MRI analysis of tibial position of the anterior cruciate ligament.

This study aimed to establish normal values for the position of the native anterior cruciate ligament (ACL) insertion on the tibia to assist in the evaluation of tunnel placement after primary ACL reconstruction or prior to revision surgery. One hundred consecutive MRI studies performed on patients with a mean age of 29 years (range 20-35) from a single MRI facility were reviewed. Patients with prior surgery, significant osteoarthritis, acute ACL injury, or evidence of ACL reconstruction were excluded. Using digital image software, measurements were taken of anterior-most and posterior-most portions of the ACL insertion on the tibia. Depth of the tibia was also measured from the anterior edge of the tibial plateau to the posterior edge at the origin of the posterior cruciate ligament. The anterior insertion of the native ACL was located at a mean of 14 ± 3 mm (28 ± 5%) from the anterior tibial articular margin; the posterior portion of the ACL was located at a mean of 31 ± 4 mm (63 ± 6%). The tibial insertion of the ACL is located between 28 and 63% of the total anterior-posterior depth of the tibia. The results from this study are clinically relevant as they provide the clinician with baseline data to describe the position of the tibial footprint of the native ACL on sagittal MR imaging. Further, this data can be used as a guide to evaluate tibial tunnel position prior to primary ACL reconstruction, revision ACL surgery, or in ACL-reconstructed patients who continue to experience pain, instability, or dysfunction postoperatively.

Four-quadrant approach to capsulolabral repair: an arthroscopic road map to the glenoid.

Advancing technology, improved instrumentation, and a desire to address intra-articular pathology with a minimally invasive approach have driven the expansion of arthroscopic shoulder surgery in the past 2 decades. Proponents cite greatly improved visualization, lack of the need to perform a capsulotomy, fewer subscapularis issues postoperatively, and improved access to the entire glenohumeral joint. Our understanding and recognition of glenohumeral joint pathology have improved, and our ability to appropriately treat it has also improved. Aside from the anteroinferior and superior capsulolabral injury, orthopaedic surgeons have encountered and are able to address combined lesions, posterior labral tears, 270 degrees to 360 degrees labral tears, capsular laxity, humeral avulsion of the glenohumeral ligaments, associated glenoid or humeral bone loss, and partial-thickness rotator cuff tears. To adequately address the extent of pathology encountered in a shoulder instability case, access to the inferior, posteroinferior, and posterior aspects is necessary. In this technical article we present a simplified approach using safe access points by dividing the glenohumeral joint into 4 quadrants that allows for ease of instrumentation and implant placement. This will provide a blueprint for the treatment of capsulolabral injuries. In addition to portal selection and location, we will discuss several instruments we believe are advantageous in tissue manipulation and suture management.

Does the literature confirm superior clinical results in radiographically healed rotator cuffs after rotator cuff repair?

PURPOSE: Because recurrent or persistent defects in the rotator cuff after repair are common, we sought to clarify the correlation between structural integrity of the rotator cuff and clinical outcomes through a systematic review of relevant studies. METHODS: Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials were searched for all literature published from January 1966 to December 2008 that used the key words shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, integrity, healed, magnetic resonance imaging (MRI), computed tomography arthrography (CTA), and ultrasound. The inclusion criteria were studies (Levels I to IV) that reported outcomes after arthroscopic rotator cuff repair in healed and nonhealed repairs based on ultrasound, CTA, and/or MRI. Exclusionary criteria were studies that included open repair or subscapularis repair and studies that did not define outcomes based on healed versus nonhealed but rather used another variable (i.e., repair technique). Data were abstracted from the studies including patient demographics, tear characteristics, surgical procedure, rehabilitation, strength, range of motion, clinical scoring systems, and imaging studies. RESULTS: Thirteen studies were included in the final analysis: 5 used ultrasound, 4 used MRI, 2 used CTA, and 2 used combined CTA/MRI for diagnosis of a recurrent tear. Statistical improvement in patients who had an intact cuff at follow-up was seen in Constant scores in 6 of 9 studies; in University of California, Los Angeles scores in 1 of 2 studies; in American Shoulder and Elbow Surgeons scores in 0 of 3 studies; and in Simple Shoulder Test scores in 0 of 2 studies. Increased range of motion in forward elevation was seen in 2 of 5 studies and increased strength in forward elevation in 5 of 8 studies. CONCLUSIONS: The results suggest that some important differences in clinical outcomes likely exist between patients with healed and nonhealed rotator cuff repairs. Further study is needed to conclusively define this difference and identify other important prognostic factors related to clinical outcomes. LEVEL OF EVIDENCE: Level IV, systematic review.

The kinetic chain in overhand pitching: its potential role for performance enhancement and injury prevention.

The overhead throwing motion is a coordinated effort of muscle units from the entire body, culminating with explosive motion of the upper extremity. The throwing motion occurs at a rapid pace, making analysis difficult in real time. Electromyographic studies and high-speed video recordings have provided invaluable details regarding the involved musculature, the sequence of muscle involvement, and associated kinematic variables. The goal of the present article is to provide an overview of the kinetic chain-that is, a detailed description of the muscular coordination during each phase of pitching-and to describe specific types of pitches. An enhanced understanding of the components of the kinetic chain and the phases of the throwing motion can provide important information for rehabilitation, performance enhancement, and injury prevention.

Platelet-rich plasma: where are we now and where are we going?

CONTEXT: Platelet-rich plasma (PRP) may affect soft tissue healing via growth factors released after platelet degranulation. Because of this potential benefit, clinicians have begun to inject PRP for the treatment of tendon, ligament, muscle, and cartilage injuries and early osteoarthritis. EVIDENCE ACQUISITION: A PubMed search was performed for studies relating to PRP, growth factors, and soft tissue injuries from 1990 to 2010. Relevant references from these studies were also retrieved. RESULTS: Soft tissue injury is a major source of disability that may often be complicated by prolonged and incomplete recovery. Numerous growth factors may potentiate the healing and regeneration of tendons and ligaments. The potential benefits of biologically enhanced healing processes have led to a recent interest in the use of PRP in orthopaedic sports medicine. There has been widespread anecdotal use of PRP for muscle strains, tendinopathy, and ligament injuries and as a surgical adjuvant to rotator cuff repair, anterior cruciate ligament reconstruction, and meniscal or labral repairs. Although the fascination with this emerging technology has led to a dramatic increase in its use, scientific data supporting this use are still in their infancy. CONCLUSIONS: The literature is replete with studies on the basic science of growth factors and their relation to the maintenance, proliferation, and regeneration of various tissues and tissue-derived cells. Despite the promising results of several animal studies, well-controlled human studies are lacking.

Does the literature support double-row suture anchor fixation for arthroscopic rotator cuff repair? A systematic review comparing double-row and single-row suture anchor configuration.

PURPOSE: The purpose of this study was to compare the clinical outcome of single-row (SR) and double-row (DR) suture anchor fixation in arthroscopic rotator cuff repair with a systematic review of the published literature. METHODS: We searched all published literature from January 1966 to December 2008 using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials for the following key words: shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, arthroscopic-assisted, single row, double row, and transosseous equivalent. The inclusion criteria were cohort studies (Levels I to III) that compared SR and DR suture anchor configuration for the arthroscopic treatment of full-thickness rotator cuff tears. The exclusion criteria were studies that lacked a comparison group, and, therefore, case series were excluded from the analysis. RESULTS: There were 5 studies that met the criteria and were included in the final analysis: 5 in the SR group and 5 in the DR group. Data were abstracted from the studies for patient demographics, rotator cuff tear characteristics, surgical procedure, rehabilitation, range of motion, clinical scoring systems, and imaging studies. CONCLUSIONS: There are no clinical differences between the SR and DR suture anchor repair techniques for arthroscopic rotator cuff repairs. At present, the data in the published literature do not support the use of DR suture anchor fixation to improve clinical outcome, but there are some studies that report that DR suture anchor fixation may improve tendon healing. LEVEL OF EVIDENCE: Level III, systematic review of Levels I to III studies.

Bioabsorbable anchors in glenohumeral shoulder surgery.

The use of implants to provide glenohumeral soft tissue fixation has changed dramatically over the past few decades, from point tack fixation to metallic suture anchors to bioabsorbable suture anchors. Bioabsorbable suture anchors have largely replaced metallic anchors because of concerns of implant loosening, migration, and chondral injury. Although the safety and efficacy of bioabsorbable anchors has been well documented, there are numerous reports regarding the early failure related to implant bioabsorbable implant breakage or premature degradation. Patients with anchor-related complications generally present with pain and/or stiffness, and the surgeon should have a high index of suspicion if a patient does not progress as expected. Glenohumeral synovitis, glenoid osteolysis, loose bodies, and chondral injury are some of the notable complications that have been reported. Careful attention to proper anchor insertion techniques can limit the potential for complications. Newer materials, such as polyetheretherketone and other composites, have recently been introduced. These materials may address concerns of biocompatibility and material strength, but additional rigorous in vitro and in vivo trials need to be conducted before their use becomes widespread.

Shoulder pain in the overhead throwing athlete.

Treatment of the overhead throwing athlete is among the more challenging aspects of orthopaedic sports medicine. Awareness and understanding of the throwing motion and the supraphysiologic forces to which the structures of the shoulder are subjected are essential to diagnosis and treatment. Pain and dysfunction in the throwing shoulder may be attributed to numerous etiologies, including scapular dysfunction, intrinsic glenohumeral pathology (capsulolabral structures), extrinsic musculature (rotator cuff), or neurovascular structures. Attention to throwing mechanics and appropriate stretching, strength, and conditioning programs may reduce the risk of injury in this highly demanding activity. Early discovery of symptoms, followed by conservative management with rest and rehabilitation with special attention to retraining mechanics may mitigate the need for surgical intervention. Prevention of injury is always more beneficial to the long-term health of the thrower than is surgical repair. An anatomic approach is used in this report, focusing on common etiologies of pain in the overhead thrower and emphasizing the clinical presentation and treatment.