Cultures of ligament fibroblasts in fibrin matrix gel.

The cellular properties of anterior cruciate ligament (ACL) and medial collateral ligament (MCL) fibroblasts have been analyzed in a three-dimensional fibrin matrix gel (FMG) system. The MCL fibroblasts proliferated significantly faster than ACL fibroblasts in 10% fetal bovine serum (FBS). FMG contraction resembles soft-tissue wound contraction. Transforming growth factor-beta1 (TGF-beta1) (5 ng/ml) caused a significantly faster rate of FMG contraction than control (0.5% FBS) in both ACL and MCL fibroblasts. Unlike the cells in 10% FBS, this faster rate of FMG contraction was achieved without increasing the initial cell number. In the FMG, the MCL fibroblasts demonstrated significantly higher collagen synthesis per cell than ACL fibroblasts between the days 2 and 6 of culture. These differences in cellular properties of the ACL and MCL fibroblasts that were observed in vitro may explain the differences in the healing potential of these ligaments in vivo.

An anatomic study of the supraspinatus muscle and tendon.

The gross and histologic anatomy of the myotendinous portion of the supraspinatus muscle was investigated with coronal and sagittal sections from 20 anatomic specimen shoulders. The anterior lateral portion of the supraspinatus contained more tendon than the posterior portion of the muscle in all 20 specimens. In seven specimens there were separate muscle fibers that originated from the most anteromedial area of the supraspinatus fossa. Knowledge of this anatomy aids in magnetic resonance image interpretation and open or arthroscopic evaluation of the supraspinatus. This consistent tendinous portion may be useful in rotator cuff repair and may provide a firm area for suture closure of the rotator interval. This prominent anterior tendinous area may serve to protect the supraspinatus during anterior forward flexion motion through the impingement arc.

Electrosurgical methods for arthroscopic meniscectomy: A review of the literature.

PURPOSE: To outline the development of electrosurgical (radiofrequency) devices, explain the basic principles, and review the current orthopaedic literature regarding the application of electrosurgery to arthroscopic partial meniscectomy. MATERIALS AND METHODS: The history and principles of electrosurgery were obtained from various pertinent texts and journal articles. A literature search was performed using MEDLINE; reviewed articles consisted of articles in the English language cataloged between 1966 and January 1999. RESULTS: The history and principles of electrosurgery are reviewed. The articles pertaining to arthroscopic electrosurgical meniscectomy are discussed with a separate discussion on the potential complications of using radiofrequency energy for meniscal ablation, including articular cartilage damage, osteonecrosis, and damage caused by irrigant. CONCLUSION: Electrosurgery has been shown to be an effective tool in arthroscopic meniscectomy. Further research and refinement is warranted because it may show superiority to other methods in certain situations.

Management of chronic deep infection following rotator cuff repair.

BACKGROUND: Deep infection of the shoulder following rotator cuff repair is uncommon. There are few reports in the literature regarding the management of such infections. METHODS: We retrospectively reviewed the charts of thirteen patients and recorded the demographic data, clinical and laboratory findings, risk factors, bacteriological findings, and results of surgical management. RESULTS: The average age of the patients was 63.7 years. The interval between the rotator cuff repair and the referral because of infection averaged 9.7 months. An average of 2.4 procedures were performed prior to referral because of infection, and an average of 2.1 procedures were performed at our institution. All patients had pain on presentation, and most had a restricted range of motion. Most patients were afebrile and did not have an elevated white blood-cell count but did have an elevated erythrocyte sedimentation rate. The most common organisms were Staphylococcus epidermidis, Staphylococcus aureus, and Propionibacterium species. At an average of 3.1 years, all patients were free of infection. Using the Simple Shoulder Test, eight patients stated that the shoulder was comfortable with the arm at rest by the side, they could sleep comfortably, and they were able to perform activities below shoulder level. However, most patients had poor overhead function. CONCLUSIONS: Extensive soft-tissue loss or destruction is associated with a worse prognosis. Extensive débridement, often combined with a muscle transfer, and administration of the appropriate antibiotics controlled the infection, although most patients were left with a substantial deficit in overhead function of the shoulder.

Technical pitfalls of meniscal surgery.

Meniscal surgery is one of the most common orthopedic procedures performed today. Orthopedic surgeons must be familiar with the indications for meniscal excision versus repair and comfortable with the diverse instrumentation used for both techniques. Numerous pitfalls exist in diagnosis, indication, and technical aspects of surgery but can be minimized or avoided by careful preoperative planning and attention to detail during the surgical procedure.

Extensor carpi radialis brevis. An anatomical analysis of its origin.

We studied the origin of extensor carpi radialis brevis using 40 fresh frozen human cadaver specimens. Ten were stained with haematoxylin and eosin and trichrome which showed the collagenous structure of the extensor tendons at their origin. Gross anatomical observation showed that there was no definitive separation between brevis and communis at the osseotendinous junction. The histological findings confirmed the lack of separation between the two tendons. The extensor tendons were in close proximity to the joint capsule but trichrome staining showed no interdigitation of the tendon with the capsule. The validity of ascribing the pain of lateral epicondylitis to extensor carpi radialis brevis must be questioned. It appears to arise more from the 'common extensor' origin.

The effects of laser-induced collagen shortening on the biomechanical properties of the inferior glenohumeral ligament complex.

The purpose of this study was to determine the effects of laser-induced collagen shortening on the biomechanical properties of the inferior glenohumeral ligament complex. Fifty-seven bone-ligament-bone specimens underwent uniaxial tensioning to 10% strain. Approximately half of the specimens then underwent 10% shortening by lasing using a holmium:yttrium-aluminum-garnet laser. Both groups were again tensioned to 10% strain, and then loaded to failure. Ultimate strain and yield strain were significantly higher in the lased specimens than in the nonlased specimens. No significant difference was found for ultimate stress, yield stress, or elastic modulus between the two groups. Failure of the ligament did not appear to occur in the lased areas. The load-to-failure results suggested that the strength of the ligament complex was not significantly compromised by this lasing protocol.

Cautious surgery for discoid menisci.

This retrospective study reviewed the outcomes of 43 knees in 38 patients with discoid menisci treated from 1977 to 1989. Patients underwent either no treatment, trimming, or subtotal or total resection. Approximately 40% of patients who underwent meniscectomy or partial meniscectomy had a fair or poor rating after an average follow-up of 6.5 years. Pathology demonstrating mucoid fibrinous degeneration within the discoid meniscus was found in many cases, showing abnormal meniscal tissue. Only one third of these knees had symptoms of locking, and only 20 (63%) of 32 had a positive arthrogram, demonstrating the diagnostic difficulties encountered with the discoid meniscus. Patients with a discoid meniscus who are symptomatic should undergo arthroscopy. A partial meniscectomy should be performed to achieve a smooth meniscus and a strong, stable peripheral rim.

Overview of treatment options for arthritis in the active patient.

The understanding of arthritis and possible treatment options continues to improve. This article discusses classification of articular cartilage degeneration, osteochondral defects, osteotomy, and a variety of treatments. Developments in the study of growth factors, molecular biology, and gene therapy make the future bright; it is contingent, however, on critical factors such as controlled studies, accurate inclusion criteria, outcome measurement, and long-term follow-up.

The effects of concentric versus eccentric isokinetic strength training of the rotator cuff in the plane of the scapula at various speeds.

This study compares the effects of three modes of isokinetic resistance training at the shoulder--concentric, eccentric, and a combination of both concentric and eccentric, with a group that received no training at all. Twenty-eight healthy volunteers (male and females), 18 to 36 years of age, with no history of shoulder pathology, were randomly assigned to one of four groups; concentric training, eccentric training, a combination of both concentric and eccentric training, or control (no training). Testing and training of the dominant shoulder was performed on an isokinetic dynamometer. All subjects were pretested and post-tested both concentrically and eccentrically for humeral internal/external rotation and abduction at speeds of 60 degrees/sec and 120 degrees/sec. Each training session consisted of a total of twelve sets of ten maximal repetitions, and was repeated three times a week for four weeks. The absolute and percent difference in peak force and peak torque for each group between the pretest and post-test was calculated for each combination of position, mode, and speed. A significant difference between the concentric/eccentric group and the eccentric group was found for abduction (p < 0.05). The eccentric group showed a significantly greater increase from the pretest to post-test for absolute differences in peak force and peak torque compared to the concentric/eccentric group (p < 0.05).

Isometry of the posterior cruciate ligament. Effects of functional load and muscle force application.

The effects of functional load and muscle force application on isometry of the posterior cruciate ligament were determined. Eight fresh-frozen cadaver knees were mounted in a custom-designed rig. A full range of motion and muscle forces were applied through the quadriceps, hamstring, and gastrocnemius tendons during a simulated static squat maneuver. The low-load isometric posterior cruciate ligament point was located 5.63 mm proximal and 0.18 mm anterior to the anatomic center of the posterior cruciate ligament origin on the femur. The high-load state, with no gastrocnemius and hamstring muscle forces applied, shifted the isometric point 6.32 mm proximal and 6.72 mm anterior (P < 0.05). Loading the hamstring and gastrocnemius muscles also shifted the isometric point (P < 0.05). This study indicated that the most isometric region of the posterior cruciate ligament femoral attachment changed significantly when functional loads and muscle forces were applied to the knee. This finding may have implications for both surgical reconstruction and rehabilitation of the posterior cruciate ligament-injured knee.

The treatment of isolated articular cartilage lesions in the young individual.

The treatment of isolated articular cartilage defects is an evolving field in orthopaedic surgery today. We have summarized the basic science and clinical date on the treatment of isolated articular cartilage defects. Further long-term controlled studies are required in order to compare definitively the efficacy of treatments in this difficult clinical area. In future studies, inclusion/exclusion criteria must be detailed, and classification systems need to be standardized Comparative analysis can then be performed to assess the efficacy of various techniques.

Transdermal delivery and accumulation of indomethacin in subcutaneous tissues in rats.

Oral non-steroidal anti-inflammatory drugs (NSAIDs) are effective pharmacotherapy for a wide variety of painful, inflammatory disorders. Development of an efficient means of topical administration of NSAIDs could increase local soft-tissue and joint concentrations while reducing systemic distribution of the drug, thereby reducing side-effects. With this in mind we studied the effects of a novel topical penetration enhancer for lipophilic compounds, a trans-phase delivery system (TPDS), a solution of benzyl alcohol, isopropanol and acetone, on the distribution of indomethacin in various tissues locally and remote from the site of application. We compared the TPDS with a 50:50 (v/v) mixture of propylene glycol and ethanol, a commonly used penetration enhancer, and with oral administration. We found that the TPDS was significantly superior to the other approaches at achieving high local-tissue concentrations in the vicinity of the site of application. In addition, comparison of these two carrier systems seems to clarify the different aqueous and hydrophobic pathways of drug penetration which emerge from various experimental findings and theoretical considerations. Our results suggest that this non-aqueous solvent system, and benzyl alcohol in particular, because of its unique physicochemical and solvating characteristics, might be able to deliver therapeutic levels of indomethacin to tissues close to the site of application in a safer and more effective manner than presently accepted forms of delivery.

Ablation rates of human meniscal tissue with the Ho:YAG laser: the effects of varying fluences.

To further define the operating parameters for Holmium laser meniscectomy, an in vitro experimental was set up to specifically measure ablation rates and the concomitant thermal injury. Using an experiment set-up with a laser fiber penetrating through meniscal tissue slices, energy levels were varied between 167 and 927 Joules (J)/cm2 per pulse to measure meniscal ablation rates. Following each experiment the adjacent thermal effects were evaluated with hematoxylin and eosin and trichrome staining. The fastest ablation rate was found at 927 J/cm2 per pulse. The increase in ablation rates was directly proportional to the increases in energy levels. Histological examination showed the average lateral thermal change to be 400 to 500 microns, with no demonstrated relation to the pulse level of energy. At these laser parameters the higher levels of energy per pulse showed better ablation of human meniscal tissue without increasing thermal effects in adjacent tissue. Higher energy levels and fluences appeared desirable for more efficient arthroscopic meniscectomy with the Holmium laser.

Collagen shortening. An experimental approach with heat.

Decreasing joint laxity is a clinical goal of ligament reconstructions. This in vitro study examined the structural and histologic effects of heat shrinkage of human collagen. Two preliminary studies were performed to assess the effect of heat on fresh frozen human tendons obtained from a local tissue bank. As heat was applied to tissue in a saline solution, the percent shrinkage was plotted against temperature. A second study used a freebeam Nd:YAG laser to maximally shrink patellar tendons measuring percent shrinkage versus energy applied. Finally, the effects of 10% shrinkage of fresh frozen human patellar tendons were analyzed mechanically and histologically. Consistent tendon shrinkage curves were found with increasing temperatures in a saline solution. A sharp increase in shrinkage to approximately 70% of resting length was noted around 70 degrees C. Tendon shrinkage by laser induced heat was precise and dose related. Tensile testing of the tendons shortened 10% of their resting length showed a decrease in load to failure to approximately 1/3 compared with that of historical control specimens. Histologic sections showed a well demarcated site of diffuse denaturation and degeneration of collagenous elements. Normal collagen was present adjacent to these thermal changes. These experiments showed that collagen tissue can be shortened precisely by the application of heat. Future studies need to examine the in vivo biologic response of shortened collagen tissue with time, especially recollagenization, restoration of length, and the long term biomechanical effects.

Upper extremity blood flow in collegiate and high school baseball pitchers A preliminary report.

The arterial and venous volume blood flow in the dominant and nondominant upper extremities of five male pitchers, ages 16 to 21, was measured using color flow duplex ultrasound. Blood-flow measurements were obtained at baseline, after warm-up, and after each sequence of 20 pitches until 100 pitches were thrown. Blood flow was additionally determined 1 hour after the last pitch. The velocity of each pitch was recorded with a speed gun. Anthropomorphic measurements of the upper extremity were obtained at baseline and immediately after Pitch 100 using a standard measuring tape. The highest average arterial volume flow in the pitching arm occurred after 40 pitches, reaching a peak of 549 ml/min (56% increase from baseline). Thereafter, the average arterial blood flow steadily declined, reaching an average of 402 ml/min after the 100th pitch (14% increase from baseline). In contrast, the arterial blood flow in the nonpitching arm increased only slightly from baseline, reaching a maximal volume flow of 448 ml/min immediately after the warm-up period (10% increase from baseline). The volume flow then persistently fell to a level 30% below baseline after the 100th pitch. Although this small pilot study does not demonstrate causation between a decline in pitching performance and arterial blood flow, it suggests arterial flow in the dominant extremity falls as the pitch count increases.

Use of lasers for meniscal repair.

Recent interest in and awareness of laser technology applications have developed in the field of orthopedic surgery. This article presents a review of the literature relevant to the use of lasers for meniscal repair and discusses techniques such as vaporization and removal of tissue using laser heat transfer to tissue as well as laser tissue "welding."

Soft tissue for allograft reconstruction of the human knee: a survey of the American Association of Tissue Banks.

With increasing use and availability of musculoskeletal soft tissue allografts, orthopaedic surgeons need current knowledge about allograft processing, costs, and availability. In conjunction with the American Association of Tissue Banks, a comprehensive survey consisting of specific questions on several topics in tissue banking was sent to 42 member banks or banks undergoing accreditation review that distribute musculoskeletal tissues. Donors came from organ procurement organizations, coroners' offices, hospital morgues, and donations; the average age of the donors was 35. Most of the 36 tissue banks responding to the questionnaire harvest patellar and Achilles tendons. Patellar tendon demand exceeded supply. Tissue processing was done by outside organizations approximately 50% of the time. Of the four types of tissue sterilization processes performed, gamma irradiation was the most common. Doses of sterilizing gamma irradiation varied from 1 to 3.5 mrad. The average approximate costs of fresh-frozen tissue were $800 for patellar tendon allograft, $615 for Achilles tendon, and $640 for menisci. There was no consensus of opinion of how to size or sterilize meniscal allografts. As demand increases for soft tissue allografts, it is essential that the orthopaedic surgeon is knowledgeable about the clinical impact of tissue banking.

Arthroscopic shoulder surgery with three different laser systems: an evaluation of laser applications.

Twelve cadaveric shoulder arthroscopies were performed to evaluate the use of lasers as an adjunctive tool in arthroscopic shoulder surgery. The three most common lasers historically used in orthopedic surgery were examined: Holmium:YAG, Neodymium:YAG, and the CO2. The following parameters were evaluated for each laser system: (1) ease of use of the laser system and handpiece; (2) ability to excise and trim bursae, synovium, ligament, tendon, bone, and articular cartilage; and (3) ability to contract ligaments and capsule by heat transfer. None of these lasers efficiently cut bone, whereas all three systems readily debrided the soft tissues around the shoulder. The free-beam Ho:YAG and CO2 systems heat contracted soft tissues with more control than the contact Nd:YAG. The fiberoptic delivery system of the Neodymium:YAG and Holmium:YAG laser performed well in the saline arthroscopy, and the CO2 delivery system was cumbersome. Overall, the CO2 system removed tissue better than the others, but its difficult use favored the Holmium laser as the best overall current laser system for shoulder arthroscopy.

Gamma irradiation: effects on biomechanical properties of human bone-patellar tendon-bone allografts.

Sixty 10-mm bone-patellar tendon-bone allografts from young human donors were placed into four test groups, a control fresh-frozen group and three fresh-frozen irradiated groups. The irradiated groups were exposed to 2.0, 3.0, or 4.0 Mrad of gamma irradiation. The specimens were tested to tensile failure. The initial biomechanical strength of fresh-frozen allografts was reduced up to 15% when compared with fresh-frozen controls after 2.0 Mrad of irradiation. Maximum force, strain energy, modulus, and maximum stress demonstrated a statistically significant reduction after 2.0 Mrad of irradiation (P < 0.01). Stiffness, elongation, and strain were reduced but not with statistical significance. A 10% to 24% and 19% to 46% reduction in all biomechanical properties were found after 3.0 (P < 0.005) and 4.0 (P < 0.0005) Mrad of irradiation, respectively. After irradiation with a 4.0 Mrad dose, the ultimate load was below that of reported values for the human anterior cruciate ligament. It is clinically important to observe and document changes in human ligaments that result from currently used doses of gamma irradiation. The results from this study provide important information regarding the initial biomechanical properties of fresh-frozen human bone-patellar tendon-bone allografts after bacterial sterilization with gamma irradiation. The current accepted dose for sterilization is between 1.5 and 2.5 Mrad. There appeared to be a dose-dependent effect of irradiation on all the biomechanical parameters studied. Four of seven parameters were found to be reduced after 2.0 Mrad of irradiation. Reductions were found in all parameters after 3.0 and 4.0 Mrad of irradiation.