Up to date diagnosis and treatment of massive irreparable cuff tears: Results of the survey of the U45 ESSKA Committee.

PURPOSE: Irreparable rotator cuff tears are disabling and can severely affect daily life activities, especially when young and active patients are involved. The definition is still debated, and they can have several clinical presentations. The treatment depends on the clinical presentation and the patient's age. METHODS: The survey was developed by the ESSKA U45 Committee and was uploaded on the ESSKA website. Fifty-seven questionnaires were returned. Several aspects of the diagnosis and treatment of massive irreparable cuff tears were investigated. Moreover, treatment options for specific clinical scenarios were given for posterior-superior and anterior-superior cuff tears in young and old patients. RESULTS: Fatty degeneration of the muscles was the most common criterion to define an irreparable tear (59.7%). In young patients with external rotation with the arm at side lag, partial repair of the cuff was the most common option (41.8%); in case of external rotation with the arm at side + external rotation at 90° of abduction lag without pseudoparalysis, the most common option was partial repair of the cuff + latissimus dorsi or lower trapezius transfer (39.3%), and in case of external rotation with the arm at side + external rotation at 90° of abduction lag with pseudoparalysis, partial repair of the cuff + latissimus dorsi or lower trapezius transfer was still the most common option (25.5%). The same scenarios in old patients yielded the following results: reverse prosthesis (49.1%), reverse prosthesis (44.6%) and reverse prosthesis ± latissimus dorsi or lower trapezius transfer (44.6%), respectively. CONCLUSIONS: The present survey clearly confirms that biological options (partial cuff repairs and tendon transfers) are the reference in the case of young patients with deficient cuffs (both posterior and anterior). Reverse shoulder prosthesis is the most common treatment option in old patients in all clinical scenarios. LEVEL OF EVIDENCE: Level IV.

Glenoid bone loss and Hill-Sachs width percentage score are useful to select optimal operation for the treatment of glenohumeral instability in overhead athletes: Arthroscopic Bankart repair with remplissage versus open Latarjet.

PURPOSE: Glenohumeral instability with combined bone lesion in contact and overhead athletes with subcritical bone loss is challenging to treat with high recurrent instability. Treatment options are arthroscopic Bankart repair with remplissage and Latarjet operations. However, there is no consensus on their effectiveness. This study aims to compare the clinical outcomes and return to sports after both operations and whether evaluating the glenoid bone loss and Hill-Sachs width to calculate the total bone loss can help determine the appropriate operation. METHODS: In this retrospective comparative analysis, 30 athletes who underwent index arthroscopic Bankart repair with remplissage (n = 16) or Latarjet procedure (n = 14) between 2017 and 2020 were included. Computed tomography (CT) and magnetic resonance imaging (MRI) were routinely performed. The quick Disabilities of the Arm, Shoulder and Hand (qDASH), American Shoulder and Elbow Surgeons (ASES), instability severity index (ISI) scores and range of motion (ROM) were recorded preoperatively and at a mean follow-up of 53 months (SD = 12). Follow-up included time-to-return sports, self-perceived sports performance level and complications/recurrent dislocations. RESULTS: Preoperative qDASH, ASES, ISI scores, ages and genders were similar. The Latarjet group had significantly larger glenoid bone loss, Hill-Sachs width and total bone loss (p < 0.01). Both groups had significant improvement in patient-reported outcomes (PROs) after the operations (p < 0.01). Athletes with a total bone loss <25% underwent arthroscopic Bankart repair with remplissage and total bone loss ≥25% underwent Latarjet procedure, and there were no differences between the groups in terms of postoperative PROs, ROM, time-to-return sports and performance. There were no re-dislocations. CONCLUSION: Arthroscopic Bankart repair with remplissage or Latarjet procedure can adequately address glenohumeral instability with combined bone lesions. Patients with total bone loss scores greater than or equal to 25 may particularly benefit from the Latarjet procedure, while the minimally invasive arthroscopic Bankart repair with remplissage can yield equally satisfying scores for total bone loss less than 25. LEVEL OF EVIDENCE: Level III.

The use of injectable orthobiologics for knee osteoarthritis: A European ESSKA-ORBIT consensus. Part 1-Blood-derived products (platelet-rich plasma).

PURPOSE: The aim of this European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) consensus is to provide recommendations based on evidence and expert opinion to improve indications, decision-making and administration-related aspects when using blood-derived orthobiologics (for simplicity indicated as PRP-platelet-rich plasma-with PRP being the most common product) for the management of knee osteoarthritis (OA). METHODS: Leading European expert clinicians and scientists were divided into a steering group, a rating group and a peer review group. The steering group prepared 28 question-statement sets divided into three sections: PRP rationale and indications, PRP preparation and characterisation and PRP protocol. The quality of the statements received grades of recommendation ranging from A (high-level scientific support) to B (scientific presumption), C (low-level scientific support) or D (expert opinion). The question-statement sets were then evaluated by the rating group, and the statements scored from 1 to 9 based on their degree of agreement with the statements produced by the steering group. Once a general consensus was reached between the steering and rating groups, the document was submitted to the peer review group who evaluated the geographic adaptability and approved the document. A final combined meeting of all the members of the consensus was held to produce the official document. RESULTS: The literature review on the use of blood-derived products for knee OA revealed that 9 of 28 questions/statements had the support of high-level scientific literature, while the other 19 were supported by a medium-low scientific quality. Three of the 28 recommendations were grade A recommendations: (1) There is enough preclinical and clinical evidence to support the use of PRP in knee OA. This recommendation was considered appropriate with a strong agreement (mean: 8). (2) Clinical evidence has shown the effectiveness of PRP in patients for mild to moderate degrees of knee OA (KL ≤ 3). This recommendation was considered appropriate with a strong agreement (mean: 8.1). (3) PRP injections have been shown to provide a longer effect in comparison to the short-term effect of CS injections. They also seem to provide a safer use profile with less potential related complications. This recommendation was considered appropriate with a very strong agreement (mean: 8.7). Six statements were grade B recommendations, 7 were grade C and 12 were grade D. The mean rating score was 8.2 ± 0.3. CONCLUSIONS: The consensus group reached a high level of agreement on all the questions/statements despite the lack of clear evidence for some questions. According to the results from this consensus group, given the large body of existing literature and expert opinions, PRP was regarded as a valid treatment option for knee OA and as a possible first-line injectable treatment option for nonoperative management of knee OA, mainly for KL grades 1-3. LEVEL OF EVIDENCE: Level II.

Information videos posted on Instagram by orthopaedics and sports traumatology surgeons mostly explain surgical technique, and the least mentioned topics are injury prevention and complications.

PURPOSE: Social media has become the new information acquisition platform for all content producers. In the current literature, there are no studies examining the content quality and the strengths and weaknesses of videos on Instagram that explain anterior cruciate ligament (ACL) injuries, which is the most discussed topic of sports surgery. The aim of this study was to evaluate the quality, strengths and weaknesses of information pertaining to ACL surgery that is disseminated on Instagram. METHOD: An Instagram search was conducted from 30 May 2023 to 30 January 2024. The search encompassed six languages (English, Spanish, German, French, Italian and Turkish) and was performed by six different observers. The investigation focused on eight subheadings derived from current literature on the ACL. These subheadings were addressed in Instagram videos, covering ACL biology or biomechanics, injury mechanism, injury prevention, injury evaluation, surgical technique, injury or surgery complications, injury rehabilitation process and return to sport or work. RESULT: The content was assessed of 127 videos from 127 Instagram accounts, spanning six different languages. Across the review of eight subheadings, the average number covered for the entire group was 3 (range, 0-8). Further analysis revealed that surgical technique was the most frequently mentioned subheading for the whole group (68.5%), followed by injury evaluation (54.3%). Prevention (10.2%) and complications (19.6%) were the least mentioned subheadings. The number of followers showed a correlation with video content quality. CONCLUSION: Although the video quality scores were found to be moderate, the content often focused on surgery and evaluation subheadings. The prevalence of incomplete information underscores the importance of developing strategies to ensure more comprehensive and accurate dissemination of medical knowledge. LEVEL OF EVIDENCE: Level V.

Platelet-rich plasma injections for the management of knee osteoarthritis: The ESSKA-ICRS consensus. Recommendations using the RAND/UCLA appropriateness method for different clinical scenarios.

PURPOSE: The aim of this consensus was to develop evidence- and expert-based patient-focused recommendations on the appropriateness of intra-articular platelet-rich plasma (PRP) injections in different clinical scenarios of patients with knee osteoarthritis (OA). METHODS: The RAND/UCLA Appropriateness Method was used by the European Society of Sports Traumatology, Knee Surgery, and Arthroscopy (ESSKA), as well as the International Cartilage Regeneration and Joint Preservation Society (ICRS) to reach a consensus and produce recommendations for specific patient categories combining best available scientific evidence with the collective judgement of a panel of experts. RESULTS: Scenarios were defined based on first treatment vs first injective treatment vs second injective treatment, age (<50/50-65/66-80/>80), tibiofemoral vs patellofemoral involvement, OA level (Kellgren-Lawrence/KL 0-I/II-III/IV), and joint effusion (dry knee, minor-mild or major effusion). Out of 216 scenarios, in 84 (38.9%) the indication was considered appropriate, in 9 (4.2%) inappropriate and in 123 (56.9%) uncertain. The parameters associated with the highest consensus were PRP use after failed injective treatments (62.5%), followed by PRP after failed conservative treatments and KL 0-III scenarios (58.3%), while the highest uncertainty was found for PRP use as first treatment and KL IV OA (91.7% and 87.5% of uncertain scenarios, respectively). CONCLUSION: This ESSKA-ICRS consensus established recommendations on the appropriateness or inappropriateness of PRP injections for the treatment of knee OA, providing a useful reference for clinical practice. PRP injections are considered appropriate in patients aged ≤80 years with knee KL 0-III OA grade after failed conservative non-injective or injective treatments, while they are not considered appropriate as first treatment nor in KL IV OA grade. LEVEL OF EVIDENCE: Level I.

Remplissage reduced sense of apprehension and increased the rate of return to sports at preinjury level of elite overhead athletes with on-track anterior shoulder instability.

PURPOSE: The purpose of this study was to compare the results of arthroscopic isolated Bankart repair (B) with Bankart repair plus Remplissage (B + R) procedure in contact overhead athletes with on-track anterior shoulder instability. METHODS: A total of 64 athletes playing basketball, volleyball and handball in elite professional level who underwent arthroscopic isolated Bankart repair (34 patients) or Bankart repair plus Remplissage procedure (30 patients) with the diagnosis of recurrent anterior shoulder instability between 2017 and 2020, were retrospectively reviewed. Radiologically all patients had on-track Hill-Sachs defects and minimal or subcritical glenoid bone loss (< 13.5%). Patients were evaluated using pre- and postoperative pVAS, SANE, ASES, ROWE, WOSI scores and postoperative active ROM assessment. Patients were also asked for the frequency of any subjective apprehension and satisfaction with the surgery in four grades. RESULTS: The mean ages of the groups B and B + R were 26.8 and 26 years (SD = 3.22), respectively; the mean follow-up times were 37.8 and 36.2 months (SD = 11.19). Compared with the preoperative status, there was a statistically significant improvement of all 5 postoperative outcome scores in both groups (P < 0.001). However, significant difference between the improvement of the groups were only found for the SANE (B: 22.3 ± 4.1, B + R: 26.3 ± 4.3; P = 0.0004), ASES (B: 26.1 ± 2.6, B + R: 30.2 ± 3.6; P < 0.001) and ROWE (B: 42 ± 3.7, B + R: 47.7 ± 2.8; P < 0.001) scores in favor of the group B + R. The loss of internal and external rotation of the adducted arm in group B + R was found to be approximately 5 degrees compared to the group B (P < 0.001). More than 80% of group B + R showed no apprehension in sports activities and almost completely returned to pre-injury athletic level, depicting statistically significant improvement compared to group B athletes (P = 0.002 and 0.036, respectively). 3 patients developed re-dislocation after isolated Bankart repair, whereas no re-dislocation occurred in the B + R group. CONCLUSION: Adding Remplissage procedure to the Bankart repair provided an advantage in terms of both return to sport at preinjury level and the frequency of apprehension sensation during sports activity. LEVEL OF EVIDENCE: III.

Assessment of learning in simulator-based arthroscopy training with the diagnostic arthroscopy skill score (DASS) and neurophysiological measures.

PURPOSE: Virtual arthroscopic training has become increasingly popular. However, there is a lack of efficiency-based tracking of the trainee, which may be critical for determining the specifics of training programs and adapting them for the needs of each trainee. This study aims to evaluate and compare the measures obtained with a non-invasive neurophysiological method with The Diagnostic Arthroscopy Skill Score (DASS), a commonly used assessment tool for evaluating arthroscopic skills. METHODS: The study collected simulator performance scores, consisting of "Triangulation Right Hand", "Triangulation Left Hand", "Catch the Stars" and "Three Rings" and DASS scores from 22 participants (11 novices, 11 experts). These scores were obtained while participants underwent a structured program of exercises for the fundamentals of arthroscopic surgery training (FAST) and knee module using a simulator-based arthroscopy device. During the evaluation, data on oxy-hemoglobin and deoxy-hemoglobin levels in the prefrontal cortex were collected using the Functional Near-Infrared Spectroscopy (fNIRS) imaging system. Performance scores, DASS scores, and fNIRS data were subsequently analyzed to determine any correlation between performance and cortex activity. RESULTS: The simulator performance scores and the DASSPart2 scores were significantly higher in the expert group compared to the novice group (200.1 ± 28.5 vs 172.5 ± 48.9, p = 0.04 and 9.4 ± 5.6 vs. 5.4 ± 5.6 p = 0.02). In the expert group, fNIRS data showed a significantly lower prefrontal cortex activation during fundamental tasks in the FAST module, indicating significantly more efficient mental resource use. CONCLUSION: The analysis of cognitive workload changes during simulation-based arthroscopy training revealed a significant correlation between the trainees' DASS scores and fNIRS data. This correlation suggests the potential use of fNIRS data and DASS scores as additional metrics to create adaptive training protocols for each participant. By incorporating these metrics, the training process can be optimized, leading to more efficient arthroscopic training and better preparedness for clinical operations. LEVEL OF EVIDENCE: III.

Arthroscopic lateral capsule resection is enough for the management of lateral epicondylitis.

PURPOSE: Controversy exists with regards to the etiology and treatment of lateral epicondylitis and the role of the lateral capsule in this pathology. The aim of this study was to compare arthroscopic lateral capsule resection with or without extensor carpi radialis brevis (ECRB) tendon debridement for treatment of lateral epicondylitis. METHODS: This is a retrospective study of 38 patients who underwent arthroscopic surgery for LE with two different techniques: Eighteen patients were treated with arthroscopic lateral capsular resection (LCR) + ECRB debridement and 20 patients were treated with arthroscopic LCR alone, without ECRB debridement. Both groups were assessed with Quick Disabilities of the Arm, Shoulder and Hand (QDASH) score for function and Visual Analog Scale (VAS) score for pain. RESULTS: Quick DASH scores were 12 [Formula: see text] 5 and 13 [Formula: see text] 4 at Groups 1 and 2, respectively, without any statistically significant difference. VAS pain scores were 15 [Formula: see text] 2 for both groups. VAS function scores were 85 [Formula: see text] 22 and 86 [Formula: see text] 18 at Groups 1 and 2 respectively. Sick leave periods in terms of weeks were 7 [Formula: see text] 5 and 7 [Formula: see text] 4 at Groups 1 and 2, respectively. There was no statistically significant difference in outcome of the two groups compared in terms of VAS pain, function scores, failure (re-operation) rates and sick leave period at the end of final follow-up. CONCLUSION: Both arthroscopic LCR alone and Arthroscopic LCR with ECRB debridement for the management of refractory LE provide significant improvement in pain and function. Isolated Arthroscopic LCR could be a sufficient surgical treatment for refractory LE. Thus, ECRB debridement or release may not be necessary in every case. LEVEL OF EVIDENCE: IV.

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.

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.

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.

Effect of adjuvant hyperbaric oxygen on healing of cartilage lesions treated with microfracture: an experimental study in rats.

PURPOSE: The purpose of this experimental study was to investigate the effect of hyperbaric oxygen (HBO2) therapy combined with microfracture technique in the treatment of cartilage lesions. METHODS: Adult Wistar rats (n=44) were divided into six groups. In Groups A, B, C and D, ICRS* (* International Cartilage Repair Society) grade 4 cartilage lesions were made on the femoral sulcus of both knees. Lesions were microfractured on the left knees; the right knees had no further procedure. Groups E and F had no surgery. Groups A, C and E received HBO2 therapy once a day, six days a week postoperatively. Groups B, D and F had no HBO2 therapy. The animals in Groups A, B, E and F were sacrificed after two weeks; Groups C and D were sacrificed after four weeks. Semiquantitative scale - including filling of defect (microfracture hole), reparative tissue thickness, cell morphology and subchondral bone maturation - was used for evaluation. The Mann-Whitney test was used to compare individual and total scores. RESULTS: Total scores of the two-week group with adjuvant HBO2 therapy were significantly higher (P=0.0007) than the two-week standard treatment group. Except for subchondral bone maturation, individual scores were significantly higher in the two-week group with adjuvant HBO2 therapy. Total scores of the four-week groups were similar. Among individual scores of the four-week groups, filling of the defect (microfracture hole), and subchondral bone maturation were significantly higher (P=0.01, P=0.03) in groups with adjuvant HBO2 therapy. CONCLUSIONS: Adjuvant HBO2 therapy accelerates the healing process of cartilage lesions treated with microfracture in rats.

Are pelvic anatomical structures in danger during arthroscopic acetabular labral repair? Definition of safe bone depth.

PURPOSE: The purpose of this study was to evaluate safe depth for suture anchor insertion during acetabular labral repair and to determine the neighbouring structures at risk during drilling and anchor insertion. METHODS: Ten human cadaveric hips (six males and four females) were obtained. Acetabular labral surface was prepared and marked for right hips as 12, 1 and 3 o'clock positions, for left hips 12, 11 and 9 o'clock positions. Those were defined as anterior, anterior-superior and superior zones, respectively. These labral positions were drilled at defined zones. After measurements, depth of the bone at 10° and 20° drill angles on zones was compared statistically. RESULTS: Acetabular bone widths at investigated labral insertion points did not statistically differ. A total of 14 injuries in 60 penetrations occurred (23.3 %) with free drill penetrations, and no injuries occurred with stopped drill penetrations. The bone depth was gradually decreasing from 10° to 20° drill angles and from anterior to superior inserting zones without significant importance. The risk of perforation to the pelvic cavity started with 20 mm drill depth, and the mean depth for all insertions was calculated as 31.7 mm (SD 2.6). CONCLUSIONS: It is anatomically possible that some pelvic structures sustain iatrogenic injury during acetabular drilling for anchor placement. Being aware of mean pelvic vault is important in which drilling after excessive pincer rim trimming could easily decrease the depth of acetabular bone without a standard. Careful drilling by using stopped drill bit is crucial to prevent iatrogenic injury.

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.

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.

Foreseeing the danger in the beach chair position: Are standard measurement methods reliable?

PURPOSE: The aim of this study is to show whether peripheral perfusion monitoring methods reflect central perfusion during shoulder arthroscopy at beach chair position. We hypothesized that mean arterial pressure (MAP), central heart rate (CHR) and peripheral oxygenation (SaO2) measurements individually will not parallel cerebral oximetry measurements by near-infrared spectroscopy (NIRS). METHODS: Between 2011 and 2012, 53 patients who had arthroscopic rotator cuff repair surgery in the beach chair position were enrolled prospectively. Median ages of the patients were 58 (range 42-68) years. The regional cerebral oxygen saturation value of each hemisphere was continuously monitored by the use of NIRS. MAP, CHR, SaO2 and both hemispheric cerebral oxygen saturation values were recorded at six time periods peri-operatively. Correlation and differences between parameters were evaluated. RESULTS: Cerebral oxygen saturation of right hemisphere was dropped >20 % in 28.3 and 45.3 % of the patients. At left hemisphere, cerebral oxygen saturation was dropped >20 % in 20.8 and 43.4 % of the patients. Peripheral saturation values were statistically different from cerebral saturation values (p < 0.001). On the other hand, there was a correlation between cerebral saturation and MAP values (p < 0.05). CONCLUSION: Cerebral oximetry by NIRS may prove useful as a monitor for cerebral ischaemia. In the absence of NIRS, CHR can partially detect abnormalities but not trustable, and MAP is the most reliable method for monitoring.

Anatomic locking plate and coracoclavicular stabilization with suture endo-button technique is superior in the treatment of Neer Type II distal clavicle fractures.

INTRODUCTION: The purpose of this retrospective study was to compare the clinical results of three different fixation techniques for the treatment of Neer Type IIb fractures. We hypothesized that anatomic locking plate and coracoclavicular stabilization with suture endo-button technique provides more stable and biomechanically superior fixation among others with low complication rates. METHODS: Thirty six patients with Neer Type IIb fractures treated were evaluated. Patients were divided into three groups according to surgical choice that was performed: tension band and coracoclavicular suture stabilization with k-wires was defined as Group 1, anatomic locking plate and coracoclavicular stabilization with screw was defined as Group 2, and anatomic locking plate and coracoclavicular stabilization with suture endo-button (LPES) was defined as group 3. Mean age was 36.1 years, and mean follow-up period was 32.4 months. Radiological follow-ups and constant were recorded and compared at 3, 6, 12 and 24 months. RESULTS: At 3rd and 12th month follow-up in the LPES group, mean constant scores were statistically higher than other two groups (p < 0.01). The difference between other two groups was insignificant (p > 0.05). At 6th month follow-up, mean constant scores in LPES group were higher than other groups; there was less statistical significance than other time zones (p < 0.05). CONCLUSION: Anatomic locking plate combined with suture endo-button for CC ligament reinforcement is a reliable method to achieve osteosynthesis and stabilization for Neer Type IIb distal clavicle fractures without compromising physiology of shoulder.

Enhancement of holding strength of cannulated screw supported with PMMA: a biomechanical study on femoral head [corrected].

OBJECTIVE: The aim of this study was to evaluate the holding strength of cannulated screw with multiple holes on threaded area, supported with PMMA in femoral head. MATERIAL AND METHODS: A total of 48 human femoral heads were divided into two groups after mineral density measurement with Q-CT. Seven-millimeter cannulated screws with multiple holes on threaded area supported with PMMA were used in the study group, while in the control group standard 7-mm cannulated screws were used. Each group was divided into three subgroups with eight femoral heads. Mineral density of each subgroup was equal to the other. Groups were compared in terms of pull-out, maximum extraction torque and cut-out. RESULTS: In pull-out group, maximum holding strength (N) was measured, while axial pull-out of 0.5 mm/sec applied with Instron. Results showed meaningful significant difference (p < 0.011) between two groups. In cut-out group, femoral heads were placed into Instron and loading was started from 5 N at 2 mm per minute at first, and it was continued until a failure, at least 5 mm, of implant was observed. Results showed significant difference (p < 0.05) between two groups. In maximum extraction group, 4° per second reverse torque (Nm) was applied with torque meter. Highest torque value was measured during extraction time, and results showed very significant difference (p < 0. 001) between two groups. CONCLUSION: The results of our new design of cannulated screw augmented with PMMA provided background data to clinical application.

The effect of environmental pH change on bovine articular cartilage metabolism: implications for the use of buffered solution during arthroscopy?

PURPOSE: The purpose of this study is to determine the immediate effects of pH change on the metabolism of bovine chondrocytes. METHODS: Bovine osteochondral explants were pre-cultured and placed in Ringer's lactate solution. Thirty explants were randomly divided into 3 groups. Buffered Ringer's lactate, pH 7.2, was used in Group I; buffered Ringer's lactate, pH 7.4 (normal bovine knee joint pH), was used in Group II; and this group was also set as the control group. Buffered Ringer's lactate, pH 7.6, was used in Group III. All specimens were soaked for 2 h. RNA yield analyses were performed to evaluate the changes in cartilage metabolism at different pH levels. RESULTS: Mean RNA yields of (hypoxia-induced factor) 1α that were immersed at pH 7.2 and 7.6 were 10.5- and 9.9-fold from base, respectively, which were lower compared to explants at pH 7.4 which was found as 15.2-fold. Mean RNA yields of aggrecan that were immersed at pH 7.2 and 7.6 were 12.2- and 13.6-fold from base, respectively, which were lower compared to explants at pH 7.4 which was found as 20-fold. RNA yields of collagen type II at pH 7.2 and 7.6 were 16.1- and 16.6-fold from base, respectively, which were lower compared to explants immersed at pH 7.4 which was found as 22.1-fold. CONCLUSION: The findings of the presented study suggest that short-term exposures to both acidic and basic pH may have effects on chondrocyte function. Our findings also indicate that exposures to solutions with a pH different from normal by only 0.2 unit could suppress chondrocyte metabolism and RNA synthesis. CLINICAL RELEVANCE: Using buffered irrigation solutions with a pH closer to the normal joint pH could be more physiologic and causes less ultra-structural damage than regular irrigation solutions. LEVEL OF EVIDENCE: II.