benefit in the evaluation of the anterior labrum when unenhanced MR imaging is inconclusive, and we speculate on the role of MR arthrography as a primary investigative tool.

Arthroscopic portals: anatomy at risk.

Proper portal placement is critical for successful and safe arthroscopic surgery. Multiple portals and their safe location are needed for evolving surgical procedures. Familiarity with these portals and their formation will aid the arthroscopist.

Arthroscopic anatomy of the glenohumeral joint and subacromial bursa.

A review of normal glenohumeral and subacromial anatomy and the clinical relevance of normal variants and pathologic conditions has been presented. This information will aid the arthroscopist in making accurate diagnoses and giving effective treatment.

MR imaging in the evaluation of SLAP injuries of the shoulder: findings in 10 patients.

OBJECTIVE: Injuries to the superior portion of the glenoid labrum, called SLAP (superior labrum, anterior and posterior) injuries, are recently recognized injuries consisting of tears of the long head of the biceps tendon anchor/superior labral complex. The purpose of this study was to determine if the MR imaging findings in patients with surgically proved SLAP injuries correspond to the abnormalities found at arthroscopy. MATERIALS AND METHODS: Four variants of SLAP lesions have been described; they are based on the degree of compromise of the superior portion of the glenoid labrum, biceps tendon, and labral-biceps anchor. A type I lesion has superior labral fraying in the region of the biceps anchor. A type II lesion has superior labral fraying and stripping of the superior part of the glenoid labrum and attached biceps off the underlying glenoid fossa. A type III lesion has a bucket-handle tear of the superior portion of the glenoid labrum in the region of the biceps anchor. A type IV lesion has a bucket-handle tear of the superior part of the glenoid labrum with extension of the tear into the proximal biceps tendon. Standard spin-echo MR imaging studies in 10 patients with surgically proved SLAP lesions were evaluated retrospectively. Correlations were made between MR imaging findings and the SLAP injury type determined from descriptions in the surgical report. MR imaging studies in a control group of seven symptomatic patients surgically proved not to have SLAP injuries also were evaluated. RESULTS: MR imaging examinations of two patients with type I lesions showed irregularity of the labral contour and a slight increase in signal intensity on all imaging sequences. MR imaging examinations of two patients with type II lesions showed globular high signal interposed between the superior part of the glenoid labrum and the superior portion of the glenoid fossa. One case showed high signal in the labral-biceps anchor. The other case showed paired cleavages in the superior and inferior aspects of the superior part of the glenoid labrum at the labral-biceps anchor. MR imaging examinations of two patients with type III lesions showed superior labral tears identified as high signal intensity within the superior part of the labrum separate from the normal superior part of the labral cavity. MR imaging examinations of the four patients with type IV lesions showed diffuse high signal intensity within the superior part of the glenoid labrum with marked abnormal high signal intensity extending into the proximal high signal intensity within the superior part of the labrum separate from the normal superior part of the labral cavity. MR imaging examinations of the four patients with type IV lesions showed diffuse high signal intensity within the superior part of the glenoid labrum with marked abnormal high signal intensity extending into the proximal biceps tendon. None of the MR imaging studies of patients in the control group showed findings seen on MR imaging studies of patients with surgically proved SLAP lesions. CONCLUSION: Although prospective data are required to document accuracy, these preliminary data suggest that an MR examination can be useful in detecting SLAP abnormalities and establishing the type of SLAP lesion before surgery, thereby permitting better operative planning.

Comparison of bipolar implants with fixed-neck prostheses in femoral-neck fractures.

A retrospective study of 76 Bateman universal proximal femoral endoprostheses with a mean follow-up period of 32 months was compared to a group of 36 Thompson endoprostheses and 16 Moore endoprostheses, with a mean follow-up period of 35 months and 31 months, respectively. Harris hip scores, when corrected for preoperatively impaired function, yielded a mean score of 85 for the Bateman group, compared to a mean of 77 for both the Thompson and Moore groups. Fifteen patients received the Bateman device for reconstructive purposes and had a mean Harris hip score of 90. Morbidity was comparable between the Bateman and Thompson groups. The deep-infection rate was 3.9%, and the 32-day perioperative mortality was 4.6%, rising to 29% at the time of review. Preselection factors placed younger, more functional patients in the Bateman group (mean age, 65 years; mortality, 11%), compared to the Thompson group (mean age, 72 years; mortality, 39%) and the Moore group (mean age, 73 years; mortality, 41%). Continued evaluation of the Bateman endoprosthesis is required to better define its potential to lessen the long-term problems of pain, loosening, and acetabular wear.

A simple method of meniscus repair.

Current understanding of knee meniscus pathology and the known consequences of meniscal loss dictate preservation of tissues wherever feasible. Surgical approaches to meniscal repair include open and combined arthroscopic-open or arthroscopic-percutaneous procedures. A variety of needles, guides, sutures, and retractors have been marketed. Over a 2 year period, we used these techniques in the repair of 19 medial and 5 lateral meniscus tears, with no known retears and no complications. We used an 18-gauge, 6-inch spinal needle and a strand of number one nonabsorbable suture.

Computed arthrotomography of the glenohumeral joint to evaluate anterior instability: correlation with arthroscopic findings.

A retrospective review of 30 patients on whom a double-contrast computed arthrotomogram of the shoulder was performed was evaluated to correlate radiographic findings with subsequent arthroscopic and surgical findings. Analysis of the data demonstrated a wide variation in abnormal computed tomography (CT) labral configurations, and experience was necessary to interpret the studies adequately. The lesions ranged from complete detachment to complete absence. The study was reliable in identifying large labral lesions suitable for arthroscopic stapling with large detachments anteriorly and anterior inferiorly. Isolated low anterior labral detachments associated clinically with instability under anesthesia were missed. The amount of tissue available for arthroscopic stapling correlated well with CT findings, making it a useful screening test to help select candidates for arthroscopic stapling. One false-positive study and two false-negative studies were noted, for an error rate of 10%. We recommend continued use of the CT arthrotomogram of the shoulder as a screening test for shoulder derangement and as a predictive adjunct for surgical planning. Modifications in our technique include tangential low anterior imaging to detect low anterior short labral detachments.

A new evaluation of gross pathologic changes and concepts of rheumatoid articular cartilage degeneration.

Fifty-one knees in 32 ambulatory patients with rheumatoid arthritis were examined arthroscopically, enabling direct observation of the pattern of gross degeneration at the joint line and synovial chondral junction. Four distinct stages of pannus ingrowth and meniscal degeneration were observed, which correlated with the extent of articular destruction. Significant direct pannus invasion of articular cartilage was not observed in any stage in the ambulatory mobile rheumatoid knee. Stage I is comprised of synovial hypertrophy. Stage II shows invasive pannus affecting meniscal surfaces. Stage III exhibits meniscal tearing and production of abrasive debris. Stage IV is end-stage loss of meniscus and denudation of articular surfaces. Articular cartilage destruction was not observed in patients without visible meniscal degeneration or pannus ingrowth but was observed in knees without roentgenographic erosion or joint space narrowing. A new evaluation of articular degeneration in the ambulatory mobile rheumatoid knee is based on mechanical destruction by torn menisci and free debris observed by arthroscopy.

The effect of alignment on results in arthroscopic debridement of the degenerative knee.

Fifty-two patients with severe degenerative joint disease of the knees were treated by arthroscopic debridement. The results of arthroscopic debridement on normally aligned degenerative knees are encouraging. A combination of arthroscopic debridement and high tibial osteotomy could be an appealing alternative to total knee arthroplasty in the young patients. Patients with varus angular deformity in the degenerative knee had a poor result and should be excluded from consideration for arthroscopic debridement.

The medial patellar plica syndrome.

A retrospective review of all patients diagnosed at arthroscopy as having a medial patellar plica with no other intraarticular pathology was conducted. Characteristic clinical findings, including pseudolocking, were identified. The clinical response of 68 patients (78 knees) to shelf resection was noted at 3 and 6 months. The 6-month review demonstrated 60% to be totally relieved of their preoperative pain and 31% with occasional discomfort, but capable of full activities. Three patients were graded with poor results (4%) due to limitations in their work and sports, and four patients were lost to followup. The overall good and excellent results totalled 91%. No surgical complications, infections, or wound dehiscences were noted.

Radiation exposure during scoliosis screening radiography.

Screening programs to detect scoliosis in the adolescent population are active in most communities. Two percent of children screened will be referred for treatment or observation. Increasing concern has been voiced regarding the amount of the potential effects of the radiation administered in such screening programs. Radiation dosage was directly measured on 19 children participating in an established school scoliosis screening program, using lithium fluoride thermoluminescence dosimeters. The mean gonadal doses are measured to be 19 mrem in males and estimated at a maximum 95 mrem in females. The mean entrance skin dose was 174 mrem. A lack of uniformity in the radiographic techniques employed by individual technician was identified. The measured doses were within established acceptable limits and are comparable or below the average dose of 100 mrem received annually by the general public from the environment.

Results of patellar realignment in patients older than thirty.

A retrospective study of patellar realignment procedures was performed on patients over the age of 30 years, with a mean follow-up of 32 months on 16 operated-on-knees in 14 patients. The best results were achieved in patients with preoperative apprehension and compression signs, as well as a typical history for patellar subluxation. when these signs were absent after operation, the result was better than seen in patients whose clinical signs persisted. There was no correlation of results with the grade of chondromalacia noted at surgery. Good or excellent results were achieved in about 75% of the patients. An accurate preoperative diagnosis in the selection of operative candidates is imperative.

A review of long-bone fractures in patients with spinal cord injuries.

In a retrospective investigation of 38 long-bone fractures in 30 spinal cord injured patients (mean follow-up, 22 months), fractures were classified acute (occurring at the time of spinal cord injury) or pathologic (occurring in the chronically injured patient). The methods of treatment and complications were recorded and evaluated. The incidence of long-bone fractures was 6.7%. Complication rates were high, ranging from 20% to 40%, with open or closed treatment of extremity fractures. Strict adherence to established operative fracture management principles in paraplegic patients irrespective of the level of neurologic deficit. Extremity fractures treated by nonoperative splinting and skin care healed well even in patients with long-standing paraplegia. Hip fractures were usually openly reduced internally fixed to improve sitting balance. The question of absolute benefit from early long-bone stabilization in the spinal cord injured patient remains unanswered.