An anatomo-functional implant positioning technique with robotic assistance for primary TKA allows the restoration of the native knee alignment and a natural functional ligament pattern, with a faster recovery at 6 months compared to an adjusted mechanical technique.

PURPOSE: An anatomo-functional implant positioning (AFIP) technique in total knee arthroplasty (TKA) could restore physiological ligament balance (symmetric gap in extension, asymmetric gap in flexion). The purposes were to compare (1) ligament balancing in extension and flexion after TKA in the AFIP group, (2) TKA alignment, implant positioning and patellar tracking between AFIP and adjusted mechanical alignment (aMA) techniques, (3) clinical outcomes between both groups at 12 months. METHODS: All robotic-assisted TKA with an AFIP technique were included (n = 40). Exclusion criteria were genu valgum (HKA angle > 183°), extra-articular deformity more than 10°, and patellar maltracking (high-grade J-sign). One control patient with a TKA implanted by an aMA technique was matched for each case, based on age, body mass index, sex, and knee alignment. Ligament balancing (medial and lateral gaps in millimeters) in full extension and at 90° of flexion after TKA in the AFIP group was assessed with the robotic system. TKA alignment (HKA angle), implants positioning (femoral and tibial coronal axis, tibial slope, joint-line orientation), patellar tracking (patellar tilt and translation) and the Knee Society Score (KSS) at 6 and 12 months were compared between both groups. The ligament balancing was compared using a t test for paired samples in the AFIP group. The radiographic measurements and KSS scores were compared between groups using a t test for independent samples. RESULTS: In the AFIP group, there was no significant difference between the medial and lateral gap laxity in extension (NS). A significant opening of the lateral gap was observed in flexion compared to extension (mean: + 2.9 mm; p < 0.0001). The mean postoperative HKA angle was comparable between both groups (177.3° ± 2.1 in the AFIP group vs 176.8° ± 3.2; NS). In the AFIP group, the femoral anatomy was restored (90.9° ± 1.6) and the tibial varus was partially corrected (87.4° ± 1.8). The improvement of Knee and Function KSS at 6 months was better in the AFIP group (59.3 ± 11.9 and 51.7 ± 20, respectively, versus 49.3 ± 9.7 and 20.8 ± 13; p < 0.001). CONCLUSION: The AFIP concept allowed the restoration of the native knee alignment and a natural functional ligament pattern. With a more physiological target for ligament balancing, the AFIP technique had equivalent clinical outcomes at 12 months compared to aMA, with a faster recovery. LEVEL OF EVIDENCE: III retrospective therapeutic case control series.

Comparison of 3 Cell-Free Matrix Scaffolds Used to Treat Osteochondral Lesions in a Rabbit Model.

BACKGROUND: Various cell-free scaffolds are already in use for the treatment of osteochondral defects (OCDs); however, a gold standard material has not yet been defined. PURPOSE: This study compared the macroscopic, histological, and scanning electron microscopy (SEM) characteristics of Chondro-Gide (CG), MaioRegen (MA), and poly-d,l-lactide-co-caprolactone (PLCL) cell-free scaffolds enhanced with small-diameter microfractures (SDMs) for OCDs in a rabbit model. STUDY DESIGN: Controlled laboratory study. METHODS: In total, 54 knees from 27 rabbits were used in this study. Three rabbits were sacrificed at the beginning of the study to form an intact cartilage control group (group IC). An OCD model was created at the center of the trochlea, and SDMs were generated in 24 rabbits. Rabbits with OCDs were divided into 4 groups (n = 12 knees per group) according to the cell-free scaffold applied: CG (group CG), MA (group MA), PLCL (group PLCL), and a control group (group SDM). Half of the rabbits were sacrificed at 1 month after treatment, while the other half were sacrificed at 3 months after treatment. Healed cartilage was evaluated macroscopically (using International Cartilage Regeneration & Joint Preservation Society [ICRS] classification criteria) and histopathologically (using modified O'Driscoll scores and collagen staining). Additionally, cell-free scaffold morphologies were compared using SEM analysis. RESULTS: ICRS and modified O'Driscoll classification and staining with collagen type 1 and type 2 demonstrated significant differences among groups at both 1 and 3 months after treatment (P < .05). The histological characteristics of the group IC samples were superior to those of all other groups, except group PLCL, at 3 months after treatment (P < .05). In addition, the histological properties of group PLCL samples were superior to those of group SDM samples at both 1 and 3 months after treatment in terms of the modified O'Driscoll scores and type 1 collagen staining (P < .05). Concerning type 2 collagen staining intensity, the groups were ranked from highest to lowest at 3 months after treatment as follows: group PLCL (30.3 ± 2.6) > group MA (26.6 ± 1.2) > group CG (23.3 ± 2.3) > group SDM (18.9 ± 0.9). CONCLUSION: OCDs treated with enhanced SDM using cell-free PLCL scaffolds had superior histopathological and microenvironmental properties, more hyaline cartilage, and more type 2 collagen compared with those treated using CG or MA scaffolds. CLINICAL RELEVANCE: OCDs treated with PLCL cell-free scaffolds may have superior histopathological properties and contain more type 2 collagen than do OCDs treated with CG or MA cell-free scaffolds.

The middle glenohumeral ligament: a classification based on arthroscopic evaluation.

BACKGROUND: Although middle glenohumeral ligament (MGHL) variations have been shown in the literature, their clinical effect and relationship with intra-articular pathologies have yet to be revealed, except for the Buford complex. This study was designed to classify MGHL and to reveal its relationship with clinical pathologies. METHODS: A total of 843 consecutive shoulder arthroscopies were evaluated retrospectively, and a classification system was proposed for MGHL with regard to its structure and its relation to the anterior labrum. The associations of each MGHL type with superior labrum anterior-posterior (SLAP) lesions, subscapularis tears, and anterior instability were investigated. RESULTS: MGHL variations were grouped into 6 types according to the classification. A significant difference in favor of type 6 MGHL (Buford complex) was observed in the distribution of SLAP lesions (P < .001). There was no significant difference between MGHL types and the distribution of anterior instability history (P = .131) and subscapularis tears (P = .324). CONCLUSION: SLAP lesions accompany type 6 MGHLs (Buford complex) significantly more frequently than other types. There is also a negative relation between the anterior instability and thicker MGHL variants.

Effects of general anaesthesia and ultrasonography-guided interscalene block on pain and oxidative stress in shoulder arthroscopy: A randomised trial.

BACKGROUND/AIM: The aim of this study was to evaluate the effects of general anaesthesia and ultrasonography-guided interscalene block on pain and oxidative stress evaluated by thiol-disulphide balance and C-reactive protein levels in patients undergoing shoulder arthroscopy. MATERIALS AND METHODS: A total of 42 patients aged 18-75 years who were scheduled to undergo shoulder arthroscopy were randomised into interscalene block group (Group-IB, n = 20) and general anaesthesia group (Group-GA, n = 22). All patients received patient-controlled analgesia during the postoperative period. Additional analgesics were administered to patients with a visual analogue scale score of >4. Native-thiol, total-thiol, disulphide and C-reactive protein levels were measured. Patients' visual analogue scale scores, morphine and additional analgesic consumption were recorded. A shift in thiol-disulphide balance towards decreased thiol and increased disulphide levels was regarded as an indicator of oxidative stress. RESULTS: Pain level, morphine and additional analgesic consumption were higher in Group-GA. Native-thiol and total-thiol levels were higher in Group-IB postoperatively and also disulphide levels were lower at postoperative 18 hours. C-reactive protein levels were similar in both the groups. CONCLUSION: Interscalene block induced less oxidative stress during the postoperative period, as evaluated by thiol-disulphide balance. In shoulder arthroscopy, interscalene block provides more stable haemodynamics perioperatively and facilitates better postoperative pain control.

Prospective, randomized evaluation of latissimus dorsi transfer and superior capsular reconstruction in massive, irreparable rotator cuff tears.

BACKGROUND: The treatment of massive, irreparable rotator cuff tears remains controversial today because there is no consensus on the ideal treatment option. This investigation aimed to prospectively evaluate and compare the outcomes of arthroscopy-assisted latissimus dorsi transfer and superior capsular reconstruction in the treatment of massive, irreparable rotator cuff tears. METHODS: Forty-two patients at an average age of 62.8 years with massive, irreparable rotator cuff tears were randomized into 2 treatment groups. Twenty-one patients underwent arthroscopy-assisted latissimus dorsi tendon transfer (LDT), and 21 patients underwent arthroscopy-assisted superior capsular reconstruction (SCR). The patients were followed up prospectively for 31 months on average. One patient in the SCR group was lost to follow-up. The outcomes were evaluated with American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Western Ontario Rotator Cuff Index (WORC), visual analog scale (VAS), and Constant scores clinically and with acromiohumeral distance (AHD) measurements radiologically. RESULTS: Both groups displayed improved results in ASES, WORC, Constant, and VAS scores in the final follow-up (P < .001). The LDT group had significantly better results in AHD (P = .006), whereas the SCR group yielded significantly higher improvements in ASES (P = .007) and Constant (P = .008) scores. The rate of successful pseudoparalysis treatment was 45% (5/11) in the LDT group and 92% (12/13) in the SCR group (P = .011). The graft failure rate was 5% (1 patient) in each group postoperatively; 1 patient in the SCR group had a traumatic graft rupture and 1 patient in the LDT group was complicated with septic arthritis, which required graft removal. CONCLUSION: Both SCR and LDT yielded promising short-term results in treatment of massive, irreparable rotator cuff tears in this study. The SCR group displayed better overall outcomes clinically, particularly in the pseudoparalytic shoulders, whereas the LDT group displayed better radiologic results.

Multiple Subscapularis Tendon Sign: A New Risk Factor for Recurrence After Arthroscopic Anterior Shoulder Instability Surgery.

BACKGROUND: Being able to predict recurrence after the treatment of shoulder instability would be helpful in planning the appropriate treatment. PURPOSE: To define the multiple subscapularis tendon sign (MSTS) as a novel anatomic variant and a possible risk factor for the recurrence of shoulder instability after anterior stabilization and to evaluate it, together with the other risk factors as described in the literature. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 87 patients met the study criteria and underwent arthroscopic stabilization for anterior shoulder instability. The MSTS was evaluated in this study group. Age, sex, hand dominance, number of preoperative shoulder dislocations, history of overhead or contact sports participation, type of labral lesion, number of anchors used in surgery, presence of the drive-through sign, presence of the MSTS, Oxford Shoulder Score results, and the association of these parameters with recurrence were assessed. The mean follow-up time was 81.0 ± 27.9 months (range, 48-139 months). RESULTS: Nine (10.3%) patients experienced recurrent instability. The presence of the MSTS (P = .009), existence of an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion (P = .04), and history of overhead or contact sports participation (P = .04) were significant risk factors for recurrence. The recurrence rates were as follows: 30.7% with the MSTS; 40% with the MSTS and an ALPSA lesion; and 75% with the MSTS, an ALPSA lesion, and a history of overhead or contact sports participation. CONCLUSION: The MSTS is a variation of the anterior shoulder joint capsule. It is a sign of capsular insufficiency or thinning, which may be a risk factor for recurrence after anterior stabilization. Considering the low success rates of anterior capsulolabral repair in patients participating in overhead or contact sports, especially when an ALPSA lesion is present, encountering the MSTS during surgery in this at-risk group may be an indicator for the surgeon to choose the surgical procedure more carefully.

The effect of erythropoietin on rat rotator cuff repair model: An experimental study.

OBJECTIVES: The aim of this study was to determine whether erythropoietin (EPO) can enhance rotator cuff healing in rats as measured by histological analysis and biomechanical testing. METHODS: A total of 72 rats were included in this study. In the control group (n = 24), repair was performed without EPO injection. In the local group (n = 24) EPO was injected in the repair site. In the systemic group (n = 24) EPO was administered as an intraperitoneal injection every day for 10 days after repair. Rats were euthanized on day 10 (n = 12 from each group) and day 28 (n = 12 from each group). Histopathological (n = 6) and biomechanical examinations (n = 6) were done. RESULTS: Biomechanical results reveal that the maximum load to failure values of the early control group were statistically lower than those of the early systemic group (p = 0.006). Comparing the the total Bonar values histopathologically reveal that the early systemic group was statistically higher than those of the early local group (p = 0.043). The late control group was statistically higher than those of the late local group (p = 0.003) and the late systemic group (p = 0.034). The late systemic group was statistically higher than those of the late local group (p = 0.003). CONCLUSIONS: EPO application had a positive effect biomechanically in the early euthanized group and histopathologically in the late euthanized group.

Arthroscopic-Assisted Latissimus Dorsi Tendon Transfer for Massive, Irreparable Rotator Cuff Tears: Technique and Short-Term Follow-Up of Patients With Pseudoparalysis.

PURPOSE: To describe a modified technique for arthroscopic-assisted transfer of the latissimus dorsi tendon in a selected group of patients with irreparable rotator cuff tears and pseudoparalysis and to evaluate its short-term results. METHODS: Fifteen patients with irreparable rotator cuff tears and pseudoparalysis treated by arthroscopic-assisted latissimus dorsi tendon transfer were included. The mean patient age was 61.53 ± 6.24 years (range, 52-71 years). Patients were assessed with physical examination, University of California Los Angeles (UCLA) Score and Constant-Murley score, as well as visual analog scale score at a mean follow-up of 26.4 ± 2.58 months (range, 24-31 months). RESULTS: At final follow-up, mean UCLA score increased to 27.47 ± 6.31 compared with the preoperative UCLA score of 6.53 ± 2.1 (P < .001). Constant-Murley score was 21 ± 7.41 and 59.73 ± 13.62 (P < .001), visual analog scale pain score was 7.47 ± 1.06 and 2.47 ± 0.91 (P < .001), active forward flexion was 58° ± 21.11° and 130° ± 30.05° (P < .001), active abduction was 51° ± 21.64° and 129.67° ± 25.45° (P < .001), and active external rotation was 13.33° ± 21.68° and 32° ± 18.03° (P < .001) preoperatively and postoperatively, respectively. Mean acromiohumeral distance was 3.13 ± 1.40 mm preoperatively, whereas it was 5.67 ± 1.67 mm postoperatively (P < .001). No significant complications requiring a revision surgery was observed during the final follow-up. CONCLUSIONS: The modified technique of arthroscopic-assisted transfer of the latissimus dorsi tendon is a feasible, minimally invasive option for the surgical treatment of irreparable rotator cuff tears in a subset of patients with pseudoparalysis. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The effect of the intercondylar notch width index on anterior cruciate ligament injuries: a study on groups with unilateral and bilateral ACL injury.

BACKGROUND: To evaluate the relationship of the intercondylar notch width with unilateral and bilateral ACL injury by using MR images. MATERIAL AND METHODS: The intercondylar notch width index was measured on the MR images of 18 patients with a bilateral ACL injury, 38 patients with a unilateral ACL injury and 53 healthy subjects with a normal ACL and the results of all groups were compared with each other. RESULTS: The mean NWI values were 0,227 (±0.008) in bilateral injured; 0,245 (±0.009) in unilateral injured and 0,272 (±0.01) in control groups and 0,251(±0.01) in unaffected side of the unilateral group. There were statistically significant differences in intercondylar notch width index (NWI) values between all groups and there was a significant difference between the affected and the unaffected sides in group with unilateral ACL injury. A cutoff value of 0.25 for NWI gave an odds ratio of 26.5 for bilateral and 3.23 for unilateral ACL injuries. CONCLUSIONS: The finding that NWI is significantly narrowed in patients with bilateral and unilateral ACL tears compared with the healthy controls suggest a relationship between a narrow NWI and an increased risk of ACL injury. The patients with a narrow NWI should also be screened contralaterally for assessment of ACL injury risk on the other knee. So, specialized training programmes for the people with narrow NWI can be prepared for preventing ACL injuries.

Assessment of function in patients with rotator cuff tears: Functional test versus self-reported questionnaire.

PURPOSE: The rotator cuff tears (RCT) are a well-known cause of shoulder pain and loss of upper extremity function. The purpose of this study was to evaluate the upper extremity function using two different methods in patients with RCT and to determine the parameters that influence the upper extremity function. MATERIALS AND METHODS: A sample of 38 patients (27-76 years; 10 men and 28 women) who were diagnosed with a chronic full-thickness RCT, confirmed by magnetic resonance imaging (MRI), was studied. Upper extremity function was determined using Western Ontario Rotator Cuff Index (WORC) and 9 Hole Peg Test (9PEG). Other assessments included active range of motion (ROM), muscle strength, shoulder pain, and scapular dyskinesis. RESULTS: There was a weak association between WORC scores and 9PEG. A statistically significant, negative relationship was found between 9PEG and ROM in supination, as well as muscle strength of shoulder extensors, adductors, internal and external rotators. CONCLUSIONS: In addition to the weak association between WORC and 9PEG, the difference between the parameters related to each method suggests that they should not be used interchangeably to determine the upper extremity function. We recommend the utilization of 9PEG instead of WORC in assessing the upper extremity function in the setting of loss of muscle strength. LEVEL OF EVIDENCE: Level IV, Therapeutic study.