The Influence of Surgical Stabilization on Glenohumeral Abduction Using 3-Dimensional Computed Tomography in Patients With Shoulder Instability.

PURPOSE: This study compared the amount of glenohumeral abduction during arm abduction in the affected and unaffected shoulders of 3 groups of patients with shoulder instability: failed surgical stabilization, successful surgical stabilization, and unstable shoulder with no prior surgical intervention. METHODS: All patients underwent bilateral shoulder computed tomography scans in 3 positions: 0° of abduction and 0° of external rotation (0-0 position), 30° of abduction and 30° of external rotation (30-30 position), and arms maximally abducted (overhead position). Three-dimensional computed tomography reconstruction was performed for both shoulders in all 3 positions. A specialized coordinate system marked specific points and directions on the humerus and glenoid of each model. These coordinates were used to calculate the glenohumeral abduction for the normal and affected sides in the 0-0, 30-30, and overhead positions. RESULTS: Thirty-nine patients with shoulder instability were included, of whom 14 had failed surgical repairs, 10 had successful surgical repairs, and 15 had unstable shoulders with no prior surgical intervention. In the overhead position, patients with failed surgical intervention had significantly less glenohumeral abduction in the failed shoulder (95.6° ± 12.7°) compared with the normal shoulder (101.5° ± 12.4°, P = .02). Patients with successfully stabilized shoulders had significantly less glenohumeral abduction in the successfully stabilized shoulder (93.6° ± 10.8°) compared with the normal shoulder (102.1° ± 12.5°, P = .03). Unstable shoulders with no prior surgical intervention (102.1° ± 10.3°) did not differ when compared with the normal shoulders (101.9° ± 10.9°, P = .95). CONCLUSIONS: Surgical intervention, regardless of its success, limits the amount of abduction at the glenohumeral joint. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Prevalence of the acetabular sublabral sulcus at MR arthrography in patients under 17 years of age: does it exist?

PURPOSE: To retrospectively determine characteristics of contrast-filled acetabular labral clefts in patients under the age of 17 years at MR arthrography (Mra) correlated with arthroscopy, which may impact the thinking regarding the existence of a sublabral sulcus. MATERIALS AND METHODS: After IRB approval, 41 patients under the age of 17 who had MRa were identified. The following observations of contrast-filled clefts were assessed: (1) presence/absence, (2) location, (3) depth, (4) abnormal signal within the labrum and (5) shape (linear, gaping, complex). Fisher's exact and the Wilcoxon matched-pairs signed-rank test were performed. Interreader agreement was calculated with Cohen's k. RESULTS: Reader 1 found clefts in 41 %. Depth was less than half in 6%, more than half in 65% and full thickness in 29%. Shape was linear in 53%, gaping in 18% and complex in 29%. Signal changes occurred in 88%. Reader 2 found clefts in 29%. Depth was less than half in 17%, more than half in 58% and full thickness in 25%. Shape was linear in 50%, gaping in 42% and complex in 17%. Signal changes occurred in 50%. None of the clefts fulfilled the criteria for a sublabral sulcus at MRa and arthroscopy. CONCLUSION: None of the clefts found in our subjects under the age of 17 years met the MRa and arthroscopy criteria for a sublabral sulcus, which supports the theory that such clefts represent labral tears.

Comparison of 3-Dimensional Computed Tomography-Based Measurement of Glenoid Bone Loss With Arthroscopic Defect Size Estimation in Patients With Anterior Shoulder Instability.

PURPOSE: The purpose of this study was to compare four 3-dimensional (3D) computed tomography (CT) methods of measuring glenoid bone loss with the arthroscopic estimation of glenoid bone loss. METHODS: Twenty patients with recurrent anterior shoulder instability underwent bilateral shoulder CT scans and were found to have glenoid bone loss. Arthroscopic estimation of glenoid bone loss was performed in all patients. Three-dimensional CT reconstruction was performed on the CT scans of each patient. The glenoid bone loss of each patient was measured using the surface area, Pico, ratio, and anteroposterior distance-from-bare area methods. The mean percent loss calculated with each method was compared with arthroscopy to determine the reliability of arthroscopy in the measurement of glenoid bone loss. RESULTS: The mean percent bone loss calculated with arthroscopic estimation, surface area, Pico, ratio, and anteroposterior distance-from-bare area methods was 18.13% ± 11.81%, 12.15% ± 8.50% (P = .005), 12.77% ± 8.17% (P = .002), 9.50% ± 8.74% (P < .001), and 12.44% ± 10.68% (P = .001), respectively. Repeated-measures analysis of variance showed that the 3D CT methods and arthroscopy were significantly different (F4,76 = 13.168, P = .02). The estimate using arthroscopy is 55% greater than the average of the 3D CT methods. CONCLUSIONS: Our findings suggest that arthroscopy significantly overestimates glenoid bone loss compared with CT and call into question its validity as a method of measurement. A more internally consistent and accurate method for the measurement of glenoid bone loss is necessary to appropriately diagnose and treat shoulder instability. LEVEL OF EVIDENCE: Level IV, case series.

Rotator cuff tear and glenohumeral instability : a systematic review.

BACKGROUND: The rotator cuff plays a significant role in the static and dynamic stability of the glenohumeral joint. Rotator cuff tears may occur after shoulder dislocations, whether in younger athletes or older patients with age-related tendon degeneration. Untreated tears may cause persistent pain, dysfunction, instability, and degenerative changes. A thorough understanding of when to look for rotator cuff tears after shoulder dislocations and how best to manage them may decrease patients' pain and improve function. QUESTIONS/PURPOSES: We systematically reviewed the available literature to better understand (1) when a rotator cuff tear should be suspected after a dislocation, (2) whether surgical or nonsurgical approaches result in better scores for pain and satisfaction in patients with rotator cuff tears resulting from shoulder dislocations, and (3) whether intraarticular lesions, rotator cuff tears, or both should be addressed when surgery is performed. METHODS: We systematically searched MEDLINE(®), CINAHL, and EMBASE for studies published from 1950 to 2012. We included studies reporting outcomes after treatment in patients with rotator cuff tears and shoulder dislocations. We excluded case reports, studies without any treatment, and studies about patients treated with arthroplasty. Five Level III and six Level IV studies were ultimately selected for review. RESULTS: Patients with persistent pain or dysfunction after a shoulder dislocation often had a concomitant rotator cuff tear. Surgical repair resulted in improved pain relief and patient satisfaction compared to nonoperative management. Repair of the rotator cuff, along with concomitant capsulolabral lesions, helped restore shoulder stability. While these findings are based on Level III and IV evidence, better long-term studies with larger cohorts are needed to strengthen evidence-based recommendations. CONCLUSIONS: Persistent pain and dysfunction after a shoulder dislocation should prompt evaluation of the rotator cuff, especially in contact or overhead athletes, patients older than 40 years, or those with nerve injury. Surgery should be considered in the appropriately active patient with a rotator cuff tear after dislocation. While the current literature suggests improved stability and function after surgical repair of the rotator cuff, higher-quality prospective studies are necessary to make definitive conclusions.

Is the all-arthroscopic tibial inlay double-bundle PCL reconstruction a viable option in multiligament knee injuries?

BACKGROUND: All-arthroscopic tibial inlay double-bundle (DB) posterior cruciate ligament (PCL) reconstruction avoids an open dissection and the "killer turn" while maintaining the advantage of an anatomic graft. However, clinical data on the viability of this surgical technique in multiligamentous knee injuries are lacking. QUESTIONS/PURPOSES: At greater than 2 years of followup, we evaluated (1) validated outcomes scores; (2) range of motion; and (3) side-to-side stability on PCL stress radiographs of a small group of patients who underwent all-arthroscopic tibial inlay DB PCL reconstruction in multiligamentous knee injuries, either shortly after injury or late. METHODS: All patients sustaining an operative multiligamentous knee injury between August 2007 and March 2009 underwent PCL reconstruction with the all-arthroscopic tibial inlay DB PCL reconstruction. Twelve patients sustained such injuries and were reconstructed during the study period and all 12 returned for followup with a minimum of 2 years (mean 3 ± 0.8 years). There were nine males and three females, with a mean age of 30 years; four patients had a subacute reconstruction (≥ 3 weeks, but < 3 months), and eight patients had chronic reconstructions (> 3 months). Mean time from injury to PCL reconstruction was 7 ± 12 months. Demographics, ROM, outcome scores (Lysholm and International Knee Documentation Committee [IKDC] scores), and PCL stress views were obtained. RESULTS: At final followup, mean Lysholm and IKDC subjective scores were 79 ± 16 and 72 ± 19, respectively. IKDC objective scores included eight nearly normal knees, three abnormal knees, and one severely abnormal knee. Mean flexion and extension losses compared with the contralateral were 10 ± 9 and 1 ± 2, respectively. Mean ± SD final side-to-side difference on PCL stress radiographs was 5 ± 3 mm. CONCLUSIONS: The clinical and radiographic results of the all-arthroscopic tibial inlay DB PCL reconstruction appear comparable to the same technique in isolated PCL injuries and, based on similar published case series, comparable to results of multiligamentous knee reconstructions using other PCL reconstruction techniques. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

A biomechanical analysis of the soft tissue and osseous constraints of the hip joint.

PURPOSE: The goal of this study was to determine the role of soft tissue and osseous constraints in hip biomechanics using a unique robotic testing apparatus. METHODS: Four fresh-frozen human cadaveric hemi-pelvises without degenerative changes or dysplasia were stripped of all soft tissue except the ligamentous capsule and the intra-articular structures. All hips were tested using a robotic manipulator/universal force-moment sensor testing system to measure and compare end-range of motion (ROM) and kinematic translations in "capsule vented" (a small hole in the capsule) and "capsule separated" (capsular ligaments separated from each other) states. Then, the "capsule vented" state was compared to the condition in which the capsule and labrum were removed to calculate bone and soft tissue forces with 40 N of load applied in six different directions along three axes. RESULTS: There were no significant differences in end-ROM or kinematic translations between the "capsule vented" and "capsule separated" states. Bone forces significantly increased with loads applied in the anterior, posterior and superior directions. Soft tissue forces increased significantly with loads applied in the medial, lateral and inferior directions. CONCLUSION: The individual hip capsular ligaments act independently of each other to resist end-ROM. Both osseous and soft tissue constraints are important to hip biomechanics depending upon the direction of applied force. The clinical relevance is that surgical management for hip disorders should preserve the soft tissue constraints in the hip when possible to maintain normal hip biomechanics.

Comparison of reconstructive procedures for glenoid bone loss associated with recurrent anterior shoulder instability.

HYPOTHESIS: A tibial plafond allograft, iliac crest allograft, and coracoid autograft in a congruent arc Latarjet reconstruction better restore radius of curvature, depth, and surface area for glenoid bone loss in recurrent instability compared with the coracoid autograft in a standard Latarjet reconstruction for anteroinferior glenoid bone loss of the shoulder. METHODS: Three-dimensional shoulder models were generated from bilateral computed tomography scans in 15 patients, who were a mean (standard deviation [SD]) age of 23 (7.7) years, with recurrent anterior shoulder instability and known glenoid bone loss. The surface areas of the glenoid in the involved and contralateral normal shoulder were measured. Virtual surgery was then performed using standard and congruent arc Latarjet reconstruction, tibial plafond, and iliac crest allografts. Grafts were optimally positioned to restore articular congruity and defect fill. Radius of curvature and restoration of glenoid depth were compared with the contralateral glenoid. RESULTS: Glenoid surface area (11.04% [6.95% SD]) and depth (0.75 [0.57 SD] vs 1.44 [0.65 SD] mm) were significantly reduced (P < .012) in the injured glenoid. The mean (SD) coronal plane radius of curvature of the congruent arc Latarjet reconstruction (60.3 [39.0 SD] mm) more closely matched the radius of curvature of the injured glenoid (67.5 [33.2 SD] mm) compared with the other grafts. Restored glenoid depth was greater in the tibial plafond (1.8 [1.1 SD] mm) and iliac crest (2.0 [0.6 SD] mm) allografts compared with other grafts (P < .002). CONCLUSION: Congruent arc Latarjet reconstruction more closely restores native glenoid coronal radius of curvature, whereas tibial plafond and iliac crest allografts more adequately restore depth compared with standard Latarjet reconstruction.

Gender and racial differences in focal and global acetabular version.

The purpose of this study was to compare the acetabular version between male and female pelvises. We hypothesized that female acetabula would demonstrate more retroversion because Pincer-type femoroacetabular impingement (FAI) is associated with acetabular retroversion, which is more commonly observed in females. 120 bony pelvic specimens were randomly collected. The version was measured at three different axial sections of each acetabulum: cranial, central, and caudal. Males demonstrated significantly less anteversion than females in every section. The global version (the average of all three measurements) was also significantly different between males and females (16° ± 7° and 19° ± 8° respectively, P<0.001). Of the 240 examined acetabuli, 21 demonstrated cranial retroversion (16 males & 5 females). The data showed no significant difference (P=0.353) between global version of African Americans (18° ± 9°) and Caucasians (17° ± 7°). The results of this study suggest that symptomatic FAI in the female population likely reflects a complex interplay of femoral and acetabular dysmorphology and cannot be explained by differences in acetabular version alone.

An increase in cranial acetabular version with age: implications for femoroacetabular impingement.

This cadaveric study aimed to determine if acetabular retroversion demonstrates predictable changes with age that could inform understanding of factors that may contribute to the pathophysiology of femoroacetabular impingement. Two-hundred forty pelves were divided into young and old groups. Version was measured at the cranial (5mm below superior rim), central (transverse of acetabulum), and caudal (5mm above inferior rim) locations. The data showed a significant difference between young (10±10°) and old (13±9°) cranial version (P=.02). Cranial retroversion increases with age and may reflect a developmental component in the etiology of the focal rim impingement lesion or ossification of the damaged labrum. Global acetabular retroversion does not appear to change with age and may reflect a congenital etiology.

Femoroacetabular cam-type impingement: global assessment of the femoral head-neck junction on a single reformatted MR image.

PURPOSE: To characterize the imaging appearance of femoral head-neck contour abnormalities on a short-axis magnetic resonance (MR) image compared with the usual anterior alpha angle measurements and multiple alpha angle measurements on radial reformatted MR images, with surgery as the reference standard. MATERIALS AND METHODS: After institutional review board approval of this HIPAA-compliant study, 21 patients who underwent arthroscopy and 24 patients who did not, all of whom were evaluated with three-dimensional MR imaging, during 1 year were identified. Short-axis MR images of the femoral head-neck junction were reformatted with multiple radial images along the axis of the femoral neck. The following measurements were made at each hour of a clock face: (a) presence and size of bone contour abnormality visible beyond a best-fit circle and (b) femoral head-neck offset angles. Mann-Whitney, Fisher exact, and Wilcoxon matched-pair signed rank tests were performed. Intra- and interreader agreement were calculated as the Cohen κ. RESULTS: Of the 21 subjects who underwent surgery, 16 were confirmed to have cam-type femoroacetabular impingement (FAI) at surgery. Comparing findings from short-axis images with those at surgery, average accuracy was 81%. Comparing findings from head-neck offset angles with those at surgery, average accuracy was 80%. On short-axis images, average bone elevation was 3.2 mm in patients with cam-type FAI and 1.4 mm in those without it. In eight of 24 subjects who did not undergo surgery, the alpha angle was normal but the short-axis MR image showed abnormal bone contour. CONCLUSION: An abnormal bone contour identified on a short-axis MR image at the femoral head-neck junction correlates with surgical findings and may allow for a global characterization of the bone abnormality with regard to location, extent, and amount of elevation compared with the alpha angle and multiple head-neck offset angles.

Capsular laxity of the hip: findings at magnetic resonance arthrography.

PURPOSE: The purpose of this study was to retrospectively investigate magnetic resonance (MR) arthrography imaging findings associated with capsular laxity of the hip joint found at surgery. METHODS: After institutional review board approval, 27 patients who had arthroscopy reports that described the presence or absence of capsular laxity of the hip joint were identified over a 2-year period. Preoperative MR images were retrospectively reviewed by 2 blinded radiologists. The following observations were recorded: (1) thickness, signal intensity, and defects of the anterior joint capsule; (2) thickness and signal intensity of the zona orbicularis; (3) width of the anterior and posterior joint recesses at the level of the femoral head; (4) presence of synovitis in the anterior joint recess; and (5) volume of intra-articular contrast and degree of hip rotation. Intrarater and inter-rater agreement was assessed. RESULTS: Of the 27 patients, 17 were positive and 10 were negative for hip joint laxity at arthroscopy. The mean thickness of the anterior hip capsule was significantly different (P = .0043), measuring 2.5 mm (95% confidence interval [CI], 2.3 to 2.8 mm) in those with hip laxity and 3.3 mm (95% CI, 2.8 to 3.8 mm) in those without laxity. The mean width of the anterior joint recess was 5.8 mm (95% CI, 5.4 to 6.3 mm) in those with laxity and 3.6 mm (95% CI, 3.3 to 3.9 mm) in those without laxity and was significantly different (P < .0001). No other variables were considered useful because of a lack of significant differences between the 2 patient groups or low inter-rater agreement. CONCLUSIONS: On the basis of 95% CIs, hip joint laxity at MR arthrography is associated with widening of the anterior hip joint recess (>5 mm) and thinning of the adjacent joint capsule (<3 mm) lateral to the zona orbicularis.

Evaluation of the painful athletic hip: imaging options and imaging-guided injections.

OBJECTIVE: This article reviews diagnostic imaging tests and injections that provide important information for clinical management of patients with sports-related hip pain. CONCLUSION: In the evaluation of sports-related hip symptoms, MR arthrography is often used to evaluate intraarticular pathology of the hip. The addition of short- and long-acting anesthetic agents with the MR arthrography injection adds additional information that can distinguish between symptomatic and asymptomatic imaging findings. Osseous abnormalities can be characterized with radiography, MRI, or CT. Ultrasound is important in the assessment of iliopsoas abnormalities, including tendon snapping, and to guide diagnostic anesthetic injection.

Diagnostic knee arthroscopy: a pilot study to evaluate surgical skills.

PURPOSE: To develop a scoring system to evaluate individual proficiency at diagnostic knee arthroscopy. METHODS: This was a prospective blinded study. Subjects included residents in postgraduate year (PGY) 1 through PGY 5 (n = 20) and staff surgeons (n = 10). All subjects performed a diagnostic arthroscopy on a cadaveric knee. Subjects were evaluated on both completeness and time required to complete the arthroscopy. The examiner viewed the arthroscopy from a remote location and was blinded to the level of training of the subjects. During the arthroscopy, 15 areas required assessment to achieve a score of 75 points. An additional 25 points were awarded depending on the time it took to complete the arthroscopy. A maximum of 100 points were available (Total score = Arthroscopy score + Time score). RESULTS: Thirty subjects were divided into 3 groups: group 1 (PGY 1 or 2) (n = 12), group 2 (PGY 3, 4, or 5) (n = 8), and group 3 (staff) (n = 10). In group 1 the mean total score was 28.25 points, the mean time to complete arthroscopy was 11.9 minutes, and the mean number of structures not examined was 8.67. In group 2 the mean total score was 76 points, the mean time to complete arthroscopy was 8.2 minutes, and the mean number of structures not examined was 1.75. In group 3 the mean total score was 100 points, the mean time to complete arthroscopy was 4.6 minutes, and the mean number of structures not examined was 0. Statistically significant differences by use of an analysis of variance test were noted for the total score, total time, and number of missed structures (P < .001). CONCLUSIONS: Using our skills assessment tool, we were able to evaluate subjects and determine their relative technical skill level in performing a diagnostic arthroscopy. This tool was able to distinguish among the novice, experienced, and expert levels in performing diagnostic arthroscopy. LEVEL OF EVIDENCE: Level III, development of diagnostic criteria on the basis of consecutive subjects.

The Development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: the International Hip Outcome Tool (iHOT-33).

PURPOSE: The purpose of this study was to develop a self-administered evaluative tool to measure health-related quality of life in young, active patients with hip disorders. METHODS: This outcome measure was developed for active patients (aged 18 to 60 years, Tegner activity level ≥ 4) presenting with a variety of symptomatic hip conditions. This multicenter study recruited patients from international hip arthroscopy and arthroplasty surgeon practices. The outcome was created using a process of item generation (51 patients), item reduction (150 patients), and pretesting (31 patients). The questionnaire was tested for test-retest reliability (123 patients); face, content, and construct validity (51 patients); and responsiveness over a 6-month period in post-arthroscopy patients (27 patients). RESULTS: Initially, 146 items were identified. This number was reduced to 60 through item reduction, and the items were categorized into 4 domains: (1) symptoms and functional limitations; (2) sports and recreational physical activities; (3) job-related concerns; and (4) social, emotional, and lifestyle concerns. The items were then formatted using a visual analog scale. Test-retest reliability showed Pearson correlations greater than 0.80 for 33 of the 60 questions. The intraclass correlation statistic was 0.78, and the Cronbach α was .99. Face validity and content validity were ensured during development, and construct validity was shown with a correlation of 0.81 to the Non-Arthritic Hip Score. Responsiveness was shown with a paired t test (P ≤ .01), effect size of 2.0, standardized response mean of 1.7, responsiveness ratio of 6.7, and minimal clinically important difference of 6 points. CONCLUSIONS: We have developed a new quality-of-life patient-reported outcome measure, the 33-item International Hip Outcome Tool (iHOT-33). This questionnaire uses a visual analog scale response format designed for computer self-administration by young, active patients with hip pathology. Its development has followed the most rigorous methodology involving a very large number of patients. The iHOT-33 has been shown to be reliable; shows face, content, and construct validity; and is highly responsive to clinical change. In our opinion the iHOT-33 can be used as a primary outcome measure for prospective patient evaluation and randomized clinical trials.

Intra-abdominal fluid extravasation during hip arthroscopy: a survey of the MAHORN group.

PURPOSE: The purpose of this study was to survey experts in the field of hip arthroscopy from the Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN) group to determine the frequency of symptomatic intra-abdominal fluid extravasation (IAFE) after arthroscopic hip procedures, identify potential risk factors, and develop preventative measures and treatment strategies in the event of symptomatic IAFE. METHODS: A survey was sent to all members of the MAHORN group. Surveys collected data on general hip arthroscopy settings, including pump pressure and frequency of different hip arthroscopies performed, as well as details on cases of symptomatic IAFE. Responses to the survey were documented and analyzed. RESULTS: Fifteen hip arthroscopists from the MAHORN group were surveyed. A total of 25,648 hip arthroscopies between 1984 and 2010 were reviewed. Arthroscopic procedures included capsulotomies, labral reattachment after acetabuloplasty, peripheral compartment arthroscopy, and osteoplasty of the femoral head-neck junction. Of the arthroscopists, 7 (47%) had 1 or more cases of IAFE (40 cases reported). The prevalence of IAFE in this study was 0.16% (40 of 25,650). Significant risk factors associated with IAFE were higher arthroscopic fluid pump pressure (P = .004) and concomitant iliopsoas tenotomy (P < .001). In all 40 cases, the condition was successfully treated without long-term sequelae. Treatment options included observation, intravenous furosemide, and Foley catheter placement, as well as 1 case of laparotomy. CONCLUSIONS: Symptomatic IAFE after hip arthroscopy is a rare occurrence, with an approximate prevalence of 0.16%. Prevention of IAFE should include close intraoperative and postoperative monitoring of abdominal distention, core body temperature, and hemodynamic stability. Concomitant iliopsoas tenotomy and high pump pressures may be risk factors leading to symptomatic IAFE. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Open tibial inlay versus arthroscopic transtibial posterior cruciate ligament reconstructions.

PURPOSE: The optimal method of posterior cruciate ligament (PCL) reconstruction is not known. The purpose was to evaluate the biomechanical and clinical literature comparing open tibial inlay and arthroscopic transtibial PCL reconstructions and determine which method of reconstruction is superior. METHODS: A systematic review of the literature was performed on PubMed. Biomechanical and clinical studies comparing the outcomes of open tibial inlay and arthroscopic transtibial PCL reconstructions were selected and reviewed. RESULTS: Biomechanical studies evaluating posterior stability found no difference or increased stability with open inlay reconstruction. Graft degradation at the killer turn after arthroscopic transtibial reconstruction was described in some of the biomechanical studies. Biomechanical studies found no significant difference in graft forces after cyclic loading between the 2 groups. Biomechanical studies were influenced by methodologic limitations of graft fixation, power analysis, graft tensioning protocol, and magnitude of load applied for cyclic loading. Clinical studies with some methodologic limitations found no significant difference in maintaining posterior stability between the 2 reconstruction groups at short-term follow-up. CONCLUSIONS: The advantage of open inlay or arthroscopic transtibial PCL reconstruction techniques remains uncertain in the setting of conflicting biomechanical studies, with notable limitations in clinical studies. The arthroscopic tibial inlay technique may provide benefits of both open inlay and transtibial reconstruction techniques and comparable stability to the conventional PCL reconstruction methods according to several biomechanical studies. LEVEL OF EVIDENCE: Level IV, systematic review.

Arthroscopic glenoid osteochondral allograft reconstruction without subscapularis takedown: technique and literature review.

Failure to address glenoid deficiency/osteochondral defects can lead to persistent shoulder instability despite a surgical stabilization procedure. In patients with significant glenoid bone loss, osteoarticular allograft transplantation has the potential benefit of restoring normal glenohumeral anatomy. It may also reduce the risk of recurrent instability and permit near-normal postoperative range of motion while avoiding the complications of nonanatomic reconstruction techniques. Numerous open methods of anatomic glenoid reconstruction have been described, including the use of iliac crest autograft, distal tibia allograft, and glenoid allograft. Our purpose is to review the literature regarding the surgical treatment of glenoid bone deficiency. We also describe a novel technique of arthroscopic anteroinferior glenoid reconstruction using glenoid osteochondral allograft without subscapularis takedown. The potential risks and benefits of our technique are also discussed.

Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology.

PURPOSE: The purpose of this study was to compare the percent relief from injection among subjects with arthroscopic findings of femoroacetabular impingement (FAI) and labral and chondral pathologies while controlling for coexisting extra-articular pathology. METHODS: We retrospectively reviewed 72 consecutive subjects (54 female and 18 male subjects), aged 29.9 ± 10.4 years (range, 16 to 55 years), who underwent hip arthroscopy. Three separate analyses of covariance compared the percent relief after injection between groups based on surgically confirmed type of impingement (none, cam, pincer, or combined), labral pathology (none, mild, or torn), and chondral pathology (none, mild acetabular abnormality, acetabular delamination, or femoral lesion) while controlling for the presence of extra-articular pathology (iliotibial band, iliopsoas tendinopathy, or bursitis). RESULTS: The results of analysis 1 (F3,67 = 1.96, P = .128, partial η² = .081) and analysis 2 (F2,68 = 0.008, P = .992, partial η² = .000) indicated no significant main effect for FAI and labral pathology, respectively, on percent relief from injection. The results for analysis 3 indicated a significant main effect for chondral pathology of the hip on the percent relief from injection (F3,67 = 3.03, P < .05, partial η² = .128). Post hoc analysis showed that those with mild chondral pathology of the acetabulum and those with acetabular delamination had significantly greater percent relief compared with those without chondral pathology. Extra-articular pathology did not influence the percent relief from injection in any of the analyses. CONCLUSIONS: Subjects with chondral damage had greater relief from injection than those without, regardless of severity. The presence and severity of FAI and labral pathology did not influence the percent relief from injection. Concurrent extra-articular pathology did not alter the interpretation of the percent relief from injection. Therefore the interpretation and diagnostic value of an anesthetic injection in those with primary intra-articular pathology does not need to be altered by the presence of coexisting extra-articular hip pathology. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Failure of operative treatment for glenohumeral instability: etiology and management.

Failure of primary shoulder stabilization procedures is often related to uncorrected anatomic pathology. Orthopaedic surgeons must recognize excessive capsular laxity or large glenohumeral bone defects preoperatively to avoid recurrence of instability. When history, physical examination, and radiographic evaluation are used in conjunction, patients at risk for failure can be identified. The instability severity index score permits precise identification of patients at risk. When treating patients in whom prior surgical intervention has failed, the success of revision procedures correlates to the surgeon's ability to identify the essential pathology and use lesion-specific treatment strategies. Revision procedures remain technically demanding. Keen preoperative and intraoperative judgment is required to avoid additional recurrence of instability after revision procedures, particularly because results deteriorate with each successive operation. Glenoid or humeral defects with greater than 25% bone loss compromise stability provided through the mechanism of concavity compression. These defects must be specifically addressed to avoid recurrence of instability. We prefer anatomic reconstruction techniques combined with capsulolabral repair and, if bone defects are present, anatomic reconstruction with osteochondral allograft.

Meniscus tears in the young athlete: results of arthroscopic repair.

BACKGROUND: The purpose of this study was to evaluate the results of arthroscopic repair of the meniscus in children and young athletes. METHODS: Arthroscopic meniscus repairs performed on 49 knees in 31 male and 14 female patients <18 years old were reviewed. All repairs were done using an inside-out technique, and 31 patients required concomitant anterior cruciate ligament (ACL) reconstruction. Age at time of injury, time to surgery, and the extent, type, and location of meniscus tear were noted. All patients underwent postoperative rehabilitation and clinical evaluation. The level of activity at follow-up and postoperative outcomes scores was determined. Analysis included t tests, Wilcoxon tests, χ tests, and Fisher exact tests, with a level of significance of P ≥ 0.05. RESULTS: Excellent clinical outcomes were noted in 43 of 45 patients, with mean length of follow-up of 27 months. Between the groups with and without ACL tears, there were no significant differences in mean age at the time of injury or surgery, or in the distribution of open versus closed physes, medial versus lateral repairs, or level-of-activity at follow-up. However, patients with ACL reconstruction had significantly longer return-to-activity times (mean 8.23 mo vs. 5.56 mo) and significantly lower Tegner scores (mean 6.8 vs. 8.0) than patients without simultaneous reconstruction. CONCLUSIONS: The clinical results after arthroscopic meniscus repair in the adolescent were excellent, despite long average time from injury to surgery and a high number of tears in poorly vascularized areas. Meniscal tears in skeletally immature athletes may have greater reparative potential, with and without simultaneous ligament reconstruction. Attempts at repair regardless of time from injury or location of tear should be strongly considered in this age group. LEVEL OF EVIDENCE: Level III retrospective cohort series.