Abstract: Purpose: To define the positions of the attachments of the anteromedial (AM) and posterolateral (PL) bundles of the anterior cruciate ligament (ACL). Methods: The shape and positions of the femoral and tibial attachments of the 2 bundles relative to bony landmarks were measured in 7 fresh-frozen, unpaired cadaveric knees by 6 independent observers. Metallic marker beads were then inserted into the defined anatomic points, and plain radiographs of the specimens were taken. We used the line described by Amis and Jakob on the tibia and the grid prepared by Bernard et al. for the femur to define AM and PL bundle attachment positions. Results: In the cadaveric specimens, referencing the position of the AM bundle tibial attachment from the retro-eminence ridge (RER) resulted in the least interobserver error. On tibial radiographs, the distance between the posterior tibial cortex and the perpendicular projection of the center of the AM bundle attachment onto Amis and Jakob's line was 35.6 ± 5.1 mm. The ratio of this distance to the length of Amis and Jakob's line (from the anterior cortex) was 36% ± 3.8% (and 52% ± 3.4% for the center of the PL bundle). On the femur, the center of the AM bundle was situated at 26.4% ± 2.6%, and the center of the PL bundle at 32.3% ± 3.9%, along the length of Blumensaat's line. Conclusions: The RER provides an easily identifiable and accurate reference point that can be used clinically. On a lateral radiograph, the positions of the tibial attachments can be referenced to Amis and Jakob's line. This method, different from Blumensaat's line, is independent of knee flexion. Clinical Relevance: This study details anatomically and radiologically the positions of the attachments of the AM and PL bundles of the ACL. This could assist with accurate tunnel placement in reconstruction surgery and provide reference data for postoperative radiographic evaluation.

Abstract: In order to optimize healing biology at a repaired rotator cuff footprint, we have developed a "transosseous-equivalent" rotator cuff repair that can be performed arthroscopically. What the arthroscopically repaired tendon experiences is "equivalent" to what is experienced with a traditional open suture-bridge technique. This repair maximizes the utility of a single-row repair technique by preserving the suture limbs of the medial single-row and bridging these sutures over the footprint insertion with distal-lateral interference screw suture fixation; the medial row uses a mattress suture configuration. The geometry of the construct compresses the tendon, optimizing tendon-to-tuberosity contact dimensions, while providing strength sufficient to withstand immediate postoperative rehabilitation.

Abstract: Purpose: The purpose of this study was to offer evidence of validity for the Hip Outcome Score (HOS) based on internal structure, test content, and relation to other variables. Methods: The study population consisted of 507 subjects with a labral tear. Internal structure was evaluated by use of factor analysis and coefficient α. Test content was evaluated by use of item response theory. Pearson correlation coefficients were used to assess relations between the Short Form 36 and the HOS. Results: The mean subject age was 38 years (range, 13 to 66 years), with 232 male and 273 female subjects. Of the subjects, 263 (52%) underwent arthroscopic surgery. Factor analysis found that 17 of 19 items on the activities-of-daily-living (ADL) subscale loaded on 1 factor. The 2 items that did not fit the 1-factor model were omitted from further testing. All 9 items on the sports subscale loaded on 1 factor. The coefficient α values were .96 and .95 for the ADL and sports subscales, respectively. The errors associated with a single measure were ±4.6 and ±3.8 points for the ADL and sports subscales, respectively. Item response theory found that all items contributed to their test information curves and were potentially responsive. The correlations between the HOS and Short Form 36 measures of physical function were significantly different than their correlation to measures of mental functioning ( P Conclusions: The results of this study provide evidence of validity to support the use of the HOS ADL and sports subscales for individuals with labral tears. This includes individuals who underwent arthroscopic surgery, as well as those who did not. Specifically, the results of this study found that the HOS ADL and sports subscales were unidimensional, had adequate internal consistency, were potentially responsive across the spectrum of ability, and contributed information across the spectrum of ability. In addition, scores obtained by the HOS related to measures of function and did not relate to measures of mental health. Level of Evidence: Level III, development of diagnostic criteria with nonconsecutive patients.

Abstract: Purpose: The purpose of this study was to compare outcomes of chondroplasty versus microfracture versus osteochondral autologous transplantation (OAT) in patients with osteochondral lesions of the talus (OLT). Methods: After prospective sample size analysis, patients with symptomatic, recalcitrant Ferkel class 2b, 3, and 4 OLT were randomized to chondroplasty, microfracture, or OAT treatment groups. Outcomes were measured with use of the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (AHS), the Subjective Assessment Numeric Evaluation (SANE) rating, Numeric Pain Intensity (NPI), and magnetic resonance imaging (MRI). Results: Eleven patients had chondroplasty, 10 ankles (9 patients) had microfracture, and 12 patients had OAT. Mean time to follow-up was 53 months (range, 24 to 119 months). AHS scores showed no differences at 12 and 24 months, and SANE ratings showed no differences at final follow-up. NPI was significantly lower ( P Conclusion: Our results demonstrate no difference between chondroplasty, microfracture, and OAT with regard to AHS and SANE ratings in patients with OLT. However, NPI at 24 hours postoperatively was significantly lower in patients who had chondroplasty and microfracture. Level of Evidence: Level I, Therapeutic study, high-quality randomized controlled trial with no statistically significant differences but narrow confidence interval.

Abstract: Purpose: It was our intent to devise a new clinical test that would more accurately diagnose subscapularis tears than the current clinical tests. This new test is called the bear-hug test. The purpose of this study was to assess the bear-hug test and compare it with the current tests of subscapularis function (lift-off, belly-press, and Napoleon tests). Methods: Between January 2004 and March 2004, 68 consecutive patients scheduled for an arthroscopic procedure were evaluated preoperatively; the preoperative clinical examination findings were then correlated with arthroscopic findings. Lift-off, belly-press, Napoleon, and bear-hug tests were included in the examination. Furthermore, for the belly-press and bear-hug tests, the strength was precisely quantified by means of an electronic digital tensiometer (Kern HBC). Diagnostic arthroscopy was the reference that determined the actual pathologic lesions. Results: Subscapularis tears occurred with a prevalence rate of 29.4%. Of the subscapularis tears, 40% were not predicted by preoperative assessment by use of all of the tests. The bear-hug test was found to be the most sensitive test (60%) of all of those studied (belly-press test, 40%; Napoleon test, 25%; and lift-off test, 17.6%). In contrast, all 4 tests had a high specificity (lift-off test, 100%; Napoleon test, 97.9%; belly-press test, 97.9%; and bear-hug test, 91.7%). No statistically significant difference was found between the area under the receiver operating characteristic curve of the bear-hug test and that of the belly-press test in diagnosing a torn subscapularis. However, the areas under the receiver operating characteristic curve for both the bear-hug test and the belly-press test were significantly greater than those for the lift-off and Napoleon tests ( P Conclusions: The bear-hug test optimizes the chance of detecting a tear of the upper part of the subscapularis tendon. Moreover, because the bear-hug test represents the most sensitive test, it can be considered to be the most likely clinical test to alert the surgeon to a possible subscapularis tear. Performing all of the subscapularis tests is useful in predicting the size of the tear. Level of Evidence: Level I, diagnostic study: testing of previously developed criteria in a series of consecutive patients with arthroscopy used as the criterion standard.

Abstract: Purpose: Intra-articular use of 0.5% bupivacaine is common in arthroscopic surgery. This study was conducted to test the hypotheses that (1) 0.5% bupivacaine is toxic to articular chondrocytes, and (2) the intact articular surface protects chondrocytes from the effects of short-term exposure to 0.5% bupivacaine. Methods Freshly isolated bovine articular chondrocytes were prepared into alginate bead cultures and were treated with 0.5% bupivacaine solution or 0.9% saline for 15, 30 or 60 minutes, washed, and returned to growth media. Chondrocytes were recovered from alginate 1 hour, 1 day, and 1 week after bupivacaine exposure; they were fluorescently labeled to identify apoptotic and dead cells and were analyzed by flow cytometry. Twelve osteochondral cores were harvested from bovine knees. The superficial 1 mm of cartilage was removed from 6 cores (top-off). Intact and top-off cores were submerged in 0.9% saline or 0.5% bupivacaine solution for 30 minutes and then maintained in chondrocyte growth media for 24 hours. Live-cell/dead-cell fluorescent imaging was assessed using confocal microscopy. Results: Greater than 99% chondrocyte death/apoptosis was observed in all bupivacaine-exposed alginate bead cultures compared with 20% cell death in saline-treated controls ( P P Conclusions: Results show that 0.5% bupivacaine solution is cytotoxic to bovine articular chondrocytes and articular cartilage in vitro after only 15 to 30 minutes' exposure. The intact bovine articular surface has some chondroprotective effects. Clinical Relevance: Because healthy chondrocytes are important for maintenance of the cartilage matrix, chondrocyte loss may contribute to cartilage degeneration. This study shows a cytotoxic effect of 0.5% bupivacaine solution on bovine articular chondrocytes in vitro. Although these results cannot be directly extrapolated to the clinical setting, the data suggest that caution should be exercised in the intra-articular use of 0.5% bupivacaine.

Abstract: Purpose: The aim of the present study was to compare the mechanical behavior of some devices used for femoral fixation of doubled hamstring tendon graft in anterior cruciate ligament (ACL) reconstruction when included in a graft fixation complex (GFC). Methods: An ACL reconstruction was performed on 90 porcine knees. The graft used was the doubled lateral extensor of toes (DLET). Nine different femoral fixation devices were tested and classified according to their fixation mechanism: compression (Bioscrew and RCI screw); expansion (Rigidfix); cortical suspension (Ligament Anchor, EndoButton-CL, and Swing Bridge); cancellous suspension (Linx-HT); and cortical-cancellous suspension (Transfix and Bio-Transfix). All GFC were subjected to a cyclic loading test, then to a load-to-failure test. Graft elongation after 1,000 load cycles, failure load, and stiffness were calculated for each device. Results: Regarding graft elongation, Bioscrew and RCI screws showed the highest mean values. All the other GFC showed no significant differences between them when δ elongation (elongation 1,000 cycles − elongation 20 cycles ) was considered. For failure load, the highest mean values were observed for Bio-Transfix, Transfix, and Swing Bridge; a homogeneous subset with the lowest mean values was formed by Ligament Anchor, RCI screw, Bioscrew, and Linx-HT. For stiffness, the greatest values were observed for Bio-Transfix, Transfix, and Swing Bridge; all other groups showed no significant differences between them. Conclusions: Cortical-cancellous suspension fixation seemed to offer the best and most predictable results in terms of elongation, fixation strength, and stiffness. For both compression and suspension, the weakest fixation was attained with cancellous fixation devices. Cortical suspension devices showed a greatly variable mechanical behavior, according to their design. Clinical Relevance: Transcondylar devices offer the best structural properties for femoral fixation of doubled hamstring tendon graft in ACL reconstruction.

Abstract: Purpose: To compile the major complications of carpal tunnel surgery and compare reported complications for open and endoscopic techniques Methods: A literature assessment was performed for published complications of open and endoscopic carpal tunnel release procedures; 80 publications, representing a period from 1966 through 2001, were reviewed Complications were identified as neurapraxia; nerve, tendon, or artery injury; and wound infection or dehiscence that required antibiotics or additional operative care Differences in the proportions of complications between carpal tunnel release procedures were explored with the use of Fisher exact tests Results: The literature review yielded 22,327 cases of endoscopic carpal tunnel release and 5,669 cases of open carpal tunnel release For structural damage to nerves, arteries, or tendons, the incidence for open carpal tunnel release is 049% and for endoscopic methods (transbursal and extra-bursal), 019% This difference is statistically significant ( P Conclusions: The proportion of complications for carpal tunnel release, performed through an endoscopic or open approach, is very low Selection of an open versus an endoscopic approach on the basis of structural complications for nerve, arteries, or tendons is not supported by statistical analysis of published complications Level of Evidence: Level III, retrospective comparative therapeutic study

Abstract: The etiology of degenerative joint disease of the hip remains unsolved. A precursor for some patients, especially younger ones, may be hip impingement. Repetitive microtrauma at maximal flexion can cause chronic pain from the abutment at the femoral head-neck junction caused by an abnormal offset. Chronic impingement from an aspherical head can lead to degenerative labral tears and acetabular chondral degeneration, which may contribute to the degenerative cascade. Arthroscopic treatment of hip impingement caused by an abnormal head-neck offset improves symptoms, restores hip morphology, and ultimately may halt the progression toward degenerative joint disease in certain patients. Early results show that if debridement of the impinging lesion and injured labrum is performed in the setting of normal femoral and acetabular articular surfaces, the results are promising.

Abstract: Arthroscopic examination before anterior cruciate ligament (ACL) reconstruction sometimes reveals that there is a relatively thick ACL remnant bridging the femur and the tibia that may function to stabilize the knee, although its attachment is not the same as the anatomic site. We have established an ACL augmentation procedure that preserves the ACL remnant with the 1-incision technique using an autogenous semitendinosus tendon and EndoButton-CL (Acufex, Smith & Nephew, Mansfield, MA) instead of ACL reconstruction. When the ACL remnant was attached to the anteroinferior portion of the anatomic femoral origin and the posterolateral (PL) bundle was well preserved, the anteromedial (AM) bundle was reconstructed. When, in contrast, the ACL remnant was attached to the high-noon position with a well-preserved AM bundle, the PL bundle should be reconstructed. We have performed 13 AM bundle reconstructions and 4 PL bundle reconstructions. The merits of our ACL augmentation procedure are (1) it is performed under arthroscopy with 1 incision, (2) it avoids resection of the ACL remnant, which contributes to prevention of anterior laxity, (3) it preserves the ACL remnant's neural elements and mechanoreceptors, and (4) it provides a favorable influence on vascularity and reinnervation to the graft.

Abstract: Purpose: To compare the clinical outcomes of patients undergoing all-arthroscopic versus mini-open rotator cuff repair. In addition, ultrasound was used to assess the integrity of the repair. Methods: A total of 38 patients who had undergone all-arthroscopic repair and 33 patients who had undergone mini-open repair with minimum 2-year follow-up were evaluated. All patients completed the American Shoulder and Elbow Surgeons' Scoring Survey (ASES), the Simple Shoulder Test, the L'Insalata Scoring Survey, and visual analog scales for pain. Physical examination, including strength testing and ultrasound evaluation to determine the integrity of the rotator cuff, was performed. Results: No statistical difference in ASES scores was noted between patients who had all-arthroscopic repair versus mini-open repair, and 24% of all-arthroscopic repairs and 27% of mini-open repairs showed recurrent defects on ultrasound at follow-up. This difference was not statistically significant. Patients with an original tear larger than 3 cm were 7 times more likely to have a recurrent defect at follow-up. Patients with persistent defects had statistically significant deficits in strength on forward elevation and external rotation when compared with those with a normal shoulder. However, no difference was observed with regard to pain or outcome scores between patients with intact repairs and those with persistent defects. Conclusions: No difference in clinical outcomes was found between patients with rotator cuffs repaired arthroscopically and those repaired with use of a mini-open technique. Level of Evidence: Level III, retrospective comparative study.

Abstract: Purpose: The goal of this prospective study was to evaluate the results of arthroscopic meniscal repair using the FasT-Fix repair system. Type of Study: Prospective case series. Methods: Sixty-one meniscal repairs with the FasT-Fix meniscal repair system in 58 patients with a mean age of 32.6 years were performed between 2001 and 2002. Concurrent anterior cruciate ligament reconstruction was performed in 36 patients (62%). All tears were longitudinal and located in the red/red or red/white zone. Criteria for clinical success included absence of joint-line tenderness, locking, swelling, and a negative McMurray test. Clinical evaluation also included the Tegner and Lysholm knee scores, and KT-1000 arthrometry. In addition, all patients were evaluated preoperatively with magnetic resonance imaging. Results: The average follow-up was 18 months (range, 14 to 28 months). Six of 61 repaired menisci (9.8%) were considered failures according to our criteria. Therefore, the success rate was 90.2%. Time required for meniscal repair averaged 11 minutes. Postoperatively, the majority of the patients had no restrictions in sports activities. The mean Lysholm significantly improved from 43.6 preoperatively to 87.5 postoperatively ( P Conclusions: Our results show that arthroscopic meniscal repair with the FasT-Fix repair system provided a high rate of meniscus healing and appeared to be safe and effective in this group of patients. Level of Evidence: Level IV, therapeutic study, case series (no control group).

Abstract: Purpose: The objective was to clinically evaluate the treatment of type II Slap lesions repaired surgically using a bioabsorbable device. Type of Study: Retrospective clinical follow-up study. Methods: Forty-one patients with isolated type II SLAP lesions who were treated with arthroscopic fixation were identified. Patients were excluded for rotator cuff tears, instability, or subacromial decompression. Patients completed the L'Insalata and the American Society of Shoulder and Elbow Surgeons (ASES) questionnaires, and underwent a thorough shoulder examination at a minimum of 2 years postoperatively. Results: At a mean of 3.7 years follow-up, 33 of 41 patients returned for physical examination and 6 others returned the L'Insalata questionnaire. The mean L'Insalata and ASES scores were 86.7 and 86.8, respectively; 27 patients reported their satisfaction as good to excellent but only 14 of the 29 athletes returned to their preinjury level of athletics. The average ASES scores were statistically different in patients who had their rotator cuff pierced versus those who did not ( P Conclusions: Despite high outcome scores, overall patient satisfaction was only 71%. In addition, up to 41% continued to experience some degree of night pain. Patients treated with a rotator cuff piercing had a significantly poorer outcome. Moreover, the patients who were athletes performed poorer on their outcomes evaluation than did their nonathletic counterparts. Whereas the outcome scores overall were high, this problem is still difficult to treat successfully. This may be because of the high demands of athletes. The data also suggest that placing portals through the rotator cuff may be associated with poorer surgical outcomes. Level of Evidence: Level III.

Abstract: Arthroscopic subscapularis repair can be technically challenging. This article summarizes a number of technical tips that can greatly simplify and expedite what otherwise might be a daunting surgical procedure. Specific tips and pearls include the following: 1. A description of a new clinical test--the bear-hug test--for detecting subscapularis tears on physical examination. 2. How to accurately place portals for precise subscapularis repair. 3. How to safely and accurately perform a coracoplasty. 4. How to identify and mobilize a retracted subscapularis tear. 5. How the comma sign can be used to simplify arthroscopic subscapularis repair. 6. How to securely repair all sizes of subscapularis tear. 7. A description of postoperative immobilization and rehabilitation to optimize results of arthroscopic subscapularis repair.

Abstract: Purpose: Collision athletes have been reported to be at high risk of redislocation after stabilization for anterior shoulder instability. However, few studies have compared the results of arthroscopic stabilization with collision and noncollision athletes. The purposes of this study were to analyze clinical outcomes of arthroscopic anterior shoulder stabilization in athletes and to compare the results between collision and noncollision athletes. Methods: A total of 29 athletes were enrolled in this study, including 14 collision athletes and 15 noncollision athletes. Mean age at the time of operation was 21.1 years, and mean follow-up period was 62.1 months (range, 25 to 117 months). All shoulders underwent arthroscopic stabilization. Results: Visual analogue scale score, Rowe score, and Constant score improved after surgery ( P P P = .118). Conclusions: Arthroscopic stabilization for anterior instability of the shoulder is a reliable procedure with respect to shoulder function, range of motion, and postoperative return to sports activities in athletes. However, a high recurrence rate (17.2%) was observed among athletes. Compared with the noncollision group (6.7%), the collision group yielded a higher failure rate (28.6%) than was expected. Level of Evidence: Level IV, prognostic case series.

Abstract: Purpose: Ulnar collateral ligament (UCL) injuries may result in disabling valgus instability in throwing athletes. We evaluated the docking technique for UCL reconstruction and describe a modification to the technique. Methods: UCL surgery was indicated in 20 high-level baseball players (13 professional and 7 collegiate) based on medial elbow pain preventing effective throwing, clinically apparent medial elbow laxity, and magnetic resonance arthrogram consistent with UCL injury. The mean age was 21.7 years (range, 17.9 to 25.3 years). One patient had previous UCL reconstruction. One had previous arthroscopic elbow debridement. The mean time between injury and treatment was 73 days. Reconstruction was performed via a muscle-splitting approach and the docking technique with palmaris or gracilis graft. For the initial 12 patients, a 2-strand construct was used; however, during the study period, we developed and began using a 3-strand construct with a double anterior bundle and a single posterior bundle, which was used in the next 8 patients. The ulnar nerve was not routinely transposed unless there were preoperative ulnar nerve symptoms (1 patient). Two patients had osteophyte debridement. One had removal of a loose body. Results: Patients were followed up for a mean of 41.9 months (range, 6.4 to 67.1 months). One player was lost to follow-up and could not be identified on a professional roster. Of the remaining 19 patients, 18 returned to their previous level of participation or higher. Two were occasional pitchers who did not wish to return to pitching but continued to play other positions. They were clinically and functionally asymptomatic. The mean time to return to play was 13.1 months (range, 6.3 to 21.3 months). By use of the Timmerman-Andrews 100-point subjective scoring system, the mean preoperative score was 77.0 (range, 65 to 80) and the mean postoperative score was 98.2 (range, 85 to 100). By use of the Conway-Jobe scoring system, the outcome was rated as excellent in 17 patients and good in 2. One patient underwent subsequent ulnar nerve transposition and returned to the previous level of professional play. Conclusions: UCL reconstruction with the docking technique is a reproducible and safe operation that can reliably return athletes to a high level of participation with limited adverse effects. Level of Evidence: Level IV, therapeutic case series.

Abstract: Purpose: The purpose of this study was to determine the relationship between anterior knee pain secondary to suspected patellofemoral malalignment and tibial tubercle lateralization, patellar tilt, and patellar lateralization on magnetic resonance imaging. Methods: We compared the bony relationships of the knee in patients with anterior knee pain and patients with nonspecific internal derangements of the knee. We measured the lateral deviation of the tibial tubercle and the patella from the trochlea, patellar tilt, and patellar and patellar tendon length. Results: The symptomatic knees of patients with anterior knee pain had significantly ( P ≤ .01) greater lateralization of the tibial tubercle and lateral patellar tilt than did knees of the control group. Patella alta appears to be more common in subjects with anterior knee pain. Conclusions: Magnetic resonance imaging determination of tibial tubercle lateralization and patellar tilt correlates positively with the clinical diagnosis of anterior knee pain, suggesting that patellofemoral pain is caused by subtle malalignment. Level of Evidence: Level III, development of diagnostic criteria on basis of nonconsecutive patients.

Abstract: Purpose: To assess the accuracy of shoulder infiltrations in the subacromial bursa (SAB) by a posterior or an anteromedial approach. Magnetic resonance imaging (MRI) and clinical outcome were used for evaluation. Type of Study: A prospective randomized study. Methods: Thirty-three patients (22 women, 11 men; average age, 46 years; range, 25 to 64 years) with clinical signs of subacromial impingement were infiltrated with a mixture of bupivacaine, methylprednisolone, and gadolinium-DTPA directly followed by MRI to determine the actual site of injection. The SAB was randomly infiltrated posteriorly (n = 17) or anteromedially (n = 16). Injection confidence of the surgeon and body-mass index of the patient were recorded. Follow-up consisted of the Constant Score, Simple Shoulder Test, and visual analog scale score for pain taken within 24 hours and 6 weeks after infiltration. Results: Thirteen injections (76%) were in the SAB with a posterior approach and 10 (69%) with an anteromedial approach. Many surrounding structures were hit as well, especially the rotator cuff. A positive correlation between the injection confidence of the orthopaedic surgeon and the MRI was found in 66%. Only injection of the SAB alone resulted in a significant decrease of the pain ( P = .004) and an increase in the functional scores. Injection in the bursa and rotator cuff muscle showed a significant increase in pain ( P = .032) but no change in clinical scores. The body mass index had no influence on the scores. Conclusions: Injections in the SAB are inaccurate, despite the confident feeling of the clinician. The finding that many different structures can be infiltrated with 1 injection can create both false-positive and -negative results. Level of Evidence: Level II.

Abstract: Purpose: As arthroscopic rotator cuff surgery has advanced, new techniques have emerged to maximize the biomechanical strength of the repair construct. The double-row repair has been recommended as a means of increasing the contact area of the repaired rotator cuff to the native bone bed. This study attempts to sequentially examine and measure the rotator cuff footprint (in vivo) before cuff repair, after an initial lateral-row repair (before the medial-row sutures are tied), and finally, after the double-row repair. In this way, the rotator cuff footprint of single- and double-row repairs can be quantified and compared. Methods: Between October 2004 and February 2005, 26 patients were enrolled in the study. These patients had rotator cuff tears that were amenable to double-row repair by means of performing the lateral-row repair before the medial-row repair. After preparation of the greater tuberosity footprint, the native footprint was measured in the medial-to-lateral direction. Next, the medial-row anchors and sutures were passed through the cuff (but not tied), and then the lateral row was secured via suture anchors and the arthroscope was reinserted into the intra-articular space. A depth gauge was introduced through the repaired cuff (lateral row only), and the residual bare footprint was measured. The medial row was then tied, and the cuff was again visualized from the intra-articular position to measure any remaining bare footprint. Results: The mean footprint measured 17.0 ± 1.9 mm from medial to lateral. After repair of the lateral row, the mean residual uncovered footprint measured 9.0 ± 2.0 mm. This constituted a 52.7% ± 9.2% uncovered area after a single lateral-row repair. After the medial row was secured, there were no remaining residual deficits of the cuff footprint. Conclusions: After an isolated lateral-row repair, 52.7% ± 9.2% of the rotator cuff footprint remains uncovered. On average, the double-row repair offered over twice the footprint coverage yielded by a single-row repair. Clinical Relevance: The arthroscopic shoulder surgeon should be aware of the enhanced footprint coverage offered by double-row rotator cuff fixation as opposed to single-row rotator cuff fixation.

Abstract: Purpose: Our purpose was to evaluate the results of transphyseal anterior cruciate ligament (ACL) reconstruction with medial hamstring autograft in skeletally immature patients. Methods: We reviewed the records of all skeletally immature patients who underwent transphyseal ACL reconstruction with medial hamstring autograft between 1988 and 2002 at our institution. Inclusion criteria were age less than 15 years for male patients, age less than 14 years for female patients, and radiographic evidence of wide open physes. We identified 16 patients (11 male and 5 female). All underwent preoperative and postoperative clinical evaluation (physical examination and modified Lysholm and International Knee Documentation Committee scores), and knee radiographs. Each patient was followed up until skeletal maturity was confirmed, with a mean clinical follow-up of 41.1 months (range, 24 to 112 months). Results: The mean time from ACL injury to reconstruction was 5.6 months (range, 0.7 to 26.9 months). During the preoperative time period, 4 patients (25%) developed meniscal tears that were not visualized on the index magnetic resonance imaging scans. At last follow-up, the mean leg length discrepancy measured 0.62 cm (range, 0.2 to 1.5 cm), and clinical or radiographic evidence of malalignment was not present in any of the patients. In 1 patient a symptomatic 1.5-cm limb overgrowth developed, which was treated with an internal shoe lift. At follow up, the mean modified Lysholm score was 98.8 (range, 94 to 100), and the mean International Knee Documentation Committee score was 89.9 (range, 73.6 to 94.3). Of the patients, 7 (43.8%) underwent a reoperation, and 2 suffered traumatic graft disruption. Conclusions: ACL reconstruction with a medial hamstring autograft via a transphyseal technique yields satisfactory clinical results in skeletally immature patients. No new meniscal tears were identified after ACL reconstruction, and most patients (87.5%) returned to their previous level of activity. The rate of reoperation was high (43.8%). Physeal growth arrest did not occur. Level of Evidence: Level IV, therapeutic case series.

Abstract: Purpose To compare the clinical and stress radiologic results of posterior cruciate ligament (PCL) reconstruction using the transtibial tunnel technique and tibial inlay technique. Type of Study Retrospective case series. Methods Patients who had received isolated PCL reconstruction without combined ligamentous reconstruction and who also had a minimum 2-year follow-up were included in the study. The transtibial tunnel technique with quadrupled hamstring autograft group (group A) was composed of 21 knees and the tibial inlay technique with bone–patellar tendon–bone autograft group (group B) of 22 knees. We compared the 2 groups with regard to Lysholm knee scores, Tegner activity scores, posterior draw tests at 90° flexion, and radiologic stability of the knees by using a Telos device (Austin & Associates, Fallston, MD). Results The Lysholm knee scores showed a significant improvement from 55.3 points preoperatively to 91.5 at the final follow-up in group A and from 51.7 preoperatively to 93.5 at the final follow-up in group B. However, intergroup differences were not significantly different ( P = .259). Activity levels, as determined using the Tegner scoring system, also showed significant improvements at the final follow-up in both groups, but again, this was not significantly different ( P = .264). On the posterior drawer test at the final follow-up, normal or grade I laxity was observed in 19 patients in group A and in 20 patients in group B. By instrumented posterior laxity testing, mean side-to-side differences were significantly improved from 12.3 mm preoperatively to 3.7 mm at the final follow-up in group A and from 11.0 mm to 3.3 mm in group B, but without significance ( P = .607). Conclusions The transtibial tunnel and tibial inlay techniques produced relatively good clinical and stress radiologic results, and no significant differences were identified between the 2 techniques. Therefore, we suggest that the transtibial tunnel and tibial inlay techniques are both satisfactory PCL reconstruction procedures. Level of Evidence Level III.

Abstract: Purpose To compare a standard suture material with a newer material using multiple arthroscopic knot configurations and to evaluate the biomechanical performance of a new sliding-locking knot compared with 4 surgical standards. Type of Study Controlled laboratory study. Methods Five knots were evaluated (Weston, Tennessee, Duncan, SMC, and the new San Diego knot) using 2 suture materials, No. 2 Ethibond (Ethicon, Somerville, NJ) or No. 2 Fiberwire (Arthrex, Naples, FL). Eight samples were tested for each knot-suture configuration. Samples were pretensioned to 10 N and then loaded from 10 to 45 N for 1,000 cycles. Intact knots were loaded to failure. Results Fiberwire had significantly higher load-to-failure (276 ± 24 N) compared with Ethibond (111 ± 13 N) ( P Conclusions Surface characteristics and suture construction affect the tendency for knot slippage. Clinical Relevance Surgeons should understand the impact of handling characteristics, frictional properties, and ultimate failure load when selecting suture materials and knots for arthroscopic repair.

Abstract: Large, engaging Hill-Sachs lesions can cause recurrent glenohumeral instability following Bankart repair of torn anterior capsulolabral structures. We offer a novel technique for correcting the posterolateral humeral head defect without significantly altering normal anatomic structures. The glenohumeral joint is exposed via a deltopectoral approach. After the defect geometry is appreciated by direct palpation and visualization, the tip of an anterior cruciate ligament tibial guide is centered in the defect. The drill sleeve is approximated to the anterior lesser tuberosity starting hole, and a graduated guidewire is advanced to the posterior subchondral surface. After confirmation of satisfactory positioning, an 8-mm cannulated acorn drill is drilled to within 1 cm of the posterior surface. Bone tamps are used to elevate the depressed area using the tunnel created within the head. Allograft cancellous bone chips are impacted into the defect to elevate and support the subchondral surface. After successful impaction grafting and restoration of the head surface, anterior capsulolabral reconstruction is undertaken using either the Bankart or Latarjet technique. A standard Bankart rehabilitation program is followed postoperatively. We confirmed the clinical efficacy of our technique in 4 patients who experienced no instability or other complications at an average of 1-year follow-up.

Abstract: The suprascapular notch is a common location for entrapment of the suprascapular nerve. Open surgical procedures for excision of the transverse scapular ligament are associated with pain relief and functional improvement. Arthroscopic procedures have been described for decompressing ganglion cysts, which compress the nerve at the spinoglenoid notch. However, there is no description of an arthroscopic procedure for decompression of the nerve at the suprascapular notch, and this is probably related to unfamiliarity with the complex anatomy of the region. The technique described herein is based on standard anatomic landmarks and utilization of these as reference points for arthroscopic orientation and reproducibility. The acromioclavicular joint, conoid ligament, and coracoid process are stepwise reference landmarks leading to the suprascapular notch. Arthroscopic identification of structures around the notch is necessary before ligament resection. A new suprascapular portal, in combination with an accessory portal, is described for retraction, blunt dissection, nerve stimulation, and ligament resection. Key instruments include a 4-mm arthroscope of standard length (160 mm), with a 70° angled lens for adequate visualization and a calibrated probe to guide and limit dissection.

Abstract: Purpose: The objective of the study was to retrospectively compare the outcome of the first series of a 2-bundle anterior cruciate ligament reconstruction technique using quadrupled semitendinosus tendon with that of a 1-bundle reconstruction technique from 1992 through 1996. Type of Study: Case-control study. Methods: The 1-bundle group consisted of 56 patients with a follow-up period of 24 months or more (average, 46.5 months). The 2-bundle group consisted of 79 patients with a follow-up period of 24 months or more (average, 40.8 months). Manual knee laxity tests, anterior stability with KT-1000 (manual maximum), and knee extension and flexion strength by Cybex were evaluated using an average and standard deviation, and data were categorized according to the International Knee Documentation Committee (IKDC) classification. The Lysholm scale and the subjective recovery scale were also evaluated. Results: A statistically greater number of patients in the 1-bundle group were positive (+ or ++) based on the Lachman test (34% in the 1-bundle group and 13% in the 2-bundle group). The average KT-1000 anterior laxity of 2.7 ± 2.3 mm in the 1-bundle group was statistically greater than the 1.9 ± 1.9 mm in the 2-bundle group, with a statistical power between 70% and 80%. The total Lysholm knee scale score was 93 points in both groups, and the subjective recovery score was equivalent, 82% in the 1-bundle group and 86% in the 2-bundle group, respectively. Conclusions: There was no statistical difference based on the IKDC, Lysholm, and subjective analysis. However, there was a statistical difference in the Lachman test, anterior drawer test, and KT-1000 measurements. Level of Evidence: Level III.

Abstract: Purpose: Our aim was to test a published methodology for arthroscopically quantifying glenoid bone loss for its dependability in a cadaver-based anatomic study with 3-dimensional (3-D) computed tomographic (CT) reconstructions of 20 embalmed glenoids. Methods: Manual macroscopic measurements were made in a standardized fashion. In addition, we marked the center of the visible bare spot in 20 embalmed glenoids with a titanium pin. The shoulder joints were carefully selected for intact rotator cuff, missing capsule-labral deficiency, and absence of severe cartilage degeneration. 3-D reconstructed CT scans were evaluated for consistency of the bare spot. Results: The mean distance from the bare spot to the anterior margin measured manually was 10.9 mm (CT-based, 13.9 mm), to the posterior margin 13.7 mm (CT-based, 16.4 mm), and to the inferior margin 9.7 mm (CT-based, 15.1 mm). Distances were significantly different. Conclusions: The bare spot did not prove its consistency in 20 carefully selected specimens. Therefore, we conclude that this methodology is not a reliable way to intraoperatively determine bony glenoid deficiency. Clinical Relevance: We recommend preoperative bilateral CT scans for evaluation of bony glenoid deficiency for exact quantification of the bone loss.

Abstract: Purpose: The purpose of this study was to investigate the results of arthroscopic treatment in 14 patients with suprascapular nerve palsy secondary to spinoglenoid ganglion cysts. Methods Fourteen patients underwent arthroscopic decompression of ganglion cysts associated with suprascapular neuropathy. The most common presenting symptoms were pain and weakness, which lasted an average of 7.5 months. Ten of 14 patients were noted on examination to have atrophy, and all 14 patients had weakness of the infraspinatus. Magnetic resonance imaging (MRI) showed spinoglenoid ganglion cysts in all 14 patients; average cyst size was 3 cm. MRI revealed labral pathology in 12 of 14 cases; labral pathology was identified intraoperatively in all 14 patients. Results: Postoperatively, the average Simple Shoulder Test (SST) score was 11.5 (12 maximum), which was improved from an estimated preoperative score of 4.3. Improvement in external rotation strength was seen in 100% of patients who were examined postoperatively. No patients were taking pain medicine at latest follow-up. No complications were reported, and there were no clinical or symptomatic recurrences at an average follow-up of 51 months. Conclusions: Arthroscopic treatment of patients with spinoglenoid ganglion cysts is safe and effective, resulting in good clinical outcomes. In our study of 14 patients, no recurrences were seen at an average of 51 months of follow-up. Level of Evidence: Level IV, therapeutic case series.

Abstract: Arthrotomy is considered standard treatment for septic arthritis of the hip; the procedure may be complicated by avascular necrosis or postoperative hip instability. Arthroscopic treatment of patients with this condition is still not an established technique, despite its minimally invasive nature and the fact that it is associated with low morbidity. A 3-portal arthroscopic technique by Byrd with the patient in the supine position was used for drainage, debridement, and irrigation in 6 patients with septic coxarthrosis. Continuous postoperative intra-articular irrigation was not provided, nor were postoperative decompression drains used. All patients were treated with intravenous antibiotics for 3 weeks, followed by oral antibiotics for an additional minimum of 3 weeks. Patients were followed for 6 to 42 months. Staphylococcus aureus was identified in 4 of the 6 patients. All patients had a rapid postoperative recovery. Mean Harris Hip Score at the last review was 97.5 points. All patients showed full range of motion of the affected hip. No complications occurred with this group of patients. Thus, 3-directional arthroscopic surgery combined with large-volume irrigation is an effective treatment modality in cases of septic arthritis of the hip. It is less invasive than arthrotomy and offers low rates of postsurgical morbidity.

Abstract: Purpose: The purpose of our study was to determine the clinical outcomes following isolated lateral meniscal allograft transplantation. Methods: Thirty-two patients were retrospectively reviewed following isolated lateral meniscal allograft transplantation. Twenty-five were available for subjective follow-up, and 17 were available for a complete physical examination and postoperative radiographs. The average duration of follow-up was 3.3 years (range, 2 to 6 years), and the average age of the subjects was 30 years (range, 19 to 45 years). In all, 17 patients had bony fixation and 8 had suture fixation of the anterior and posterior horns of the meniscal allograft. Results: Ninety-six percent of patients believed that their overall function and activity level were improved following surgery. Short Form-36 (SF-36) physical and mental component summary scores for these subjects were higher than age- and sex-matched scores from the US population. Joint space narrowing of the transplanted lateral compartments was not significantly different when compared with the joint space narrowing of the lateral compartment of the contralateral knee. In addition, preoperative and postoperative radiographic joint space measurements of the involved lateral compartment were significantly associated with subjective assessment, symptoms, sports activity score, Lysholm score, and final International Knee Documentation Committee (IKDC) rating at latest follow-up. Finally, patients fixed with the bony technique had significantly better range of motion, according to IKDC criteria at latest follow-up, compared with the suture fixation group. Conclusions: Our results suggest that isolated meniscal allograft transplantation can be a beneficial procedure in properly selected symptomatic patients with a lateral meniscus–deficient knee. The data also suggest that earlier meniscal transplantation, before the onset of significant joint space narrowing, may result in improved outcomes. Finally, bony fixation may have a significant advantage over suture fixation, particularly with regard to knee range of motion. Level of Evidence: Level IV, therapeutic case series.