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.

Endobutton Fixation Technique for Multifragmented Coronoid Fractures.

Coronoid fractures commonly occur in a part of unstable elbow fractures. Stable coronoid fracture fixation is important for early elbow motion. It may be difficult to fix multifragmented coronoid process fractures with loose capsular attachment. Thus, we demonstrated the endobutton suspensory technique to fix the anterior coronoidal fragments due to its suspensory effect providing capsular attachment. This technique allows stable fixation to the small multifragmented coronoid fractures with early range of motion.

Arthroscopic synovectomy in the treatment of functional ankle instability: outcomes and gait analysis.

BACKGROUND: Natural consequence of repetitive ankle sprains is the chronic ankle instability. Objective of this study was to clarify the gait patterns of functional ankle instability (FAI) patients after arthroscopic synovectomy, but also assessment of postoperative recovery. PATIENTS AND METHODS: Arthroscopic synovectomy was performed to 14 FAI patients with history of unilateral repetitive ankle sprains, pain, and subjective sensation of instability. At a mean 54 months of follow-up (27-84), clinical assessment was conducted with respect to pain, number of ankle sprains, and American Orthopaedics Foot and Ankle Society (AOFAS) scores. Gait analysis was conducted to determine the temporospatial, kinetic and kinematic parameters at the last follow-up. RESULTS: Mean AOFAS scores increased from 68 (range 55-75) to 89 (range 77-100) points (P < 0.01). Mean ankle sprains was 13 in a period of 23 (range 14-48) months (0.58 per month) and decreased to three sprains in a mean time period of 54 months (0.053 per month) (P < 0.01). Mean preoperative and postoperative VAS scores were 8.0 and 2.9, respectively (P < 0.01). During gait analysis, no significant differences were found in ankle joint, including foot progression angles, ankle dorsi-plantar flexion degrees and ground reaction forces (P > 0.01). Among temporospatial parameters, only double support time showed a significant difference (P < 0.01). All patients were satisfied from the procedure and returned to their previous activity level. CONCLUSION: Improved long-term clinical results and scores were obtained in our patient group when compared with the preoperative scores. Also, three-dimensional gait analysis showed that the involved ankles demonstrate similar gait patterns to the uninvolved ankles in patients with FAI.

Comparison of two different measurement methods to determine glenoid bone defects: area or width?

BACKGROUND: This study compared two different techniques that have been used to measure the glenoids of patients with recurrent anterior shoulder dislocation. METHODS: We analyzed 36 patients who had received arthroscopic Bankart repair for anterior shoulder instability. Retrospectively, 3-dimensional computed tomography images of both shoulders were available for these patients. Two measurement methods were compared to determine the glenoid defects. One of these techniques is based on linear measurement, previously defined as the glenoid index. The other method is based on surface area measurement. Subsequently, 3 more diameters and the average values obtained from these diameters were compared with the surface measurement method. Pearson correlation coefficient (r) was assessed to determine the relationship. RESULTS: There was an almost perfect relationship between measurement methods when the defect area was less than 6% of the inferior glenoid circle (r, 0.915; P < .001). This relation decreased and the difference became more pronounced (r, 0.343; P = .657) when the bone loss exceeded 14% of the inferior glenoid circle. The highest correlations with the actual defects were the average values obtained from 4 different diameters (r, 0.964; P < .001) and the 4-o'clock position of the single diameter measurements (r, 0.860; P = .001). In addition, 11 patients had crescent-like defects, demonstrating a relatively low correlation between the measurement methods (r, 0.679; P = .021). CONCLUSION: Although the best correlation was achieved from average values obtained from different diameter positions, in practical use, we advise a linear measurement to estimate the glenoid bone loss at the 4-o'clock position to achieve a high correlation between the measurement techniques.

Simultaneous and spontaneous bilateral quadriceps tendons rupture.

Simultaneous and spontaneous bilateral quadriceps tendon rupture is an uncommon injury that is usually seen in association with multiple medical conditions and some medications. We report a case of simultaneous and spontaneous bilateral quadriceps tendon rupture that may be related to the long-term use of a statin.

Relationship between the size of bone marrow edema of the talus and ankle pain.

BACKGROUND: We sought to determine the changes in the size of the edema observed on MRI scans and its relation to the patient's pain during activity and pain during rest in bone marrow edema. METHODS: A total of 26 patients were followed up at 3-month intervals for a period of 1 year. During the follow-ups, magnetic resonance imaging scans of the patients' ankles were obtained; the scores obtained on the American Orthopaedic Foot and Ankle Society functional rating scale and visual analog scale were determined. The changes in these parameters and the correlation between them were examined. RESULTS: The size of the edema as observed on magnetic resonance imaging scans decreased, and the pain during activity and rest decreased. Although there is a correlation between the decrease in the edema size observed on magnetic resonance imaging scans and decrease in the pain during activity, there is no correlation between the decrease in the edema size observed on magnetic resonance imaging scans and the decrease in pain during rest. CONCLUSIONS: Patients can be informed more precisely, that the pain during rest and activity may not decrease after the third and sixth month, respectively. Magnetic resonance imaging may not alter after the ninth month, so it may not be necessary to be performed again.

Giant cell tumor of second and third metatarsals and a simplified surgical technique: report of two cases.

Giant cell tumor (GCT) is a rare benign tumor that often arises in tendon sheath as well as long bones of the lower extremity in adults, although localization in the metatarsus is rare. In this report, the authors describe the rare case of GCT localized to the third metatarsal GCT in a skeletally mature 17-year-old girl, and also describe the results of distal metatarsal resection with Kirschner wire stabilization for the treatment of this condition.

Accuracy of anterior glenohumeral injections: a cadaver study.

PURPOSE: Intra-articular glenohumeral injections have an important role for therapeutic benefit and diagnostic information. Therefore, it is very important that the injected material should reach its desired target. This study assessed the accuracy of an anterior intra-articular injection in fresh cadavers. METHODS: A total of 50 shoulders of 25 fresh cadavers were included in the study. Anterior placement of a spinal needle using a location just 1 cm lateral to the coracoid, without radiographic assistance were performed. After the needle was placed and estimated to be intra-articular 1 cc of acrylic dye was injected into the joint to determine accuracy of position. RESULTS: Ninety-six percent of injections were accurately administered into the glenohumeral joint and 4% in the surrounding soft tissues and capsule. CONCLUSION: Based on our cadaveric study, an unassisted anterior injection to the glenohumeral joint could be accurately placed.

Arthroscopic capsular release for refractory shoulder stiffness: a critical analysis of effectiveness in specific etiologies.

HYPOTHESIS: The purpose of this study is to report and compare the outcome of arthroscopic capsular release in patients with shoulder stiffness with post-traumatic, postsurgical, and idiopathic etiologies. We hypothesize that patients with idiopathic or post-traumatic stiffness have better outcomes after arthroscopic capsular release than those with shoulder stiffness with a postsurgical etiology. MATERIALS AND METHODS: A retrospective review of 115 patients who underwent arthroscopic capsular release for refractory shoulder stiffness was performed. There were 60 men and 55 women with a mean age of 49 years (range, 27 to 81 years). The patients were divided into 3 groups according to the etiology of stiffness: post-traumatic (26 patients), postsurgical (48 patients), and idiopathic (41 patients). Arthroscopic capsular release was performed in all patients after a mean of 9 months of physical therapy (range, 6 to 13 months). RESULTS: At a mean follow-up of 46 months (range, 25 to 89 months), the overall subjective shoulder value in all groups improved from 29% to 73% and the age- and gender-adjusted Constant score improved from 35% to 86%. The mean pain score decreased from 7.5 to 1, and mean active forward flexion, external rotation, and internal rotation increased from 97 degrees , 14 degrees , and the L5 vertebral level, respectively, to 135 degrees , 38 degrees , and the T11 vertebral level, respectively (P < .0001). There was no significant difference between the outcomes of idiopathic and post-traumatic stiffness (P = .7). However, the Constant score and subjective shoulder value were significantly lower in the postsurgical group compared with the idiopathic and post-traumatic groups (P = .0001 and P = .006, respectively). CONCLUSIONS: Arthroscopic capsular release is an effective treatment for refractory shoulder stiffness. Patients with idiopathic and post-traumatic shoulder stiffness have better outcomes than patients with postsurgical stiffness.

Open versus arthroscopic acromioclavicular joint resection: a retrospective comparison study.

PURPOSE: The purpose was to compare open and arthroscopic acromioclavicular joint (ACJ) resection. METHODS: We retrospectively reviewed 103 patients (105 shoulders) who underwent ACJ resection between 2000 and 2005. There were 56 women and 47 men with a mean age of 48 years. The mean duration of follow-up was 51 months (range, 15 to 91 months). Arthroscopic ACJ resection by use of a direct approach was performed in 81 shoulders (group A), and open ACJ resection was performed in 24 shoulders (group B). Results were graded according to pain relief both subjectively and objectively with cross-body adduction testing and direct palpation of the ACJ, subjective shoulder value, Constant score, and improved function. RESULTS: The Constant scores increased from 50 (range, 34 to 65) to 89 (range, 39 to 100) in group A (P < .0001) and from 46 (range, 22 to 63) to 87 (range, 43 to 100) in group B (P < .0001). There was no statistical difference in the postoperative normalized Constant score between group A and group B (P = .47). Pain with cross-body adduction testing and palpation of the ACJ improved in 76 shoulders (94%) in group A and 22 shoulders (92%) in group B. No patients had signs or symptoms of ACJ anteroposterior instability. Revision ACJ resection was performed in 5 patients (5 shoulders [6.2%]) in group A and 1 shoulder (4.2%) in group B (P = .37). The radiographs of the patients who underwent revision showed that 3 patients (3.7%) from group A had regrowth of the distal clavicle; in addition, 2 patients (2.5%) from group A and 1 patient (4.3%) from group B had incomplete distal clavicle excision. CONCLUSIONS: This study did not show a significant difference in the outcome between arthroscopic and open ACJ resection. Incomplete excision and regrowth of the distal clavicle are the most common causes of revision. Although only the arthroscopic group showed a small percentage of patients (3.7%) with regrowth of the distal clavicle, the number is too small to assume that this complication is the result of the arthroscopic technique only. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Acromioclavicular joint injuries: diagnosis and management.

Acromioclavicular joint injuries represent nearly half of all athletic shoulder injuries, often resulting from a fall onto the tip of the shoulder with the arm in adduction. Stability of this joint depends on the integrity of the acromioclavicular ligaments and capsule as well as the coracoclavicular ligaments and the trapezius and deltoid muscles. Along with clinical examination for tenderness and instability, radiographic examination is critical in the evaluation of acromioclavicular joint injuries. Nonsurgical treatment is indicated for type I and II injuries; surgery is almost always recommended for type IV, V, and VI injuries. Management of type III injuries remains controversial, with nonsurgical treatment favored in most instances and reconstruction of the acromioclavicular joint reserved for symptomatic instability. Recommended techniques for stabilization in cases of acute and late symptomatic instability include screw fixation of the coracoid process to the clavicle, coracoacromial ligament transfer, and coracoclavicular ligament reconstruction. Biomechanical studies have demonstrated that anatomic acromioclavicular joint reconstruction is the most effective treatment for persistent instability.

Soft-tissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old.

BACKGROUND: Soft-tissue resurfacing of the glenoid, with arthroplasty of the humeral head, has been proposed as a viable treatment option for younger patients with symptomatic osteoarthritis of the shoulder. The purpose of this study was to evaluate our results with soft-tissue resurfacing of the glenoid in patients with glenohumeral arthritis who were less than fifty years of age, as we were concerned that this type of procedure was leading to poor outcomes. METHODS: Between 2000 and 2006, thirteen patients with an average age of thirty-four years underwent soft-tissue resurfacing of the glenoid and humeral head arthroplasty. Achilles tendon allograft was used in eleven patients; fascia lata autograft, in one; and anterior shoulder joint capsule, in one. Three patients had resurfacing of the humeral head with a stemless resurfacing implant, and ten patients had a hemiarthroplasty. The patients were followed for a minimum of two years or until failure, and the duration of follow-up averaged forty-eight months. The results were graded with a visual analog pain scale, the subjective shoulder value, and the Constant and Murley score. Radiographic review was performed in order to determine the degree of joint space loss and glenoid erosion. RESULTS: Ten of the thirteen patients required a revision total shoulder arthroplasty at a mean of fourteen months (range, six to thirty-four months) postoperatively. The principal reasons for revision were persistent pain and a decreased range of motion. Radiographic evaluation at the time of the revision surgery demonstrated loss of joint space and glenoid erosion in all cases. At the revision surgery, the allograft was found to be absent, and thick scar tissue, which may have been a graft remnant, was found at the perimeter of the glenoid. Of the three patients who did not have a revision arthroplasty, one had good function, pain relief, and an improved range of motion; however, the postoperative course of the other two was complicated by infection. One of them had a salvage with early irrigation and débridement as well as intravenous antibiotics, whereas the other underwent resection arthroplasty because of persistent infection. CONCLUSIONS: Soft-tissue resurfacing of the glenoid with an Achilles tendon allograft combined with humeral head arthroplasty is not a reliable method of treatment of glenohumeral arthritis in an active patient younger than fifty years of age, as the clinical outcome is poor. Moreover, we found no evidence that the graft acts as a durable bearing surface.

[Crescentic distal metatarsal osteotomy for the treatment of hallux valgus: a prospective, randomized, controlled study of two different fixation methods]. / Halluks valgus tedavisinde kresentik distal metatarsal osteotomi: Iki farkli tespit yöntemiyle ileriye dönük, randomize, kontrollü bir çalisma.

OBJECTIVES: This study was designed to draw attention to a distal metatarsal osteotomy technique, which has been somewhat overlooked for the treatment of hallux valgus, and to compare the clinical and radiographic results of two different fixation methods. METHODS: The study included 16 feet of 13 patients (11 women, 2 men) who were treated with crescentic distal metatarsal osteotomy for mild-to-moderate hallux valgus (<35 degrees ). The patients were randomized to two fixation methods with two cross K-wires (group 1; 7 patients, 8 feet) and a compressive screw (group 2; 6 patients, 8 feet). The results were evaluated using the AOFAS (American Orthopaedic Foot and Ankle Society) clinical rating scale for hallux, and a visual analog scale for pain. Radiographic measurements included the hallux valgus angle (HVA), first/second intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA), before and 12 months after surgery. RESULTS: There were no significant differences between the two groups with regard to pre- and postoperative AOFAS scores and pain scores, which showed significant improvements in both groups at the end of one-year follow-up (p<0.001). The HVA and IMA significantly decreased from 32 degrees to 19 degrees and from 12 degrees to 6 degrees in group 1, and from 30 degrees to 17 degrees and from 12 degrees to 8 degrees in group 2, respectively (p<0.001). A similar improvement was also seen in the DMAA (p<0.001). Postoperative radiographic improvements were similar in both groups. One patient in group 1 underwent revision surgery with the same technique due to recurrence, and one patient in group 2 had delayed union. CONCLUSION: Crescentic distal metatarsal osteotomy may be an appropriate technique in the treatment of mild-to-moderate hallux valgus.

Results of arthroscopic capsulolabral repair: Bankart lesion versus anterior labroligamentous periosteal sleeve avulsion lesion.

PURPOSE: The purpose of this study was to evaluate the results of arthroscopic capsulolabral repair for traumatic anterior shoulder instability and to compare the outcome in patients who have Bankart lesions versus those with anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions. METHODS: This study included 99 patients (93 shoulders), 72 male and 17 female, with a mean age of 32 years, who underwent arthroscopic Bankart repair for traumatic, recurrent anterior shoulder instability, by use of suture anchors. In 67 shoulders (72%) a discrete Bankart lesion was repaired, and in 26 shoulders (28%) an ALPSA lesion was repaired. The 2 groups were analyzed with regard to the number of preoperative dislocations and number of postoperative recurrences. RESULTS: At a mean follow-up of 47 months (range, 24 to 98 months), recurrence of instability was documented in 10 shoulders (10.7%). Of the shoulders, 5 had Bankart lesions (7.4%) and 5 had ALPSA lesions (19.2%) (P = .0501). The mean number of dislocations or subluxations before the index surgery was significantly higher in the ALPSA group (mean, 12.3 [range, 2 to 57]) than in the Bankart group (mean, 4.9 [range, 2 to 24]) (P < .05). However, there were no significant differences in the number of anchors used, incidence of minor glenoid erosion, or incidence of bony Bankart lesions between the groups (P > .05 for all). CONCLUSIONS: Patients with ALPSA lesions present with a higher number of recurrent dislocations than those with discrete Bankart lesions. In addition, the failure rate after arthroscopic capsulolabral repair is higher in the ALPSA group than in the Bankart group. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

[The effect of debridement performed before capsular plication on biomechanical properties of the knee joint capsule: an experimental study in rabbits]. / Plikasyondan önce debridman uygulamasinin diz kapsülünün biyomekanik özelliklerine etkisi: tavsanda deneysel çalisma.

OBJECTIVES: The purpose of this study was to evaluate early postoperative biomechanical changes in plicated joint capsules and to determine the effect of debridement to create a bleeding inner capsular surface on the healing process. METHODS: Fifty-four mature New Zealand white rabbits were used. Plication was performed in unilateral medial knee joint capsules of 48 rabbits either alone (n=24) or following debridement (n=24) to create a bleeding inner capsular surface. Six rabbits remained untreated for the control group. The operated knee joints were immobilized in flexion postoperatively. The rabbits from the two study groups were sacrificed in groups of six immediately after operation, in the first, second, and third weeks, of which five were evaluated in tensile tests and one was evaluated histologically. RESULTS: Compared to the controls, tensile strengths were significantly higher in both study groups until the third week (p<0.01), after which the difference became insignificant (p>0.05). The strength of the plicated capsules was significantly higher in the first week in both study groups than those measured in subsequent weeks (p<0.01), whereas similar tensile strengths were recorded in the second and third weeks (p>0.05). Compared to its absence, the use of debridement was associated with a significantly lower strength in the first week (p<0.01), but this difference was not observed afterwards (p>0.05). Histological findings were similar in the two study groups and were characterized by healing with increased fibrosis starting from the first week. CONCLUSION: A plicated capsule would not be weaker than an intact one. Our findings do not favor debridement for a more rapid and better healing process. Rather, it might have adverse effects on the biomechanical properties of the capsule.

[Long-term results of conservative treatment for thoracolumbar compression fractures]. / Torakolomber omurga kompresyon kiriklarinda konservatif tedavinin uzun dönem sonuçlari.

OBJECTIVES: We evaluated the radiologic and clinical outcomes of conservative treatment for thoracolumbar compression fractures. METHODS: Forty-three patients (28 males, 15 females; mean age 39 years; range 24 to 54 years) were treated conservatively for 47 thoracolumbar compression fractures. All the patients were assessed by plain radiograms and computed tomography. According to the Denis classification, there were eight type A, 20 type B, 12 type C, and seven type D fractures. Involvement was at L1 in 30, L2 in five, and T12 in 12 fractures. There were no neurological deficits. Treatment involved use of a body cast for two months, followed by a thoracolumbosacral orthosis for four months. Radiographically, local kyphosis angle and sagittal index were measured before treatment, after casting, and at the final follow-ups. Pain and functional scales proposed by Denis et al. were also utilized. The mean follow-up was 7.5 years (range 6 to 11 years). RESULTS: The mean local kyphosis angle and sagittal index were measured as 12.6 and 13.7 degrees before treatment, and 5.9 and 7.0 degrees after casting, respectively (p<0.05). However, both did not differ significantly from the baseline at the final measurements (12.7 and 13.9, respectively; p>0.05). The mean pain and functional scores were 1.4 and 1.6, respectively. Four patients had moderate to severe back pain despite mean kyphosis angles of 12 (baseline), 13.5 (after casting), and 14.8 (final). Two patients required substitution of the body cast for orthosis due to excessive sweating, and three patients received local treatment for skin problems secondary to the use of orthosis. CONCLUSION: If the kyphosis angle is less than 30 degrees, compression fractures are supposed to be stable to be treated conservatively with satisfactory clinical results. Functional results seem to be unaffected from the fact that casting does not improve radiographic parameters in the long-term.

Glenoid reconstruction in revision shoulder arthroplasty.

Failed shoulder arthroplasty associated with glenoid bony deficiency is a difficult problem. Revision surgery is complex with unpredictable outcome. We asked whether revision shoulder arthroplasty with glenoid bone grafting could lead to good outcome. We retrospectively reviewed 21 patients who underwent glenoid bone grafting using corticocancellous bone grafting or impaction grafting using cancellous bone graft. Three patients underwent revision TSA, five patients hemiarthroplasty, 10 patients hemiarthroplasty with biologic resurfacing of the glenoid, and three patients revision to reverse TSA. The patients had minimum 25 months followup (average, 45 months; range, 25-92 months). All patients had improvement in their range of motion and the Constant-Murley score. Most improvement occurred in patients with glenoid reimplantation. Patients who underwent revision reverse TSA had improvement in shoulder flexion but decrease in external rotation motion. We conclude revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcome and glenoid component reinsertion should be attempted whenever possible.

The use of anchors in shoulder surgery: a shift from metallic to bioabsorbable anchors.

With major advances in arthroscopy, suture anchors became the primary devices used to assist in fixing soft tissues to bone. Metallic anchors were first produced and used in soft tissue fixation around the shoulder. However, their use resulted in some reported complications, including articular surface damage from migrating implants and distortion and artifact production in postoperative magnetic resonance imaging. Bioabsorbable anchors were developed to avoid these problems. Their newer versions were proven to have pulling-out strength equal to that of metallic anchors, with a reported lower complication rate. This had led to a major shift away from metallic anchors toward bioabsorbable anchors.