Collagen Scaffold Application in Arthroscopic Reconstruction of Osteochondral Lesions of the Talus With Autologous Cancellous Bone Grafts.

Background: Single-step all-arthroscopic techniques have gained popularity recently in the treatment of osteochondral lesions of the talus (OLT). Concomitant subchondral bone defects led surgeons to add autologous bone grafting to the surgical procedures. Collagen scaffolds have been used widely for stabilization of the reconstruction and regeneration of the articular surface. Purpose: To compare single-step all-arthroscopic treatment of OLT consisting of debridement, microfracture, autologous bone grafting, and application of fibrin sealant in 2 patient groups: with versus without collagen scaffold. Study Design: Cohort study; Level of evidence, 3. Methods: Included were 94 patients who underwent single-step all-arthroscopic treatment for OLT. Autologous bone grafting was applied to 48 patients (BG group), while autologous bone grafting plus collagen scaffold was applied to 46 patients (BG+S group). A fibrin sealant was applied to both groups. Clinical outcomes were assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) score and the visual analog scale (VAS) for pain. Radiological outcomes were evaluated with the magnetic resonance observation of cartilage repair tissue score. The mean follow-up time was 69.3 ± 20.7 months. Results: Patients in both groups showed statistically significant improvement in pre- to postoperative AOFAS and VAS scores (P < .001 for all), with no difference between groups in AOFAS and VAS score improvement. Complete healing with or without hypertrophy was achieved in 42 patients in the BG group (87.5%) and 38 patients in the BG+S group (82.6%). Conclusion: The treatment of bone lesions in OLT may be the ultimate goal to obtain successful outcomes, in which case using a collagen scaffold besides grafting may not affect clinical and radiological outcomes.

Partial Rotator Cuff Repair With Superior Capsular Reconstruction Using the Biceps Tendon Is as Effective as Superior Capsular Reconstruction Using a Tensor Fasciae Latae Autograft in the Treatment of Irreparable Massive Rotator Cuff Tears.

BACKGROUND: Several treatment options are available for stable massive rotator cuff tears, including partial repair with or without tissue augmentation, tendon transfer, superior capsular reconstruction (SCR), and reverse shoulder arthroplasty. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the outcomes and effectiveness of partial rotator cuff repair with SCR using the long head of the biceps tendon (PRCR-SCRB) and SCR with a tensor fasciae latae autograft (SCRTF) for the treatment of rotator cuff tears with severe fatty degeneration. The hypothesis of this study was that SCRTF would be superior to PRCR-SCRB in functional and anatomic outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 26 consecutive patients with massive and fatty degenerative rotator cuff tears were treated surgically. Patients were divided into either the PRCR-SCRB group (n = 14) or SCRTF group (n = 12). Functional outcomes were assessed at final follow-up, and the acromiohumeral distance (AHD) was measured. RESULTS: All functional scores significantly improved in both groups at final follow-up. The PRCR-SCRB group showed better overall outcomes in terms of the visual analog scale for pain; American Shoulder and Elbow Surgeons score; and Quick Disabilities of the Arm, Shoulder and Hand, but these differences were not statistically significant. Better outcomes were found for only the AHD for the PRCR-SCRB group without statistical significance (P = .4). No statistical difference was found in terms of retear rate. CONCLUSION: PRCR-SCRB had comparable outcomes and improvement in AHD compared with SCRTF without the need for additional graft harvesting.

Suture configuration techniques have no effect on mid-term clinical outcomes of arthroscopic meniscus root repairs.

BACKGROUND: The aim of this study was to evaluate the clinical and radiological outcomes of arthroscopic transtibial pullout repair (ATPR) for the medial meniscus with both two modified loop stitches (TLS) and two simple stitches (TSS) techniques. METHODS: Between January 2013 and January 2016, 41 patients who had undergone ATPR for medial root tears with TLS and TSS techniques were retrospectively evaluated. The mean age at operation was 53 years (range 45-58). The mean follow-up period was 44.6 months (range 26-64). Lysholm knee score was used for clinical evaluation before and after surgery. For all patients, meniscal extrusion distances in the coronal plane were measured using magnetic resonance imaging and were recorded both preoperatively and at final follow-up. RESULTS: There was no difference in terms of meniscus extrusion measurements between groups preoperatively (P > .05). Postoperative meniscus extrusion measurements were 2.1 ± 0.3 and 2.9 ± 0.6 in TLS and TSS groups, respectively. The difference between groups was statistically significant (P < .01). The increase in postoperative Lysholm score was found to be statistically significant in both groups (P < .01). Postoperative Lysholm scores were 88.8 ± 3.7 and 87.6 ± 4.8 in TLS and TSS groups, respectively. The difference between groups was statistically insignificant (P > .05). CONCLUSIONS: There was a significant improvement in Lysholm knee scores postoperatively in patients that underwent transtibial pullout medial meniscus posterior root repair regardless of meniscus reduction level and suture configuration types. Although TLS technique was superior to TSS technique in terms of meniscus reduction, this meniscus reduction did not create any clinical difference at clinical outcome.

Effect of suprascapular nerve injury on rotator cuff enthesis.

BACKGROUND: Numerous reports have shown that retracted rotator cuff tears may cause suprascapular nerve injury, and nerve injury causes atrophy and fat accumulation in the rotator cuff muscles. However, the effect of suprascapular nerve injury on rotator cuff enthesis has not been directly defined. This study aimed to investigate the effect of suprascapular nerve injury on rotator cuff enthesis. METHODS: Twenty-four Wistar albino rats underwent bilateral transection of the suprascapular nerve. Additional 6 rats were used as the sham group. Bilateral supraspinatus and infraspinatus entheses were examined after 1, 4, 8, and 12 weeks of nerve transection. Histomorphometric analyses were performed for each zone of enthesis. RESULTS: Compared with normal enthesis, significant and consistent decrease in cellularity were observed in the tendon and bone at all time points (P < .001). Collagen bundle diameter in the tendon also decreased in a similar manner (P < .001). Apart from the tendon and bone zones, fibrocartilage and calcified fibrocartilage zones showed similar response, and significant decrease in cellularity was observed 8 weeks after nerve transection (P < .001). CONCLUSION: This study identifies suprascapular nerve injury as an underlying mechanism leading to compromise of the rotator cuff enthesis structure. Suprascapular nerve injury may be considered as an etiologic factor for the impaired healing after repair of a massive tear.

Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability.

PURPOSE: The aim of the study was to compare the intermediate-term clinical outcomes between lateral ligaments augmentation using suture-tape and modified Broström repair in a selected cohort of patients. The hypothesis of the presented study is that suture-tape augmentation technique has comparable clinical and radiological outcomes with arthroscopic Broström repair technique. METHODS: Sixty-one consecutive patients with chronic ankle instability were operated between 2012 and 2016 randomized to 2 groups. First group was composed of 31 patients whom were operated using an arthroscopic Broström repair technique (ABR) and second group was composed of 30 Patients whom were operated using arthroscopic lateral ligaments augmentation using suture-tape internal bracing (AST). At the end of total follow-up time, all patients were evaluated clinically using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiological evaluation was performed using anterior drawer and varus stress radiographs with standard Telos device in 150 N. Talar tilt angles and anterior talar translation were measured both preoperatively, 1 year postoperatively and at the final follow-up. RESULTS: Preoperative total FAOS scores for ABR and AST groups were 66.2 ± 12 and 67.1 ± 11, respectively. Postoperative Total FAOS scores for ABR and AST groups were 90.6 ± 5.2 and 91.5 ± 7.7, respectively. There was no statistical difference in between 2 groups both pre- and postoperatively (n.s). According to FAAM, sports activity scores of ABR and AST groups were 84.9 ± 14 and 90.4 ± 12 at the final follow-up, which showed that AST group was significantly superior (p = 0.02). There were no significant differences in preoperative and postoperative stress radiographs between the two groups. Mean operation time for AST and ABR groups were 35.2 min and 48.6 min, respectively, which shows statistically significantly difference (p < 0.05). There was no significant difference in recurrence rate of instability between to operation techniques (n.s). CONCLUSIONS: Arthroscopic lateral ligament augmentation using suture tape shows comparable clinical outcomes to arthroscopic Broström repair in the treatment of chronic ankle instability at intermediate-term follow-up time. Arthroscopic lateral ligament augmentation using suture tape has a significant superiority in the terms of less operation time and no need for cast or brace immediate after surgery which allows early rehabilitation. It also has a significant superiority in the terms of FAAM scores at sports activity. However, there was no difference during daily life. LEVEL OF EVIDENCE: II.

Low pH irrigation fluids have positive effect on intra-articular chondral healing.

PURPOSE: The aim of this study was to evaluate the effect of Ringer's lactate (RL) solutions with different pH values on early histologic healing in a microfracture model in vivo. The null hypothesis of the presented study is that irrigation fluids with lower pH (6.4) have negative effects on fibrous cartilage healing. METHODS: Eighteen Wistar albino rats were randomly divided into three groups. Anterior midline incision was performed. Microfracture procedure was performed with a 1.2 mm k-wire at the lateral femoral condyle of each knee. the skin was sutured and joints were irrigated for 30 min with low pH (6.4) RL in Group 1, high pH (7.6) RL in Group 2 and no irrigation in Group 3. Three rats from each group were randomly selected and killed on the 3rd and 7th day. On the 3rd day, the healed chondral area was examined. On the 3rd and 7th day, the chondral depth and morphology were evaluated. On the 7th day, bone cellularity was assessed with osteoblast; osteoclast number and bone quality were evaluated with trabecular area and the number of trabeculae. RESULTS: Chondral healing area on the 3rd day was significantly higher in Group 1 compared to other groups. Chondral morphology was also qualitatively superior in Group 1 compared to other groups on the 3rd and 7th day. There were no differences in chondral depths between the groups on the 3rd day; however, increased chondral depths were observed in Group 1 on the 7th day. There were statistically significant increases in trabecular area and the number of trabeculae, as well as the number of osteoblasts and osteoclasts in Group 1 on the 7th day. CONCLUSIONS: The presented study revealed that low pH irrigation fluids have positive effects on the healing characteristics of intra-articular fibrous cartilage after microfracture procedure in vivo. In light of this study, we can assume that lower pH solutions could be safely used during microfracture procedures and it can also facilitate intra-articular fibrous cartilage formation and cartilage healing. Selection of irrigation solution is also important for intra-articular fibrous cartilage healing after microfracture procedure in vivo.

Completion repair exhibits increased healing characteristics compared with in situ repair of partial thickness bursal rotator cuff tears.

PURPOSE: Little information is available regarding the healing capacity of in situ and completion repair for the treatment of partial thickness rotator cuff tears. The purpose of the study was to analyze the healing characteristics of both techniques. METHODS: Twenty-four adult Sprague-Dawley rats were operated. Partial thickness bursal side tears were created bilaterally at the supraspinatus tendons. Additional 6 rats were used as the sham group. The right shoulders were repaired in situ, and the left shoulders were repaired using the tear completion technique on the 10th day after detachment surgery. Rats were sacrificed on the 10th and 30th days after repair surgery. Type I collagen, the TNF-α concentrations, the number and diameter of fibroblasts, and neovascularization were examined at two different time points. RESULTS: The collagen concentration (ng/mg total protein) was significantly increased in both groups at T1 and decreased in the in situ group, whereas completion repair continued to increase at T2 (P < 0.05). The mean fibroblast diameter in the completion repair group continued to increase at both time points (P < 0.05). Neovascularization was significantly increased with tear completion compared with in situ repair (P < 0.05) at T1. No significant (n.s.) differences regarding the TNF-α concentration (pg/mg total protein) were noted for both surgical techniques at T2 (P > 0.05). CONCLUSION: Despite the concerns of detaching the intact tendon, the completion repair technique exhibited increased healing characteristics compared with the in situ technique. The reason for this finding might be the refreshing effect of debridement at the chronic degenerated tendon that could improve the healing response.

Palmaris longus tendon graft versus modified Weaver-Dunn procedure via dynamic button system for acromioclavicular joint reconstruction in chronic cases.

BACKGROUND: The hypothesis of this clinical study was that coracoclavicular (CC) reconstruction using autogenic palmaris longus graft through the GraftRope (PLG) system (Arthrex, Inc., Naples, FL, USA) would provide superior clinical and radiologic results compared with modified Weaver-Dunn procedure with the dynamic TightRope (Arthrex, Inc.) system (WDT). METHODS: Between 2008 and 2013, 32 patients (average age, 39.7 years; range, 22-60 years) underwent surgical reconstruction of chronic acromioclavicular (AC) joint dislocation. A modified WDT procedure was performed in 16 patients and autogenous PLG was performed in the other 16 patients. Patient data were collected retrospectively, with a final follow-up of 44.9 months (range, 29-60 months). The degree of AC joint displacement was evaluated by measuring the CC distance on the anteroposterior and axillary view. Clinical and functional outcomes were compared by American Shoulder and Elbow Surgeons and the Constant scores at final follow-up. RESULTS: Comparison between the WDT and PLG groups showed a significantly better outcome in the American Shoulder and Elbow Surgeons and the Constant scores (P < .01), in favor of the PLG group. Both groups showed an increased CC distance compared with the uninjured side, with a mean difference of 1.1 mm for the PLG and 3.3 mm for the WDT groups. A tolerable loss of reduction within the follow-up time was observed. Reduction loss was higher with the WDT group (P < .05). CONCLUSION: CC palmaris longus tendon graft reconstruction with GraftRope system was associated with functional and radiologic benefits. The palmaris longus graft with GraftRope system could be used in chronic cases.

Drilling through lateral transmuscular portal lowers the risk of suprascapular nerve injury during arthroscopic SLAP repair.

PURPOSE: The aim of our study was to evaluate the risk of medial glenoid perforation and possible injury to suprascapular nerve during arthroscopic SLAP repair using lateral transmuscular portal. METHODS: Ten cadaveric shoulder girdles were isolated and drilled at superior glenoid rim from both anterior-superior portal (1 o'clock) and lateral transmuscular portal (12 o'clock) for SLAP repairs. Drill hole depth was determined by the manufacturer's drill stop (20 mm), and any subsequent drill perforations through the medial bony surface of the glenoid were directly confirmed by dissection. The bone tunnel depth and subsequent distance to the suprascapular nerve, scapular height and width, were compared for investigated locations. RESULTS: Four perforations out of ten (40 %) occurred through anterior-superior portal with one associated nerve injury. One perforation out of ten (10 %) occurred through lateral transmuscular portal without any nerve injury. The mean depth was calculated as 17.6 mm (SD 3) for anterior-superior portal and 26.5 mm (SD 3.6) for lateral transmuscular portal (P < 0.001). CONCLUSIONS: It is anatomically possible that suprascapular nerve could sustain iatrogenic injury during labral anchor placement during SLAP repair. However, lateral transmuscular portal at 12 o'clock drill entry location has lower risk of suprascapular nerve injury compared with anterior-superior portal at 1 o'clock drill entry location.

Evaluation of absorbable and nonabsorbable sutures for repair of achilles tendon rupture with a suture-guiding device.

BACKGROUND: The purpose of this study was to compare the functional and clinical results of Achilles tendon repairs with an Achilles tendon suture-guiding device using nonabsorbable versus absorbable sutures. We hypothesized that the absorbable suture would have clinical results comparable to those of the nonabsorbable suture for Achilles tendon repair with an Achilles tendon suture-guiding system. METHODS: From January 2010 to September 2013, 48 consecutive patients who had sustained a spontaneous rupture of the Achilles tendon underwent operative repair with an Achilles tendon suture-guiding device using 2 different suture types. All ruptures were acute. The patients were divided equally into 2 groups according to suture type. In the nonabsorbable suture group, No. 2 braided nonabsorbable polyethylene terephthalate sutures were used, and in the absorbable suture group, braided absorbable polyglactin sutures were used. The average age of the patients was 38 years (range, 28-50 years). Functional outcome scores and complications were evaluated. RESULTS: All patients had an intact Achilles repair after surgery. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot clinical outcome scores were 98 (range, 90-100) in the nonabsorbable suture group and 96.8 (range, 87-100) in the absorbable suture group. All patients returned to their previous work. The absorbable suture group had fewer postoperative complications (0%) than the nonabsorbable suture group (12.5%) (P < .05). CONCLUSION: Use of an absorbable suture in the treatment of Achilles tendon repair by an Achilles tendon suture-guiding system was associated with a lower incidence of suture reaction; however, functionally the results were not notably different from those using a traditional nonabsorbable suture. We conclude that repair with absorbable sutures is appropriate for Achilles tendon ruptures. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Carotid sinus hypersensitivity due to shoulder sling pressure after arthroscopic rotator cuff repair: a case report.

The beach chair position is one of the most commonly used positions in arthroscopic shoulder surgery because of its anatomical nature and easy modifiability to open surgery. Despite these advantages, thromboembolic and neurologic complications have been reported. We report a case of carotid sinus hypersensitivity due to shoulder sling pressure after arthroscopic shoulder surgery.