Common Ice Hockey Injuries and Treatment: A Current Concepts Review.

Injuries are common in ice hockey, a contact sport where players skate at high speeds on a sheet of ice and shoot a vulcanized rubber puck in excess of one hundred miles per hour. This article reviews the diagnoses and treatment of concussions, injuries to the cervical spine, and lower and upper extremities as they pertain to hockey players. Soft tissue injury of the shoulder, acromioclavicular joint separation, glenohumeral joint dislocation, clavicle fractures, metacarpal fractures, and olecranon bursitis are discussed in the upper-extremity section of the article. Lower-extremity injuries reviewed in this article include adductor strain, athletic pubalgia, femoroacetabular impingement, sports hernia, medial collateral and anterior cruciate ligament tears, skate bite, and ankle sprains. This review is intended to aid the sports medicine physician in providing optimal sports-specific care to allow their athlete to return to their preinjury level of performance.

A 70° Arthroscope Significantly Improves Visualization of the Bicipital Groove in the Lateral Decubitus Position.

PURPOSE: The purpose of this study was to quantify the length of the bicipital groove viewable with a 70° arthroscope and to compare this distance visualized with use of a 30° arthroscope in both cadavers and living subjects. METHODS: Diagnostic glenohumeral arthroscopy in the lateral decubitus position was performed on 10 fresh-frozen cadaveric shoulders from a posterior portal. Using 70° and 30° arthroscopes, the distalmost viewable portion of the bicipital groove was percutaneously marked. Dissection of each specimen was then performed, and the distances between the articular margins of the humeral head to each marked portion of bicipital groove were recorded. Subsequently, a similar technique was used to measure the visible length of the bicipital groove in a series of 11 patients at the time of diagnostic glenohumeral arthroscopy performed in the lateral decubitus position using 70° and 30° arthroscopes. Descriptive statistics were used for continuous data. Means were compared with a Mann-Whitney test. Statistical significance was set at P ≤ .05. RESULTS: The cadaveric analysis revealed a significant increase in the amount of bicipital groove visualized with the 70° arthroscope versus that visualized with the 30° arthroscope (18.0 ± 6.9 mm v 11 ± 4.7 mm, P = .01). In similar fashion, the results of the in vivo analysis showed that the 70° arthroscope allowed for significantly more visualization of the bicipital groove than the 30° arthroscope (26.3 ± 6.2 mm v 14 ± 4.7 mm, P = .025). CONCLUSIONS: The use of a 70° arthroscope significantly increases the length of bicipital groove visualized during glenohumeral arthroscopy in the lateral decubitus position compared with that of the 30° arthroscope in both cadavers and living subjects. CLINICAL RELEVANCE: Routine use of a 70° arthroscope significantly improves visualization of the bicipital groove and all relevant intra-articular structures compared with that of a 30° arthroscope during diagnostic glenohumeral arthroscopy performed in the lateral decubitus position.

Is arthroscopic remplissage a tenodesis or capsulomyodesis? An anatomic study.

PURPOSE: Arthroscopic remplissage of a Hill-Sachs lesion is classically described as a capsulotenodesis of the infraspinatus within the posterolateral humeral head. The aim of this cadaveric study was to evaluate the anatomic relationship between the position of anchors and sutures placed for remplissage and the infraspinatus and teres minor. The hypothesis was that remplissage actually corresponds to a capsulomyodesis of the infraspinatus and teres minor muscles. METHODS: A two-anchor arthroscopic remplissage was performed followed by open dissection of ten fresh-frozen human cadaveric shoulders. The exit point of sutures related to muscle-tendon unit as well as the distance between the anchors and the rotator cuff was measured. RESULTS: The superior sutures were localized generally in the infraspinatus, near the musculotendinous junction. The inferior sutures passed through the teres minor muscle in seven of ten cases. The distance between the superior and inferior anchors and the posterolateral greater tuberosity was 14 ± 2 and 12 ± 3 mm, respectively. CONCLUSIONS: Arthroscopic remplissage is a capsulomyodesis of infraspinatus and teres minor rather than a capsulotenodesis of the infraspinatus alone as previously believed. Muscular damage may explain posterosuperior pain observed in patients who underwent remplissage.

The effect of long and short head biceps loading on glenohumeral joint rotational range of motion and humeral head position.

PURPOSE: To evaluate the effect of loading the long and short heads of the biceps on glenohumeral range of motion and humeral head position. METHODS: Eight cadaveric shoulders were tested in 60° abduction in the scapula and coronal plane. Muscle loading was applied based on cross-sectional area ratios. The short and long head of the biceps were loaded individually followed by combined loading. Range of motion was measured with 2.2 Nm torque, and the humeral head apex position was measured using a MicroScribe. A paired t test with Bonferroni correction was used for statistics. RESULTS: Long head loading decreased internal rotation in both the scapular (17.9 %) and coronal planes (5.7 %) and external rotation in the scapular plane (2.6 %) (P < 0.04). With only short head loading, maximum internal rotation was significantly increased in the scapular and coronal plane. Long head and short head loading shifted the humeral head apex posteriorly in maximum internal rotation in both planes with the long head shift being significantly greater than the short head. Long head loading also shifted the humeral apex inferiorly in internal rotation and inferiorly posteriorly in neutral rotation in the scapular plane. With the long head unloaded, there was a significant superior shift with short head loading in both planes. CONCLUSION: Loading the long head of the biceps had a much greater effect on glenohumeral range of motion and humeral head shift than the short head of the biceps; however, in the absence of long head loading, with the short head loaded, maximum internal rotation increases and the humeral head shifts superiorly, which may contribute to impingement following tenodesis of the long head of the biceps. These small changes in rotational range of motion and humeral head position with biceps tenodesis may not lead to pathologic conditions in low-demand patients; however, in throwers, biceps tenodesis may lead to increased contact pressures in late-cocking and deceleration that will likely translate to decreased performance therefore every effort should be made to preserve the biceps-labral complex.

Best Practices During Hip Arthroscopy: Aggregate Recommendations of High-Volume Surgeons.

PURPOSE: To survey surgeons who perform a high volume of hip arthroscopy procedures regarding their operative technique, type of procedure, and postoperative management. METHODS: We conducted a cross-sectional survey of 27 high-volume orthopaedic surgeons specializing in hip arthroscopy to report their preferences and practices related to their operative practice and postoperative rehabilitation protocol. All participants completed the survey in person in an anonymous fashion during a meeting of the American Hip Institute. RESULTS: All surgeons perform hip arthroscopy with the patient in the supine position, accessing the central compartment of the hip initially, using intraoperative fluoroscopy. All surgeons perform labral repair (100%), with the majority performing labral reconstructions (77.8%) and gluteus medius repairs (81.5%). There is variability in the type of anchors used during labral repair. Most surgeons perform capsular closure in most cases (88.9%), inject either intra-articular cortisone or platelet-rich plasma at the conclusion of the procedure (59%), and prescribe a postoperative hip brace for some or all patients (59%). There is considerable variability in rehabilitation protocols. All surgeons routinely prescribe postoperative heterotopic ossification prophylaxis to their patients, with most surgeons (88.9%) prescribing a nonsteroidal anti-inflammatory medication for 3 weeks. Forty percent of the respondents use the modified Harris Hip Score as the most important outcome measure. CONCLUSIONS: Consistent practices such as use of intraoperative fluoroscopy, heterotopic ossification prophylaxis, and labral repair skills were identified by surveying 27 hip arthroscopy surgeons at high-volume centers. Most of the surgeons performed routine capsular closure unless underlying conditions precluded capsular release or plication. The survey identified higher variability between surgeons regarding postoperative rehabilitation protocols and use of intra-articular pharmacologic injections at the end of the procedure. These data may provide surgeons with a set of aggregate trends that may help guide training, clinical practice, and research in the evolving field of hip arthroscopy.

Arthroscopic labral base repair in the hip: clinical results of a described technique.

PURPOSE: The purpose of this study was to evaluate the clinical outcomes of a cohort of patients who underwent labral repair by use of a previously published labral base repair suture technique for the treatment of acetabular labral tears and pincer-type femoroacetabular impingement (FAI). METHODS: Patients who received hip arthroscopy for symptomatic intra-articular hip disorders and underwent the previously described labral base repair technique were included in the study group. Patients who had Tönnis arthritis grade 2 or greater, had Legg-Calves-Perthes disease, or underwent simple looped stitch repair were excluded. The patient-reported outcome scores included the modified Harris Hip Score, the Non-Arthritic Hip Score, the Hip Outcome Score-Activities of Daily Living, and the Hip Outcome Score-Sport-Specific Subscale obtained preoperatively and at 2 years' and 3 years' follow-up. Any complications, revision surgeries, and conversions to total hip arthroplasty were noted. RESULTS: Of the patients, 54 (82%) were available for follow-up. The mean length of follow-up for this cohort was 2.4 years (range, 1.7 to 4.1 years). At final follow-up, there was significant improvement in all 4 patient-reported outcome scores (modified Harris Hip Score, 63.7 to 89.9; Non-Arthritic Hip Score, 60.9 to 87.9; Hip Outcome Score-Activities of Daily Living, 66.9 to 91.0; and Hip Outcome Score-Sport-Specific Subscale, 46.5 to 79.2) (P < .0001). A good or excellent result was achieved in 46 patients (85.2%). There was significant improvement in pain as measured by the change in visual analog scale score from 6.5 to 2.3 (P < .0001), and the patient satisfaction rating was 8.56 ± 2.01. There were no perioperative complications. Revision surgery was required in 3 patients (5.6%), and 2 patients (3.7%) required conversion to total hip arthroplasty. CONCLUSIONS: The clinical results of this labral base repair technique showed favorable clinical improvements based on 4 patient-reported outcome questionnaires, visual analog scale, and patient satisfaction. More clinical, biomechanical, and histologic studies are needed to determine the optimal repair technique. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Outcome instruments for the shoulder.

Outcome surveys may play a vital role in the future of orthopaedics. Institutions may increasingly look toward determining the effectiveness of treatment options, but different validation studies often yield different results. There is a clear need for consistency when reporting patient-reported outcome scores. Knowledge of the available outcome scores and their strengths and weaknesses will allow orthopaedic surgeons to practice evidence-based medicine, offer their patients the most appropriate treatments, and successfully navigate the increasingly complex reimbursement system. Orthopaedic surgeons will need to show conclusively that their procedures improved patient outcomes and were cost-effective. We conducted a review of upper extremity outcome systems commonly used in the shoulder and their scoring and validation.

Relationship of the subscapular nerves to the base of the coracoid.

PURPOSE: This study was performed to determine the relation of the subscapular nerves to the medial base of the coracoid when using an arthroscopic approach. METHODS: Twenty human cadaveric shoulder specimens were dissected, and measurements were taken from the medial base of the coracoid to the innervation points of the upper and lower subscapular nerves. Measurements were obtained with the humerus in both neutral and maximal external rotation. RESULTS: The average distance of the upper subscapular nerve from the coracoid base was 31.6 ± 6.6 mm (range, 22 to 45 mm) in neutral rotation and 24.2 ± 7.4 mm (range, 11 to 35 mm) in external rotation. The lower subscapular nerve's insertion point averaged 42.6 ± 7.6 mm (range, 25 to 55 mm) from the coracoid base in neutral rotation and 33.9 ± 6.9 mm (range, 24 to 45 mm) in external rotation. For both nerves, their distance from the coracoid significantly decreased when the humerus was placed in external rotation. CONCLUSIONS: The closest that the innervation point of either the upper or lower subscapular nerve came to the medial aspect of the coracoid was 11 mm. CLINICAL RELEVANCE: Understanding the relationship of the subscapular nerves to the base of the coracoid allows a safe arthroscopic release of a retracted subscapularis muscle that has formed adhesions to the inferior aspect of the coracoid. Use of an arthroscopic elevator to release adhesions between the subscapularis and the inferior aspect of the coracoid does not appear to risk denervation of the subscapularis muscle.

Biomechanical properties of repairs for dislocated AC joints using suture button systems with integrated tendon augmentation.

PURPOSE: To evaluate the biomechanical performance of different techniques for CC reconstruction using suture button systems with integrated tendon augmentation. Hypothesis was that (1) reconstructions using a cortical button combined with a biological augmentation (semitendinosus allograft) will demonstrate improved stability than a modified Weaver-Dunn procedure and (2) constructs using two tunnels at the clavicle for fixation will show superior horizontal stability than single-tunnel constructs. METHODS: The acromioclavicular joints of 47 cadaveric shoulders were tested for anterior, posterior, and superior translations (70 N load) and maximal load to failure (superior). Shoulders were assigned to 4 groups: (1) native (n = 18) and after sectioning the AC and CC ligaments; (2) CC reconstruction with 1 clavicular and 1 coracoid tunnel (GR-ST) augmented with semitendinosus graft (n = 15); (3) CC reconstruction augmented with semitendinosus tendon (GR-DT) with 2 clavicular and 1 coracoid tunnel (n = 8); and (4) modified Weaver-Dunn reconstruction (n = 6). RESULTS: The Weaver-Dunn demonstrated statistically more translation than the native joint for posterior direction (P = 0.038). The GR-ST had significantly less translation than the Weaver-Dunn for anterior and posterior translations (P = 0.003, P = 0.004) and compared to the native for superior translation (P = 0.028). The GR-DT differed significantly in anterior and posterior translations compared to the Weaver-Dunn (P = 0.002, P = 0.001). The modified Weaver-Dunn failed at significantly less load to failure compared to all other groups (P = 0.002, P = 0.002, P = 0.005). There was no significant difference between the native and the other reconstructions. CONCLUSION: The evaluated techniques for isolated CC ligament reconstruction (GR-ST) in AC joint dislocation showed biomechanical stability superior to the modified Weaver-Dunn procedure and obtained similar measures compared to the native control. A modified technique (GR-DT), which used two fixation points at the clavicle, did not result in decreased horizontal or vertical translation and therefore no superiority of the GR-DT technique could be shown compared to the GR-ST. LEVEL OF EVIDENCE: Controlled laboratory study.

Fragility Fractures: Diagnosis and Treatment.

Fragility fractures are estimated to affect 3 million people annually in the United States. As they are associated with a significant mortality rate, the prevention of these fractures should be a priority for orthopedists. At-risk patients include the elderly and those with thyroid disease, diabetes, hypertension, and heart disease. Osteoporosis is diagnosed by the presence of a fragility fracture or by dual-energy x-ray absorptiometry (DXA) in the absence of a fragility fracture. In 2011, the United States Preventive Services Task Force (USPSTF) recommended that all women ≥65 years should be screened for osteoporosis by DXA. Women <65 years with a 10-year fracture risk =∕> than that of a 65-year-old white woman should also be screened for osteoporosis. Lifestyle changes, such as calcium and vitamin D supplementation, exercise, and smoking cessation, are non-pharmacologic treatment options. The National Osteoporosis Foundation recommends treating osteoporosis with pharmacotherapy in patients with a high risk for fracture (T score <-2.5) or history of fragility fracture. Understanding risk factors and eliminating medications known to cause decreased BMD are vital to prevention and will be necessary to limit these fractures and their associated expenses in the future.

Lower Extremity Injuries in Ice Hockey: Current Concepts.

Ice hockey is a fast-paced, collision sport requiring tremendous skill and finesse, yet ice hockey can be a harsh and violent game. It has one of the highest musculoskeletal injury rates in all of competitive sports. Razor sharp skates, aluminum sticks and boards made from high density polyethylene (HDPE), all contribute to the intrinsic hazards of the game. The objective of this article is to review evaluation, management, and return-to-the-rink guidelines after common lower extremity ice hockey injuries.

Precision and Accuracy of Identification of Anatomical Surface Landmarks by 30 Expert Hip Arthroscopists.

We conducted a study to assess 30 expert hip arthroscopists' ability to identify common surface landmarks used during hip arthroscopy. Thirty hip arthroscopists independently performed a blinded examination of an awake supine human volunteer for identification of 5 surface landmarks: anterior superior iliac spine (ASIS), tip of greater trochanter (GT), rectus origin (RO), superficial inguinal ring (SIR), and psoas tendon (PT). The examiners applied the labels ASIS, GT, RO, SIR, and PT to the landmarks. An ultrasonographer performed a musculoskeletal ultrasound examination and applied labels as well, and a photographer documented the examiner labels after obtaining overhead and lateral digital images with use of fixed camera mounts. Digital overlay composite images of arthroscopist and ultrasonographer labels were analyzed. Direction and distance of inaccurately placed labels were compared with known values for neurovascular structures previously reported for common arthroscopic portals. Average distance from examiner-applied labels to ultrasonographer-applied labels was 31 mm for ASIS, 24 mm for GT, 26 mm for RO, 19 mm for SIR, and 35 mm for PT. Interobserver variability of examiner-applied labels was recorded as areas of 95% predictive interval: 65 cm2 for ASIS, 16 cm2 for GT, 221 cm2 for RO, 38 cm2 for SIR, and 29 cm2 for PT. Examiner labels demonstrated the highest potential for injury because of anterior portal inaccuracy. Expert hip arthroscopists varied in their ability to accurately and precisely identify common surface landmarks about the hip, using only manual palpation.

Stem-Based Repair of the Subscapularis in Total Shoulder Arthroplasty.

Management of the subscapularis is an important component of total shoulder arthroplasty. This technique article describes a stem-specific approach to repairing the subscapularis.

Acute Management of Anterior Cruciate Ligament Injuries Using Novel Canine Models.

The objective of this study was to compare treatment options for acute management of anterior cruciate ligament (ACL) injuries using preclinical models. Twenty-seven adult purpose-bred research hounds underwent knee surgery (sham control, exposed ACL, or partial-tear ACL) and were assessed over the following 8 weeks. Dogs were randomized into three treatment groups: standard of care (i.e., rest and nonsteroidal anti-inflammatory drugs [NSAIDs]), washout, or leukoreduced platelet-rich plasma (PRP) so that a total of nine dogs received each treatment. Data from the two ACL-injury groups were pooled for each treatment (n = 6 per treatment group) and analyzed for treatment effects. The washout and PRP groups experienced less lameness, pain, and effusion, and greater function and comfortable range of motion compared with the NSAID group, with the PRP group showing most benefits. PRP was associated with the lowest severity of ACL pathology based on arthroscopic assessment. Measurable levels of inflammatory and degradative biomarkers were present in synovial fluid with significant differences noted over time. Based on these findings, washout had positive clinical effects compared with the standard-of-care group especially within the first week of treatment, but became less beneficial over time. A single injection of leukoreduced PRP was associated with favorable clinical results. However, no treatment was significantly "protective" against progression toward osteoarthritis after ACL injury.

Nonoperative treatment of unicompartmental arthritis of the knee.

Treatment of the knee with unicompartmental osteoarthritis remains a challenging clinical problem. Despite pharmacologic advances and surgical innovations, the ideal strategy for the patient who has single-compartment degenerative disease can be complicated. The understanding and management of this problem are further confounded by the fact that so much of the data are unreliable. Given these constraints, this article outlines the current alternatives available in nonoperatively managing the symptomatic unicompartmental arthritic knee.

Rupture of the biceps tendon after arthroscopic thermal capsulorrhaphy.

The use of thermal energy in the shoulder to tighten capsular tissues through collagen denaturation is well established. Although reported complication rates are low, the natural history of thermal manipulation to both target and collateral tissue is poorly defined. We report two cases of biceps tendon rupture after arthroscopic capsular shrinkage. Both patients were young, athletic men with normal long head biceps tendons at the time of surgery. Each patient experienced a complete tear of the long head with distal muscle retraction, resulting in a "Popeye" deformity, at 3 months postoperatively. One patient elected further surgery with biceps tenodesis. Both patients have returned to their athletic activities with minimal functional deficits.

Biomechanical validation of load-sharing rip-stop fixation for the repair of tissue-deficient rotator cuff tears.

BACKGROUND: Poor-quality tendon is one of the most difficult problems the surgeon must overcome in achieving secure fixation during rotator cuff repair. A load-sharing rip-stop construct (LSRS) has recently been proposed as a method for improving fixation strength, but the biomechanical properties of this construct have not yet been examined. PURPOSE: To compare the strength of the LSRS construct to that of single-row fixation for rotator cuff repair. STUDY DESIGN: Controlled laboratory study. METHODS: Rotator cuff tears were created in 6 cadaveric matched-pair specimens and repaired with a single row or an LSRS. In the LSRS repair, a 2-mm suture tape was placed as an inverted mattress stitch in the rotator cuff, and sutures from 2 anchors were placed as simple stitches that passed medial to the suture tape. The suture tape limbs were secured with knotless anchors laterally before sutures were tied from the medial anchors. Displacement was observed with video tracking after cyclic loading, and specimens were loaded to failure. RESULTS: The mean load to failure was 371 ± 102 N in single-row repairs compared with 616 ± 185 N in LSRS repairs (P = .031). There was no difference in displacement with cyclic loading between the groups (3.3 ± 0.8 mm vs. 3.5 ± 1.1 mm; P = .561). In the single-row group, 4 of 6 failures occurred at the suture-tendon interface. In the LSRS group, only 1 failure occurred at the suture-tendon interface. CONCLUSION: The ultimate failure load of the LSRS construct for rotator cuff repair was 1.7 times that of a single-row construct in a cadaveric model. CLINICAL RELEVANCE: The LSRS rotator cuff repair construct may be useful in the repair of difficult tears such as massive tears, medial tears, and tears with tendon loss.

Open reduction internal fixation of distal clavicle fracture with supplementary button coracoclavicular fixation.

Distal clavicle fractures are common, and no standard treatment exists. Many different surgical modalities exist. This report describes an open reduction internal fixation technique that achieves both plate and coracoclavicular stabilization using a button device. A precontoured superior-lateral plate is secured to the clavicle. A 3.2-mm spade-tipped drill bit is drilled across the clavicle and coracoid, passing through 4 cortices. The button is loaded onto an insertion device, passed across the 4 cortices, and captured on the undersurface of the coracoid under fluoroscopic guidance. This construct is linked to the distal clavicle plate by heavy sutures using a second button that sits in the plate. The lateral locking holes are then filled to finalize fixation. This technique provides for a simplified way to achieve coracoclavicular stabilization when using a plate for fixation of distal clavicle fractures.

Knot Strength Varies Widely Among Expert Arthroscopists.

BACKGROUND: While most surgeons can tie visually appealing knots under an arthroscope, few surgeons have undergone an objective evaluation of their ability to consistently tie knots with maximum loop and knot security. PURPOSE/HYPOTHESES: The purpose of this study was to evaluate and compare variations in ultimate load to failure, 3-mm displacement (clinical failure), and knot stack height of arthroscopic suture knots tied by 73 independent expert orthopaedic arthroscopists. The hypotheses were (1) that skilled arthroscopic surgeons would be able to routinely tie arthroscopic knots of similar strength, (2) that surgeons with <10 years of clinical practice would tie stronger and more consistent knots, and (3) that surgeons who performed >200 arthroscopic shoulder cases per year would produce stronger and more consistent knots than would surgeons who performed fewer cases. STUDY DESIGN: Controlled laboratory study. METHODS: Each surgeon tied 5 of the same type of their preferred arthroscopic knot and half-hitch locking mechanism. Each knot was mechanically tested for ultimate load to failure and clinical failure. RESULTS: For the 365 individual knots tested, the mean ultimate load across each knot was 231 N (range, 29-360 N). The mean clinical failure load was 139 N (range, 16-328 N). The average knot stack height among the 365 knots was 5.61 mm (range, 2.89-10.32 mm). For an individual surgeon, the standard deviations of the 5 consecutive knots tied ranged from 6 to 133 N. The ultimate load and clinical failure load for surgeons with <10 years of practice (n = 39) were 248 ± 93 N and 142 ± 56 N, respectively. The mean ± SD ultimate and clinical failure loads for surgeons with >10 years of practice (n = 34) were 211 ± 111 N and 136 ± 69 N, respectively. When knot strength was used to measure performance, significant differences existed in ultimate load (P = .001); however, there were no differences in clinical failure load (P = .329). Surgeons with <10 years of practice were able to tie knots more consistently than were surgeons in practice for >10 years, for both ultimate load (P = .018) and clinical failure load (P = .005). There was no significant difference based on number of cases performed with respect to ultimate load or clinical failure load (P = .292 and .479, respectively). There was no difference in consistency, as both groups had similar standard deviations (P = .814 for ultimate load, P = .545 for clinical failure). CONCLUSION: Considerable variations in knot strength exist between arthroscopic knots tied by surgeons. Study findings revealed that surgeons were unable to tie 5 consecutive knots of the same type consistently; that for both ultimate load and clinical failure load, surgeons with <10 years in practice were able to tie knots more consistently than surgeons with >10 years; and that surgeons performing >200 arthroscopic shoulder cases annually failed to tie stronger or more consistent knots than their counterparts performing fewer cases. CLINICAL RELEVANCE: This variation in knot tying has the potential to affect the integrity of arthroscopic repairs. Independent objective testing of the ability to tie secure knots as part of a surgeons' training may be necessary.