Promising radiological outcome after repair of acetabular chondral defects by microfracture augmented with chitosan-based scaffold: mid-term T2 mapping evaluation.

PURPOSE: Radiological evaluation of the repair tissue produced after arthroscopic treatment of acetabular chondral lesions associated with femoroacetabular impingement (FAI) by the chitosan-based scaffold. METHODS: Patients of age 18-55 years with clinical and radiological features of FAI and non-arthritic non-dysplastic hips were selected for arthroscopic treatment. Full-thickness acetabular chondral defects were filled with chitosan-based scaffold material after microfracture. T2 mapping was carried out for all patients after 24 months using a 1.5-T machine. Nine regions of interest (ROIs) were localized from three consecutive sagittal slices including the area of repair. T2 relaxation times of ROIs in the repair area were compared with the corresponding posterior cartilage. RESULTS: Twenty-one patients, 17 men and 4 women, underwent arthroscopic treatment of full-thickness acetabular chondral defects with mean size of 3.6 ± 1 cm2 (range 2-6 cm2). Zone 2 was affected in all cases while zone 3 was involved in 13 cases. T2 relaxation values were collected from 189 ROIs for quantitative analysis. Within the peripheral repair area, the mean T2 value was 49.1 ± 7.2 ms (ms), while ROIs of the central repair area had mean T2 values of 50.2 ± 7.1 ms. Posterior cartilage showed mean T2 value of 46.2 ± 7.6 ms CONCLUSION: Arthroscopic microfracture of large full-thickness acetabular chondral defects with chitosan-based scaffold produced a homogenous repair tissue similar to the corresponding native cartilage of the same joint on quantitative T2 mapping at mid-term follow-up. CLINICAL RELEVANCE: augmentation of the microfracture by chitosan-based scaffold is a promising modality for treatment of large full-thickness acetabular defects. LEVEL OF EVIDENCE: IV.

Radiographic parameters and a novel fluoroscopic control view for posterior screw fixation of coracoid base fractures - A cadaveric study.

INTRODUCTION: Coracoid fractures have the potential to lead to inadequate shoulder function. Most coracoid base fractures occur with scapular fractures and the posterior approaches would be utilized for surgical treatment. We investigated the possibility of fixing the coracoid through the same approach without an additional anterior approach. MATERIALS AND METHODS: Multi-slice CT scans of 30 shoulders were examined and the following measurements were performed by an independent specialized radiologist: posterior coracoid screw entry point measured form infraglenoid tubercle, screw trajectory in coronal plane in relation to scapular spine and lateral scapular border, screw trajectory in sagittal plane in relation to glenoid face bisector line and screw length. We used the results from the CT study to guide postero-anterior coracoid screw insertion under fluoroscopic guidance on two fresh frozen cadaveric specimens to assess the reproducibility of accurate screw placement based on these parameters. We also developed a novel fluoroscopic projection, the anteroposterior (AP) coracoid view, to guide screw placement in the para-coronal plane. RESULTS: The mean distance between entry point and the infraglenoid tubercle was 10.8 mm (range: 9.2-13.9, SD 1.36). The mean screw length was 52 mm (range: 46.7-58.5, SD 3.3). The mean sagittal inclination angle between was 44.7 degrees (range: 25-59, SD 5.8). The mean angle between screw line and lateral scapular border was 47.9 degrees (range: 34-58, SD 4.3). The mean angle between screw line and scapular spine was 86.2 degrees (range: 75-95, SD 4.9). It was easy to reproduce the screw trajectory in the para-coronal plane; however, multiple attempts were needed to reach the correct angle in the parasagittal plane, requiring several C-arm corrections. CONCLUSION: This study facilitates posterior fixation of coracoid process fractures and will inform the "virtual visualization" of coracoid process orientation.

Outcomes of hip arthroscopy for femoroacetabular impingement: The effect of morphological type and chondrolabral damage.

INTRODUCTION: Hip arthroscopy for treatment of femoroacetabular impingement (FAI) has shown significant pain and functional improvement. However, the differential outcome of each of the FAI morphological types in contrast to one another remains largely unknown. This study was conducted to detect a possible difference in outcome among different FAI types treated using hip arthroscopy. METHODS: In this prospective non randomized comparative study, after exclusion of non-FAI cases and cases with advanced arthritic changes, 90 hips in 85 patients that had hip arthroscopy for the treatment of FAI between 2011 and 2015 in our center were analyzed. The collected patient reported outcome measures (PROMs) included visual analog scale (VAS) of pain, the modified Harris hip score (mHHS), and the non arthritic hip score (NAHS) both preoperatively and at final follow-up. Patient satisfaction was collected at final follow-up. Postoperative PROMs were subjected to three main comparisons based on each of FAI type, labral procedure, and extent of cartilage damage. Repeat comparison based on FAI type after matching of exact chondrolabral condition was also attempted. RESULTS: Mean follow-up was 32.8 months (five patients lost from follow-up). There was a significant improvement in the overall PROMs. This improvement was significantly higher in the cam group in contrast to the mixed group. After matching for chondrolabral condition, this difference was consistent and more evident. DISCUSSION: The outcome of arthroscopic treatment of pure cam FAI is significantly better than that of mixed FAI. Matching of the same chondrolabral condition and repeating the comparison yields similar results.

Basics in hip chondrolabral lesions and state of the art.

Chondrolabral complex is a weak point along an histological transition zone. Most cartilage and labral lesions in the femoroacetabular impingement syndrome are located in this area. Different classifications are used to evaluate the severity and predict the prognosis of chondrolabral complex injuries. Acetabular Labrum Articular Disruption (ALAD) and Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN) classifications are commonly used with a prognosis and treatment implication. Treatment of chondrolabral lesions detected on magnetic resonance imaging (MRI), should only be considered when clinical symptoms are presented. A wide range of treatment options include debridement with or without microfracture, repair or regenerate therapies. The future of hip joint preservation should be directed towards to the development of the treatment of chondrolabral injuries.

A Shortcut to Arthroscopic Suprascapular Nerve Decompression at the Suprascapular Notch: Arthroscopic Landmarks and Surgical Technique.

Arthroscopic suprascapular nerve decompression at the suprascapular notch is a technically demanding surgical procedure with a steep learning curve. The aim of this Technical Note is to describe important pearls for an arthroscopic decompression of the suprascapular nerve relying on the palpation of the coracoclavicular ligaments before starting the arthroscopic visualization. This reduces the time and minimizes the resection of the surrounding fat.

Arthroscopic skills assessment and use of box model for training in arthroscopic surgery using Sawbones - "FAST" workstation.

PURPOSE: Arthroscopic skills training outside the operative room may decrease risks and errors by trainee surgeons. There is a need of simple objective method for evaluating proficiency and skill of arthroscopy trainees using simple bench model of arthroscopic simulator. The aim of this study is to correlate motor task performance to level of prior arthroscopic experience and establish benchmarks for training modules. METHODS: Twenty orthopaedic surgeons performed a set of tasks to assess a) arthroscopic triangulation, b) navigation, c) object handling and d) meniscus trimming using SAWBONES "FAST" arthroscopy skills workstation. Time to completion and the errors were computed. The subjects were divided into four levels; "Novice", "Beginner", "Intermediate" and "Advanced" based on previous arthroscopy experience, for analyses of performance. RESULTS: The task performance under transparent dome was not related to experience of the surgeon unlike opaque dome, highlighting the importance of hand-eye co-ordination required in arthroscopy. Median time to completion for each task improved as the level of experience increased and this was found to be statistically significant (p < .05) e.g. time for maze navigation (Novice - 166 s, Beginner - 135.5 s, Intermediate - 100 s, Advance - 97.5 s) and the similar results for all tasks. Majority (>85%) of subjects across all the levels reported improvement in performance with sequential tasks. CONCLUSION: Use of the arthroscope requires visuo-spatial coordination which is a skill that develops with practice. This simple box model can reliably differentiate the arthroscopic skills based on experience and can be used to monitor progression of skills of trainees in institutions.

Meniscus delivery: a maneuver for easy arthroscopic access to the posterior horn of the medial meniscus.

Pathology of posterior horn of medial meniscus is common and often presents a difficult approach during arthroscopy for various reasons. We describe an easy maneuver to facilitate "delivery of the medial meniscus" during arthroscopy.

Osteoid osteoma (OO) of the coracoid: a case report of arthroscopic excision and review of literature.

Osteoid osteoma (OO) of the coracoid is a rare entity that may present with variable symptoms from shoulder leading to delay in diagnosis and treatment. We present the clinical and radiological findings and management of one such case along with a review of similar cases reported in the literature. There was a delay of 2 years in diagnosis, which was later confirmed by computed tomography in addition to magnetic resonance imaging (MRI). The lesion was accessed arthroscopically and excised by unroofing and curettage. "OO" should be included in the differential diagnosis of shoulder pain in young patients not responding to long-term conservative treatment. Arthroscopic excision and curettage provide a good choice for management, with low morbidity and rapid recovery.

Neglected ununited tibial eminence fractures in the skeletally immature: arthroscopic management.

PURPOSE: The purpose of this study was to prospectively evaluate outcomes of arthroscopic management of neglected ununited tibial eminence fractures in skeletally immature patients. METHODS: The study was conducted and cases performed by two surgeons from two centres as a prospective case series of 13 patients with neglected ununited tibial eminence fractures: nine were girls and four were boys; ten were right knees and three were left. The average age at surgery was ten [standard deviation (SD) 2.6] years. Average follow-up was 10.8 (SD 6.8) months. Primary outcome measures used for evaluation were the Objective International Knee Documentation Committee Score (IKDC), subjective IKDC and modified Lysholm knee score. Secondary outcome measures were visual analogue scales (VAS) for pain and patient satisfaction. RESULTS: Twelve patients had grade A objective IKDC score and one patient had grade B. Average subjective IKDC score was 80.5 (SD 16.7). Average modified Lysholm score was 91.2 (SD 8.9). Average VAS for operation satisfaction was 9.6 (SD 0.5) and for pain was 0.4 (SD 0.5). All patients showed radiological union and anatomical reduction at an average of 12.4 weeks postoperatively. At follow-up, all 13 patients showed complete range of motion (ROM). Eleven patients had negative Lachman, anterior drawer and pivot-shift tests, while two patients had grade 1 positive Lachman and negative anterior drawer and pivot-shift tests. No patient had complained of instability. CONCLUSION: Neglected ununited tibial eminence fractures in skeletally immature patients achieve good functional outcome results when treated with arthroscopic reduction and internal fixation using sutures.

Hip arthroscopy for excision of osteoid osteoma of femoral neck.

Osteoid osteoma (OO) is the most commonly seen benign bone-forming lesion. It can occur anywhere, including the metaphyseal regions of small and large bones. We present 2 cases that underwent an arthroscopic technique for removal of OO of the femoral neck. The diagnosis was confirmed by computed tomography in addition to magnetic resonance imaging. The lesions were accessed arthroscopically and excised by unroofing and curettage. The clinical and radiographic findings are presented, along with the surgical management. The patients improved dramatically postoperatively. OO of the femoral neck should be included in the differential diagnosis of hip pain in young patients. Arthroscopic excision and curettage provide a good choice for management, with low morbidity and rapid recovery.

Two-stage surgical treatment for non-union of a shortened osteoporotic femur.

INTRODUCTION: We report a case of non-union with severe shortening of the femur following diaphysectomy for chronic osteomyelitis. CASE PRESENTATION: A boy, aged 16 years presented with a dangling and excessively short left lower limb. He was using an elbow crutch in his right hand to help him walk. He had a history of diaphysectomy for chronic osteomyelitis at the age of 9. Examination revealed a freely mobile non-union of the left femur. The femur was the seat of an 18 cm shortening and a 4 cm defect at the non-union site; the knee joint was ankylosed in extension. The tibia and fibula were 10 cm short. Considering the extensive shortening in the femur and tibia in addition to osteoporosis, he was treated in two stages. In stage I, the femoral non-union was treated by open reduction, internal fixation and iliac bone grafting. The patient was then allowed to walk with full weight bearing in an extension brace for 7 months. In Stage II, equalization of leg length discrepancy (LLD) was achieved by simultaneous distraction of the femur and tibia by unilateral frames. At the 6 month follow- up, he was fully weight bearing without any walking aid, with a heel lift to compensate the 1.5 cm shortening. Three years later he reported that he was satisfied with the result of treatment and was leading a normal life as a university student. CONCLUSIONS: Two-stage treatment succeeded to restore about 20 cm of the femoral shortening in a severely osteoporotic bone. It has also succeeded in reducing the treatment time of the external fixator.