Mobility Assessment of the Supraspinatus in a Porcine Cadaver Model Using a Sensor-Enhanced, Arthroscopic Grasper.

Tendon mobility is highly relevant in rotator cuff surgery. Objective data about rotator cuff mobility is rare. Tendon mobility still needs to be evaluated subjectively by the surgeon. This study aims to establish a porcine animal model for mobility analysis of the supraspinatus. In this context, we introduce a sensor-enhanced, arthroscopic grasper (SEAG) suitable for objective intraoperative measurements of tendon mobility in clinical praxis. Tendon mobility of 15 fresh porcine cadaver shoulders with artificial rotator cuff tears was evaluated using the SEAG. Mobility characteristics (load-displacement curves, maximum load, stiffness) were studied and inter- and intraobserver agreement (intraclass correlation coefficient (ICC)) were tested. Factors with a potential adverse effect (plastic deformation and rigor mortis) were also evaluated. All shoulders showed characteristic reproducible load-displacement curves with a nonlinear part at the start, followed by a linear part. Mean maximum load was 28.6 N ± 12.5. Mean stiffness was 6.0 N/mm ± 2.6. We found substantial interobserver agreement (ICC 0.672) and nearly perfect intraobserver agreement (0.944) for maximum load measurement. Inter- (0.021) and intraobserver (0.774) agreement for stiffness was lower. Plastic deformation and rigor mortis were excluded. The animal model demonstrates reliable and in vivo-like measurements of tendon mobility. The SEAG is a reliable tool for tendon mobility assessment.

Assessment of arthroscopic shavers: a comparison test of resection performance and quality.

BACKGROUND: Arthroscopic shavers play an indispensable role in arthroscopic debridement. They have exquisite structures and similar designs. The purpose of this study was to establish a reproducible testing protocol to compare the resection performance and the quality (tensile strength, torsional strength, and corrosion resistance) of different arthroscopic shavers with comparable designs. We hypothesized that there could be little difference in resection performance and quality between these shavers. METHODS: Incisor Plus Blade (IPB; Smith & Nephew, Andover, MA) and Double Serrated Plus Blade (DSPB; BJKMC, Shanghai, China) were selected for resection performance and quality test. For resection performance testing, the resection torque, which is the minimum torque required to cut off silicone blocks with the same cross-sectional area, was measured to evaluate the resection performance of shaver blades when the other factors remain the same. For quality testing, tensile and torsion tests of the shavers' joint part were performed, and ultimate failure load and maximum torque were measured and compared. The corrosion resistance of these blades was assessed by the boiling water test based on the ISO13402. RESULTS: No significant difference existed in the resection torque between the shaver blades of IPB and DSPB (P = 0.54). To the failure load of shavers' joint parts, IPB was significantly higher than DSPB, both in the outer and inner blades (P < 0.0001). The maximum torque of the joint part had no significant difference between IPB and DSPB (for inner blades P = 0.60 and outer blades P = 0.94). The failure load (for both IPB and DSPB P < 0.0001) and maximum torque (for IPB P = 0.0475 and DSPB P = 0.015) of the inner blades were higher than those of the outer blades. No blemishes were observed on the surface of the blades after corrosion resistance tests. CONCLUSIONS: This study provided some new methods to evaluate the resection performance and quality of different shavers. The resection performance, the torsional strength of the joint part, and the corrosion resistance of IPB and DSPB may show comparable properties, whereas the tensile strength of the shavers' joint part showed some level of difference.

Nondestructive Assessment of Articular Cartilage Electromechanical Properties after Osteochondral Autologous and Allogeneic Transplantation in a Goat Model.

OBJECTIVE: To determine the applicability of a minimally invasive diagnostic device to evaluate the quality of articular cartilage following autologous (OAT) and allogeneic (OCA) osteochondral graft transplantation in goat model. DESIGN: OAT grafts were harvested from lateral femoral condyles (LFCs) and transplanted into osteochondral defects created in medial femoral condyles (MFCs) of contralateral knees. OCA grafts were transplanted into MFC condyles after in vitro storage. Autologous platelet-rich plasma (PRP) was administered intraarticularly after the surgery and at 1 and 2 months postoperatively. OAT and OCA grafts were evaluated macroscopically (Oswestry arthroscopy score [OAS]), electromechanically (quantitative parameter, QP), and histologically (O'Driscoll score, safranin O staining intensity) at 3 and 6 months after transplantation. Results were compared with preoperative graft evaluation. RESULTS: Transplanted cartilage deteriorated within 6 months in all groups. Cartilage quality was better retained in OAT group compared with a decline in OCA group. QP and OAS scores were comparable in OAT and OCA groups at 3 months, but superior in OAT group at 6 months, according to all the methods applied. PRP injections significantly improved QP and OAS score at 6 months compared with 3 months in OAT group. QP moderately correlated with OAS, O'Driscoll score, and safranin O staining intensity. CONCLUSIONS: Grafts did not retain preoperative quality parameters at 6 months follow-up; however, OAT were superior to OCA grafts. PRP may have a beneficial effect on macroscopic and electromechanical properties of cartilage; however, histological improvement is yet to be proved. Electromechanical diagnostic device enables reliable assessment of transplanted cartilage.

Artroscopia de cadera como tratamiento de la cadera dolorosa / Hip arthroscopy as a treatment for painful hip

CONTEXTO CLÍNICO: El dolor de cadera es una consulta traumatológica frecuente con múltiples causas posibles, ya sean articulares, extrarticulares o dolor referido, muchas de las cuales son pasibles de tratamiento com artroscopia de cadera. La anamnesis y el examen físico orientan el diagnóstico, que habitualmente se confirma con métodos por imagen. La artroscopia de cadera es un procedimiento que se realiza con mayor frecuencia para tratar diversas patologías de esta articulación. El pinzamiento femoro-acetabular (PFA), también llamado atrapamiento o choque femoro-acetabular o en inglés femoroacetabular impingement, se produce por un roce o choque anormal entre la cabeza del fémur y el acetábulo. La causa de una alteración en la forma del fémur (PFA tipo leva o "cam"), del acetábulo (PFA tipo pinza o "pincer") o ambas (PFA tipo mixta). La prevalencia radiológica de estas alteraciones es del 10-15%, aunque sólo un porcentaje mínimo producen síntomas y complicaciones. El 75% de los pacientes en los que se diagnostica esta patología son adultos jóvenes que practican un deporte con asiduidad, especialmente los que suponen flexión de la cadera y/o impacto sobre ella (p. ej. salto de vallas, gimnasia o artes marciales). El síntoma inicial es el dolor, el cual puede localizarse en la ingle, en la zona lateral o posterolateral de la cadera comprometida. Además, pueden presentarse resaltos o restricción en algunos movimientos. Si se prolonga en el tiempo, el PFA puede producir daño articular y artrosis traumática, con limitación funcional y la posibilidad de requerir un reemplazo de cadera. Los pacientes con clínica de PFA, sin respuesta al tratamiento conservador y sin evidencia clara de artrosis serían candidatos a una corrección quirúrgica. TECNOLOGÍA: La artroscopia de cadera es un procedimiento quirúrgico que se realiza con anestesia general. La correcta posición del paciente (y por lo tanto se debe disponer de camillas multi-posición), con tracción del miembro, es importante para la realización del procedimiento. Bajo guía radioscópica se colocan, un puerto (acceso) para la óptica y uno o dos puertos adicionales de trabajo por donde entra el instrumental que realizará los diferentes gestos quirúrgicos (desbridamiento, resección, biopsia). OBJETIVO: El objetivo del presente informe es evaluar la evidencia disponible acerca de la eficacia, seguridad y aspectos relacionados a las políticas de cobertura del uso de artroscopia de cadera. MÉTODOS: Se realizó una búsqueda en las principales bases de datos bibliográficas, en buscadores genéricos de internet, y financiadores de salud. Se priorizó la inclusión de revisiones sistemáticas (RS), ensayos clínicos controlados aleatorizados (ECAs), evaluaciones de tecnologías sanitarias (ETS), evaluaciones económicas, guías de práctica clínica (GPC) y políticas de cobertura de diferentes sistemas de salud. RESULTADOS: Se incluyeron 3 ECAs, 4 RS, 1 ETS, 2 evaluaciones económicas, y 14 informes de políticas de cobertura de artroscopia de cadera. CONCLUSIONES: Evidencia de muy baja calidad no permite establecer conclusiones acerca de la efectividad comparativa entre la cirugía artroscópica o la cirugía abierta para para el pinzamiento femoroacetabular. Evidencia de moderada calidad (por imprecisión y riesgo de sesgos) sobre el tratamiento quirúrgico mediante artroscopia de cadera en comparación con rehabilitación física estructurada para el tratamiento del pinzamiento femoro-acetabular sugiere que mejora levemente la calidad de vida al año de seguimiento. Evidencia de muy baja calidad no permite establecer conclusiones sobre la eficacia de la artroscopia de cadera para el tratamiento de lesiones de labrum, displasia de cadera, enfermedades sinoviales, desgarro del músculo aductor, lesiones del ligamento teres, artritis séptica, defectos condrales, retroversión acetabular, osteomas osteoides o trauma. No se encontraron guías de práctica clínica que mencionen esta tecnología. Las asseguradoras estadounidenses relevadas cubren, tanto la artroscopia como la cirugía abierta, para el tratamento de casos seleccionados de pinzamiento femoro-acetabular; algunas de estas aseguradoras también cubren estos procedimientos para otras indicaciones. El sistema de salud de Reino Unido cubre la artroscopia para pinzamiento femoro-acetabular. El resto de los financiadores de Latinoamérica y países de altos ingresos relevados no mencionan su uso. No se encontraron evaluaciones económicas en la región que evalúen esta tecnología.

Biceps Tenodesis: Biomechanical Assessment of 3 Arthroscopic Suprapectoral Techniques.

Biceps tenodesis maintains the cosmetic appearance and length-tension relationship of the biceps with an associated predictable clinical outcome compared with tenotomy. Arthroscopic suprapectoral techniques are being developed to avoid the disadvantages of the open subpectoral approach. This study biomechanically compared 3 arthroscopic suprapectoral biceps tenodesis techniques performed with a suture anchor with lasso loop technique, an interference screw, and a compressive rivet. For a total of 15 randomized paired tests, 15 pairs of human cadaveric shoulders were used to test 1 technique vs another 5 times with 3 customized setups. Biomechanical testing was performed with an electromechanical testing system. The tendon was preloaded with 10 N and cyclically loaded at 0 to 40 N for 50 cycles. Load to failure testing was performed at 1 mm/s until failure occurred. The compressive rivet, interference screw, and suture anchor with lasso loop had mean load to failure of 97.1 N, 146.4 N, and 157.6 N, respectively. The difference in ultimate strength between the suture anchor with lasso loop and the compressive rivet was statistically significant (P=.04). No significant differences were found between the suture anchor with lasso loop and the interference screw (P=.93) or between the interference screw and the rivet (P=.10). When adjusted for sex, the load to failure overall among the 3 constructs was not significantly different. All 3 techniques had a different predominant mechanism of failure. The suture anchor with lasso loop showed superior load to failure compared with the compressive rivet. The minimum load to failure required to achieve clinically reliable biceps tenodesis is unknown. [Orthopedics. 2017; 40(6):e1009-e1016.].

The assessment of portal-tract healing after knee arthroscopy.

OBJECTIVE: The aim of this study was to analyse the pattern of portal-tract healing, to compare the healing time of anteromedial and anterolateral portal tracts and to assess the impact of portal-tract delayed healing on the post-operative sub-acute and chronic anterior knee tenderness. METHODS: The study included 104 patients (68 males and 36 females; mean age: 49 ± 3.16 years (range; 17-66)) who have undergone knee arthroscopy. Puncture wounds were divided into two groups, (1) anteromedial and (2) anterolateral groups. Each group contained 104 portal-tracts. Healing of portal tracts was evaluated using sequential superficial ultrasonographic examinaitons. Visual analogue scale (VAS) was used to measure pain related to delayed tract healing and its association with the post-operative sub-acute and chronic anterior knee tenderness. RESULTS: Anteromedial and anterolateral tracts total healing time average values were 47 days and 28 days respectively. The VAS average values of anteromedial tracts after 2 weeks, one month, three months, six months and one year were 8.2, 6.3, 4, 1.9 and 0.6 respectively, and for the anterolateral tracts 7.4, 5.5, 2.8, 1.2 and 0.2 respectively. A statistical significance was detected between the two groups at the first and third months with P values 0.042 and 0.0035 respectively. CONCLUSIONS: Anteromedial tracts closed later than anterolateral tracts. Both portal-tracts delayed closure is a potential for post-operative sub-acute and chronic anterior knee tenderness after arthroscopic surgery. Four grades of tract healing were recognized. Portal-tract ultrasonography is advised in persistent post-operative sub-acute and chronic anterior knee tenderness. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Construct Validity for a Cost-effective Arthroscopic Surgery Simulator for Resident Education.

INTRODUCTION: Arthroscopy is one of the most challenging surgical skills to assess and teach. Although basic psychomotor arthroscopic skills, such as triangulation and object manipulation, are incorporated into many simulation exercises, they are not always individually taught or objectively evaluated. In addition, arthroscopic instruments, arthroscopy cameras, and the cadaver or joint models necessary for practice are costly. METHODS: A low-cost arthroscopic simulator was created to practice triangulation, probing, horizon changes, suture management, and object manipulation. The simulator materials were purchased exclusively from national hardware stores with a total cost averaging $79. The universal serial bus (USB) camera is included in the total cost. Three residency programs accredited by the Accreditation Council for Graduate Medical Education were tested on the simulator. Replica boards were created at each institution. Participants included medical students (20), residents (46), and attending physicians (9). RESULTS: Construct validity-the ability to differentiate between novice, intermediate, and senior level participants-was obtained. On all tasks, junior residents scored at a statistically significant lower rate than senior residents and attending physicians. CONCLUSIONS: This cost-effective arthroscopic surgical simulator objectively demonstrated that attending physicians and senior residents performed at a higher level than junior residents and novice medical students. The results of this study demonstrate that this simulator could be an important training tool for resident education.

Proximity of the Triangular Fibrocartilage Complex to Key Surrounding Structures and Safety Assessment of an Arthroscopic Repair Technique: A Cadaveric Study.

PURPOSE: To quantify the distance of the dorsal ulnar sensory branch, floor of the extensor carpi ulnaris (ECU) subsheath, and ulnar neurovascular bundles from the triangular fibrocartilage complex (TFCC), and secondarily to assess the safety of an all-inside arthroscopic repair of the TFCC with a commonly used meniscal repair device with respect to the aforementioned structures. METHODS: A custom K-wire with 1-mm gradation was used to determine the distance of at-risk structures from the periphery of the TFCC in 13 above-elbow human cadaver specimens. An all-inside repair of the TFCC at the location of a Palmer 1B tear was then performed using a commonly employed meniscal repair device. The distance from the deployed devices to the structure in closest proximity was then measured using digital calipers. RESULTS: The mean distance from the deployed device to the nearest structure of concern for iatrogenic injury was 9.4 mm (range, 5-15 mm). The closest structure to iatrogenic injury was usually, but not always, the dorsal ulnar sensory nerve in 9 of 13 wrists (69.2%) at 9.3 mm (range, 5-15 mm); on 3 occasions it was instead the ulnar nerve (23.1%) at 9.5 mm (range, 9-10 mm), and on 1 occasion 6 mm from the flexor digitorum profundus to the little finger (7.7%). Forearm rotation had no significant effect on measured distances (ulnar nerve: P = .98; dorsal sensory: P = .89; ECU: P = .90). The largest influence of forearm rotation was a 0.4-mm difference between pronation and supination with respect to the distance of the TFCC periphery on the ECU subsheath. CONCLUSIONS: An all-inside arthroscopic TFCC repair using a commonly used meniscal repair device appears safe with respect to nearby neurovascular structures and tendons under typical arthroscopic conditions. CLINICAL RELEVANCE: An all-inside arthroscopic TFCC repair using a commonly employed meniscal repair device appears safe in terms of proximity to important structures although further clinical investigation is warranted.

Surgeons' knowledge about the costs of orthopaedic implants.

PURPOSE. To investigate consultant surgeons' knowledge about the costs of implants for various joint surgeries. METHODS. Questionnaires were distributed to consultant orthopaedic surgeons at 2 hospitals. Respondents were asked to estimate the implant costs of any brand for low-demand and high-demand total hip replacement (THR), total knee replacement (TKR), uni-compartmental knee replacement, arthroscopy shaver blade, total anterior cruciate ligament (ACL) fixation, and meniscal repair. The actual cost of each implant was obtained from the manufacturer. RESULTS. 16 consultant surgeons completed the questionnaires. The respective mean estimated and actual costs for a low-demand THR implant were £1714 (range, £600-3000) and £1448 (range, £985- 2335), with an overestimation of 18.4%. The respective costs for a high-demand THR implant were £2172 (range, £600-6000) and £1737 (range, £1192-2335), with an overestimation of 25%. The respective costs for a TKR implant were £1550 (range, £600-6000) and £1316 (range, £995-1535), with an overestimation of 17.8%. The respective costs for a uni-compartmental knee replacement implant were £1040 (range, £600-2000) and £1296 (range, £698-1470), with an underestimation of 19.7%. The respective costs for an arthroscopy shaver blade were £110 (range, £75-150) and £94 (range, £80-100), with an overestimation of 16.6%. The respective costs for a total ACL fixation implant were £246 (range, £80-500) and £306 (range, £272-335), with an underestimation of 19.4%. The respective costs for a meniscal repair implant were £153 (range, £50-250) and £242 (range, £170-260), with an underestimation of 37%. CONCLUSION. The knowledge among consultant orthopaedic surgeons about implant costs was poor. To reduce implant costs, cooperation between surgeons and hospital managers and measures to increase surgeons' awareness about cost-reduction programmes are needed.

Development of an arthroscopic ultrasound probe for assessment of articular cartilage degeneration.

Quantitative assessment of articular cartilage is important for the early diagnosis of osteoarthritis, intra-operation joint tissue evaluation and judgment of repaired cartilage quality. This technique is also applicable to the cartilage if arthroscopic instrument embedding this technique can be developed. In this study, an arthroscopic water-jet ultrasound indentation probe was developed with the help of a small profile intra-articular ultrasound imaging (IAUS) catheter for the intra-articular measurement of cartilage condition. The probe can provide measurement of morphological, acoustical and mechanical properties of articular cartilage. Preliminary tests were conducted on 10 intact porcine knees with the guide of arthroscopy for the evaluation of cartilage degeneration, which was induced by trypsin digestion. Results showed the cartilage stiffness decreased significantly after the digestion (p < 0.001) with the measurement conducted by the developed probe. In summary, an arthroscopic ultrasound probe has been successfully developed and its utility in detecting the cartilage degeneration was demonstrated in this study. Future work includes the improvement of the probe design and studies on measurement of animal or human samples in vivo.

Prospective assessment of outcomes following disposable arthroscopy of the temporomandibular joint.

Temporomandibular disorder (TMD) is a common cause of chronic facial pain that is often treated successfully without operation, but when no improvement is seen arthroscopy may be considered as a therapeutic and diagnostic tool. We prospectively assessed the outcome of 115 arthroscopic procedures to assess the effectiveness and reliability of a 1.2mm disposable arthroscope (OnPoint, Biomet Microfixation, Jacksonville, USA). All patients included had not improved after standard conservative management. Discharge from clinic was classed as a successful outcome. Measurements taken before, during, and after operation included mouth opening and lateral deviations (mm). Pain was assessed before and after operation using a 10 cm visual analogue scale. Mean improvement in pain scores was 69% and in mouth opening was 19%, and overall success was 76%. Compared with a previous study using a 1.9 mm scope there were fewer complications after arthroscopy with the small diameter scope.

Long-term outcome after arthroscopic repair of type II SLAP lesions: results according to age and workers' compensation status.

PURPOSE: The purpose of this study was to determine the long-term functional outcome of anatomic arthroscopic repair of type II SLAP lesions with suture anchors. METHODS: We examined all arthroscopic repairs of isolated type II SLAP lesions from January 2002 through December 2007. Fifty-five patients were available for long-term follow-up at a mean of 77 months. The mean patient age at the time of surgery was 39.7 years (range, 17 to 65 years); 23 patients were aged younger than 40 years, and 32 patients were aged 40 years or older. Fourteen cases involved Workers' Compensation claims. RESULTS: Overall, functional outcome was improved from baseline compared with final follow-up for both American Shoulder and Elbow Surgeons scores (44.1 points v 86.2 points, P < .001) and University of California, Los Angeles scores (19.1 points v 31.2 points, P < .001). According to the University of California, Los Angeles grading system, 87% of cases had good or excellent results. Although the percentage of good and excellent results among patients aged 40 years or older (81%) was lower than that among patients aged younger than 40 years (97%), this difference did not reach statistical significance (P = .219). The percentage of good and excellent results among the non-Workers' Compensation cases (95%) was significantly higher than that in Workers' Compensation cases (65%) (P = .009). Overall, patient satisfaction was reported in 91% of cases, and return to normal sport or activity was reported in 82% of cases. CONCLUSIONS: In 87% of cases, a good or excellent functional outcome can be anticipated after arthroscopic repair of type II SLAP lesions with the described techniques. Variables associated with a poor outcome include Workers' Compensation cases and possibly older age (≥40 years). LEVEL OF EVIDENCE: Level IV, therapeutic case series.