Elbow arthroscopy for neglected osteochondritis dissecans of the capitellum.

We reviewed results of elbow arthroscopy for neglected osteochondritis dissecans (OCD) of the capitellum. Of more than 140 patients having elbow arthroscopy at our institution, 10 patients (11 elbows) had OCD of the capitellum and fulfilled inclusion criteria. Criteria included symptoms of at least 2 years' duration, loss of motion for at least 6 months, or radiographic evidence of secondary degenerative changes. One patient was lost to follow-up. The remaining 9 (10 elbows) were male patients with a median age of 20 years (range, 15 to 58 years). Follow-up averaged 4.6 years (range, 2 to 8 years). Using a 100-point system, postoperative elbow scores averaged 92 (range, 55 to 100). All patients returned to preoperative activities, though only 8 of 10 believed that surgery resulted in improvement. Elbow arthroscopy for neglected OCD can result in functional improvement. However, results are not as good as those reported with earlier intervention.

Bioscrew fixation of patellar tendon autografts.

Biodegradable interference screw fixation was studied using patellar tendon autografts in a randomized, prospective multicenter comparison of the PLLA Bioscrew and a metal interference screw. sixty-eight of 114 (60%) patients (34 Bioscrew and 34 metal screw) enrolled were available for follow up an average of 35 months after surgery (range 24-65). There were 42 males and 26 females with an average age of 29 years (16-50). Tourniquet times and associated surgical findings were similar for the two groups. Postoperative KT, Tegner, and Lysholm scores were not statistically different between the two groups. Average follow up KT maximum manual side-to-side difference was 0.9 mm for Bioscrews and 1.4 mm for metal screws. Postoperative Lachman and pivot shift testing were equivalent for the two groups. Other than six of the 7 mm Bioscrews breaking during insertion in the femoral tunnel, there were no problems related to the PLLA implants. No statistical difference was found between the Bioscrew and the metal screw groups, and there were no osteolytic or other reactive bone changes observed associated with the PLLA Bioscrew. These data indicate that the PLLA Bioscrew functions reliably as an interference fixation screw for patellar tendon autografts.

Bioabsorbable interference screws for graft fixation in anterior cruciate ligament reconstruction.

The central one third of the patellar tendon autograft is popular because the bone-tendon-bone (BTB) construct provides several graft fixation options, robust graft incorporation, and a mechanically sufficient substitute. Interference screw fixation is one method used to secure the graft. Bioabsorbable interference screws may offer advantages over metal interference screws. Bioabsorbable screws are made from poly L-lactic acid (PLLA) and are absorbed by the body. This prospective, randomized study compared the safety and efficacy of the PLLA screw with that of the metal cannulated interference screw for anterior cruciate ligament reconstruction. There were 204 patients randomly assigned to the Bioscrew (Linvatec, Largo, FL) (n = 103) or the metal interference screw (n = 101) groups at four sites. The mean age was 30 years. There were 66 women and 138 men. Mean follow-up was 30 months for Bioscrews and 28 months for metal screws; the average follow-up interval was 2.4 years. The Lysholm mean scores at 4 years for the 32 patients seen at this interval were 95.0 and 97.2 for the Bioscrew and metal screw group, respectively. Ligament laxity comparisons made with an instrumented arthrometer at manual maximum force resulted in side-to-side mean score differences of B = 1.8mm and M = 1.6mm. The Tegner activity level score means were B = 6.1 and M = 5.8. Other variables examined included pain, thigh size, meniscal tests, Lachman's test, range of motion, anterior drawer, pivot shift, patellofemoral crepitus and tenderness, and joint effusion. None of these variables showed a statistically significant difference between groups. No radiographic evidence of osteolytic change or bone resorption around the Bioscrews was observed. There were no complications related to loss of fixation, toxicity, allergenicity, or other evidence of osteolytic or inflammatory reaction. In every assessment between groups there was no difference found. There were 12 PLLA screws that broke during insertion without any adverse effects. The PLLA headless cannulated interference fit screws produce equal results to similarly designed metal screws.

Is an anterior cruciate ligament reconstruction outcome age dependent?

Treatment of a torn anterior cruciate ligament (ACL) in older patients must be considered in relation to healing delays, rehabilitation difficulties, stiffness, arthritis, and actual athletic demands. This study compares ACL reconstructions in patients 40-years old and older with those under 40-years old and contrasts these to published nonoperative data in the 40 and older patient. Patients undergoing ACL reconstruction between 1992 and 1994 were preoperatively and postoperatively assessed with Lysholm, Tegner, KT, radiographic, and clinical examinations. They were divided into two groups: those 40 years and older (group 1) and those 39 years and younger (group 2). Group 1 had 33 patients with an average age of 44 years (range, 40 to 52 years). Radiographic Fairbank changes were absent. Group 2 had 170 patients with an average age of 27 years (range, 16 to 39 years). Group 1 preoperative instability and intake data were not statistically different from those of group 2. Average follow-up was 21 months for both groups. Both groups showed significant improvement in all parameters at 12- and 24-month follow-up examinations. Lysholm scores, Tegner scores, average KT manual maximum side-to-side differences, Lachman tests, and pivot shift testing were not statistically different in either group. Using Lysholm criteria, in group 1, 89% had excellent/good results, and 11% fair/poor results. This was not statistically different from group 2, which showed 91% excellent/good results and 9% fair/poor results at 24-month follow-up examination. For this age group, nonoperative treatment reports indicate 57% excellent/good results and 43% fair/poor results. The outcomes between these groups are the same and fail to establish the age of 40 years as a barrier to successful ACL reconstruction.

Preliminary results of an absorbable interference screw.

A randomized, prospective multicenter comparison was done of a bioabsorbable interference screw (Bioscrew; Linvatec Corp, Largo, FL) made from poly L-lactic acid and a metal interference screw produced by the same company. Assignment was randomized by sealed envelopes. A total of 110 patients underwent arthroscopic patellar tendon autografts. A minimum 12 months follow-up is available on 85 patients (mean 19 months, range 12 to 33) including 42 with Bioscrews and 43 with metal screws. There were 56 male and 29 female patients. The average age was 29 years (16 to 50 years). Tourniquet times and associated surgical findings were similar for the two groups. Postoperative Tegner and Lysholm scores were not statistically different between the two groups. KT tests at 1 year showed an average 20-lb laxity of 1.8 mm for the Bioscrew and 1.2 mm for the metal screw groups. The average 1-year KT maximum manual side-to-side difference was 1.6 mm for Bioscrews and 1.6 mm for metal screws. A pivot shift was absent in 83% of Bioscrews and 90% of metal screws at follow-up. Six of 85 Bioscrews inserted (7%) broke on insertion (all were 7-mm diameter screws at the femoral site). No additional fixation was required in four cases. In two, the broken screw was replaced. No lytic bone changes or tunnel widening were found with any Bioscrew. One metal screw had tibial tunnel widening. No statistical difference was found between the Bioscrew and the metal screw groups. Short-term data support the conclusion that the Bioscrew is a reasonable alternative to metal interference screws.

Surgical treatment of tears of the rotator cuff in athletes.

Forty-five athletes with either a partial or a complete tear of the rotator cuff were treated with anterior acromioplasty and repair of the tear. The minimum duration of follow-up was twenty-four months (average, forty-two months). Thirty patients had an incomplete tear and fifteen had a complete tear. Postoperatively, thirty-nine (87 per cent) of the patients stated that they were improved compared with their preoperative status, although only thirty-four patients (76 per cent) felt that they had a significant reduction of pain postoperatively. Objectively, twenty-five (56 per cent) of the patients were rated as having a good result, which allowed them to return to their former competitive level without significant pain. Twelve (41 per cent) of the twenty-nine athletes who had been involved in pitching and throwing returned to their former competitive status. Seven (32 per cent) of the twenty-two pitchers and throwers who had been active at a professional or collegiate level returned to the same competitive level. In our experience, a repair of the rotator cuff combined with an acromioplasty in a young athletic population provides satisfactory relief of pain but does not guarantee that the patient will be able to return to his or her former competitive status in all sports.

Changes in the synthesis of minor cartilage collagens after growth of chick chondrocytes in 5-bromo-2'-deoxyuridine or to senescence.

Analyses were made of the minor collagens synthesized by cultures of chondrocytes derived from 14-day chick embryo sterna. Comparisons were made between control cultures, cultures grown for 9 days in 5-bromo-2'-deoxyuridine (BrdU) and clones of chondrocytes grown to senescence. Separation of minor collagens from interstitial collagens was achieved by differential salt precipitation in the presence of carrier collagens in acid conditions. The precipitate at 0.9 M NaCl 0.5 M acetic acid from control cultures was shown by CNBr peptide analysis to contain only the alpha 1(II) chain of type II collagen, whereas after BrdU treatment or growth to senescence synthesis of only alpha 1(I) and alpha 2(I) chains occurred. The synthesis of type III collagen was not detected. Analysis of the precipitate at 2.0 M NaCl, 0.5 M HAc from control cultures demonstrated the synthesis of 1 alpha, 2 alpha and 3 alpha chains together with the synthesis of short chain (SC) collagen of Mr 43000 after pepsin digestion. After BrdU treatment or growth to senescence alpha chains were isolated which possessed the migration positions on polyacrylamide gel electrophoresis (PAGE), or the elution positions on CM-cellulose chromatography, of the alpha 1(V) and alpha 2(V) chains of type V collagen. In addition, for BrdU-treated but not for control cultures, intracellular immunofluorescent staining was observed with a monoclonal antibody which specifically recognizes an epitope present in the triple helix of type V collagen. Synthesis of short chain (SC) collagen was not detected after BrdU treatment or growth to senescence. These results suggest that chick chondrocytes grown in conditions known to cause switching of collagen synthesis from type II to type I collagen also undergo a switch from the synthesis of 1 alpha, 2 alpha and 3 alpha chains to the synthesis of the alpha 1(V) and alpha 2(V) chains of type V collagen. It appears that there are several cartilage-specific collagens which together undergo a regulatory control to the synthesis of collagens typical of other connective tissues.