Effects of slow and accelerated rehabilitation protocols on range of motion after arthroscopic rotator cuff repair.

OBJECTIVE: The aim of the study was to investigate the effects of the early initiation of passive and active range of motion exercises following arthroscopic rotator cuff repair. METHODS: The study included 40 patients who underwent arthroscopic rotator cuff repair. Patients were quasi-randomly assigned into accelerated (ACCEL) protocol (n=19) and slow (SLOW) protocol (n=21) groups. Patients in both groups were treated with the same protocol. Active range of motion was begun at the 3rd week in the ACCEL group and the 6th week in the SLOW group. Range of motion was recorded at postoperative weeks 3, 5, 8, 12, and 24. RESULTS: While active range of motion for all measurements improved across weeks, there were no differences between groups, with the exception of active total elevation which was greater at all time point measurements in the ACCEL group (p<0.05). CONCLUSION: The early initiation of passive and gentle controlled active motion exercise following rotator cuff repairs does not appear to affect range of motion in the first 6 postoperative months.

Development of the femoral trochlear groove in rabbits with patellar malposition.

PURPOSE: The geometry of the trochlear groove is considered to be an important determinant in the pathogenesis of the patellofemoral joint disorders. However, the effect of patellar position during the development of the femoral trochlear groove is unclear. This animal study aimed to investigate the relationship between the position of the patella and development of the femoral trochlear groove in growing rabbits. METHODS: Thirty-two knees from 16 rabbits were included in this study and were divided into two groups. First group consisted of the left knees and was used as a control group with no surgical interventions. The second group involved the right knees on which patellar tendon Z-plasty lengthening was performed to cause patellar malposition (patella alta) before 1 month of age. Computed tomographic (CT) evaluations of both knees were obtained when the animals were 1 month age before the surgical intervention and also at 6 months after the surgical intervention. Angle and depth measurements were acquired from the proximal, middle, and distal reference points along the femoral trochlear groove. After the CT scan acquisition at 6 months following the surgical procedures, rabbits were killed and additional measurements of the trochlear groove angles were performed manually. RESULTS: The mean middle and distal trochlear groove angles for the experiment group with patella alta were significantly higher compared to that of control group (p < 0.017). The increase in mean trochlear depth for the animals in the control group was found to be significantly higher compared to experiment group at the distal zone (p < 0.017). CONCLUSION: Distal femoral groove with an inadequately positioned patella becomes more flattened and this may be a predisposing factor for patellar instability. LEVEL OF EVIDENCE: Controlled laboratory study, Level II.

The effectiveness of manual therapy in supraspinatus tendinopathy.

OBJECTIVES: The aim of this randomized controlled study was to assess the efficacy of manual therapy in the treatment of patients with symptomatic supraspinatus tendinopathy. METHODS: Seventy-seven patients (age range, 30 to 55 years) with supraspinatus tendinopathy, were randomly assigned to one of the three treatment groups: a supervised exercise program (Group 1), a supervised exercise program combined with joint and soft tissue mobilization (Group 2), or a home-based rehabilitation program (Group 3). All patients had rehabilitation for 12 weeks. Pain level was evaluated with a visual analogue scale (VAS) and the range of motion (ROM) was measured with a goniometer. The Modified American Shoulder and Elbow Surgery (MASES) score was used in functional assessment. Flexion, abduction, internal and external rotation strengths were measured with a manual muscle test. All patients were evaluated before, and at the 4th and 12th week of the rehabilitation. RESULTS: All groups experienced significant decrease in pain and an increase in shoulder muscle strength and function by both the 4th and 12th weeks of treatment (p<0.05). There was no significant difference between the groups in terms of function (p>0.05). However, the greatest improvement in functionality was found in Group 2. CONCLUSION: Supervised exercise, supervised and manual therapy, and home-based exercise are all effective and promising methods in the rehabilitation of the patients with subacromial impingement syndrome. The addition of an initial manual therapy may improve the results of the rehabilitation with exercise.

Comparison of slow and accelerated rehabilitation protocol after arthroscopic rotator cuff repair: pain and functional activity.

OBJECTIVES: In this study, we sought to compare the effects of the slow and accelerated protocols on pain and functional activity level after arthroscopic rotator cuff repair. METHODS: The study included 29 patients (3 men, 26 women) who underwent arthroscopic repair of stage 2 and 3 rotator cuff tears. Patients were randomized in two groups: the accelerated protocol group (n=13) and slow protocol group (n=16). Patients in the accelerated protocol group participated in a preoperative rehabilitation program for 4-6 weeks. Patients were evaluated preoperatively and for 24 weeks postoperatively. Pain was assessed by visual analog scale, and functional activity level was assessed by The Disabilities of The Arm Shoulder and Hand (DASH) questionnaire. The active range of motion was initiated at week 3 after surgery for the accelerated rehabilitation protocol and at week 6 for the slow protocol. The rehabilitation program was completed by the 8th week with the accelerated protocol and by the 22nd week with the slow protocol. RESULTS: There was no significant difference between the slow and accelerated protocols with regard to pain at rest (p>0.05). However, the accelerated protocol was associated with less pain during activity at weeks 5 and 16, and with less pain at night during week 5 (p<0.05). The accelerated protocol was superior to the slow protocol in terms of functional activity level, as determined by DASH at weeks 8, 12, and 16 after surgery (p<0.05). CONCLUSION: The accelerated protocol is recommended to physical therapists during rehabilitation after arthroscopic rotator cuff repair to prevent the negative effects of immobilization and to support rapid reintegration to daily living activities.

Arthroscopy-assisted fracture fixation.

PURPOSE: the purpose of this article was to systematically analyze the results of published studies in the literature which evaluated the use of arthroscopically assisted techniques in intra-articular fracture fixation. METHODS: published investigations to date were analyzed by classifying them according to joints that were involved with intra-articular fractures including: knee, ankle, hip, shoulder, elbow, and wrist joints. The results were studied to assess the feasibility, efficiency, and outcomes of arthroscopy-assisted fracture fixation. RESULTS: arthroscopy-assisted techniques have been used successfully for the treatment of fractures of the tibial plateau, tibial eminence, malleoli, pilon, calcaneus, femoral head, glenoid, greater tuberosity, distal clavicle, radial head, coronoid, distal radius, and scaphoid. The major advantages of arthroscopic fracture fixation over open methods are direct visualization of the intra-articular space, decreased invasiveness, and the possibility for multitask interventions through which fixation of the fracture, and repair of the soft tissues and the cartilage can be performed simultaneously. The time-consuming and technically demanding nature of the procedures with a prolonged learning curve and limited fixation alternatives are the main disadvantages of this technique. CONCLUSION: arthroscopic fixation is increasingly utilized for certain intra-articular fracture types due to the minimally invasive nature of the procedures and high accuracy. Randomized controlled trials are needed to justify wider use of arthroscopy-assisted techniques for treatment of intra-articular fractures.

Bilateral lipoma arborescens of the knee in a child: a case report.

We report a case of childhood lipoma arborescens of both knee joints who had been erroneously diagnosed to have initially acute rheumatic fever and subsequently oligoarticular juvenile rheumatoid arthritis. She had taken anti-inflammatory medication for 8 years without remission of the effusion. Magnetic resonance imaging (MRI) and synovectomy revealed the diagnosis of lipoma arborescens. Lipoma arborescens should be kept in mind in the differential diagnosis of refractory chronic joint effusion and synovial hypertrophy in the childhood period, and MRI yields the correct diagnosis in this setting.

The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture.

PURPOSE: The purpose of this study was to compare the accuracy of clinical examination versus magnetic resonance imaging (MRI) in diagnosing meniscal and anterior cruciate ligament (ACL) pathology. TYPE OF STUDY: Prospective, longitudinal study. METHODS: Between August 2001 and December 2001, we prospectively evaluated 50 consecutive patients (37 male, 13 female) with 65 pathologies of medial meniscal tears, lateral meniscal tears, and/or ACL rupture. The average preoperative period for the patients was 5 weeks (range, 5 days to 5 months) and their mean age was 22 years (range, 12 to 42 years). After initial clinical examination, the same sports medicine fellowship-trained orthopaedic surgeon (10-year practice profile of 100% sports medicine) evaluated the MRI of the patients and performed their arthroscopic procedure. Accuracy, sensitivity, specificity, and positive and negative predictive values were calculated comparing clinical examination, MRI, and arthroscopic evaluation. RESULTS: There was no statistical difference between MRI or clinical examination in diagnosing medial or lateral meniscal tears or ACL tears ( P >.05). The accuracy of the clinical examination and MRI evaluation was equal for diagnosing meniscal tears and ACL ruptures. CONCLUSIONS: A well-trained qualified surgeon can safely rely on clinical examination for diagnosing meniscal and ACL injuries. Clinical examination is at least as accurate as MRI in the skilled orthopaedic surgeon's hand. MRI should be reserved for more complicated and confusing cases. The routine ordering of an MRI scan of the knee before examination by a well-trained orthopaedic surgeon is not recommended. LEVEL OF EVIDENCE: Level II, diagnostic.

[Patellar instability: arthroscopic surgery, indications and techniques]. / Patellar instabilite: Artroskopik cerrahi, uygulama, endikasyon ve teknikler.

A significant incidence of knee pain and disability arises from patellofemoral disorders. An accurate diagnosis relies both on a comprehensive history and a careful physical examination; radiologic modalities also play an important part in the diagnosis and follow-up. Most patellofemoral disorders can be examined in three groups: pain due to soft tissue abnormalities, patellar instability, and patellofemoral osteoarthritis. Conservative therapy can be successful in many patellofemoral disorders. Surgical treatment consists of lateral release, medial plication and reconstruction of the medial patellofemoral ligament, proximal and distal realignments, patellar osteotomies, and patellectomy. In traumatic dislocations primary reconstruction or arthroscopy assisted medial stabilization can be performed.

Age-related changes in human PCLs: a light and electron microscopic study.

No studies have previously compared ultrastructural differences in human posterior cruciate ligaments in different age groups, but such differences may be of importance in the reconstruction of this ligament. We used light and transmission electron microscopy to compare ultrastructural differences in the posterior cruciate ligaments of 36 patients by age and sex. We found no differences between the sexes or in the groups aged between 30 and 59 years. However, collagen fibers with variable diameters were observed in those aged 10-19 years, with many oxytalan fibers between the collagen fibers. We also found a decrease in collagen fiber diameter and increase in collagen fibril concentration with aging, with a maximum increase in collagen fibril concentration in those aged 60-69 years.

Management of discoid lateral meniscus tears: observations in 34 knees.

PURPOSE: The goal of this study was to evaluate arthroscopic partial resection of discoid lateral meniscus tears with an emphasis on radiographic evidence of degenerative changes after this procedure. TYPE OF STUDY: Retrospective clinical study. METHODS: Of 41 patients with an arthroscopic diagnosis of discoid meniscus over an 8-year period, 34 symptomatic lateral discoid meniscus tears in 33 patients were analyzed at an average follow-up of 5.6 years. The average age at operation was 19.8 years and most patients had vague and intermittent symptoms that caused delay in clinical diagnosis. RESULTS: Eight patients were lost to follow-up and were excluded from the study. Magnetic resonance imaging, performed in 12 cases, and arthroscopy in all of these patients provided the precise diagnosis. All of the knees with symptomatic torn discoid menisci underwent arthroscopic partial meniscectomy. Only 1 Watanabe Wrisberg ligament type of discoid meniscus with posterior instability was totally meniscected. Based on Ikeuchi's grading, 39% of the knees had an excellent result, 46% had a good result, and 15% had a fair result; none of the results was poor. CONCLUSIONS: At an average 5-year follow-up, partial meniscectomy in patients with a Watanabe complete or incomplete discoid meniscus showed 85% good or excellent clinical results. However, a significant percentage of patients show femoral condyle flattening on radiography.

MR imaging of meniscal bucket-handle tears: a review of signs and their relation to arthroscopic classification.

Our objective was to review the MR imaging signs of meniscal bucket-handle tears and assess the relevance of these signs to the arthroscopic classification of displaced meniscal tears. Forty-five menisci in 42 patients who had a diagnosis of bucket-handle tear either on MR imaging or on subsequent arthroscopy (in which Dandy's classification of meniscal tears was used) were retrospectively analyzed for MR imaging findings of double posterior cruciate ligament (PCL), fragment within the intercondylar notch, absent bow tie, flipped meniscus, double-anterior horn, and disproportional posterior horn signs. Arthroscopy, which was considered as the gold standard, revealed 41 bucket-handle tears (either diagnosed or not diagnosed by MR imaging) in 38 patients (33 males, 5 females). There was a statistically significant male preponderance for the occurrence of meniscal bucket-handle tears. Overall, sensitivity and positive predictive value of MR imaging for the detection of meniscal bucket-handle tears were calculated as 90%. Common MR imaging signs of meniscal bucket-handle tears in arthroscopically proven cases of such tears were the fragment in the notch and absent bow tie signs (98% frequency for each). Double-PCL, flipped meniscus, double-anterior horn, and disproportional posterior horn signs, however, were less common (32, 29, 29, and 27%, respectively). An arthroscopically proven bucket-handle tear was found in all patients who displayed at least three of the six MR imaging signs of meniscal bucket-handle tears. The presence of three or more MR imaging signs of meniscal bucket-handle tears is highly suggestive of this condition.

Symptomatic ring-shaped lateral meniscus: magnetic resonance imaging and arthroscopy.

A ring-shaped lateral meniscus is a very rare entity within the spectrum of abnormalities of lateral meniscus. We present the second case in the literature of a symptomatic ring-shaped lateral meniscus in combination with a meniscal cyst and in association with an osteochondritis dissecans lesion of the medial femoral condyle. A potential pitfall of magnetic resonance imaging (i.e., displaced meniscal tear) is addressed in the diagnosis of this entity, as well as the role of magnetic resonance imaging in revealing associated abnormalities.

Conservative treatment of eminentia intercondylaris fractures of the tibia in children.

Seventeen patients (16 children, 1 adolescent) were reviewed 31 months to 71 months after sustaining the common childhood fracture of the eminentia intercondylaris of the tibia. The aim was to assess long-term results and prognosis by clinical and radiological examination and to discover whether conservative treatment was adequate for type I and type II fractures according to Meyers and McKeever. Early improvement occurred in all patients after conservative treatment, but long-term results were not satisfactory in displaced fractures,which were treated with closed reduction and immobilization in extension. Therefore, anatomic reduction and rigid fixation should be obtained for displaced fractures of the eminentia intercondylaris of the tibia.

MR imaging of the anterior intermeniscal ligament: classification according to insertion sites.

Our objective was to study the frequency of anterior intermeniscal ligament on MR imaging and to make a classification according to its insertion sites on MR images. Sagittal T1-weighted and thin-section transverse T2*-weighted MR images of the knee were prospectively evaluated in 229 subjects without significant synovial effusion or total rupture of the anterior cruciate ligament. By using thin-section transverse images, the ligament was classified into three types according to its insertion sites (type A: between anterior horns of medial and lateral menisci; type B: between anterior horn of medial meniscus and anterior margin of lateral meniscus; type C: between anterior margins of medial and lateral menisci). On sagittal images location of the ligament was determined with respect to a line drawn between anterior of the tibial epiphysis and posterior of the intercondylar notch to look for a relation between its type on transverse images and location on sagittal images. Separately, arthroscopy was made in 36 patients to verify the MR assessment of the presence of the ligament. Anterior intermeniscal ligament was found in 53% of the subjects. Type B was the most common group (58%). Magnetic resonance imaging has a sensitivity and a specificity of 67 and 100%, respectively, in the detection of the ligament. Types A and C had a statistically significant location posterior and anterior, respectively, to the master line on sagittal images. In arthroscopy, the ligament was either cord-like (67%) or flat (33%) in appearance. Routine sagittal MR images can help identify anterior intermeniscal ligament.

Anterior labroligamentous periosteal sleeve avulsion lesion at the superior glenoid labrum.

An unusual type of anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion in the superior, instead of the usual inferior, part of the anterior glenoid labrum is presented in a 33-year-old man who sustained a traumatic dislocation of his left shoulder. Magnetic resonance imaging raised the possibility of an ALPSA lesion and later arthroscopy confirmed the diagnosis. Arthroscopic repair of the lesion was performed after the labral avulsion was lateralized.