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A 30 degrees arthroscope is introduced via the posterior soft spot portal, and an anterosuperior portal is created with the use of a 7-mm disposable cannula. The anterosuperior portal is used for instrumentation. An 18-gauge spinal needle is passed via the portal of Neviaser and the rotator cuff into arthroscopic view above the superior labrum. A No. 1 polydioxanone suture (PDS; Ethicon, Somerville, NJ) is advanced through the spinal needle. An arthroscopic retriever or meniscal clamp is used to retrieve the free end of the suture and bring it out through a small anterior stab wound. A suture anchor is inserted via the anterosuperior portal into the superior neck of the glenoid. The more medial limb of the No. 2 Ethibond suture (Ethicon) from the suture anchor is retrieved with the inferior limb of the No. 1 PDS suture, and both are brought out through the anterosuperior cannula. The opposite end of the No. 1 PDS suture is then manually pulled, while, under direct arthroscopic visualization, the No. 2 Ethibond suture, now tied to the opposite end of the PDS, is pulled through the superior labral tissue. That anchor suture is retrieved and is placed outside the cannula that contains the other anchor suture. Standard arthroscopic knot tying is then employed.

Darren L. Johnson and Scott D. Mair, editors. Philadelphia: Mosby-Elsevier; 2006. 764 pages. $149.00. The book is a winner. The organization is superb, particularly with the color-coded sections dividing the sub-topics, making it wonderfully easy to use as …

A variety of factors contribute to the failure of primary anterior cruciate ligament (ACL) reconstruction; most commonly, it is technical error related to tunnel placement. Recently, the increasing popularity of the all-endoscopic ACL reconstruction and concern about graft impingement may have led to more posterior placement of the tibial tunnel by surgeons. Working through a tibial tunnel placed too posterior makes it more difficult to recognize the correct starting position on the femur, and more likely to start the femoral tunnel in a central 12 o'clock position. The combination of subtle posterior placement of the tibial tunnel and central placement of the femoral tunnel results in a graft that is malpositioned in both the sagittal and coronal planes—a "vertical graft." We present a novel method of ACL revision surgery applicable to a specific subset of ACL revision patients with an intact "vertical graft" and instability that is rotational more than translational. In these patients, a double-bundle revision ACL augmentation technique can be used, leaving the original graft in place. A new tibial tunnel is placed anterior to the original and a new femoral tunnel lateral to the original. Reconstruction is performed with allograft and the combined ACL construct provides robust translational and rotational stability to the tibiofemoral joint.

Fifteen patients noted at surgery to have an isolated defect in the rotator interval and no other pathologic abnormality underwent closure of the defect as an iso lated procedure for recurrent instability symptoms. In traoperative assessment of each of these shoulders after the closure demonstrated adequate stability, and no other stabilization procedures were performed. The average age of the patients was 24 years, and 10 of the 15 patients were women. Examination under anesthe sia revealed increased inferior translation in all patients, as illustrated by at least a 1 + sulcus sign. The rotator interval defect averaged 2.75 cm in width and 2.3 cm in height. The rotator interval defect edges were fresh ened and approximated (nine patients) or imbricated (six patients), depending on the anterior capsular laxity and the degree of glenohumeral joint translation pos sible. Followup averaged 3.3 years (range, 2.2 to 5.3), and all patients achieved either a good or excellent re sult using the American Shoulder and Elbow Surgeons evaluation scale and the Rowe rating scale. Although most patients with a defect in the rotator interval require a standard stabilization procedure as a supplement to closure of the defect, approximation or imbrication of the defect as an initial step at surgery may confer adequate stability in selected patients and obviate the need for formal capsular advancement.

We evaluated the use of the beach-chair, or sitting, position for arthroscopic shoulder surgery in 50 consecutive patients. Routine arthroscopy, arthroscopic subacromial decompression, and arthroscopic shoulder stabilizations were performed, with no complications. The advantages of this position include ease of setup, lack of brachial plexus strain because no traction is used, excellent intraarticular visualization for all types of arthroscopic shoulder procedures, and ease of conversion to the open approach if needed. The positioning technique is described.

Thirty-two patients (64 hips) in whom avascular necrosis (AVN) of the femoral heads was highly suspected clinically were studied by magnetic resonance (MR) imaging, radionuclide bone scintigraphy, and conventional radiography. MR studies were positive for AVN in 37 hips, compared with 30 positive scintigraphic studies. In all cases in which scintigraphy and radiography were positive, MR imaging demonstrated decreased signal from the affected femoral heads, indicative of bone marrow disease. Imaging results were confirmed by biopsy or subsequent imaging appearances. In patients with negative initial scintigraphic and radiographic studies, the MR imaging criterion for a positive study was a moderately decreased bone marrow signal displaying segmental patterns within an otherwise normal-appearing femoral head on relatively T1-weighted images. In this series of high-risk patients, radionuclide scintigraphy had a sensitivity of 81%, compared with 100% for MR imaging. MR imaging should be the imaging modality of choice for early evaluation of bone marrow changes indicative of AVN.

Fourteen patients with severe angular knee deformities (range, 30 degrees varus to 35 degrees valgus) had total knee arthroplasty using autogenous bone graft to the tibia. Twelve knees had osteoarthritis, one rheumatoid arthritis, and one gouty arthritis. The preoperative knee motion averaged -5 degrees of extension to 80 degrees of flexion and the average motion arc was 70 degrees. All tibial defects were greater than 25% of the tibial component support surface and more than 10 mm deep. Twelve knees were reconstructed with Insall-Burstein posterior stabilized total condylar knee implants and two knees, with severe preoperative ligamentous instability, with the constrained Total Condylar III implant. Postoperative rehabilitation was routine, and weight bearing was begun, on average, on the third postoperative day. The follow-up period averaged 4.1 years (range, 2-7.3 years). Radiographic analysis revealed no change in knee or component alignment compared with immediate postoperative position. All grafts consolidated without evidence of collapse, resorption, or prosthetic subsidence. All patients had good or excellent clinical results (Hospital for Special Surgery Knee Rating Scale). The average postoperative arc of motion was 90 degrees. There were no infections and no need for implant removal. The technique developed by the senior author (T.P.S.) utilizes bone resected from the distal femur during knee arthroplasty. An oblique planar cancellous surface is created on the recipient side, and coaptation of cancellous distal femoral graft surface to this recipient bed is ensured by vitallium screw fixation. The proximal tibia is reconstituted by the graft, and subchondral femoral bone after shaping of the graft forms the tibial periphery.