Biomechanical comparison of knotless anchor repair versus simple suture repair for type II SLAP lesions.

PURPOSE: The purpose of this study was to evaluate glenohumeral motion after knotless anchor repair of type II SLAP lesions versus repair with simple suture arthroscopic knot-tying techniques and to compare the initial fixation strength of the 2 repair techniques. METHODS: Six matched-pair cadaveric shoulders were tested in an uninjured condition, after creation of a type II SLAP tear, and after repair with either a knotless repair with two 3.5-mm Bio-PushLock anchors (Arthrex, Naples, FL) or a simple suture repair with two 3.0-mm Bio-SutureTak anchors (Arthrex) placed anterior and posterior to the biceps tendon. Glenohumeral rotation, translation, and kinematics were measured. The SLAP repairs were then loaded to failure perpendicular to the glenoid face. RESULTS: Glenohumeral rotation increased after creation of a type II SLAP lesion and was restored to the intact state after both repairs. There was no significant difference in glenohumeral translation or kinematics with SLAP lesion or either repair technique. There was no significant difference between stiffness, yield load, or ultimate load of the 2 repairs. Simple suture repairs failed most commonly by knot breakage, and knotless repairs failed by suture slippage around the anchor. CONCLUSIONS: Knotless anchor repairs of type II SLAP lesions restore glenohumeral rotation as well as simple suture arthroscopic repair techniques without overconstraining the shoulder. In addition, the initial fixation strength of knotless anchor repairs of type II SLAP lesions is similar to that of simple suture repairs. CLINICAL RELEVANCE: Knotless anchor repairs of type II SLAP lesions restore capsulolabral anatomy without overconstraining the shoulder.

An evaluation of the provocative tests for superior labral anterior posterior lesions.

BACKGROUND: Although our understanding of superior labral anterior posterior lesions has grown, the physical diagnosis remains imperfect. STUDY DESIGN: Cohort study (diagnostic); Level of evidence, 2. PURPOSE: To determine the most effective provocative maneuver with which to diagnose superior labral anterior posterior lesions. METHODS: A series of 132 consecutive patients scheduled to undergo diagnostic shoulder arthroscopy were examined preoperatively over a 6-month period, and the final diagnosis in each case was made arthroscopically. The following assessments were included: active compression (O'Brien), anterior slide, pain provocation, crank, Jobe relocation, Hawkins, Neer, Speed, and Yergason tests. RESULTS: The most sensitive diagnostic tools for type II superior labral lesions were the active compression, Hawkins, Speed, Neer, and Jobe relocation tests. When type I and type II lesions were combined, the results were similar. However, none of the sensitive tests were specific for either type I or type II lesions. CONCLUSIONS: The authors' results contradict the current literature regarding provocative testing for both stable and unstable superior labral lesions. There is no single maneuver that can accurately diagnose superior labral anterior posterior lesions; arthroscopy remains the standard by which to diagnose such lesions.

Revision anterior cruciate ligament reconstruction: three- to nine-year follow-up.

PURPOSE: With the increasing number of primary anterior cruciate ligament (ACL) reconstructions, revisions are more frequent. The literature quotes inferior results for revision cases when compared with primary ACL reconstruction. The purpose of the study was to review our institution's experience with revision ACL reconstruction. TYPE OF STUDY: Retrospective case series. METHODS: Thirty-five revision cases were performed between 1993 and 1999. Twenty-nine were available for follow-up. Subjective scores were calculated for Lysholm, Tegner, and International Knee Documentation Committee (IKDC) forms. Objective IKDC scores were determined. KT-1000 measurements were performed as well as isokinetic strength testing of quadriceps and hamstrings. Plain film radiographs were obtained to assess degenerative changes. RESULTS: The average patient age at time of revision was 30.2 years, the average time to revision was 56 months, the follow-up from last revision was 67 months. Twenty-two patients had bone-patellar tendon-bone (BPTB) allograft, 6 had contralateral BPTB autograft, and 1 patient had Achilles allograft. Overall, KT-1000 measurement showed an average of 2.78 mm side-to-side difference of displacement. The allograft versus the autograft group was 3.21 mm versus 1.33 mm, respectively. Prerevision data were unavailable. However, all patients had a positive pivot-shift test before revision. Average postrevision Lysholm, Tegner, and subjective IKDC scores were 86.6, 11.86, and 85.86, respectively. Concerning the IKDC objective scores, 15 patients had an A score, 8 had a B score, and 4 had a C score. All 29 patients available for follow-up reported that they would have the surgery again. The average strength of quadriceps and hamstrings ranged from 82% to 88% of uninvolved side. CONCLUSIONS: This study provides long-term follow-up with good results for revision ACL reconstruction. Attention to principles when performing revision ACL surgery is critical to provide satisfactory results. LEVEL OF EVIDENCE: Level IV.

Outcomes of revision arthroscopic type II superior labral anterior posterior repairs.

BACKGROUND: Outcomes of arthroscopic type II superior labral anterior posterior (SLAP) repairs have been reported with success. However, published data regarding outcomes of revision arthroscopic type II SLAP repairs are lacking. HYPOTHESIS: Outcomes of revision arthroscopic type II SLAP repairs are inferior to those of primary repairs. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective chart review was performed to identify patients who had undergone revision arthroscopic type II SLAP repairs at our institution. Patients who underwent concomitant rotator cuff repairs or labral repairs for instability were excluded. Twelve patients were contacted, and the following outcome data were prospectively gathered: American Shoulder and Elbow Surgeons (ASES) score, patient satisfaction level, return to work, return to sports, and physical examination. Demographics and intraoperative report data were also collected from the charts. RESULTS: The mean age at the time of revision arthroscopic type II SLAP repairs was 32.6 years (range, 19-67 years) with a mean follow-up of 50.5 months (range, 8-81 months). There were 5 workers' compensation patients and 6 overhead athletes. Pain was the chief complaint at the time of initial and revision SLAP repairs. The mean ASES score was 72.5, patient satisfaction level was 6.4 (scale of 0-10), mean return to work was at 57.8% of the previous level, and mean return to sports was at 42.2% of the previous level. In overhead athletes, mean return to sports was at 41.3% of the previous level, and none of the 4 baseball players returned to preinjury level. The mean values for all outcome data and range of motion values were lower in workers' compensation patients. There were no reported complications, but 2 patients required additional arthroscopic surgeries. CONCLUSION: Arthroscopic revision type II SLAP repairs yield worse results than primary repairs as reported in the literature, with workers' compensation patients and overhead athletes doing especially worse. A larger prospective study of this relatively rare procedure is needed to better determine which patients may benefit from this procedure.

A biomechanical comparison of 2 technical variations of double-row rotator cuff fixation: the importance of medial row knots.

BACKGROUND: Previous studies have shown comparable biomechanical properties of double-row fixation versus double-row fixation with a knotless lateral row. SutureBridge is a construct that secures the cuff with medial row mattress suture anchors and knotless lateral row fixation of the medial suture ends. Recent completely knotless constructs may lead to lesser clinical outcomes if the construct properties are compromised from lack of suture knots. HYPOTHESIS: A completely knotless construct without medial row knots will compromise the biomechanical properties in both cyclic and failure-testing parameters. STUDY DESIGN: Controlled laboratory study. METHODS: Six matched pairs of cadaveric shoulders were randomized to 2 groups of double row fixation with SutureBridge: group 1 with medial row knots, and group 2 without medial row knots. The specimens were placed in a materials test system at 30 degrees of abduction. Cyclic testing to 180 N at 1 mm/sec for 30 cycles was performed, followed by tensile testing to failure at 1 mm/sec. RESULTS: Data included cyclic and failure data from the materials test system and gap data using a video digitizing system. All data from paired specimens were compared using paired Student t tests. Group 1 had a statistically significant difference (P < .05) for gap formation for the 1st (3.47 vs 5.05 mm) and 30th cycle (4.22 vs 8.10 mm) and at yield load (5.2 vs 9.1 mm). In addition, there was a greater energy absorbed (2805 vs 1648 N-mm), yield load (233 vs 183.1 N), and ultimate load (352.9 vs 253.9 N) for group 1. The mode of failure for the majority (4/6) of group 2 was lateral row failure, whereas all group 1 specimens failed at the clamp. CONCLUSION: Although lateral row knotless fixation has been shown not to sacrifice structural integrity of this construct, the addition of a knotless medial row compromises the construct leading to greater gapping and failure at lower loads. CLINICAL RELEVANCE: This may raise concerns regarding recently marketed completely knotless double row constructs.

Accuracy of subacromial injection: anterolateral versus posterior approach.

Subacromial bursa injection is commonly performed via an anterolateral or posterior approach. No study has compared the accuracy rates of these approaches. Twenty cadaveric shoulders were injected with radiocontrast in the subacromial bursa via an anterolateral approach and twenty via a posterior approach. Ten shoulders were injected with methylene blue via each technique for dissection. The anterolateral approach was accurate by fluoroscopy in 18 shoulders (90%), but dissection of 10 shoulders revealed successful injection in only 6 (60%). The posterior approach was judged to be successful in 16 shoulders (80%), and dissection of 10 shoulders confirmed 8 injections (80%) were accurate. There was no significant difference in the accuracy by fluoroscopy (P=.38) or dissection (P=.33). The accuracy rates of the anterolateral and posterior approaches to subacromial bursa injections are not significantly different. The anterolateral approach may place injected material medial to the medial bursal boundary, and fluoroscopy may not accurately assess this placement.

The effects of home interferential therapy on post-operative pain, edema, and range of motion of the knee.

OBJECTIVE: We studied the effects of home interferential current therapy (IFC) on postoperative pain, range of motion, and edema in subjects undergoing anterior cruciate ligament (ACL) reconstruction, menisectomy, or knee chondroplasty. DESIGN: Randomized, double-blind, placebo-controlled prospective study. SETTING: A tertiary care outpatient orthopaedic clinic/ambulatory surgery center. SUBJECTS OR PARTICIPANTS: Eighty-seven subjects were separated into three groups based on their type of knee surgery and within each group randomized into a treatment or placebo group. INTERVENTIONS: All subjects received home IFC units. Subjects randomized to treatment group received a working IFC unit. Placebo subjects received units that were previously set to deliver no current. MAIN OUTCOME MEASUREMENTS: Post-operative edema at 24, 48, and 72 hours, and weeks 1-8; range of motion at 1, 3, 6, and 9 weeks; pain immediately after surgery, at 24, 48, and 72 hours, and weeks 1-7; and amount of pain medication taken at days 1-10 were compared between treatment and placebo groups. RESULTS: All IFC subjects reported significantly less pain and had significantly greater range of motion at all post-operative time points. ACL and menisectomy IFC subjects experienced significantly less edema at all time points, while chondroplasty subjects experienced significantly less edema until 4 weeks postoperatively. CONCLUSIONS: These findings indicate that home IFC may help reduce pain, pain medication taken, and swelling while increasing range of motion in patients undergoing knee surgery. This could result in quicker return to activities of daily living and athletic activities.