Faculty Bibliography

The treatment of anterior glenohumeral instability has been a topic of debate in the recent literature. Current surgical management of shoulder instability has included a variety of open and arthroscopic procedures. Open techniques for anterior reconstruction have been quite successful in preventing recurrent dislocations and continue to be the gold standard of care. In an attempt to address some of the disadvantages associated with open procedures, arthroscopic stabilization procedures have been developed. Arthroscopic capsuloligamentous repair presumably has clear advantages including better cosmesis, decreased perioperative morbidity, and a possible decrease in the loss of external rotation. Advances in arthroscopic instrumentation and improved arthroscopic techniques have increased the popularity of arthroscopic stabilization. The art of diagnosing the anatomic pathology associated with instability and proper patient selection continues to evolve. Most previous reports of arthroscopic stabilization have included small numbers of patients, variable patient pathology, and a variety of surgical techniques, making comparisons between stabilization procedures difficult. Arthroscopy can be valuable in both the confirmation of the degree and severity of the instability and to correct the pathoanatomy responsible for the instability

The article describes a simple technique for anatomic anterior cruciate ligament (ACL) tibial graft fixation at the level of the intercondylar floor within a standard endoscopic tibial tunnel. Fixation is achieved with a retrograde positioned cannulated bio-interference screw delivered over a No. 5 permanent suture from a standard anteromedial portal. The screw is inserted into the tibial tunnel in an inside-out position, so that the head of the screw is flush with the intra-articular orifice of the tibial tunnel. Recent experimental, animal, and clinical studies have reported that the advantages of this type of anatomic graft fixation over nonanatomic tibial graft fixation include increased fixation strength, a more stable reconstruction through full knee range of motion, absence of postoperative tunnel expansion, and final biologic graft incorporation at or near the native ACL tibial insertion

PURPOSE: The study was performed to determine the incidence and eventual outcome of patella fractures after anterior cruciate ligament (ACL) reconstructions using bone-patella tendon-bone autograft. TYPE OF STUDY: Retrospective review. METHODS: Between 1989 to 1999, 618 consecutive primary, single-incision bone-patella tendon-bone autograft ACL reconstructive procedures were performed by 3 surgeons at our institution. Of this group, 8 (1.3%) had postoperative patella fracture of the donor knee. The charts of these patients were retrospectively reviewed, and patients were followed with physical examination and outcome questionnaires. RESULTS: The patella fractures occurred at a mean of 57 days after the ACL reconstruction (range, 24-121 days). Five patients sustained indirect trauma, whereas 3 experienced direct trauma. Three patients had nondisplaced transverse fractures treated nonoperatively. Five patients had displaced fractures (3 transverse and 2 Y-shaped) requiring surgical intervention. All 8 patients have full flexion when compared with their opposite knee. Two patients did not regain 5 degrees of hyperextension but were not symptomatic. The mean length of follow-up for the questionnaire was 4 years (range, 1.5 to 6.5 years). The mean score on the Lysholm knee questionnaire was 89.6 (range, 77-98). The mean Single Assessment Numeric Evaluation score was 85.8 (range, 50-100). CONCLUSIONS: Most cases of postoperative patella fractures, in our experience, have caused minor changes postoperatively and no differences in the outcome of these patients. Seventy-five percent of our patients had excellent or good Lysholm scores. This study confirms previous reports in the literature that observed minimal residual sequelae from postoperative patella fractures after ACL reconstruction with bone-patella tendon-bone autograft

The role of arthroscopic procedures in the management of glenohumeral instability continues to evolve and represents an effective alternative for addressing the pathology associated with this condition. Patient selection criteria, operative techniques, and implants all continue to evolve and have resulted in improved rates of success. Arthroscopic procedures benefit patients by avoiding the common morbidities associated with the disruption of the anterior soft tissues, including a loss of external rotation associated with open procedures. Arthroscopic procedures remain technically demanding and require skills to address all of the existing pathology. The surgeon must be prepared to address many conditions beyond the Bankart lesions including glenoid bone lesions. capsular laxity, rotator interval lesions, and SLAP lesions. In addition to the documentation of recurrence, the success of this procedure must be evaluated within the context of retained ranges of motion, recovery time, proprioceptive control, and the return to prior levels of activity. Further studies are necessary to continue to validate the efficacy of arthroscopic stabilization