A 70° Arthroscope Significantly Improves Visualization of the Bicipital Groove in the Lateral Decubitus Position.

PURPOSE: The purpose of this study was to quantify the length of the bicipital groove viewable with a 70° arthroscope and to compare this distance visualized with use of a 30° arthroscope in both cadavers and living subjects. METHODS: Diagnostic glenohumeral arthroscopy in the lateral decubitus position was performed on 10 fresh-frozen cadaveric shoulders from a posterior portal. Using 70° and 30° arthroscopes, the distalmost viewable portion of the bicipital groove was percutaneously marked. Dissection of each specimen was then performed, and the distances between the articular margins of the humeral head to each marked portion of bicipital groove were recorded. Subsequently, a similar technique was used to measure the visible length of the bicipital groove in a series of 11 patients at the time of diagnostic glenohumeral arthroscopy performed in the lateral decubitus position using 70° and 30° arthroscopes. Descriptive statistics were used for continuous data. Means were compared with a Mann-Whitney test. Statistical significance was set at P ≤ .05. RESULTS: The cadaveric analysis revealed a significant increase in the amount of bicipital groove visualized with the 70° arthroscope versus that visualized with the 30° arthroscope (18.0 ± 6.9 mm v 11 ± 4.7 mm, P = .01). In similar fashion, the results of the in vivo analysis showed that the 70° arthroscope allowed for significantly more visualization of the bicipital groove than the 30° arthroscope (26.3 ± 6.2 mm v 14 ± 4.7 mm, P = .025). CONCLUSIONS: The use of a 70° arthroscope significantly increases the length of bicipital groove visualized during glenohumeral arthroscopy in the lateral decubitus position compared with that of the 30° arthroscope in both cadavers and living subjects. CLINICAL RELEVANCE: Routine use of a 70° arthroscope significantly improves visualization of the bicipital groove and all relevant intra-articular structures compared with that of a 30° arthroscope during diagnostic glenohumeral arthroscopy performed in the lateral decubitus position.

Outcome instruments for the shoulder.

Outcome surveys may play a vital role in the future of orthopaedics. Institutions may increasingly look toward determining the effectiveness of treatment options, but different validation studies often yield different results. There is a clear need for consistency when reporting patient-reported outcome scores. Knowledge of the available outcome scores and their strengths and weaknesses will allow orthopaedic surgeons to practice evidence-based medicine, offer their patients the most appropriate treatments, and successfully navigate the increasingly complex reimbursement system. Orthopaedic surgeons will need to show conclusively that their procedures improved patient outcomes and were cost-effective. We conducted a review of upper extremity outcome systems commonly used in the shoulder and their scoring and validation.

Biomechanical properties of repairs for dislocated AC joints using suture button systems with integrated tendon augmentation.

PURPOSE: To evaluate the biomechanical performance of different techniques for CC reconstruction using suture button systems with integrated tendon augmentation. Hypothesis was that (1) reconstructions using a cortical button combined with a biological augmentation (semitendinosus allograft) will demonstrate improved stability than a modified Weaver-Dunn procedure and (2) constructs using two tunnels at the clavicle for fixation will show superior horizontal stability than single-tunnel constructs. METHODS: The acromioclavicular joints of 47 cadaveric shoulders were tested for anterior, posterior, and superior translations (70 N load) and maximal load to failure (superior). Shoulders were assigned to 4 groups: (1) native (n = 18) and after sectioning the AC and CC ligaments; (2) CC reconstruction with 1 clavicular and 1 coracoid tunnel (GR-ST) augmented with semitendinosus graft (n = 15); (3) CC reconstruction augmented with semitendinosus tendon (GR-DT) with 2 clavicular and 1 coracoid tunnel (n = 8); and (4) modified Weaver-Dunn reconstruction (n = 6). RESULTS: The Weaver-Dunn demonstrated statistically more translation than the native joint for posterior direction (P = 0.038). The GR-ST had significantly less translation than the Weaver-Dunn for anterior and posterior translations (P = 0.003, P = 0.004) and compared to the native for superior translation (P = 0.028). The GR-DT differed significantly in anterior and posterior translations compared to the Weaver-Dunn (P = 0.002, P = 0.001). The modified Weaver-Dunn failed at significantly less load to failure compared to all other groups (P = 0.002, P = 0.002, P = 0.005). There was no significant difference between the native and the other reconstructions. CONCLUSION: The evaluated techniques for isolated CC ligament reconstruction (GR-ST) in AC joint dislocation showed biomechanical stability superior to the modified Weaver-Dunn procedure and obtained similar measures compared to the native control. A modified technique (GR-DT), which used two fixation points at the clavicle, did not result in decreased horizontal or vertical translation and therefore no superiority of the GR-DT technique could be shown compared to the GR-ST. LEVEL OF EVIDENCE: Controlled laboratory study.

Fragility Fractures: Diagnosis and Treatment.

Fragility fractures are estimated to affect 3 million people annually in the United States. As they are associated with a significant mortality rate, the prevention of these fractures should be a priority for orthopedists. At-risk patients include the elderly and those with thyroid disease, diabetes, hypertension, and heart disease. Osteoporosis is diagnosed by the presence of a fragility fracture or by dual-energy x-ray absorptiometry (DXA) in the absence of a fragility fracture. In 2011, the United States Preventive Services Task Force (USPSTF) recommended that all women ≥65 years should be screened for osteoporosis by DXA. Women <65 years with a 10-year fracture risk =∕> than that of a 65-year-old white woman should also be screened for osteoporosis. Lifestyle changes, such as calcium and vitamin D supplementation, exercise, and smoking cessation, are non-pharmacologic treatment options. The National Osteoporosis Foundation recommends treating osteoporosis with pharmacotherapy in patients with a high risk for fracture (T score <-2.5) or history of fragility fracture. Understanding risk factors and eliminating medications known to cause decreased BMD are vital to prevention and will be necessary to limit these fractures and their associated expenses in the future.

Lower Extremity Injuries in Ice Hockey: Current Concepts.

Ice hockey is a fast-paced, collision sport requiring tremendous skill and finesse, yet ice hockey can be a harsh and violent game. It has one of the highest musculoskeletal injury rates in all of competitive sports. Razor sharp skates, aluminum sticks and boards made from high density polyethylene (HDPE), all contribute to the intrinsic hazards of the game. The objective of this article is to review evaluation, management, and return-to-the-rink guidelines after common lower extremity ice hockey injuries.

Precision and Accuracy of Identification of Anatomical Surface Landmarks by 30 Expert Hip Arthroscopists.

We conducted a study to assess 30 expert hip arthroscopists' ability to identify common surface landmarks used during hip arthroscopy. Thirty hip arthroscopists independently performed a blinded examination of an awake supine human volunteer for identification of 5 surface landmarks: anterior superior iliac spine (ASIS), tip of greater trochanter (GT), rectus origin (RO), superficial inguinal ring (SIR), and psoas tendon (PT). The examiners applied the labels ASIS, GT, RO, SIR, and PT to the landmarks. An ultrasonographer performed a musculoskeletal ultrasound examination and applied labels as well, and a photographer documented the examiner labels after obtaining overhead and lateral digital images with use of fixed camera mounts. Digital overlay composite images of arthroscopist and ultrasonographer labels were analyzed. Direction and distance of inaccurately placed labels were compared with known values for neurovascular structures previously reported for common arthroscopic portals. Average distance from examiner-applied labels to ultrasonographer-applied labels was 31 mm for ASIS, 24 mm for GT, 26 mm for RO, 19 mm for SIR, and 35 mm for PT. Interobserver variability of examiner-applied labels was recorded as areas of 95% predictive interval: 65 cm2 for ASIS, 16 cm2 for GT, 221 cm2 for RO, 38 cm2 for SIR, and 29 cm2 for PT. Examiner labels demonstrated the highest potential for injury because of anterior portal inaccuracy. Expert hip arthroscopists varied in their ability to accurately and precisely identify common surface landmarks about the hip, using only manual palpation.

Stem-Based Repair of the Subscapularis in Total Shoulder Arthroplasty.

Management of the subscapularis is an important component of total shoulder arthroplasty. This technique article describes a stem-specific approach to repairing the subscapularis.

Acute Management of Anterior Cruciate Ligament Injuries Using Novel Canine Models.

The objective of this study was to compare treatment options for acute management of anterior cruciate ligament (ACL) injuries using preclinical models. Twenty-seven adult purpose-bred research hounds underwent knee surgery (sham control, exposed ACL, or partial-tear ACL) and were assessed over the following 8 weeks. Dogs were randomized into three treatment groups: standard of care (i.e., rest and nonsteroidal anti-inflammatory drugs [NSAIDs]), washout, or leukoreduced platelet-rich plasma (PRP) so that a total of nine dogs received each treatment. Data from the two ACL-injury groups were pooled for each treatment (n = 6 per treatment group) and analyzed for treatment effects. The washout and PRP groups experienced less lameness, pain, and effusion, and greater function and comfortable range of motion compared with the NSAID group, with the PRP group showing most benefits. PRP was associated with the lowest severity of ACL pathology based on arthroscopic assessment. Measurable levels of inflammatory and degradative biomarkers were present in synovial fluid with significant differences noted over time. Based on these findings, washout had positive clinical effects compared with the standard-of-care group especially within the first week of treatment, but became less beneficial over time. A single injection of leukoreduced PRP was associated with favorable clinical results. However, no treatment was significantly "protective" against progression toward osteoarthritis after ACL injury.

Nonoperative treatment of unicompartmental arthritis of the knee.

Treatment of the knee with unicompartmental osteoarthritis remains a challenging clinical problem. Despite pharmacologic advances and surgical innovations, the ideal strategy for the patient who has single-compartment degenerative disease can be complicated. The understanding and management of this problem are further confounded by the fact that so much of the data are unreliable. Given these constraints, this article outlines the current alternatives available in nonoperatively managing the symptomatic unicompartmental arthritic knee.