Thermal capsular shrinkage: Basic science and clinical applications.

Recently, the use of thermal energy to shrink the redundant glenohumeral joint capsule in patients with instability has generated a great deal of interest. Proponents assert that the procedure avoids the need for an open stabilization and it may be used as an adjunct to an open or arthroscopic capsulolabral repair. The use of nonablative thermal energy to shrink soft-tissue collagen appears to induce ultra-structural and mechanical changes at or above 60 degrees C. The microscopic changes reflect the unwinding of the collagen triple helix and loss of the fiber orientation. The fibrils contract into a shortened state and reactive fibroblasts have been shown to grow into this treated area and synthesize the collagen matrix. The biomechanical properties of the tissue do not appear to be detrimentally altered if shrinkage is limited to less than 15% and if ablation or excess focal treatment is avoided. The endpoint of optimal shrinkage is not known and clinical estimations of tissue changes and volumetric reduction are used as guides to treatment. The first clinical follow-up study was only recently published in the peer-reviewed literature and prior preliminary reports were optimistic regarding the use of thermal energy for the treatment of glenohumeral instability. Thermal capsular shrinkage has been used as an adjunct to a capsulolabral repair, as well as an isolated treatment for the disorders of internal impingement and multidirectional instability. Additional evaluation is necessary to determine the optimal quantity of energy needed for tissue shrinkage without inadvertent tissue destruction. The long-term clinical effect, mechanical properties, and durability of the newly produced collagen need to be analyzed further. The basic science and clinical applications of this newly applied technology are reviewed in this article.

Practical considerations in anterior cruciate ligament replacement surgery.

The endoscopic method of anterior cruciate ligament (ACL) reconstruction using a patellar tendon graft that is secured with interference screws is a commonly performed procedure. It has many potential pitfalls, the majority of which are secondary to technical errors. Prevention of errors starts with a full knowledge of normal ACL anatomy and any discrepancies with the size and shape of the graft substitute. Accurate tibial and femoral tunnel placement is essential and involves using consistent intra-articular landmarks and achieving specific radiographic criteria. Accurate tunnel placement minimizes graft excursion and impingement against the roof of the intercondylar notch. This will result in maximum knee stability and motion. Much has been written about the principles of graft-tunnel mismatch and interference screw-bone plug divergence. The clinical implications of these potential sources of error remain somewhat controversial and are discussed in this article.

Gender disparity of anterior cruciate ligament injury. Etiological theories in the female athlete.

The gender disparity of anterior cruciate ligament injury has recently been demonstrated and is striking. Numerous etiological factors have been implicated but definitive causation has not yet been determined. An overview of the various hypotheses has been presented and it appears that the etiology is multifactorial. The intrinsic factors are primarily anatomical and cannot be altered in an effort to reduce injury rate. Presently, neuromuscular factors appear to be the most contributory to female ACL injury. Physicians, trainers, and coaches participating in the care of female athletes should encourage proper conditioning. A particular emphasis should be placed on hamstring and gastrocnemius strengthening, as female athletes tend to be quadriceps dominant. Movement training that encourages landing and pivoting with increased knee flexion should also be emphasized. Structured plyometric and jump training programs have been documented to significantly reduce the rate of female ACL injury and continued research in this area may provide more explanation to the gender disparity of ACL injury rates.

MR imaging of impingement and rotator cuff disorders. A surgical perspective.

The role of MR imaging in the diagnosis of impingement and rotator cuff disorders is expanding greatly. This article discusses the clinically pertinent history, physical examination, and surgical treatment of rotator cuff problems. A rationale for consideration of open, "mini-open," and arthroscopic surgical intervention is proposed. The utilization of MR imaging by the orthopedic surgeon for nonoperative, preoperative, and postoperative decision-making are presented. A close working relationship between the radiologist and the orthopedist is emphasized.

A historical perspective on meniscal repair.

The treatment of meniscal injuries has changed drastically over the past 50 years. This evolution has been fueled by research on the natural history, basic science, and biomechanics of meniscal injury and by the advent of arthroscopy. This article presents a brief overview of these developments.

Patellar tendon length after anterior cruciate ligament reconstruction.A prospective study.

Shortening of the patellar tendon after anterior cruciate ligament (ACL) reconstruction has been implicated as a cause of postoperative complications such as anterior knee pain, patella infera syndrome, and traumatic patellar tendon rupture. This prospective study was designed to asses whether closure of the patellar tendon defect during ACL reconstruction with mid-third bone-patellar tendon-bone autograft leads to radiographic evidence of patellar tendon shortening. One hundred fourteen patients underwent arthroscopically assisted ACL reconstruction using mid-third bone-patellar tendon-bone autograft. Group I (59 patients) had the patellar tendon defect left open. Group II (55 patients) had the defect sutured closed. The paratenon was approximated in all patients. Lateral knee radiographs were taken pre- and post-operatively. The pre- and postoperative patellar tendon lengths were measured and compared. Group I (defect left open) showed virtually no patellar tendon shortening (average 0.3%). Group II (defect closed) showed minimal but slightly more shortening (average: 0.51%). The maximum shortening was 2.3% in Group I and 4.3% in Group II. Therefore, closure of the patellar tendon defect does not significantly alter the length of the patellar tendon after ACL reconstruction.

Complications of arthroscopic meniscal repair.

The results of 101 consecutive arthroscopic meniscal repairs were studied to determine the nature and frequency of associated complications. All arthroscopic repairs were done by the senior author (OS) between November 1984 and June 1991. Our data include 65 patients with associated anterior cruciate ligament injuries, of which 49 underwent concurrent arthroscopic anterior cruciate ligament reconstruction. There was an overall complication rate of 18%. There was a 20% risk of complication with meniscal repair when associated with anterior cruciate ligament injury and 14% without anterior cruciate ligament injury. There was a 10% incidence of arthrofibrosis when meniscal repair was performed with anterior cruciate ligament reconstruction and a 6% incidence when performed in an anterior cruciate ligament-deficient, non-reconstructed knee. Overall, there was a 13% risk of complication with lateral repairs compared with 19% with medial repairs. In the subset of patients with intact anterior cruciate ligaments and isolated meniscal lesions, there were no complications associated with lateral repair and an 18% risk of complication with medial repair. Female patients demonstrated a higher likelihood of complication (29%) than male patients (13%). Excluding repair failures, there was an 8% reoperation or rehospitalization rate.

Instrumented measurements of laxity in patients who have a Gore-Tex anterior cruciate-ligament substitute.

Twenty patients who had substitution of the anterior cruciate ligament with a Gore-Tex synthetic ligament were evaluated preoperatively and postoperatively with the University of California at Los Angeles instrumented clinical-testing apparatus, which records anterior-posterior force versus displacement-response curves of the tibia with respect to the femur at 20 degrees of flexion of the knee. The mean age of the patients was thirty-three years (range, nineteen to fifty-four years). The duration of follow-up ranged from twenty-four to forty-four months (mean, thirty-one months). The mean preoperative difference in anterior laxity between the injured knee and the normal knee (4.5 millimeters with neutral rotation of the foot) was unchanged two years after the operation; at that time, all patients had an anterior laxity of the injured knee of more than eight millimeters, and 90 per cent had a difference in anterior laxity of more than two millimeters between sides. The mean values for anterior stiffness at fifty and 100 newtons of anterior force were unchanged after the operation, remaining at 40 to 50 per cent of normal levels. At 200 newtons, or 20.4 kilograms (forty-five pounds) of anterior force, the mean stiffness of the involved knee was 11 to 17 per cent greater than that of the normal knee. Clinically, there were improvements in both subjective and objective knee-rating scores. All but four patients had a reduction of at least one grade in the pivot-shift score; in thirteen, the pivot-shift sign was eliminated.(ABSTRACT TRUNCATED AT 250 WORDS)

The perioperative management of the arthroscopic patient.

This article has described the perioperative management of the arthroscopic patient. As emphasized, preoperative planning requires a precise diagnosis, patient education, and selective procedures. The operative management is sophisticated, exacting, and challenging, as discussed in other articles of this issue. Finally, the postoperative management is specifically directed toward pathology and procedure. Recovery times are variable, and complications are not insignificant and can lead to prolonged patient morbidity and financial loss. It is important to consider patient goals versus reality, patient willingness to opt for acceptable versus optimal results, and if the procedure is necessary versus justified versus contraindicated. If all of these factors are kept in mind by the surgeon and conveyed to the patient, arthroscopic surgery can be extremely rewarding to both.

Measurements of anterior laxity in normal and anterior cruciate absent knees with two instrumented test devices.

A new portable model of the University of California at Los Angeles (UCLA) instrumented clinical knee testing apparatus and the KT-1000 knee arthrometer were used to measure anterior laxity in normal and anterior cruciate absent knees. Normal ranges for both devices were established for a control group of 48 normal subjects. With the UCLA device at 200 N of applied tibial force, 95% of normal knees have an anterior laxity less than 8.0 mm and a side to side difference less than 2.0 mm; corresponding values for the KT-1000 at 89 N are 9.0 mm and 2.0 mm. Both devices showed that anterior laxity of 19 anterior cruciate absent knees was approximately double that for normal knees. Measurements taken with these two testing instruments do not have a one-to-one correlation, as the method of femoral constraint and the amount of applied tibial force will influence the magnitude of the recorded laxities. Proper interpretation of laxities measured with each device requires consideration of right-left scatter in a normal population tested with that particular device. Both devices were 90%-95% accurate in correctly classifying an anterior cruciate absent knee outside the normal range.

Patellar instability: treatment by arthroscopic electrosurgical lateral release.

We reviewed the results of arthroscopic lateral release using electrosurgery in 39 patients (45 knees) with a history of recurrent patellar subluxation or dislocation. The average follow-up time was 28 months (range, 24-36). At follow-up, the patients had decreased swelling, instability, and pain. There was an improvement in flexion activities, sports participation, and overall functional ability. Only 20% of the knees had completely normal physical findings: 11.1% of the knees were rated as excellent; 64.4% were improved; and 24.5% were poor. Dislocators had more frequent poor results. The complication rate was 4.4%. There were no postoperative hemathroses. One patient was considered a surgical failure. The technique yields results comparable with those of open extensor realignment procedures and avoids the complications inherent to lateral release in general. The place for this procedure in patellar instability is well-documented.

Nine-year functional nonunion of a femoral neck stress fracture: treatment with internal fixation and fibular graft. A case report.

Open reduction and internal fixation utilizing a full thickness fibular graft was performed on a patient who presented with a 9-year-old functional nonunion of a femoral neck stress fracture. During this period, the patient had remained fully ambulatory, with intermittent episodes of hip pain. Our experience indicates that the treatment of old, nonunited stress fractures of the femoral neck with a fibular bone graft and internal fixation contributes to a successful result, lending support while stimulating osteogenesis as the nonunion heals. Use of rigid internal fixation will eliminate motion at the site of the fracture, enhancing incorporation of the bone graft and, thereby, speeding the patient's recovery.

Arthroscopy--"no-problem surgery". An analysis of complications in two thousand six hundred and forty cases.

In a retrospective review of 3,261 arthroscopic procedures on the knee, 2,640 met the criteria for inclusion in this analysis. The patients' ages ranged from eight to eighty-three years. There were 1,541 male and 1,099 female patients. Eight hundred and ninety-five of the injuries were work-related. A tourniquet was used in 1,175 procedures and the average tourniquet time was thirty minutes. There were 216 complications over-all (8.2 per cent), 126 being designated as major and ninety-seven, as minor. The major complications that were evaluated were infections, hemarthrosis, adhesions, effusions, cardiovascular, neurological, reflex sympathetic dystrophy, and instrument breakage, and the minor complications were difficulties with wound-healing and ecchymosis. Chi-square analysis showed the following factors to be significant (p less than 0.05). Patients with an industrial injury had a higher rate of neurological complications and reflex sympathetic dystrophy. Diagnostic arthroscopy had the lowest over-all complication rate. Partial medical meniscectomy was associated with a higher over-all complication rate and the highest hemarthrosis rate, and partial lateral meniscectomy was associated with the highest rate of instrument breakage. Abrasion arthroplasty had the highest rate of complications of wound-healing, and subcutaneous lateral release was associated with the most adhesions. The sex of the patient and whether or not a tourniquet had been used had no effect on complications. The experience of the surgeon with arthroscopic procedures also had no correlation with the complication rate. Multiple regression analysis showed that two factors (age and, if a tourniquet was used, the tourniquet time) were dominant predictors of complications. From these data, a model was devised for predicting which patients were at risk for complications and their relative levels of risk. Certain complications may be preventable, and for others the risk factors can be reduced. The high-risk patients in our series were fifty years old or older and had a tourniquet time of sixty minutes or longer.

Autogeneic anterior cruciate ligament (ACL) anterior reconstruction of the knee. A review.

Anterior cruciate ligament (ACL) reconstruction with patellar-tendon-bone, semitendinosus/gracilis, iliotibial band, and meniscus have all given "success" rates between 75% and 85% with reasonably short (less than three years) follow-up periods. A 7.9-year average follow-up evaluation of patellar tendon ACL reconstruction would probably represent the overall success rate of the above procedures at 69% good or excellent. All of these procedures require significant dissection and lengthy rehabilitation periods of six months to a year. In attempting to compare these various reconstructions, it is obvious that it will be necessary to develop a consistent and reproducible subjective and objective knee rating system that is presently not used by these authors. Prior to the use of the various prosthetic ACL reconstructions, careful follow-up analysis of the existing body of autogenous ACL reconstructions must be constantly reviewed and assessed in light of the newer data. As Ivar Palmer stated in 1938, "However, it cannot be denied that interferences of this kind are extensive, time-consuming and rather risky, and at the best of times, they cannot result in a restitutio ad integrum."

Arthroscopic anterior cruciate ligament repair: preliminary results and instrumented testing for anterior stability.

The authors present their preliminary results of arthroscopic primary repair of anterior cruciate ligament tears performed on five patients, with a mean follow-up time of 9.2 months. All patients were re-evaluated by subjective questionnaire and clinical examination, and tested for anterior drawer at 20 degrees flexion using the KT-1000 Knee Ligament Arthrometer and the UCLA Instrumented Clinical Knee Testing Apparatus. Subjectively, four patients were rated as fair and one as good. The Lachman test was negative in two and trace or mildly positive in three patients. Pivot shift test was negative in all. Instrumented testing demonstrated three patients with increased anterior laxities outside the normal range, and two of these patients also showed reduced anterior stiffnesses which were beyond the normal range. Based on these results, the authors question the feasibility of arthroscopic repair of anterior cruciate ligament tears and suggest a more objective evaluation of this procedure.

Triceps tendon avulsion in a professional body builder. A case report.

We have reported a case of triceps tendon avulsion in a professional body builder, treated successfully by delayed repair, allowing him to return to competition. Triceps tendon ruptures, besides being rare injuries, differ from tendon ruptures in other locations. First, the injury can occur through healthy tissue. Second, the time of delay, from injury to repair, seems to have little effect on the functional outcome, as we demonstrated in our patient.