A MAR-like antibody in a DCWe/DCWe person.

BACKGROUND: MAR (RH51), a high-incidence antigen in the Rh blood group system, is absent from RBCs with a double dose of CW or CX or a single dose each of CW and CX antigens, as well as from rare Rh phenotypes including D- - and Rh(null). The MAR antigen is associated with the presence of Ala36 and Gln41 on the RhCe protein. The original example of anti-MAR, described in 1994, was made by a DCWe/DCXe woman. It was possible that the antibody directed against a high-incidence antigen in the Rh system made by a DCXe/DCXe woman (CM) in 1983 was anti-MAR. CASE REPORT: A 52-year-old, multiply transfused, white woman (CJ) with pre-existing anti-c, -E, and -Jk(a) presented for preoperative work-up for her fifth open heart procedure. The strength of the reaction of her RBCs with anti-CW suggested a double dose of CW antigen. Her serum, which unexpectedly was strongly reactive with c-, E-, Jk(a-) RBCs by PEG indirect antiglobulin test, was incubated with E-c-, Jk(a-) RBCs, and an eluate was prepared. This eluate reacted 3+ with E-c-, Jk(a-) RBCs but did not react with Rh(null) (n = 5), - - (3), DCW- (2), Dc- (1), or DCWe/DCWe (1) RBCs. Two related DCXe/DCXe and two unrelated DCWe/DCXe RBC samples were weakly agglutinated. The patient's RBCs were negative with the original anti-MAR but reacted as strongly as the positive control RBCs with the antibody made by the DCXe/DCXe person. CONCLUSION: This is the first example of a MAR-like antibody made by a DCWe/DCWe woman. The specificity cannot be called anti-MAR, because some MAR-negative samples react, albeit weakly. The original anti-MAR, made by a DCWe/DCXe woman, did not react with DCWe/DCWe, DCWe/DCXe, or DCXe/DCXe RBCs. It is apparent that the specificity of "anti-MAR" differs slightly, depending on the CW/CX status of the antibody maker.

Arthroscopic rotator cuff repair using a transhumeral approach to fixation.

A new technique for arthroscopic rotator cuff repair using arthroscopically placed transhumeral sutures is presented. After an adequate acromioplasty is performed, a modified anterior cruciate ligament tibial drill guide is used to drill two or more transhumeral holes from the metaphyseal-diaphyseal junction of the humerus to the greater tuberosity. Sutures are then passed into these holes and through the rotator cuff using cannulated needles. The sutures are tied manually and the repair is inspected. The postoperative protocol is presented. The new technique may be superior to the current methods for arthroscopic rotator cuff repair in that (1) the strength of fixation does not rely on the quality of the bone in the greater tuberosity of the humeral head (which can be quite poor) as suture anchor techniques do, (2) the sutures are easily passed through the rotator cuff without relying on complicated suture passing techniques, (3) the knots are tied without the aide of an arthroscopic knot-tying device, and (4) in cadaveric studies, the failure strength of this new repair was equal to the strength of a traditional open repair. Prospective studies are ongoing to assess the efficacy of this new technique.

Arthroscopic Bankart repair.

Recurrent instability in athletes may lead to decreased athletic performance and interference with activities of daily living. When a Bankart lesion is created, the probability that instability will recur is high. Open Bankart repairs have been shown to produce greater than 95% good to excellent results but do require extensive dissection and may result in significant loss of external rotation of the shoulder. This loss of external rotation may interfere or prevent the resumption of athletic activities. Arthroscopic Bankart repair offers the hope of re-creating shoulder stability surgically with minimal damage to the surrounding tissues, resulting in little, if any, loss of external rotation. Arthroscopic Bankart repair is demanding and is associated with an increased risk of failure compared with open techniques. If the surgeon remains cognizant of the precise technical details of arthroscopic Bankart repair, greater than 90% good to excellent results should be achieved with arthroscopic shoulder stabilization. In discussing arthroscopic versus open repair with an athlete, however, the surgeon should talk about his or her own results with the procedure to allow an athlete to make an informed decision. The author believes that arthroscopic Bankart repair is appropriate for all overhead athletes requiring as much external rotation of the shoulder as possible, noncontact athletes, athletes who have dislocated three or fewer times, and those who do not have a significant degree of generalized ligamentous laxity. It also may be appropriate for the low-demand patient who dislocates a shoulder in an accident (e.g., a fall) and, after stabilization, is not expected to place significant demands on the shoulder. The author also believes that arthroscopic Bankart repair is not appropriate in patients with generalized ligamentous laxity, in patients with more than three dislocations (unless they are an overhead athlete), in patients who are found to have poor quality tissue at the time of arthroscopy, or in athletes who are perceived to be noncompliant. Open procedures are probably more appropriate in each of these groups of patients.

Initial failure strength of open and arthroscopic Bankart repairs.

Surgical repair of recurrent anterior shoulder instability requires secure fixation of the separated inferior glenohumeral complex to bone. Many techniques of fixation are in use for both arthroscopic and open repair. The specific aim of this study was to compare the initial failure strength of eight repair techniques using a previously described canine model of Bankart repair. Intact capsule-to-bone complexes failed at the bony interface at 236 N. Traditional Bankart repair failed at 122.1 N (2 sutures) and 74.7 N (1 suture), Acufex TAG rod (Acufex Microsurgical, Mansfield, MA) at 143.5 N (2 sutures) and 79.8 N (1 suture), transglenoid suture technique (2 sutures) at 166.6 N, Mitek GII (Mitek, Norwood, MA) (1 suture) at 96.4 N, Zimmer Statak (Zimmer Inc, Warsaw, IN)(1 suture) at 95.2 N, and Acufex bioasbsorpable Suretac at 82.2 N. The two-suture repairs were statistically equivalent in strength to each other, as were the one-suture repairs and the Suretac device. Two-suture repairs were significantly stronger than the one-suture repairs (P < .01) failure. In the single-suture specimens, failure occurred by suture breakage in 46% (18 of 39) of specimens and soft-tissue failure around the suture in 54% (21 of 39). Failure in the two-suture techniques primarily occurred by soft-tissue failure (23 of 25) and this proved a statistically significant difference (P < .003). No device broke or pulled out of bone.

A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy.

BACKGROUND AND OBJECTIVES: An increasing percentage of all surgery is performed in an ambulatory surgery setting. Concurrently, arthroscopy of the shoulder joint has allowed definitive repair of shoulder pathology to occur in this environment. This study was designed to ascertain whether interscalene block is reliable and efficient for use in same-day surgery compared with general anesthesia for shoulder arthroscopy. METHODS: The authors retrospectively reviewed patients treated at the University of Connecticut over a 42-month period in the same-day surgery unit. Of 263 patients, 160 had a general anesthetic and 103 had an interscalene block. All times recorded for the study were contemporaneously logged into the operating room computer data base from which they were extracted. Data on complications were retrieved from individual patient charts and hospital quality assurance files. RESULTS: Compared to general anesthesia, regional anesthesia required significantly less total nonsurgical intraoperative time use (53 +/- 12 vs. 62 +/- 13 minutes, P = .0001) and also decreased postanesthesia care unit stay (72 +/- 24 vs. 102 +/- 40, P = .0001). Interscalene block anesthesia resulted in significantly fewer unplanned admissions for therapy of severe pain, sedation, or nausea/vomiting than general anesthesia (0 vs. 13, P = .004) and an acceptable failure rate (8.7%). CONCLUSIONS: Interscalene block should be considered as a viable alternative to general anesthesia for shoulder arthroscopy in ambulatory surgery patients.

Preoperative computed tomography scanning and arthroscopy in predicting outcome after lateral retinacular release.

We initiated a study to look at preoperative, flexed-knee, midpatellar computed tomography (CT) scans and intraoperative arthroscopic findings of lateral patellar articular degeneration in predicting the results after lateral retinacular release for failed nonoperative treatment of anterior knee pain. Twenty patients with 30 painful knees underwent preoperative flexed-knee, midpatellar CT scans that were retrospectively classified by the method of Fulkerson into normal alignment, lateral subluxation, lateral patellar tilt, and combined tilt and subluxation. Arthroscopy was performed before open lateral release. The lateral facet of the patella was graded as either minimal changes (Outerbridge I or II) or advanced (Outerbridge III or IV) changes. Patients were followed for a minimum of 2 years and graded on a standard patellofemoral rating scale. Only 22 of 30 knees that were thought to be clinically malaligned, actually were malaligned by CT scan; eight CT scans were interpreted as normal. The results were further stratified into group A (CT-documented tilt, minimal facet changes), group B (CT-documented tilt, advanced facet changes), and group C (normal CT). Ninety-two percent of group A were rated good or excellent. Twenty-two percent of Group B rated good/excellent, 33% fair, 44% poor. Only 13% of group C rated good (one patient). Based on the results of the study, we recommend lateral release for anterior knee patients with CT-proven patellar tilt who have not responded to conservative treatment and have minimal facet changes with minimal or no subluxation. Lateral retinacular release should not be offered as a treatment to the patient with a normally aligned patella because poor results will most likely result.

Comparison of initial pull-out strength of arthroscopic suture and staple Bankart repair techniques.

This study was performed to investigate the initial failure strength of arthroscopic suture and staple techniques use to treat recurrent anterior shoulder instability. Eight canine shoulder complexes were fashioned so that four 1-cm wide strips of capsule remained attached to the glenoid in each specimen (total of 32 test specimens) these specimens were tested to tensile failure on an Instron model 1331 testing machine either intact (n = 5), or after the capsule was sharply dissected off the bone and repaired with an arthroscopic staple (n = 11) or arthroscopic suture technique (n = 12). The control group failed at 17.75 +/- 7.14 kg, the suture repair at 11.0 +/- 2.56 kg, and the staple repair at 4.77 +/- 2.32 kg. These failure strengths were all statistically different from each other (p less than 0.0001). All failures occurred at the capsular bone interface. The authors do not advance one technique over the other but do advise surgeons to be mindful of the results when instituting early shoulder motion after arthroscopic Bankart procedures.

Scapulothoracic penetration of a Beath pin: an unusual complication of arthroscopic Bankart suture repair.

The arthroscopic Bankart suture repair technique is an alternative to open procedures that control anterior shoulder instability. A case is presented in which a Beath pin traveled through the scapula and penetrated the scapulothoracic articulation during arthroscopic Bankart repair. The authors caution that strict adherence to Morgan's technique should minimize complications with this procedure.

Water sports injuries.

Water sports can be a great source of fun and fitness but can also be a source of injury. Overuse injuries are common in both the recreational and competitive athlete and in the young and old alike. Proper attention to preseason conditioning, adequate warmup, early recognition and treatment of injuries, and a common sense approach to the athletic environment should minimize time off from sports and result in maximum enjoyment and performance.

Acetabular epiphysis-labrum entrapment following traumatic anterior dislocation of the hip in children.

Traumatic anterior dislocations of the hip during childhood are rare injuries. Although a concentric reduction can usually be achieved with closed techniques, open reduction is occasionally required. We recently treated two children, 10 and 13 years of age, with nonconcentric closed reductions following traumatic anterior dislocation sustained 6 weeks and 6 months previously, respectively. Preoperative evaluation revealed intraarticular entrapment of the acetabular epiphysis and its contiguous labrum as the cause of the nonconcentric reduction. This was confirmed at surgery. Although displacement of the acetabular epiphysis has not been previously described, it is probably a common source for cartilaginous and osteocartilaginous fragments that have been recognized at open reduction following both traumatic anterior and posterior hip dislocations in children. Damage to this secondary center of ossification does not appear to affect adversely further growth and development of the acetabulum.