Faculty Bibliography

Over recent years, appreciation for the critical role of the meniscus in joint biomechanics has led to an emphasis on meniscal preservation. Meniscal allograft transplant (MAT) is a promising biological solution for the symptomatic young patient with a meniscus-deficient knee that has not developed advanced osteoarthritis. As surgical techniques are refined and outcomes continue to improve, it is vital to consider the utility of such procedures and offer a straightforward approach to MAT. This article and accompanying video provide a step-by-step tutorial on how to perform a MAT using the bridge and slot technique, its key pearls and pitfalls as well as the relevant advantages and disadvantages of MAT.

The acetabular labrum and the transverse acetabular ligament form a continuous ring of tissue on the periphery of the acetabulum that provides a seal for the hip joint and increases the surface area to spread load distribution during weight-bearing. When a labral tear is suspected, the treatment algorithm always begins with conservative management, including physical therapy and nonsteroidal anti-inflammatory drugs. When conservative management fails, patients become candidates for arthroscopic labral repair. In the last 2 decades, the rate of hip arthroscopy has increased nearly 4-fold. However, as hip arthroscopy is performed more frequently, there is a need for a proper technique to minimize morbidity, because hip arthroscopy has been known to have a steep learning curve. We present a method for arthroscopic hip labral repair using suture anchors without a capsular repair. This Technical Note highlights our technique for labral repair, along with pearls and pitfalls of hip arthroscopy.

PURPOSE: Injury to the anterolateral ligament (ALL) of the knee has recently received attention as a potential risk factor for failure of anterior cruciate ligament reconstruction. However, evaluation of the anterolateral ligament is currently difficult, and radiologic data are sparse with regard to the normal appearance of this ligament. The purpose of the present study was to determine whether the ALL could be identified and visualized using ultrasonography. METHODS: Ten non-paired, fresh-frozen cadaveric knees underwent ultrasound by an experienced musculoskeletal radiologist using a Siemens S2000 Acuson Ultrasound machine with a 14-MHz linear transducer. After first identifying anatomical landmarks by palpation, a thin band of tissue originating in the vicinity of the fibular collateral ligament (FCL) origin was identified and followed up distally. The tibia was held at 30 degrees of flexion and internally rotated to verify tightening of the structure. Under ultrasound guidance, 25-gauge hypodermic needles were placed at what were sonographically determined to be the origin and insertion points of the ligament. One-tenth of a CC of aniline blue dye was injected. The specimens were then dissected to confirm the presence and location of the ALL. If an ALL was found, distances between the epicentre of the injected dye and the actual origin and insertion points were calculated. Additionally, ligament length based on dissection images and ultrasound images was calculated. RESULTS: Eight of ten specimens had an anterolateral structure that originated from the lateral femoral epicondyle just posterior and superior to the origin of the FCL and inserted on the lateral plateau approximately halfway between Gerdy's tubercle and the fibular head. The average length based on ultrasound was 3.8 cm (+/-.7; range 3.1-4.7) and 4.1 cm (+/-1.1; range 2.6-6.1) based on dissection. Length based on dissection and ultrasound had minimal agreement (ICC = .308; 95 % confidence interval .257-.382, p = .265). The average width of the structure on dissection was .8 cm (+/-.24; range .5-1.2). The mean distance from ultrasound-determined origin and insertion points to anatomical origin and insertion based on dissection was 10.9 mm (+/-2.9, range 7.0-15.8) and 12.5 mm (+/-5.7 range 3.2-19.3), respectively. Inter-observer reliability was excellent for all measurements based on dissection and ultrasound. CONCLUSION: Ultrasound was unable to reliably identify the anterolateral structure from its femoral to tibial attachment sites. Distinguishing it from the posterior IT band and anterolateral capsule was challenging, and it is possible that the structure is a thickened band of fascia rather than a true ligament. As a clinical diagnostic tool, ultrasound likely offers little utility in the evaluation of the ALL for injury. LEVEL OF EVIDENCE: IV.

PURPOSE: Rib fractures are a common chest injury that can typically be treated nonoperatively. However, a percentage of these will go on to nonunion, either because of unique characteristics of the fracture itself or because of a variety of poor healing factors of the host. If a patient has continued symptomology beyond 3 months, surgeons may consider operative management. METHODS: Although isolated resection of fibrous scar tissue from the nonunion site may be sufficient in some cases, it may also be necessary to provide additional structural integrity to the rib depending on the extent of the fracture pattern and resection. This goal can be achieved operatively with rib plating and bone grafting to promote healing. RESULTS: This video demonstrates the use of plating in the treatment of rib nonunion. It begins with relevant background information on rib fractures and nonunions, then details the approach, open reduction and internal fixation of 3 ribs using plates and bone graft aspirate. Pearls and pitfalls are included during the surgical technique aspect of the video to both help guide surgeons new to the procedure and provide potentially advantageous technical details to more experienced surgeons.

PURPOSE: To establish how synovial fluid biomarker concentrations change in patients after anterior cruciate ligament (ACL) tears, with and without associated cartilage injury, with comparisons made to healthy controls. METHODS: Patients were prospectively enrolled between January 2013 and December 2014. Inclusion criteria included any patient undergoing knee arthroscopy. Patients with a confirmed ACL tear were allocated to either the ACL tear with cartilage injury group or the ACL tear without cartilage injury group based on intraoperative assessment. Patients who underwent an arthroscopic procedure with no injury history or symptoms in their contralateral knee were asked to provide samples to serve as healthy controls. These subjects may or may not have been the same ones with noted ACL pathology. The concentrations of 20 biomarkers were determined using a multiplex magnetic bead immunoassay. Biomarker concentrations were then compared between the 3 study groups (ACL tears with and without cartilage injury, and uninjured contralateral knees) using an analysis of variance test with pairwise comparisons. The minimal clinically important difference was calculated based on the standard error of measurement. RESULTS: The study included synovial fluid samples from 134 knees: 34 ACL tears without cartilage injury (mean age 34.0 years), 28 ACL tears with cartilage injury (mean age 36.3 years), and 72 healthy controls (mean age 41.1 years). Analysis of variance testing showed significant differences among groups for matrix metalloproteinase-3 (F = 81.8; P < .001), tissue inhibitor of metalloproteinase (TIMP)-1 (F = 7.9; P