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The aim of this study was to evaluate the mid-term clinical and radiological results of patients who underwent arthroscopic subscapularis (SSC) tendon repair and to address the possible effect of repair technique(single or double row), tear pattern, and concomitant procedures among supraspinatus tears and long head of biceps tendon (LHBT) pathologies on outcomes and failure parameters.45 patients (24 female; mean age = 55.9 years, age range = 37 - 78) who underwent arthroscopic repair of an SSC tear between January 2009 and December 2016 were retrospectively identified and included inthe study. Pre- and postoperative internal rotation strength and shoulder joint range of motion angles were measured. Clinical outcomes were assessed by Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), Constant-Murley, Rotator cuff-quality of life (RC-QoL), and University of California Los Angles (UCLA) scores preoperatively and at the final follow-up.The mean follow-up was 45.2 (range = 36-104) months. 14 patients had isolated SSC tears. The mean preoperative VAS, ASES, Constant-Murley, RC-QoL, and UCLA scores for all patients were respectively 8.6, 21.2, 24, 28.9, and 12. Significant improvement was observed in each clinical outcome at the final follow-up: 0.96, 88.4, 86.4, 90.2, and 32.2, respectively. Improvement in outcome scores was more prominent in patients with Lafosse grade I and II SSC tendon tears repaired by singlerow technique and in patients with concomitant supraspinatus tendon repairs. The mean preoperativeinternal rotation strength according to theOxford scalewas 3.4 (±0.6) / 5 and raised to 4.7 (±0.4) / 5 at the final follow-up (P.001).Although concomitant biceps interventions significantly improved the outcome scores; this improvement was not clinically significant. Failure was only seen in 6 patients with high-grade (Lafosse III or IV) tears.Significant improvement in clinical outcomes and lower failure ratios were more prominent in patients with Lafosse grade I or II tears than grade III or IV. Concomitant biceps interventions made a positivecontribution to the clinical outcome. Early diagnosis and repair seem to be advantageous before low-grade SSC tendon tears turn into high-grade tears.Level IV, Therapeutic Study.

One of the factors affecting the healing of a meniscus repair is the primary stability of the tear. The purpose of this study is to compare single and double vertical loop (SVL vs. DVL) meniscal suture configurations by measuring elongation under cyclic loading and failure properties under ultimate load. We hypothesized that DVL configuration would have superior biomechanical properties than SVL. Twenty-two intact lateral menisci were harvested from patients who required total knee arthroplasty. A 20-mm longitudinal full-thickness cut was made 3 mm from the peripheral rim to simulate a longitudinal tear. Two groups were formed and group randomization was done according to patient age and gender (SVL group: mean age 68.3 years [range, 58–78 years], five males, six females; DVL group: mean age 67.4 years [range, 59–77 years], six males, five females). Cyclic loading was performed between 5 and 30 N at a frequency of 1 Hz for 500 cycles. Then, the meniscus repair construct was loaded until failure. Statistical analysis was performed using the t-test and the Mann–Whitney's U-test. During the early phases of cyclic loading, three specimens from each group failed because of suture pull out and are excluded from the study. At the end of 500 cycles, there was significantly less displacement in the DVL group than the SVL group (6.13 ± 1.04 vs. 9.3 ± 2.59 mm) (p 0.05). All specimens in SVL and five specimens in DVL groups failed in the form of suture pull out from the meniscus tissue. Longitudinal meniscal tears repaired with DVL configuration had less elongation value under cyclic loading compared with SVL configuration. Because of its superior biomechanical properties, it would be more secure to repair large and instable longitudinal meniscal tears by the DVL technique. This is a level II study.

The aim of this study was to assess the proprioception of the partial meniscectomized knee and to assess if there is an effect on the knee proprioception.We performed a case-control study involving patients with meniscus tear at the posterior horn of medial meniscus. Group 1 composed of 19 patients, with an average age of 26.3 years, who were enrolled after sustaining an injury to the medial meniscus. Twenty healthy individuals, with an average age of 25.1, without history of knee injury, constituted Group 2. In order to document the proprioceptive capabilities of the knee, angle reproduction tests were performed.At a mean of 2 years after the surgery, there was no difference between the meniscectomized and healthy knee regarding the angle deviations in the lower flexion angles (15 degrees , 30 degrees , 45 degrees ). However, mean knee joint position sense (KJPS) at 60 degrees reproduction in Group 1 and 2 was 64.3 (SD 5.3) and 69.2 (SD 4.9), respectively. Concomitantly, mean KJPS at 75 degrees reproduction in Group 1 and 2 were 80.1 (SD 6.59) and 74.4 (SD 5.6), respectively. Paired t test showed a statistically significant difference between Group 1 and 2 when compared to control angle deviations at 60 degrees and 75 degrees reproductions (P0.05).KJPS of the patients in meniscectomized group was poorer than the patients in healthy knee group at 60 degrees and 75 degrees knee flexion degrees. Those results indicated that even a partial absence of menisci causes a deterioration of proprioceptive functions of the knee.

Elbow problems in goalkeepers in team hand- ball ''handball goalie's elbow'' is common. The accepted mechanism in the common injuries is hyperextension of the elbow. The purpose of this study was to describe the elbow position at the time of impact of the ball on the hand. This study is based on video-analysis. Fifteen handball goalies (ten females and five males) who had been playing hand- ball for a mean time of 6.5 years were used in the study. The participants were not aware of the details of the study. A national team member attacker performed repetitive shots toward the right side of each goalkeeper. The goal- keepers blocked the ball with their own usual style. Each block was videotaped with three digital cameras (one side view, one superior view, and one frontal view). The cap- tured shots were later evaluated by three analysts as to the elbow position at the time of the impact. Seventy-eight out of 101 shots (77%) were valgus or mostly valgus load producing shots. The remaining 23 (23%) were hyper- extension or mostly hyperextension load producing shots. This study shows that the elbows of the handball goal- keepers experience valgus loads at the time of ball blockade during the penalty shoot-out. A detailed under- standing of the mechanism of the loads on the handball goalkeepers' elbow will help in defining ways to prevent and to treat handball goalie's elbow.

Hoffa fracture associated with ipsilateral femoral shaft fractures is a rare clinical entity. We present a previously unreported multi-trauma case with a unique fracture combination of ipsilateral Hoffa, tibial eminence, femoral shaft and Malgaigne fractures. The Malgaigne fracture was treated non-operatively while the other three fractures were operated with arthroscopic and assisted techniques. Despite the use of minimally invasive techniques, the patient experienced postoperative soft tissue problems. In follow-up, all fractures healed with a good functional outcome. The application of a minimally invasive technique in such a high-energy trauma is crucial for prevention of soft tissue complications., Hoffa kırıklarının femur şaft kırıkları ile birlikte izlenmesi nadir bir klinik tablodur. Bu sunumda, aynı tarafta Hoffa, tibial eminens, femoral şaft ve Malgaigne kırıklarının birlikte izlendiği, literatürde bildirilmemiş nadir bir çoklu travma olgusu sunulmaktadır. Konservatif olarak tedavi edilen Malgaigne kırığı dışında kalan üç farklı kırık artroskopi destekli teknikler kullanılarak tedavi edilmiştir. Minimal invaziv tekniklerin kullanılmasına karşın, olguda yumuşak doku problemleri ile karşılaşılmış, takiplerde tüm kırıklar iyi fonksiyonel sonuçlar ile iyileşmiştir. Yüksek enerjili benzer travma olgularında minimal invaziv tekniklerin uygulanması yumuşak doku komplikasyonlarının engellenmesi açısından büyük önem taşımaktadır.

Tuberculosis may develop in the skeletal system apart from its primary location, the lungs. A 22-year-old male patient presented with complaints of severe pain and swelling in the left knee and difficulty in walking. The symptoms first appeared 12 years before and he underwent open surgical debridement and arthroscopic debridement at two other centers, at which time aspiration cultures taken from the knee yielded no growth. Physical examination showed a painful left knee with swelling, increased temperature, effusion, and limited range of motion. Based on history, physical examination, radiological studies, and laboratory findings, knee osteoarthritis was considered secondary to nonspecific septic arthritis and knee arthrodesis was performed. At surgery, marked destruction of articular cartilage and synovial hypertrophy were observed. In addition, a cavitary lesion was detected, about 1x1 cm in size, in the lateral femoral condyle without articular involvement. Biopsy cultures taken from the lesion showed growth of Mycobacterium tuberculosis in the third week. This enabled a diagnosis of tuberculosis of the knee joint and antituberculous drug therapy was instituted. At six months postoperatively, the patient was on antituberculous treatment and had a painless knee., Tüberküloz, esas tutulum yeri olan akciğerler dışında iskelet sisteminde de görülmektedir. Yirmi iki yaşında erkek hasta, sol dizde şiddetli ağrı, şişlik ve yürümekte güçlük yakınmalarıyla başvurdu. Yakınmaları 12 yıl önce başlayan hastaya daha önce başka merkezlerde açık cerrahi debridman ve artroskopik debridman yapılmış ve dizden alınan aspirasyon kültürlerinde herhangi bir üreme saptanmamıştı. Fizik muayenesinde sol dizde şişlik, ısı artışı ve efüzyon izlenirken, diz ağrılı ve hareket açıklığı sınırlıydı. Öykü, fizik muayene, radyoloji ve laboratuvar sonuçlarına dayanılarak, hastada geçirilmiş non-spesifik septik artrite bağlı diz osteoartiriti düşünüldü ve diz artrodezi uygulandı. Ameliyat sırasında, eklem kıkırdaklarında yaygın destrüksiyon ve sinovyal dokuda belirgin hipertrofi izlendi. Femoral lateral kondilde, ekleme uzanım göstermeyen kaviter yapıda, yaklaşık 1x1 cm büyüklükteki lezyondan alınan biyopsi kültüründe üçüncü haftada Mycobacterium tuberculosis üremesi üzerine hastaya diz eklemi tüberkülozu tanısı kondu ve antitüberküloz ilaç tedavisine başlandı. Ameliyat sonrası altıncı ay kontolü sırasında hastanın antitüberküloz tedavisi devam etmekteydi ve ağrı yakınması tamamen düzelmişti.

Arthroscopic knot tying is an important part of arthroscopic shoulder surgery. The "Pretzel" knot is a new locking slip-knot, which is simple to learn and prepare. It can slide easily to maintain desired tension and can be locked by a simple maneuver.

Purpose: The aim of this study was to predict the hamstring graft sizes prior to anterior cruciate ligament reconstruction surgery in adults by using preoperative magnetic resonance imaging (MRI). Methods: Fifty-one patients with anterior cruciate ligament rupture were prospectively evaluated. Diameter and cross-sectional areas of the gracilis and the semitendinosus tendons at two different levels were measured separately by preoperative MRI. In surgery, harvested gracilis and semitendinosus tendons were measured individually (2-stranded) and together (4-stranded) by using a graft sizing block. Radiological and operative sizes of the grafts were compared by Pearson's correlation test. ROC analysis was done to determine a possible cutoff value for the preoperative measurements. Results: There were statistically significant correlations between the MR cross-sectional areas of gracilis, semitendinosus, gracilis + semitendinosus and intraoperative graft sizes of 2-stranded gracilis, 2-stranded semitendinosus and 4-stranded gracilis + semitendinosus tendons [P < 0. 05]. No significant correlation was observed between the MR diameters of the gracilis, semitendinosus, gracilis + semitendinosus tendons and intraoperative graft sizes of 2-stranded gracilis, 2-stranded semitendinosus and 4-stranded gracilis + semitendinosus tendons [n. s]. Conclusion: Cross-sectional areas of the hamstring tendons in MR images can be used to estimate the sizes of hamstring grafts prior to anterior cruciate ligament reconstruction surgery which may be very helpful to predict possible graft insufficiencies and take precautions if needed. Level of evidence: Level IV. © 2011 Springer-Verlag.

Aim of this paper is to compare the biomechanical properties of the Pretzel knot with the selected arthroscopic knots and to test the mechanical safety of this knot. The hypothesis was that the Pretzel knot may have equal or better mechanical properties than the arthroscopic knots tested in this study.SMC, Giant, Dines, Nicky's, Tennessee Slider knots were chosen for comparison. Original and backed configuration of knots were prepared with no. 2 braided polyester sutures. Cyclic loading and load to failure tests were performed. Parameters tested were loop security, maximum elongation and load at failure. Number of steps needed for preparation of each knot was also recorded. One-way ANOVA for repeated measures was performed for all knots.Steps needed for preparation were 2 for Pretzel and Tennessee Slider, 3 for Nicky's, SMC and Dines and 4 for Giant. The Pretzel knot in original configuration had significantly better loop security compared to SMC, Dines, Nicky's and Tennessee knots (P = 0.01). Loads at failure were not significantly different between knots in their original configurations. Giant and Dines knots showed better maximum elongations in cyclic loading (P = 0.0059) and load to failure tests (P = 0.0001). Backing up the knots with 3-RHAPs eliminated most of these significant differences.Clinically, simplicity and safety are two important components in arthroscopic knot tying. Despite its simple configuration, Pretzel knot has some similar and increased mechanical properties compared to the tested knots that are widely used.

The goals of the present study were (1) to measure the previously unstudied isometric forces of activated human Gracilis (G) muscle as a function of knee joint angle and (2) to test whether length history effects are important also for human muscle. Experiments were conducted intraoperatively during anterior cruciate ligament (ACL) reconstruction surgery (n = 8). Mean peak G muscle force, mean peak G tendon stress and mean optimal knee angle equals 178.5 +/- 270.3 N, 24.4 +/- 20.6 MPa and 67.5 +/- 41.7 degrees, respectively. The substantial inter-subject variability found (e.g., peak G force ranges between 17.2 and 490.5 N) indicate that the contribution of the G muscle to knee flexion moment may vary considerably among subjects. Moreover, typical subject anthropometrics did not appear to provide a sound estimate of the peak G force: only a limited insignificant correlation was found between peak G force and subject mass as well as mid-thigh perimeter and no correlation was found between peak G force and thigh length. The functional joint range of motion for human G muscle was determined to be at least as wide as full knee extension to 120 degrees of knee flexion. However: the portion of the knee angle-muscle force relationship operationalized is not unique but individual specific: our data suggest for most subjects that G muscle operates in both ascending and descending limbs of its length-force characteristics whereas, for the remainder of the subjects, its function is limited to the descending limb, exclusively. Previous activity of G muscle at high muscle length attained during collection of a complete set of knee angle-force data showed for the first time that such length history effects are important also for human muscles: a significant correlation was found between optimal knee angle and absolute value of % force change. Except for two of the subjects, G muscle force measured at low length was lower than that measured during collection of knee joint-force data (maximally by 42.3%). (C) 2010 Elsevier Ltd. All rights reserved.

Aim of this study is to introduce, evaluate, and propose a basic arthroscopy training course with interactive methods as using bovine knees, joint models but mainly focusing on practices with motor skill-learning devices. This study presents the results of a skill training program which is based on “motor skill training” theory and using “bovine knees” to simulate a specific task as arthroscopy both in education and evaluation. The participants gave feedback regarding their expectations, fulfillment, and self-evaluation on the degree of their improvement levels, after which their skills were evaluated by an expert while they performed the arthroscopic procedure. During this evaluation of the task, a four-dimensional checklist which was prepared previously by the consensus of three experts was used, and a global grading of each rater was added at the end of the checklist. In this 2-day course, small group teaching sessions are integrated with active and experiential learning methods consisting of short presentations by the educators, demonstrations using joint models and audio-visual teaching material, and significant continuous feedback by the teachers during the proceedings. Participants’ expectations and post-course feedback results were obtained using a brief questionnaire which involved mostly open-ended questions. The self-rating of “own basic diagnostic arthroscopy skill” on a scale of 0–10 was completed by the participants both previous to and following the course to establish a student-centered learning environment. Overall rating of the course was asked on a 1–5 (poor–excellent) Likert scale. The questioning of the participants who took part in the course during the last five terms involved a 100% feedback. The overall rating of the course was 4.36 ± 0.47 on the 1–5 scale. The majority of the participants (90%) mentioned that the course met their expectations. The most beneficial activities were accepted to be the arthroscopic procedure applications on bovine knee, repetition of the manipulations under the supervision of the trainers, continuous feedback by experienced staff, and chance for immediate correction during the procedures (35/64). Pre- and post-course self-ratings of the participants inquiring about their ability to perform an arthroscopy alone showed significant improvement (4.2 vs. 7.7 P = 0.000, paired samples t test). All participants were found to be competent in the evaluation of their diagnostic arthroscopy skills on bovine knees. To design a skill teaching course based on the needs of the trainees, focusing on basic motor skill training exercises, and using bovine knee as a simulator is a safe, inexpensive, humanistic, and replicable method that proves a foundation for basic arthroscopic skills learning prior to patient encounter.

Objectives: One of the methods in motor skill teaching is to furnish the students with the individual skills drawn from the target procedure. This method requires identification and defining of all components of the target procedure. This study aimed to define basic motor skills composing arthroscopic skillfulness.Methods: A total of 42 orthopedists (mean age 38±8 years) were enrolled. The study group was comprised of 17 experienced orthopedists working at least for 10 years as a specialist and performing more than 50 arthroscopic procedures per year. The control group included 25 young orthopedists or residents having an arthroscopic experience of less than three years. All the participants were assessed simultaneously and in the same experimental setting. Each participant was tested after having been shown to use in vitro skill development instruments simulating arthroscopic basic motor skills.Results: Compared to the control group, the experienced group had significantly higher mean age (42 vs. 34.4 years), longer duration of arthroscopic experience (12.4 vs. 1.6 years), and greater number of the arthroscopies performed per year (93.9 vs. 26.9) (p=0.000). The mean anticipation time (p=0.028) and two-arm coordination time (p=0.043) were significantly shorter in the experienced group. In correlation analysis, duration of arthroscopic experience was correlated with the mean anticipation time (r=-0.41, p=0.008) and twoarm coordination time (r=-0.33, p=0.033). In addition, the mean anticipation time decreased significantly as the number of arthroscopies increased (r=-0.446, p=0.003).Conclusion: Some basic motor skills correlate with arthroscopic competence. The use of these motor skill instruments in arthroscopy training may aid to improve arthroscopic skills., Amaç: Motor beceri eğitimi içerisinde yer alan yöntemlerden biri, hedef işlemi oluşturan bireysel becerileri öğrenciye ayrı ayrı öğretmektir. Bu eğitim yöntemi hedef işlemin parçalarının tanımlanmasını gerektirir. Bu çalışmada, artroskopik girişimi oluşturan temel motor becerilerin tanımlanması amaçlandı.Çalışma planı: Çalışmaya toplam 42 ortopedist (ort. yaş 38±8) katıldı. Çalışma grubuna, en az 10 yıldır uzman olarak çalışmakta olan ve yıllık artroskopi sayıları 50’nin üzerinde olan 17 deneyimli ortopedist; kontrol grubuna ise deneyimi üç yıldan daha az olan 25 genç ortopedist ve asistan alındı. Tüm katılımcılar aynı zamanda ve aynı eğitim ortamında değerlendirildi. Laboratuvar ortamında, temel motor becerileri simüle eden aletler her katılımcıya tek tek tanıtıldı ve her katılımcının asıl değerlendirme öncesinde bir kez deneme yaparak işlemi tanıması sağlandı. Sonuçlar: Deneyimli grupta, kontrol grubuna göre ortalama yaş (42 ve 34.4), artroskopi deneyimi süresi (12.4 ve 1.6 yıl) ve yıllık ortalama artroskopi sayısı (93.9 ve 26.9) anlamlı derecede fazla bulundu (p=0.000). Deneyimli grupta, ortalama önceleme zamanı (p=0.028) ve iki kol koordinasyon zamanı (p=0.043) anlamlı derecede kısaydı. Korelasyon analizinde, artroskopi deneyim süresi ile ortalama önceleme zamanı (r=-0.41, p=0.008) ve iki kol koordinasyon zamanı (r=-0.33, p=0.033) arasında anlamlı ilişki saptandı. Yapılan artroskopi sayısı arttıkça ortalama önceleme zamanı anlamlı olarak kısalmaktaydı (r=-0.446, p=0.003). Çıkarımlar: Bazı temel motor beceriler artroskopik beceriklilik ile ilişkilidir. Motor becerileri geliştiren bu araçların artroskopi eğitiminde kullanılmasının artroskopik beceri geliştirilmesini kolaylaştıracağı söylenebilir.

Congenital absence of the anterior cruciate ligament (ACL) is a very rare anomaly. It is usually diagnosed during arthroscopic intervention. We presented a 15-year old male patient whose diagnosis was based on findings of physical examination and magnetic resonance imaging. Congenital absence of the ACL was associated with femoral shortening, dysplasia of the tibial intercondylar eminence, valgus knee, and compensatory scoliosis. Since the patient had no instability symptoms, and due to the presence of a negative pivot-shift test and multiple congenital anomalies, surgical treatment was not considered., Ön çapraz bağın (ÖÇB) doğuştan agenezisi nadir rastlanan bir durumdur. Tanısı genellikle artroskopi sırasında fark edilerek konmaktadır. Bu yazıda, tanısı fizik muayene ve manyetik rezonans görüntüleme ile konan 15 yaşında bir erkek hasta sunuldu. Hastada doğuştan ÖÇB agenezisine ek olarak, femur boyunda kısalık, tibial interkondiler eminenste displazi, dizde valgus ve omurgada kompansatuvar skolyoz vardı. Hastanın diziyle ilgili hiçbir instabilite şikayetinin bulunmaması, pivot-shift testinin negatif olması ve çoklu doğuştan anomaliler bulunması nedeniyle ameliyat düşünülmedi.

Dislocation of the os trigonum presenting as a loose body is a rare clinical entity. In this report, we describe the case of a 34-year-old male who presented with symptoms of acute left ankle pain that was aggravated by motion and weight bearing. He also displayed lateral collateral ligamentous laxity, without the presence of an effusion. Radiographic inspection revealed a 10 × 15-mm loose body within the ankle joint cavity. Arthroscopic intervention showed the loose body to be round and smooth, and it could not be deformed with the tip of a probe, although it could be displaced up to 5 mm with ankle manipulation, in particular with inversion stress of the ankle. The loose body was removed with an arthroscopic forceps. Based on its location within the ankle, and the lack of any articular cartilage on the removed joint fragment, we determined the loose body to represent a dislocated os trigonum. The rarity of this case presentation makes one consider the association of symptomatic os trigonum with ankle instability. Level of Clinical Evidence: 4

Superior excursion of the humeral head on the face of the glenoid was investigated to determine whether a relationship exists between the degree of humeral head excursion and the identity of the injured tendon in a shoulder with a torn rotator cuff. Twenty-seven patients with unilateral full-thickness rotator cuff tears diagnosed by either positive arthrogram or magnetic resonance imaging were included in this study. Three groups were formed based on intraoperative findings: 10 patients had isolated supraspinatus tendon tears (group 1), 11 patients had supraspinatus and infraspinatus tears (group 2), and 6 patients had supraspinatus, infraspinatus, and subscapularis tendon tears (group 3). There was no statistically significant difference between the degree of humeral head excursion in groups 1 and 2. However, patients in group 3 had a statistically significantly higher degree of excursion of the humeral head (P.05) when compared with groups 1 and 2. In addition, an inverse relationship between the degree of humeral head excursion and preoperative Constant scores was found. Superior excursion of the humeral head on the glenoid had a significantly higher incidence in patients with subscapularis tears, and a larger amount of excursion was present in patients who had lower preoperative Constant scores.