This study aimed to determine the extent to which the medial collateral ligament (MCL) can be visualized during a standard posterior arthroscopic view of the elbow.
Eight fresh human cadaveric elbows ...were placed in a simulated lateral decubitus position. Standard elbow arthroscopy was performed on each specimen using a standard posterior portal for visualization with a 30° arthroscope. The most distal borders of the visible part of the MCL were marked using a spinal needle and tagged using nylon sutures. Subsequently, the elbow was dissected. The overall surface area of the entire MCL and that defined by the suture tags were calculated for each specimen.
The mean area of the visible part of the MCL represented 48% of the mean overall area. The arthroscopically tagged part of the posterior band of the MCL represented <50% of the entire MCL. Arthroscopic visualization was not available for most of the posterior bands of the MCL.
Less than half of the MCL is visible with a 30° arthroscope from standard posterior portal. Thus, sole reliance on arthroscopic visualization with this manner is not enough to release of the MCL. The variable effort is required to improve the limited visualization during the procedure. Moreover, the individual attention is essential to protect the ulnar nerve because the ulnar nerve is very close to the MCL especially to the anterior band.
Background:
Femoroacetabular impingement (FAI) is increasingly recognized as a cause of hip pain in young adults. The condition leads to chondrolabral separation and chondral delamination and ...eventually predisposes to osteoarthritis of the hip. FAI that inflicts cartilage damage has been observed in hips with abnormal morphological characteristics and is related to a long-term evolution toward osteoarthritis. Arthroscopic surgery, which allows for correction of morphological characteristics and restores impingement-free motions, is the current standard of treatment.
Hypothesis:
Arthroscopic cam resection can restore the normal mechanical environment of the hip joint in cam-type FAI.
Study Design:
Descriptive laboratory study.
Methods:
Patient-specific discrete element models from 10 patients with cam-type FAI (all male; age, 18-40 years) were defined based on preoperative computed tomography scans and postoperative magnetic resonance imaging (MRI) scans. Complete cam resection postoperatively on MRI was confirmed with alpha angles <55°. The preoperative and postoperative peak contact stress findings during impingement testing were compared against a matched control group.
Results:
Peak contact stress was significantly elevated in patients with cam-type FAI during impingement testing, with increasing amounts of internal hip rotation (26.6 ± 11.64 MPa in cam patients preoperatively, 12.1 ± 4.62 MPa in those same patients postoperatively, and 11.4 ± 1.72 MPa in the virtual control group during impingement testing at 20° of internal hip rotation; P < .01). This effect was normalized after arthroscopic cam resection and loading patterns matched those of the control group.
Conclusion:
Accurate arthroscopic cam resection restored the normal peak joint contact stresses in the hip joint. This highlights the importance of early and complete cam resections in the face of a positive diagnosis of cam-type FAI.
Clinical Relevance:
Treatment of cam-type FAI effectively normalizes hip joint contact mechanics.
Tears of the Ligamentum Teres Botser, Itamar B.; Martin, Dorea E.; Stout, Chris E. ...
The American journal of sports medicine,
07/2011, Letnik:
39, Številka:
1_suppl
Journal Article
Recenzirano
Background
The ligamentum teres (LT) anatomy has been known for many years. While its functionality remains debatable, it is well recognized that the LT can be a source of pain in the hip joint. In ...1997, a landmark publication by Gray and Villar established a classification for LT tears and increased the awareness of LT disorders. However, the incidence of LT tears and the various tear types is unknown.
Purpose
The authors report the prevalence of LT tears in a population of patients who underwent hip arthroscopy, using both the Gray and Villar classification and a new descriptive classification.
Study Design
Case series; Level of evidence, 4.
Methods
Between February 2008 and January 2011, 616 hip arthroscopies were performed by the senior author. After excluding revision surgeries, a total of 558 surgeries (502 patients) were included in the study. Data were collected regarding patients’ demographics, mechanism of injury, range of motion, magnetic resonance results, and intraoperative findings. Preoperative hip-specific questionnaire scores and pain level were recorded as well. Ligamentum teres tears were classified according to Gray and Villar's classification, and were also categorized using a descriptive grading system as follows: 0, no tear; 1, <50% tear; 2, >50% tear; or 3, 100% tear.
Results
A total of 284 (51%) of the 558 surgeries in this cohort revealed LT tears. According to the descriptive grading system, 22% were grade 1, 24% were grade 2, and 5% were grade 3. According to the Gray and Villar classification 3.7% had full rupture, 43% had a partial tear, and 4.5% had a degenerative tear. Patients with LT tears were significantly older and had worse preoperative functional scores; they did, however, have a greater range of motion. Intraoperatively, an association with larger labral tear size and acetabular chondral damage was found. Magnetic resonance arthrography was found to have low accuracy and sensitivity in detection of LT tears. No correlation to the pain level was found.
Conclusion
Ligamentum teres tears had a higher prevalence in this study than was published in the past, most probably attributable to a lower threshold used in defining a tear. The incidence is defined both using the Gray and Villar classification, as well as a new descriptive classification system that categorizes the LT according to amount of tearing.
Trends in Long Head Biceps Tenodesis Werner, Brian C.; Brockmeier, Stephen F.; Gwathmey, F. Winston
The American journal of sports medicine,
03/2015, Letnik:
43, Številka:
3
Journal Article
Recenzirano
Background:
Tenodesis of the long head of the biceps tendon has become a popular surgical treatment option for patients with pain or instability attributed to a diseased or unstable biceps tendon. No ...previous studies have characterized the practice patterns of surgeons performing biceps tenodesis in the United States.
Purpose:
To investigate current trends in both arthroscopic and open biceps tenodesis across time, sex, age, and region of the United States as well as associated charges.
Study Design:
Descriptive epidemiology study.
Methods:
Patients who underwent biceps tenodesis (Current Procedural Terminology CPT codes 23430 and 29828) for the years 2008 through 2011 were identified using the PearlDiver Patient Record Database, including both private-payer and Medicare data. These cohorts were then assessed for associated diagnoses using International Classification of Diseases, 9th Revision, codes and concomitant procedures using CPT codes. These searches yielded procedural volumes, sex and age distribution, regional volumes, and average per-patient charges. A χ2 linear-by-linear association analysis, Student t test, and linear regression were used for comparisons, with P < .05 considered significant.
Results:
A total of 44,932 biceps tenodesis procedures were identified from 2008-2011. The incidence of biceps tenodesis procedures per 100,000 database patients increased 1.7-fold over the study period, from 8178 in 2008 to 14,014 in 2011 (P < .0001). An increase in the overall percentage volume was noted in patients aged 60-69 years (P = .039) and 20-29 years (P = .016). The overall charges for arthroscopic tenodesis increased at a rate significantly greater than that of open tenodesis (P < .0001). Rotator cuff tear or sprain, bicipital tenosynovitis, biceps tendon rupture, superior labral lesion, and osteoarthritis were the most common diagnoses associated with biceps tenodesis procedures. A significant increase in isolated biceps tenodesis was also observed over the study period, from 1967 patients in 2008 to 3565 patients in 2011, representing a 1.8-fold increase.
Conclusion:
The incidence of biceps tenodesis has increased yearly from 2008-2011. Arthroscopic tenodesis has emerged as a more popular technique. Charges associated with the procedure have increased significantly. Significant regional variations in procedural incidences exist.
Introduction
Osteochondrosis dissecans (OCD) at the capitellum is a common pathology in young patients. Although arthroscopic interventions are commonly used, there is a lack of information about the ...accessibility of the defects during elbow arthroscopy by using standard portals.
Materials and methods
An elbow arthroscopy using the standard portals was performed in seven fresh frozen specimens. At the capitellum, the most posterior and anterior cartilage surface reachable was marked with K-wires. Using a newly described measuring method, we constructed a circular sector around the rotational center of the capitellum. The intersection of K-wire “A” and “B” with the circular sector was marked, and the angles between the K-wires and the Rogers line, alpha angle for K-Wire “A” and beta angle for K-wire “B”, and the corridor not accessible during arthroscopy was digitally measured.
Results
On average, we found an alpha angle of 53° and a beta angle of 104°. Leaving a sector of 51° which was not accessible via the standard portals during elbow arthroscopy.
Conclusion
Non-accessible capitellar lesions during elbow arthroscopy should be considered preoperatively, and the informed consent discussion should always include the possibility of open procedures or the use of flexible instruments.
Level of Evidence
4.
Purpose
To evaluate the outcomes of two commonly used transosseous-equivalent (TOE) arthroscopic rotator cuff repair (RCR) techniques for full-thickness supraspinatus tendon tears (FTST) using a ...robust multi-predictor model.
Methods
155 shoulders in 151 patients (109 men, 42 women; mean age 59 ± 10 years) who underwent arthroscopic RCR of FTST, using either a knotted suture bridging (KSB) or a knotless tape bridging (KTB) TOE technique were included. ASES and SF-12 PCS scores assessed at a minimum of 2 years postoperatively were modeled using propensity score weighting in a multiple linear regression model. Patients able to return to the study center underwent a follow-up MRI for evaluation of rotator cuff integrity.
Results
The outcome data were available for 137 shoulders (88%;
n
= 35/41 KSB;
n
= 102/114 KTB). Seven patients (5.1%) that underwent revision rotator cuff surgery were considered failures. The median postoperative ASES score of the remaining 130 shoulders was 98 at a mean follow-up of 2.9 years (range 2.0–5.4 years). A higher preoperative baseline outcome score and a longer follow-up had a positive effect, whereas a previous RCR and workers’ compensation claims (WCC) had a negative effect on final ASES or SF 12 PCS scores. The repair technique, age, gender and the number of anchors used for the RCR had no significant influence. Fifty-two patients returned for a follow-up MRI at a mean of 4.4 years postoperatively. Patients with a KSB RCR were significantly more likely to have an MRI-diagnosed full-thickness rotator cuff re-tear (
p
< 0.05).
Conclusions
Excellent outcomes can be achieved at a minimum of 2 years following arthroscopic KSB or KTB TOE RCR of FTST. The preoperative baseline outcome score, a prior RCR, WCC and the length of follow-up significantly influenced the outcome scores. The repair technique did not affect the final functional outcomes, but patients with KTB TOE RCR were less likely to have a full-thickness rotator cuff re-tear.
Level of evidence
Level III, Retrospective Comparative Study.
Background
The management of massive, irreparable rotator cuff tears (RCT) is challenging and associated with high failure rates. There are no current consensus or definitive guidelines concerning ...the optimal surgical treatment for this devastating condition. This study was designed to confirm the long-term safety and efficacy of the biodegradable inflatable InSpace™ system in patients with massive reparable or irreparable RCTs.
Methods
In this open-label, single arm, prospective study, subjects with massive RCT underwent subacromial implantation with the biodegradable spacer. Follow-up visits were scheduled according to routine clinical practice. Shoulder function was evaluated using Total Constant Score (TCS).
Results
Twenty-four patients were treated and assessed. Four patients had partial tears, and in three of them RC repair was performed. These patients were not included in the efficacy analyses. Of the participating subjects who reached the 5-year follow-up, 84.6% of the patients showed a clinically significant improvement of at least 15 points in their score, while 61.54% showed at least 25 points of improvement. Only 10% of the treated patients showed no improvement or worsening in the shoulder score comparing to their baseline. An overall improvement in the total CS commencing at 3 months and sustained by 6 months through to 5 years of follow-up (
P
< 0.0001) was demonstrated.
Conclusions
We conclude that in this initial cohort, arthroscopic implantation of InSpace™ system represented an effective alternative to the existing arthroscopic procedures in patients with painful massive RCT refractory to conservative management. Further randomized controlled trials comparing the clinical and functional outcomes after implantation of the InSpace™ device are warranted.
Background:
Although hip arthroscopy has been shown to have favorable results, there is a paucity of literature describing predictive factors of 5-year clinical outcomes.
Purpose:
To identify ...predictive factors of midterm outcomes after hip arthroscopy in a cohort of 1038 patients whose outcomes at minimum 2-year follow-up were previously reported. In addition, to provide a comparison of short- and midterm predictive factors in outcome measures after hip arthroscopy.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
Data were prospectively collected and retrospectively reviewed on all patients undergoing hip arthroscopy between February 2008 and June 2012. Patients were included if they had minimum 5-year follow-up on 2 patient-reported outcomes: Nonarthritic Hip Score (NAHS) and modified Harris Hip Score. Patients were excluded if they had any previous ipsilateral hip conditions. Using bivariate and multivariate analyses, we analyzed the effect of 36 pre- and intraoperative variables on the NAHS, modified Harris Hip Score, and conversion to total hip arthroplasty.
Results:
A total of 1038 patients met the inclusion criteria for the 2-year study, and 860 met our listed inclusion criteria for the 5-year study. The mean follow-up time was 62.0 months (range, 60.0-120.0 months). The bivariate analysis identified 10 variables (4 categorical and 6 continuous) that were predictive of 5-year postoperative NAHS. For the multivariate analysis, 7 variables were identified as being significant: preoperative NAHS, body mass index (BMI), age, lateral joint space, alpha angle, revision hip arthroscopy, and acetabular microfracture. These 7 variables were also predictive in the bivariate analysis. Age, BMI, revision hip arthroscopy, Tönnis grade, sex, trochanteric bursectomy, femoral head cartilage damage, and acetabular inclination were significant predictors of conversion to total hip arthroplasty.
Conclusion:
This study reports favorable midterm clinical outcomes in the largest cohort of hip arthroscopies with minimum 5-year follow-up in the literature to date. Seven variables were identified as being significant predictors of postoperative NAHS in the bivariate and multivariate analyses: preoperative NAHS, BMI, age, lateral joint space, alpha angle, revision hip arthroscopy, and acetabular microfracture. Of these, preoperative NAHS, BMI, age, and revision hip arthroscopy were predictive of 2- and 5-year postoperative NAHS. These predictive factors may prove useful to clinicians in determining indications for hip arthroscopy and counseling patients on its expected outcomes.
This study assessed the outcomes of arthroscopic management of avulsion fractures of the tibial attachment of the posterior cruciate ligament (PCL), with holding of the PCL with two ''cinch knots''.
...15 patients with avulsion fractures of the tibial attachment of the PCL were treated with arthroscopic reduction and fixation with holding of the PCL with two ''cinch knots''. All patients were males with mean age of 28 (range, 15–44) years. Patients were assessed by the Lysholm Tegner knee scale and IKDC (International knee documentation committee) objective grade.
The mean follow-up period was 40 (range, 12–60) months. Mean postoperative flexion was 134.7° (range, 120–150). Mean Lysholm score was 90.27 (range, 67–99). Lysholm score was excellent in seven (46.7%) patients, good in six (40%) patients, fair in two (13.3%) patients, and none of the patients was poor. 11 (73.3%) patients had IKDC grade A, and four (26.7%) patients had IKDC grade B due to residual grade 1+ posterior drawer. Current Tegner activity level remained the same in nine (60%) patients, decreased one level in three (20%) patients, and decreased two levels in three (20%) patients as compared to the preinjury level. There wasn't any vascular or nerve complications.
Arthroscopic treatment of PCL tibial avulsion fractures with the cinch knot technique has many advantages, and it proved to be safe and effective. The technique is simple and easy to be reproduced. Early results are promising to encourage surgeons to make this novel technique.
Therapeutic study, prospective case series with no comparison group, Level IV.
Inadvertent perioperative hypothermia (IPH), defined as core body temperature below 36°C, is associated with various complications. Shoulder arthroscopy is a risk factor of IPH. This study aimed to ...compare the incidence of IPH between general anesthesia (GA) and interscalene brachial plexus block (ISBPB) for shoulder arthroscopy.
Patients scheduled for shoulder arthroscopy were prospectively enrolled and randomly assigned to GA or ISBPB groups. The body temperature of the patients was measured from baseline to the end of anesthesia and in the post-anesthetic care unit to compare the incidence of IPH.
Of the 114 patients initially identified, 80 were included in the study (GA = 40, ISBPB = 40). The incidence of IPH differed significantly between the groups, with GA at 52.5% and ISBPB at 30.0% (P = .04). Profound IPH (defined as < 35.0°C) occurred in 2 patients with GA. Upon arrival at the post-anesthesia care unit, the GA group exhibited a significantly lower mean body temperature (35.9 ± 0.6°C) than the ISBPB group (36.1 ± 0.2°C, P = .04).
The incidence of IPH in the GA group was higher than that in the ISBPB group during shoulder arthroscopy, suggesting that ISBPB may be a preferable anesthetic technique for reducing risk of IPH in such procedures.
