Grafts and Patches in Rotator Cuff Surgery: Bioinductive Scaffolds, Augmentation, Interposition, and Superior Capsule Reconstruction.

Rotator cuff repair can be challenging because of the compromised state of the tendon tissue. These challenges range from simply degenerative tendons to complete tendon loss in patients which can impair soft-tissue healing. Various grafts and patches are currently available to help address these challenges. The ideal solution for the treatment of irreparable rotator cuff tears or those prone to retear remains controversial. Sometimes augmentation with a patch is appropriate. However, at times a completely retracted and immobile tendon remnant is found. Reconstruction of the superior capsule has demonstrated promising results in several short-term series. The indications for these procedures, the optimal surgical technique, and their limitations are evolving. This chapter discusses the current literature related to bioinductive scaffolds, graft augmentation, graft interposition, and superior capsular reconstruction.

Bony Incarceration of the Extensor Pollicis Longus Tendon Mimicking Rupture.

Background Distal radius fractures are a relatively common injury, and rupture of the extensor pollicis longus (EPL) has been known to occur in a small number of nondisplaced distal radius fractures. In contrast, bony incarceration of the EPL tendon is an exceedingly rare occurrence and warrants special attention. Case Description Here we present a case of bony incarceration of the EPL tendon following distal radius fracture that mimicked tendon rupture. Following EPL release, the patient had improved function and pain in the wrist. Literature Review We identified three case reports of EPL tendon entrapment following distal radius fracture, and compared and contrasted the clinical features of tendon rupture versus bony entrapment. Clinical Relevance Our results suggest that both the type of fracture (displaced vs. nondisplaced) and the chronicity of symptoms may provide important diagnostic clues for the hand surgeon managing distal radius fracture patients presenting with EPL dysfunction.

Reliability of the Tönnis Classification and Its Correlation With Magnetic Resonance Imaging and Intraoperative Chondral Damage.

PURPOSE: To evaluate the reliability of the Tönnis classification in the setting of femoroacetabular impingement (FAI) hips without dysplasia. METHODS: Forty-nine patients with FAI underwent preoperative radiography and magnetic resonance imaging (MRI). Radiographs were evaluated in 2 separate settings by 5 observers and graded according to the Tönnis classification. Interobserver and intraobserver reliability was calculated using the κ coefficient. Intraoperative chondral damage was assessed, and chondral damage to the acetabulum (acetabular labrum articular disruption [ALAD] classification) and to the femur (Outerbridge classification) was graded. The Spearman coefficient was computed to quantify the degree of correlation between the Tönnis grade and MRI-detected chondral damage, as well as intraoperative chondral damage. RESULTS: The average intraobserver reliability of the Tönnis classification was moderate (κ = 0.472), and the interobserver reliability was fair (κ = 0.287). Statistically significant positive correlations were found between the Tönnis classification and the ALAD classification (P = .0087) and between the Tönnis classification and femoral chondral damage detected by MRI (P = .0247). A statistically significant correlation was not found between the Tönnis grade and the intraoperative Outerbridge classification of the femur (P = .4969), between the Tönnis grade and acetabular chondral damage on MRI (P = .4969), or between the Tönnis grade and the ability to detect a chondral flap on MRI (P = .2160). No statistically significant correlation was found between the ALAD classification and the presence or absence of a chondral flap on MRI (P = .3538), between the ALAD classification and MRI-detected chondral damage to the acetabulum (P = .103), or between the Outerbridge classification and the degree of chondral damage observed on MRI of the femur (P = .1922). CONCLUSIONS: The Tönnis classification and MRI have substantial limitations when evaluating nondysplastic hips with FAI for the degree of chondral damage and arthritis. LEVEL OF EVIDENCE: Level III, retrospective comparative study of prospective data.

Editorial Commentary: To Scope or Not to Scope: Labral Tears in the Early Arthritic Hip.

As hip arthroscopy is increasingly performed, the indications for surgery still remain unclear. How much arthritis is too much? How do we judge this? At this juncture, we need to better define inclusion and exclusion criteria in our studies, and further studies are needed to shed light on which patients are the best candidates for this procedure.

Arthroscopic Implantation of a Bio-Inductive Collagen Scaffold for Treatment of an Articular-Sided Partial Rotator Cuff Tear.

The treatment of articular-sided partial rotator cuff tears remains a challenge to the treating orthopaedic surgeon. Treatment algorithms have included nonoperative management, debridement alone, and debridement and subacromial decompression, as well as articular-sided rotator cuff repair and completion of the tear on the bursal side followed by a traditional arthroscopic rotator cuff repair. Implantation of a bio-inductive collagen scaffold on the bursal side of the rotator cuff to potentially heal an articular-sided tear represents a novel approach to this difficult clinical entity.

Neuromuscular problems in foot and ankle: evaluation and workup.

It is essential to determine the functional goals of the patient during the workup and treatment planning stages of neuromuscular disorders involving the foot and ankle. Accurate diagnosis, and informed discussion of treatment options, must be in the context of the patient's disease, cognition, comorbidities, functional attributes, and family environment. A thorough history and physical examination aid in appropriate diagnostic workup and optimal orthopedic management of each patient. In this article, general considerations in the workup of suspected neuromuscular disorders and issues pertinent to specific congenital and acquired neuromuscular disorders affecting foot and ankle function are reviewed.

Ischiofemoral impingement of the hip: a novel approach to treatment.

Ischiofemoral impingement (IFI) is an uncommon source of hip pain recently described in the non-surgical hip, associated with decreased space between the lesser trochanter and the ischium. There are no reports in the English literature of surgical treatment of this problem. We describe a case of IFI in a 19-year-old female who failed conservative management and underwent endoscopic surgical intervention to increase the space between her ischium and proximal femur. More than 2 years later, the patient is doing very well with an improvement of her iHOT score of 53 points to 85.

Supraphysiologic temperature enhances cytotoxic effects of bupivacaine on bovine articular chondrocytes in an in vitro study.

PURPOSE: The purpose of this study was to determine the effects of temperature or 0.25% bupivacaine treatment in combination with supraphysiologic temperatures on chondrocyte viability. METHODS: Bovine articular chondrocytes in suspension culture were treated with phosphate-buffered saline solution at 20°C, 37°C, 40°C, 42°C, 45°C, 47°C, and 50°C for 15, 30, and 60 minutes or with phosphate-buffered saline solution at 37°C, 45°C, and 50°C for 30 and 60 minutes followed by 0.25% bupivacaine at 20°C for 60 minutes. Chondrocyte viability was analyzed by flow cytometry with the LIVE/DEAD Viability/Cytotoxicity Kit (Molecular Probes, Eugene, OR). Annexin V and ethidium double staining determined whether apoptosis or necrosis occurred. RESULTS: Temperatures from 20°C to 42°C did not cause chondrocyte death. Temperatures at or above 45°C caused significant chondrocyte death, particularly at 50°C for 60 minutes, compared with 37°C at 60 minutes (P < .01). When the chondrocytes were incubated at 50°C, subsequent exposure to bupivacaine significantly increased chondrocyte death compared with the saline solution-treated control group (P < .001). There were additive cytotoxic effects when bupivacaine was combined with supraphysiologic temperatures. It was also found that bupivacaine at supraphysiologic temperatures caused necrosis of articular chondrocytes. CONCLUSIONS: Temperatures at or above 45°C caused significant chondrocyte death. Bupivacaine treatment in the presence of 45°C and 50°C temperatures significantly increased necrosis of bovine articular chondrocytes in this in vitro study. CLINICAL RELEVANCE: Immediate intra-articular injection of bupivacaine after heat-generating procedures may cause damage to the cartilage because of the additive cytotoxic effects of bupivacaine and elevated temperature.

Special considerations for ACL graft selection in the young, active military patient.

Anterior cruciate ligament (ACL) injury is an extremely common injury in the young, physically demanding active duty military population. The diagnosis of an ACL injury in active duty military personnel often requires special consideration in terms of return to function, reliability, and performance of the knee-often in life-threatening situations when one has to rely on a stable knee for survival. This article outlines the considerations of ACL surgical treatment in the active duty military population, with an emphasis on the young, physically competitive athlete to optimize outcomes. Numerous treatment options and controversies regarding ACL surgery will be reviewed to provide a framework for which to perform a reliable and effective ACL surgery in active duty military personnel.

Technique: bone-patellar tendon-bone autograft ACL reconstruction in the young, active patient.

Successful treatment of the anterior cruciate ligament tear in the young, active population can be reliably achieved with an arthroscopic bone-patellar tendon-bone (BTB) autograft reconstruction. Although some contraindications exist, the BTB autograft has been proven to provide for a durable, stable, and highly functional knee. Complications associated with the use of BTB can occur, but measures can be taken to minimize these risks. In addition to appropriate graft selection, meticulous surgical technique is required. This article outlines the step-by-step surgical technique including graft harvest, tunnel placement, graft preparation and passage, and interference screw fixation. Potential complications and the surgical decision-making options incurred are also discussed in detail.

Arthroscopic revision Bankart repair: a preliminary evaluation.

Arthroscopic stabilization of primary, recurrent anterior shoulder instability has become the procedure of choice with infrequent exceptions. Failures of stabilization can and do occur. This is a Level IV retrospective analysis of arthroscopic revision Bankart surgery performed on 15 non-consecutive patients over a 4-year period with an average 22-month follow-up. The average patient age was 27.5 with 12 men and 3 women. Four of the 15 failures were from the senior author's (R.K.N.R.) practice with the remaining 11 referred for treatment. Four of the 15 failures resulted from open surgery while the remaining 11 failed an arthroscopic stabilization procedure. Four contact/collision athletes were included, and significant bone loss was recorded in 5 patients. Operative findings included 10 recurrent Bankart lesions while 9 patients were felt to demonstrate capsular attenuation. Fourteen of the 15 had a Hill-Sachs lesion while chondromalacic change involving the anterior glenoid was noted in 13 of the 15 patients. A suture anchor technique was used with an average of 2.5 double-loaded suture anchors. In this series, 4 failures occurred after revision arthroscopic stabilization (27%) with an average SANE score of 86 (range, 65-100). One of the 5 patients with significant bone loss sustained a recurrence while 1 of 4 contact athletes failed the revision arthroscopic stabilization. Two of the 4 failures in this study subsequently underwent an open bone block procedure. Arthroscopic revision Bankart repair can be an effective alternative, but should only be considered in the properly selected patient.

Postarthroscopic glenohumeral chondrolysis of the shoulder.

Postarthroscopic glenohumeral chondrolysis is a devastating, poorly understood, and relatively rare complication. True chondrolysis involves the dissolution of articular cartilage, including the matrix and cellular elements, leading to premature and irreversible articular cartilage loss. Several factors have been implicated in this phenomenon; however, to date, no study has conclusively ascertained the causation. Potential causative agents include subclinical infection, high volume intra-articular infusion of certain anesthetics, arthroscopic implants, suture material, and thermal energy. One must also consider the possibility that chondrolysis represents an ongoing immunogenic process interrupted or possibly potentiated by surgical intervention. The complex homeostasis of articular cartilage is undoubtedly sensitive to agents introduced into the joint including mechanical, chemical, and temperature-dependent interventions. To date, several papers have described the phenomenon and the potential associations; however, there is no definitive answer although the use of high-dose bupivacaine as an intra-articular anesthetic seems to be contraindicated. The purpose of this article is to review the basic science regarding chondrolysis and to assess the current literature which focuses on postarthroscopic glenohumeral chondrolysis, as well as innovative treatment alternatives. It is unlikely that postoperative chondrolysis will be clearly understood until controlled studies are available, of which there are currently none.

Rehabilitation of biceps tendon disorders in athletes.

The diagnosis and management of an active patient with biceps disease can be challenging for the treating physician. A careful review of the function, anatomy, and pathology of biceps in conjunction with a thorough, knowledgeable history and physical examination can yield a working diagnosis in this challenging patient population. The physician must also be aware of the physiology of postsurgical repair and advocate appropriate rehabilitation activities that correlate with the timeline of secure tissue healing. This article focuses on nonsurgical rehabilitation and postoperative rehabilitation of biceps tendon injuries.

Displacement of the posterior horn of the lateral meniscus into posterolateral compartment: an unusual injury pattern.

We report a case of acute ACL injury with an unusual lateral meniscal tear pattern. The entire posterior horn of the lateral meniscus was avulsed from its attachments while remaining in continuity with the body of the meniscus. It was displaced posteriorly and laterally to the popliteus tendon so that it was not immediately visible at the time of arthroscopy. This type of displacement of the posterior horn of the lateral meniscus is difficult to identify at arthroscopy and has not previously been described in the literature to our knowledge. We recommend to surgeons who encounter an absent posterior horn of the lateral meniscus to consider this injury pattern.

Sac hygroma after endovascular abdominal aortic aneurysm repair: successful treatment with endograft relining.

Aneurysm sac expansion following endovascular abdominal aortic aneurysm repair (EVAR) is typically associated with endoleaks that can be readily diagnosed on computed tomographic angiography (CTA), ultrasound, or catheter-directed arteriography. Sac hygromas are a cause of sac expansion without apparent endoleak and are presumed to be a result of ultrafiltration of serum manifested by accumulation of fibrinous, gelatinous material within the aneurysm sac following EVAR. Although there are no reported associated ruptures, sac expansion is nevertheless disconcerting and intervention is presumably indicated. We report a case of an expanding aneurysm after EVAR secondary to sac hygroma that was successfully treated with relining of the existing, original endograft.