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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.

Background Simultaneous repairs of rotator cuff and biceps tenodesis can be managed by tenodesis of long head of biceps tendon to a subpectoral or suprapectoral area. This review investigated long head of biceps tendon tenodesis with concomitant rotator cuff repair and evaluated the clinical outcomes and incidences of complications based on tenodesis location. Methods Medline, Cochrane, and Embase databases were searched for published, randomized or nonrandomized controlled studies and prospective or retrospective case series with the phrases “suprapectoral,” “subpectoral,” “tenodesis,” and “long head of biceps tendon”. Those with a clinical evidence Level IV or higher were included. Non-English manuscripts, review articles, commentaries, letters, case reports, and sole long head of biceps tendon tenodesis articles were excluded. Results From 481 studies, 13 were chosen. In total, 1194 subpectoral and 2520 suprapectoral tenodesis cases were investigated. Postoperative Constant-Murley and American Shoulder and Elbow Surgeons mean scores showed similar good results. In terms of complication incidences, while transient nerve injuries were more commonly seen in patients with subpectoral tenodesis, persistent bicipital pain and Popeye deformity are mostly seen in patients with suprapectoral tenodesis. Discussion Biceps tenodesis to suprapectoral or subpectoral area with concomitant rotator cuff repair demonstrated similar outcomes. Popeye deformity and persistent bicipital pain were higher in suprapectoral area and transient neuropraxia was found to be higher in subpectoral area. Level of evidence: IV.

Reverse shoulder arthroplasty (RSA) has been a great aide to the orthopedic surgeons for cuff tear arthropathies. RSAs should have a good biomechanical baseline; otherwise it may lead to some complications. First, the lack of rotator cuff muscles may predispose to instability. Next, stress on the deltoid from lateralization and/or distalization may lead to acromial fractures or deltoid insufficiency. Furthermore, changing the center of rotation may result in impingement between prosthesis and osseous structures. The purpose of this chapter is to define the biomechanics of failure of RSA in patients with cuff tear arthropathies.

Anterior cruciate ligament (ACL) reconstruction in most cases is an elective surgery with many potential complications. Early (non-emergent) surgery may increase the risk of certain complications including significant postoperative stiffness with loss of motion. Delaying surgery by a few weeks to allow the acutely injured knee to regain motion and gain quad control decreases the risk for these adverse effects. However, delayed ACL reconstruction with the intent of returning to normal activities months after the initial injury may lead to an increased risk of injury to cartilage and menisci. By choosing a delayed surgical treatment pathway, we are not intending to return the patient to sports; rather, we plan to get them through the acute inflammatory phase prior to reconstruction. We know by experience and by numerous well-designed studies that returning a patient with a potentially unstable knee to at risk activities including sports and certain occupations can lead to further injuries with irreversible damage.

The purpose of this study was to investigate the effect of Mitomycin C on reduction in intra-articular fibrotic adhesion formation after knee surgery. Twenty female Wistar Albino rats were divided into two equal study groups. After skin incision, the right knees of animals were opened through a medial parapatellar approach, and the medial and lateral sides of the femoral condyle were exposed. A partial capsulotomy and synovectomy were performed. In group I, Mitomycin C was applied in the articular cavity of rats after hemostasis. An identical volume of sterile normal saline was applied in group II, which served as controls. All rats received weekly (6 weeks) intra-articular both Mitomycin C and saline starting from the day of operation. Animals were killed at 45 days after surgery. The presence and severity of osteo-capsular adhesion was assessed with both macroscopic and microscopic adhesion scoring systems. Results of macroscopic observations showed a significant reduction in both incidence and severity of adhesions in group I compared to group II. Histologically, adhesions in group I were thinner with less collagenic fibers. Microscopic determination of adhesion formation was less in group I, and the difference between groups was statistically significant. Our results suggest that post-operative administration of Mitomycin C may be considered a promising preventive therapy for the reduction in fibro-adhesive scars and consequent stiffness after knee surgery.

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.

Sensorimotor relates to activity involving both sensory and motor pathways of the nerves (Oxford English Dictionary 2014).

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.

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.

Anterior shoulder instability; which is the most common type of all shoulder instabilities, needs to be evaluated carefully to achieve good prognosis. Every case should be evaluated by its own and proper treatment options should be planned according to this. Anatomy and biomechanics of the shoulder joint, especially the knowledge about the static and the dynamic factors are so important. In addition to the instability terminology; hyperlaxity which is a physiological condition should be mastered as well. For the proper treatment; correct diagnosis and the addressing of the involved pathology are two main points. Good history with proper physical examination and radiology are the crucial steps for the diagnosis. Acute anterior shoulder luxation with the first episode has totally a different treatment algorithm than recurrent anterior shoulder instability. The incidence of re-dislocation after the first episode is between 30% and 100%.; and the risk of re-dislocation will be higher if the first episode is at the age of 20 or below. The activity level is also important; especially patients with contact sports are in great risk. Generally our approach to acute anterior dislocation is conservative, but in recurrent anterior instability cases the aim of surgical treatment is to have anatomical reconstruction of the pathological lesion which is the fixation of capsulolabral tissue on the glenoid. Bony lesions, which might be the main reason of the failure should be evaluated carefully.

This animal model was designed to evaluate the effect of intra-articular iron-chelator treatment in the prevention of blood-induced joint disease.Thirty domestic male rabbits were divided into three equal groups. One milliliter of homologous blood was injected into the left knee of each rabbit in groups 1 and 2. In the second group, 0.1 ml desferroxamine mesilate (DM) was also injected to the blood. In group 3, the animals received injections of 0.1 DM which was mixed with equal amounts of sterile saline solution. The joints were injected three times each week for 12 weeks. At the end of 12 weeks, the knee joints of each rabbit were examined.The synovium in group 1 was found statistically significantly thicker than in group 2. Obvious erosion and ulceration of the cartilage were seen in all joints in group 1 and absent in group 2. Iron-chelator treatment reduced the formation of blood-induced joint damage in rabbit knees by inhibiting the iron-catalyzed formation of destructive oxygen metabolites that has an effect on joint cartilage and synovium.

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.

Detachment of the deltoid muscle and tendon is a rare complication that is reported to result in poor outcome after rotator cuff surgery. We performed a delayed primary repair of the detached deltoid in a 53-year-old female patient who underwent an open acromioplasty procedure. A successful result was achieved after surgical restoration of the deltoid muscle origin back to the acromion. At 25 months' follow-up the patient had recovered almost the full range of motion of the glenohumeral joint and was free of pain. Due to lack of literature on this rare condition, there are no well-defined treatment principles for the management of deltoid muscle detachments that develop as a complication of rotator cuff surgery. This paper describes a repair procedure for the management of deltoid muscle detachments. In addition, it discusses the importance of the guidelines that have to be followed during primary rotator cuff surgery.