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Purpose: To validate the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function computer adaptive test (PF CAT) with current patient-reported outcome (PRO) instruments in patients with cartilage injuries of the knee., Methods: Patients scheduled for osteochondral autograft or allograft transplant, microfracture, autologous chondrocyte implantation, allograft cartilage resurfacing, and chondroplasty were prospectively enrolled in the study and completed PROMIS PF CAT, Knee Injury and Osteoarthritis Outcome Score (KOOS activities of daily living, pain, symptoms, sport, and quality of life), Short Form-36 Health Survey (SF-36 physical function [PF] and Physical Component Summary), and EuroQol-5 Dimension questionnaires. The Spearman correlation coefficient was used to compare instruments. Instrument correlations were defined as excellent (>0.7), excellent to good (0.61-0.69), good (0.4 to 0.6), and poor (<0.39), with significance defined as P < .05., Results: A total of 293 knees in 275 patients (54.5% male) undergoing 319 cartilage procedures were analyzed. The most commonly performed cartilage procedure was chondroplasty (n = 118; 37.0%), followed by microfracture (n = 100; 31.3%). The mean age was 34.0 ± 14.7 and the mean body mass index was 30.0 ± 6.9. The PROMIS PF CAT had an excellent correlation with the SF-36 PF (r = 0.819; P < .001), SF-36 Physical Component Summary (r = 0.766; P < .001), KOOS activities of daily living (r = 0.733; P < .001), KOOS Sport (r = 0.709; P < .001), and EuroQol-5 Dimension (r = 0.752; P < .001) instruments; an excellent-good correlation with the KOOS pain (r = 0.662; P < .001), and KOOS quality of life (r = 0.640; P < .001) scores; and a good correlation with the KOOS symptoms (r = 0.519; P < .001) scale. The PROMIS PF CAT had no floor or ceiling effects and the smallest question burden (mean 4.17 ± 0.93 questions). Dimensionality analyses demonstrated that the smallest amount of unexplained variance was present in the PROMIS PF CAT (3.6%)., Conclusion: The PROMIS PF CAT is an effective tool for preoperative outcome assessment in patients with cartilage defects of the knee. It correlates strongly with legacy PRO measures of physical function with no ceiling and floor effects and a minimal time burden for completion. Further study is warranted to determine postoperative performance and to evaluate the responsiveness of PROMIS to change within a patient., Level of Evidence: III; Prognostic retrospective comparative study., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze the complications of arthroscopic heterotopic ossification (HO) excision and compare them with those of open removal of HO or a combined open-arthroscopic approach., Methods: We performed a retrospective review of elbow HO removal cases performed by a single surgeon from 1997 to 2014. In all cases studied, the intention was to restore range of motion owing to the presence of HO causing functional impairment. The arthroscopic, open, and combined treatment groups were compared., Results: The study cohort consisted of 223 surgical procedures performed on 213 elbows in 211 patients. Fifty major complications occurred in 46 cases (21%): 17 hematomas (8%) treated by irrigation and debridement, 8 cases of HO requiring reoperation (4%), 7 deep infections (3%), 4 contractures (2%), 3 cases of delayed-onset ulnar neuritis (1%), 2 cases of distal humeral avascular necrosis (1%), 2 tendon ruptures (1%), 2 cases of instability requiring reconstruction (1%), 2 postoperative fractures (1%), 1 intraoperative fracture (<0.5%), 1 case of worsening of pre-existing neuropathic pain (<0.5%), and 1 permanent partial posterior interosseous nerve injury (<0.5%). Of these 46 cases, the major complications occurred in 6 of the 41 (15%) performed arthroscopically, in 36 of the 158 (23%) performed open and in 4 of the 21 (17%) with combined (i.e. open + arthroscopic) HO removal. Preventive strategies, introduced to prevent hematomas and delayed-onset ulnar neuritis, reduced the rate of major complications from 35% during the period from 1997 to 2005 to 10% during the period from 2006 to 2014 (P < .0001). Moreover, the rate of reoperations was reduced from 34% to 10% in the same periods (P < .0001). Minor complications occurred in 36 cases (16%), including 17 cases of transient nerve palsy, 9 cases of superficial infection or delayed wound healing, 6 cases of mild instability, and 4 cases of hematoma resolved by aspiration., Conclusions: The use of arthroscopy-or a combination of arthroscopic and open techniques-to remove HO around the elbow by a surgeon skilled in both arthroscopic and open elbow surgery does not increase the risk of major complications or need for reoperation compared with traditional open surgery. Preventive strategies, such as avoiding raising skin flaps by using multiple separate incisions for open and prophylactic ulnar nerve decompression in arthroscopic cases, were developed during the study period. These strategies were monitored prospectively and found to be effective in preventing two-thirds of the major complications needing reoperation with both open and arthroscopic HO removal., Level of Evidence: Level III, retrospective comparative study of prospectively collected data., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the relationship between the intraoperative monitoring factors with intra-abdominal fluid extravasation (IAFE) in patients who underwent hip arthroscopy. The secondary purpose was to describe the main intraoperative variables between cases with and without IAFE., Methods: We carried out a prospective observational study of 106 hip arthroscopies between June 2017 and June 2018. Within procedures, 54 cases with deep gluteal syndrome (DGS) were included. Ultrasonography was performed by a trained anesthesiologist before and after the surgery to identify the presence of fluid. The hepatorenal (Morison's pouch), splenorenal, retroaortic, suprapubic (longitudinal and transverse), and pleural spaces were examined. During the surgery, the blood pressure, heart rate, temperature, peak inspiratory pressure (PIP), pulmonary compliance, oxygen saturation, and end-tidal carbon dioxide were registered., Results: The incidence of IAFE was 31.1% (33/106; 95% confidence interval 23.0%-40.5%). IAFE in cases with isolated FAI was 15.9% (7/44) in comparison with 52.9% (9/17) of the cases with isolated DGS. Maximum values of PIP greater than 20 mm Hg were associated with fluid extravasation (odds ratio 3.22; 95% confidence interval 1.07-9.68). No statistically significant relationship was found in blood pressure, heart rate, temperature, oxygen saturation, end-tidal carbon dioxide, and pulmonary compliance between cases with and without IAFE., Conclusions: Asymptomatic IAFE, as measured by ultrasound, is a frequent event in patients who underwent hip arthroscopy, mainly in cases with DGS. PIP was found to be a useful intraoperative monitoring parameter for the early identification of IAFE in hip arthroscopy., Level of Evidence: Level II, observational prospective cohort study., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: This review explores the current literature regarding both the clinical indications and utility of minimally invasive in-office needle arthroscopy (IONA) relative to conventional imaging modalities., Methods: In compliance with R-AMSTAR (Revised Assessment of Multiple Systematic Reviews) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, 3 databases (MEDLINE, Embase, and PubMed) were searched in July 2018, in addition to the conference abstract databases of 5 prominent meetings between 2013 and 2018, for studies using IONA for diagnostic purposes. Study quality was assessed with the Methodological Index for Non-Randomized Studies (MINORS) criteria., Results: Among 932 conference abstracts and 369 studies identified, 11 publications involving 404 patients (395 knees and 9 shoulders) were included, with 9 clinical studies and 2 cost analyses. The median Methodological Index for Non-Randomized Studies (MINORS) score was 9 for noncomparative and 23 for comparative studies. Among the 9 clinical studies, IONA had a superior sensitivity, specificity, positive predictive value, and negative predictive value to magnetic resonance imaging (MRI) in the evaluation of knee osteoarthritis, anterior cruciate ligament insufficiency, and meniscal tears. IONA was comparable or inferior to MRI in the same parameters for the diagnosis of osteochondral defects and rotator cuff tears. In the 2 cost analyses, IONA had lower costs when used in place of MRI for treatment algorithms involving medial meniscal tears and rotator cuff tears but not lateral meniscal tears., Conclusions: IONA holds potential for cost savings and improved diagnostic accuracy relative to MRI, primarily for intra-articular meniscal, ligamentous, and chondral defects of the knee. However, its current indications for use in other joints are limited to rotator cuff tears in the shoulder, making its diagnostic value in other joints much more limited. The current quality and breadth of evidence are significantly lacking, with numerous practical shortcomings. To improve acceptance of IONA, priority should be placed on establishing defined protocols, indications, contraindications, and patient perspectives for the procedure., Level of Evidence: Level IV, systematic review of Level II, III, and IV studies., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To accurately evaluate the effects of bone marrow aspirate (BMA) augmentation on osteochondral allograft (OCA) integration on early postoperative magnetic resonance imaging (MRI) using the comprehensive Osteochondral Allograft MRI Scoring System (OCAMRISS)., Methods: This imaging study compared patients who underwent OCA transplantation with and without BMA augmentation for the treatment of focal osteochondral defects in the knee performed by a single surgeon between July 2013 and July 2017. Patients were excluded if they underwent implantation of premade plugs, had an overlapping OCA configuration ("snowman" technique), or did not undergo MRI at 6 months postoperatively. Patients were matched by lesion location, lesion size, age, and body mass index, as well as whether they underwent previous surgical procedures. Data were analyzed using descriptive statistics, Spearman correlation, the independent t test, the Mann-Whitney U test, and the χ 2 test., Results: A total of 58 patients (29 per group) were included in this study, with an average age of 36.4 ± 10.1 years and mean body mass index of 28.6 ± 5.1. The mean size of the analyzed OCA plugs was 3.3 ± 1 cm 2 . At an average imaging follow-up of 5.6 ± 1 months, 86.2% of the grafts had achieved osseous integration at the graft-host junction and 75.9% did not show any cystic changes in the subchondral bone. No difference in any OCAMRISS subscale was seen comparing OCAs with and without BMA augmentation (P > .05). Specifically, osseous integration and subchondral cyst formation were comparable between groups (P = .128 and P = .539, respectively)., Conclusions: OCAs showed excellent osseous integration at the graft-host junction on 6-month postoperative MRI. The treatment of OCAs with autogenous BMA did not result in superior imaging outcomes when analyzed using the OCAMRISS., Level of Evidence: Level III, case-control study., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare clinical and radiologic outcomes and complication rates of the arthroscopic wafer procedure (AWP) and ulnar shortening osteotomy (USO) for idiopathic ulnar impaction syndrome (UIS)., Methods: From May 2009 to June 2014, 42 patients who were aged 45 years or older with idiopathic UIS underwent either the AWP or USO under the following identical surgical indications: (1) less than 4 mm of positive ulnar variance, (2) Palmer classification 2C or 2D lesion of the triangular fibrocartilage complex, (3) stable distal radioulnar joint (DRUJ) and/or lunotriquetral joint, and (4) no evidence of osteoarthritis of the DRUJ or ulnocarpal joint. The patient assignment was not randomized. Were used a visual analog scale for ulnar wrist pain; grip strength; range of motion; the Mayo Wrist Score (MWS); and the Disabilities of the Arm, Shoulder and Hand (DASH) score at 3, 6, 12, and 24 months after surgery to compare clinical outcomes. Ulnar variance, cystic changes of the lunate and triquetrum, and DRUJ arthritis on radiographs and operation-related complications were compared., Results: This study evaluated 19 patients after the AWP and 23 patients after USO. At 3 months, the AWP produced significantly better outcomes than USO regarding grip strength (79.6% ± 14.3% vs 62.7% ± 12.6%, P < .001), MWS (81.8 ± 7.9 points vs 71.3 ± 14.2 points, P = .005), and DASH score (19.4 ± 8.4 vs 31.5 ± 14.0, P = .001); clinical outcomes were similar at 6, 12, and 24 months. The complication rates were 34.8% for USO and 10.5% for the AWP; complications included DRUJ arthritis (n = 4), implant irritation (n = 6), and refracture after implant removal (n = 2) in the USO group and secondary surgery (n = 1) and tendinopathy (n = 1) in the AWP group., Conclusions: The AWP and USO for idiopathic UIS with subtle positive ulnar variance achieved similar clinical and radiologic outcomes at 2 years after surgery. However, compared with USO, the AWP showed lower complication rates and better grip strength, MWS values, and DASH scores at 3 months after surgery., Level of Evidence: Level III, comparative trial., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To establish the accuracy of the long-stride walking (LSW) and ischiofemoral impingement (IFI) tests for diagnosing IFI in patients whose primary symptom is posterior hip pain., Methods: Confirmed IFI cases and cases in which IFI had been ruled out were identified considering imaging, injections, and endoscopic assessment, combined with pain relief and negative IFI-specific tests after treatment. Demographic data, duration of symptoms, pain location, ischiofemoral space, quadratus femoris space, quadratus femoris edema, surgical findings, and visual analog scale score for pain before and after treatment were computed for all patients included in this study. Sensitivity, specificity, predictive values, likelihood ratios, and diagnostic odds ratios were computed individually for the LSW test and IFI test., Results: Cases from 1,166 consecutive hip operations and charts from 564 consecutive outpatients were retrospectively reviewed to identify patients who underwent injection and/or endoscopic surgery because of posterior hip pain. Thirty individuals (21 women and 9 men) with a mean age of 49.8 years (range, 20 to 76 years; standard deviation, 13.0 years) were included for analysis. Of the 30 patients, 17 (56.6%) were confirmed as positive for IFI and 13 (43.4%) were confirmed as negative for IFI. The IFI test had a sensitivity of 0.82, specificity of 0.85, positive predictive value of 0.88, negative predictive value of 0.79, positive likelihood ratio of 5.35, negative likelihood ratio of 0.21, and diagnostic odds ratio of 25.6. The LSW test had a sensitivity of 0.94, specificity of 0.85, positive predictive value of 0.89, negative predictive value of 0.92, positive likelihood ratio of 6.12, negative likelihood ratio of 0.07, and diagnostic odds ratio of 88.8., Conclusions: In patients with complaints of posterior hip pain and negative evaluation findings for lumbosacral spine involvement or static/dynamic mechanical axis malalignment, the IFI and LSW tests are highly accurate to help identify those with or without IFI. LEVEL OF EVIDENCE: Level III, diagnostic study., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To employ a national database of Medicare patients to evaluate the association of ipsilateral intra-articular knee corticosteroid injections at the time of knee arthroscopy with the incidence of postoperative infection., Methods: A national Medicare insurance database was queried for patients who underwent ipsilateral intra-articular corticosteroid injection of the knee at the time of knee arthroscopy from 2005 to 2012. Patients who underwent arthroscopically assisted open procedures, those who underwent more complex arthroscopic procedures, and those for whom laterality were not coded were excluded. This study group was compared to a control cohort of patients without intraoperative steroid injections that was matched to the study group for age, gender, obesity, diabetes mellitus, and smoking status. Infection rates within 3 and 6 months postoperatively were assessed using International Classification of Diseases, 9th Revision, and Current Procedural Terminology codes., Results: The incidence of postoperative infection rates after knee arthroscopy was significantly higher at 3 months (0.66%; odds ratio [OR], 2.6; P < .0001) and 6 months (1.92%; OR, 3.6; P < .0001) in patients who underwent ipsilateral intra-articular knee steroid injection at the time of knee arthroscopy (n = 2,866) compared with matched controls without intraoperative injections (n = 170,350) at 3 months (0.25%) and 6 months (0.54%)., Conclusions: The present study demonstrates a significant increase in postoperative infection in Medicare patients who underwent ipsilateral intra-articular knee corticosteroid injections at the time of knee arthroscopy compared with a matched control group without intraoperative injection., Level of Evidence: Therapeutic Level III, retrospective comparative study., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement., Methods: A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was performed. Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Two reviewers independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review., Results: Twenty articles were included in this systematic review. Overall, good results were found for arthroscopic treatment in patients with anterior ankle impingement. In the studies that reported patient satisfaction rates, high percentages of good to excellent satisfaction were described (74% to 100%). The percentages of patients who would undergo the same procedure again under the same circumstances were also high (94.3% to 97.5%). Complication rates were low (4.6%), particularly with respect to major complications (1.1%). The high heterogeneity of the included studies made it impossible to compare the results of the studies, including between anterolateral impingement and anteromedial impingement., Conclusions: Arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the findings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome., Level of Evidence: Level IV, systematic review of Level II and IV studies., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To design and validate an objective practical assessment tool for diagnostic shoulder arthroscopy that would provide residents with a method to evaluate their progression in this field of surgery and to identify specific learning needs., Methods: We designed and evaluated the shoulder Objective Practical Assessment Tool (OPAT). The shoulder OPAT was designed by us, and scoring domains were created using a Delphi process. The shoulder OPAT was trialed by members of the British Elbow & Shoulder Society Education Committee for internal consistency and ease of use before being offered to other trainers and residents. Inter-rater reliability and intrarater reliability were calculated. One hundred forty orthopaedic residents, of varying seniority, within 5 training regions in the United Kingdom, were questioned regarding the tool. A pilot study of 6 residents was undertaken., Results: Internal consistency was 0.77 (standardized Cronbach α). Inter-rater reliability was 0.60, and intrarater reliability was 0.82. The Spearman correlation coefficient (r) between the global summary score for the shoulder OPAT and the current assessment tool used in postgraduate training for orthopaedic residents undertaking diagnostic shoulder arthroscopy equaled 0.74. Of the residents, 82% agreed or strongly agreed when asked if the shoulder OPAT would be a useful tool in monitoring progression and 72% agreed or strongly agreed with the introduction of the shoulder OPAT within the orthopaedic domain., Conclusions: This study shows that the shoulder OPAT fulfills several aspects of reliability and validity when tested. Despite the inter-rater reliability being 0.60, we believe that the shoulder OPAT has the potential to play a role alongside the current assessment tool in the training of orthopaedic residents., Clinical Relevance: The shoulder OPAT can be used to assess residents during shoulder arthroscopy and has the potential for use in medical education, as well as arthroscopic skills training in the operating theater., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze the clinical and radiologic outcomes of arthroscopic cyst decompression and labral repair in patients with inferior paralabral cysts with chronic shoulder pain., Methods: Between March 2006 and September 2012, 16 patients who were identified as having inferior paralabral cysts presented with chronic shoulder pain. All patients underwent a thorough physical examination and preoperative magnetic resonance arthrographic evaluation. The mean age was 30 years (range, 17 to 50 years). The mean follow-up period was 38 months (range, 16 to 60 months). Clinical outcome scores (American Shoulder and Elbow Surgeons; University of California, Los Angeles; and Simple Shoulder Test) and passive shoulder range of motion were evaluated at last follow-up. Follow-up magnetic resonance imaging was performed at a mean of 8 months to determine the labral healing status and assess for cyst recurrence., Results: The incidence of isolated inferior paralabral cysts was 0.6% (16 of 2,656 cases). Of the patients, 8 had multiple cysts and 8 had a single cyst. The mean length and width of the cysts were 1.0 cm and 0.4 cm, respectively. Eight cases had a history of trauma, and 13 patients were involved in sports activities. Seventy-five percent of cases showed a positive relocation test. The mean American Shoulder and Elbow Surgeons; University of California, Los Angeles; and Simple Shoulder Test scores improved from 64, 22, and 8.7, respectively, preoperatively to 83, 31, and 10, respectively (P < .001), at final follow-up. Shoulder range of motion did not show any significant improvement. The location of the labral tear was as follows: anteroinferior tear in 5 cases, posteroinferior tear in 8 cases, and combined anteroinferior and posteroinferior tear in 3 cases. All cysts were found to be in association with a labral tear. A mean of 2.7 anchors were used for inferior labral repair. These cysts were found only in male patients. None of the patients showed any evidence of cyst recurrence on follow-up magnetic resonance imaging., Conclusions: Inferior labral tears treated with cyst decompression and labral repair showed satisfactory clinical results without any recurrence. Inferior paralabral cysts should be considered in the differential diagnosis in patients presenting with chronic shoulder pain, particularly active male patients., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: We aimed to analyze how different positions of the tibial and femoral tunnels when used for anterior cruciate ligament (ACL) reconstruction affect relations with the posterior cruciate ligament (PCL) at different degrees of knee flexion. Information gained from this study may be helpful in determining optimal placement of the graft in ACL reconstructive surgery., Methods: We divided 10 cadaveric knees into 2 groups of 5 and had either their femoral or tibial ACL insertion detached. For each specimen, 16 different positions were reproduced during ACL reconstruction based on a combination of 4 different tunnels in the tibia for group A (anterior-medial, anterior-lateral, posterior-medial, and posterior-lateral) and 4 in the femur for group B (anterior-proximal, anterior-distal, posterior-proximal, and posterior-distal) with 4° of knee flexion for each (0°, 45°, 90°, and 135°). We performed a magnetic resonance imaging (MRI) study for each configuration and analyzed the cruciate ligament positioning., Results: We identified 3 different situations: no contact between cruciate ligaments, contact without deformity, and contact with deformity. In group A, the degree of flexion (P = .003) and ligament insertion positioned in the posterior quadrants (P < .05) were statistically significant for the presence of ACL impingement. Ligament contact with deformity was identified in 18 (22.5%) configurations, mostly when the knee was flexed 45° and 90° and the ACL was in the posterior quadrants. For group B, "contact with deformity" was identified in 23 MR images, mostly (12 cases) with the graft position being in the anterior-distal configuration, but it was not significant for the occurrence of cruciate impingement., Conclusions: Impingement with ligament deformity is greater when the graft is fixed at the posterior quadrants of the tibial footprint, regardless of the degree of knee flexion. Although quite common, the ligament position in the femoral footprint was not a primary cause of ACL impingement with deformity., Clinical Relevance: This study helps identify positions of the tibial or femoral tunnels during ACL reconstruction to avoid impingement between cruciate ligaments., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To understand why professional female ballet dancers often complain of inguinal pain and experience early hip osteoarthritis (OA). Goals were to examine clinical and advanced imaging findings in the hips of dancers compared with those in a matched cohort of nondancers and to assess the femoral head translation in the forward split position using magnetic resonance imaging (MRI)., Methods: Twenty professional female ballet dancers and 14 active healthy female individuals matched for age (control group) completed a questionnaire on hip pain and underwent hip examination with impingement tests and measurement of passive hip range of motion (ROM). All had a pelvic 1.5 T MRI in the back-lying position to assess femoroacetabular morphologic features and lesions. For the dancers, additional MR images were acquired in the split position to evaluate femoroacetabular congruency., Results: Twelve of 20 dancers complained of groin pain only while dancing; controls were asymptomatic. Dancers' passive hip ROM was normal. No differences in α neck angle, acetabular depth, acetabular version, and femoral neck anteversion were found between dancers and controls. MRI of dancers while performing splits showed a mean femoral head subluxation of 2.05 mm. MRI of dancers' hips showed labral tears, cartilage thinning, and herniation pits, located in superior and posterosuperior positions. Lesions were the same for symptomatic and asymptomatic dancers. Controls had proportionally the same number of labral lesions but in an anterosuperior position. They also had 2 to 3 times fewer cartilage lesions and pits than did dancers., Conclusions: The results of our study are consistent with our hypothesis that repetitive extreme movements can cause femoral head subluxations and femoroacetabular abutments in female ballet dancers with normal hip morphologic features, which could result in early OA. Pathologic changes seen on MRI were symptomatic in less than two thirds of the dancers., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate whether and how arthroscopic rotator cuff repair changes the appearance of fatty infiltration and muscle atrophy as shown on magnetic resonance imaging (MRI) by comparing measurements taken before and immediately after surgery., Methods: The first study determined appropriate measurements of fatty infiltration and muscle atrophy, and the second study assessed immediate postoperative changes caused by surgery per se. Forty-two patients who underwent arthroscopic shoulder surgery for reasons other than rotator cuff repair were included in the first study, and 101 patients who underwent arthroscopic rotator cuff repair were included in the second study. MRI was undertaken preoperatively and 3 days after surgery. Fatty infiltration was evaluated with the Goutallier grade and by measuring signal intensities of rotator cuff muscles, and muscle atrophy was assessed with the tangent sign, occupation ratio, and cross-sectional areas of muscles., Results: In the first study, only the cross-sectional area of the subscapularis significantly changed after surgery and was excluded in the second study. In the second study, fatty infiltration seemingly improved by at least 1 grade in 50.0%, 75.0%, and 95.8% of patients with Goutallier grade 2, 3, and 4, respectively, in the supraspinatus (P < .001) and in 28.6%, 57.1%, and 66.7%, respectively, in the infraspinatus (P < .001). Muscle atrophy of the supraspinatus changed by at least 1 grade in 93.6% of patients with a grade 2 tangent sign and 100.0% with a grade 3 tangent sign, as well as 84.0% of patients with a grade 3 occupation ratio; cross-sectional areas of the supraspinatus and infraspinatus significantly increased by 21.6% and 7.0%, respectively (all P < .001)., Conclusions: This study showed that arthroscopic rotator cuff repair changed the appearance of both fatty infiltration and muscle atrophy of the supraspinatus and infraspinatus on MRI. We suggest that these changes be considered when one is assessing rotator cuff muscle changes by comparing the appearance on MRI before surgery with that at a certain time after surgery., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: Femoroacetabular impingement (FAI) and labral pathology have been recognized as causative factors for hip pain. The clinical diagnosis is now based on MRI-A (magnetic resonance imaging-arthrogram) because the physical diagnostic tests available are diverse and information on diagnostic accuracy and validity is lacking. The purpose of this systematic review was to identify the diagnostic accuracy and validity of physical tests that are used to assess FAI and labral pathology of the hip joint., Methods: We performed a computerized literature search using PubMed, Medline, Web of Science, PEDro, the Cochrane Library, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) (through EBSCO). Studies describing tests and diagnostic accuracy studies were included. All included studies were assessed by the Levels of Evidence for Primary Research Questions list. All diagnostic accuracy studies were assessed by the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) score., Results: We included 21 studies in which 18 different tests were described. For 11 of these tests, diagnostic accuracy figures were presented. Sensitivity was examined for all tests. Other diagnostic accuracy figures were often lacking, and when available, these were low. All articles describing tests had Level IV or V evidence. All diagnostic accuracy studies, except 1, had Level II or III evidence. Three articles had a good QUADAS score., Conclusions: In previous studies a wide range of physical diagnostic tests have been described. Little is known about the diagnostic accuracy and validity of these tests, and if available, these figures were low. The quality of the studies investigating these tests is too low to provide a conclusive recommendation for the clinician. Thus, currently, no physical tests are available that can reliably confirm or discard the diagnoses of FAI and/or labral pathology of the hip in clinical practice., Level of Evidence: Level III, systematic review of Level III studies., (Copyright © 2012 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to identify whether leptin and connective tissue growth factor (CTGF) occur in the degenerative fibrocartilage disk and whether cartilage cells express leptin receptors., Methods: The study included 23 patients diagnosed with degenerative articular disk tears of the triangular fibrocartilage (TFC) (Palmer type 2C). Patients were divided into 2 groups based on ulna length: 1 group consisted of patients with an ulna-positive variance (group A), and the other group included patients with ulna-negative or -neutral variance (group B). After arthroscopic debridement of the TFC, histologic sections of biopsy specimens were prepared. The biopsy specimens were immunohistochemically analyzed, and the quantity of leptin-, CTGF-, and leptin receptor-positive cells was assessed., Results: Cells positive for leptin, leptin receptor, and CTGF were found. The number of cells positive for leptin was significantly increased in specimens of patients with an ulna-negative variance (group B). In contrast, no significant difference was found for leptin receptor and CTGF in biopsy specimens of patients with ulna-positive or ulna-negative/neutral variance. The inner, middle, and outer zones of the disk do not express significantly different quantities of marker-positive cells., Conclusions: Degenerative fibrocartilage disk tissue cells exhibit leptin receptors and are exposed to the markers leptin and CTGF, providing evidence of a local paracrine system and regenerative processes. Cells of disks from patients with an ulna-neutral/negative length express significantly higher numbers of leptin-positive cells., Level of Evidence: Level II, diagnostic study., (Copyright © 2011 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to systematically evaluate the technique and tests used in the physical examination of the adult hip performed by multiple clinicians who regularly treat patients with hip problems and identify common physical examination patterns., Methods: The subjects included 5 men and 6 women with a mean age (+/-SD) of 29.8 +/- 9.4 years. They underwent physical examination of the hip by 6 hip specialists with a strong interest in hip-related problems. All examiners were blind to patient radiographs and diagnoses. Patient examinations were video recorded and reviewed., Results: It was determined that 18 tests were most frequently performed (>or=40%) by the examiners, 3 standing, 11 supine, 3 lateral, and 1 prone. Of the most frequently performed tests, 10 were performed more than 50% of the time. The tests performed in the supine position were as follows: flexion range of motion (ROM) (percentage of use, 98%), flexion internal rotation ROM (98%), flexion external rotation ROM (86%), passive supine rotation test (76%), flexion/adduction/internal rotation test (70%), straight leg raise against resistance test (61%), and flexion/abduction/external rotation test (52%). The tests performed in the standing position were the gait test (86%) and the single-leg stance phase test (77%). The 1 test in the prone position was the femoral anteversion test (58%)., Conclusions: There are variations in the testing that hip specialists perform to examine and evaluate their patients, but there is enough commonality to form the basis to recommend a battery of physical examination maneuvers that should be considered for use in evaluating the hip., Clinical Relevance: Patients presenting with groin, abdominal, back, and/or hip pain need to have a basic examination to ensure that the hip is not overlooked. A comprehensive physical examination of the hip will benefit the patient and the physician and serve as the foundation for future multicenter clinical studies., ((c) 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of our study was to evaluate the impact of preoperative magnetic resonance imaging (MRI) assessment of articular knee pathology on the clinical management of patients presenting with joint line pain., Methods: A preliminary study on 100 patients was performed to assess the accuracy of specific MRI sequences, using arthroscopy as a gold standard. Six hundred and eighteen consecutive patients with knee symptoms presenting to 2 specialist knee surgeons were then recruited. A clinical diagnosis of an arthroscopically treatable lesion was made in all cases. Clinical assessment data were correlated to subsequent MRI findings, recording any discrepancy and in particular whether or not MRI findings influenced management decisions., Results: In the preliminary study, MRI sequences had an overall sensitivity of 83.2% and a specificity of 94.3% for the detection of chondral lesions. However, when considering arthroscopic grade III and IV lesions, MRI sensitivity and specificity were improved to 84.5% and 97.1%. In the second phase of the study, 141 (22.8%) of the 618 patients presenting with knee symptoms had an altered clinical management subsequent to MRI. The presence of unexpected chondral lesions was found in 77 of these patients. Conversely, 22 patients with clinical symptoms suspicious for simple chondral degeneration had unstable meniscal tears., Conclusions: We suggest that preoperative MRI scanning identifies a group of patients who have more advanced degenerative joint disease than the clinical assessment and the plain radiographs suggest. This would expedite definitive surgery in patients with advanced osteoarthritis on MRI scans., Level of Evidence: Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.

Shoulder stiffness is commonly encountered in clinical practice but varies greatly in severity and etiology. Loss of shoulder range of motion can be a patient's primary complaint or may be a secondary finding. Possible causes of stiffness include guarding due to pain or secondary gain issues (nonanatomic), true mechanical blockage due to acute or chronic trauma, adhesive capsulitis, rotator cuff disease, or surgery on or near the shoulder. This review includes a more detailed discussion of these causes as well as the appropriate history and physical and diagnostic testing recommended for each. Finally, treatment strategies for each group of patients will be presented.

Purpose: This study describes a new test to detect SLAP lesions. The sensitivity, specificity, and positive and negative predictive values with respect to the diagnosis of a SLAP lesion were determined in comparison to Speed's test and the O'Brien test., Methods: One hundred fifty patients presenting for arthroscopic surgery with persisting pain or functional disability of the shoulder underwent a complete shoulder examination. All patients underwent Speed's test, the O'Brien test, and the new supine flexion resistance test. The clinical results of the tests were correlated with the presence of a SLAP lesion by direct arthroscopic visualization., Results: The supine flexion resistance test had a sensitivity of 80% and a specificity of 69%, whereas Speed's test and the O'Brien test had sensitivities of 60% and 94%, respectively, and specificities of 38% and 28%, respectively. Regarding isolated SLAP lesions, the supine flexion resistance test was highly sensitive, with a sensitivity of 92% (58% for Speed's test and 75% for the O'Brien test). For isolated tears of the supraspinatus, the specificity of the supine flexion resistance test was 75% (14% for Speed's test and 17% for the O'Brien test)., Conclusions: Compared with the O'Brien test and Speed's test, the supine flexion resistance test proves to be more specific, with a specificity of 69% for the whole study population (28% for the O'Brien test and 38% for Speed's test) and with a specificity of 75% for the group of patients with isolated supraspinatus lesions (17% for the O'Brien test and 14% for Speed's test). The new test is a useful and effective test for detecting type II SLAP lesions. The high specificity enables the elimination of false-positive results of other clinical tests that are more sensitive but not specific., Level of Evidence: Level II, development of diagnostic criteria with consecutive patients and universally applied gold standard.

Hip arthroscopy is becoming increasingly popular for the diagnosis and treatment of hip pathology, and the indications continue to evolve. The two most common approaches are the supine and lateral decubitus position. Both approaches can be performed effectively; however, each approach has its own benefits and drawbacks. In this review we will describe the indications for hip arthroscopy, the pros and cons of each approach, and the necessary equipment, portals, portal placement, commercially available distraction devices, and complications.

Arthroscopic access to the inferior glenohumeral recess is necessary in several surgical procedures on the shoulder. Posteroinferior portals described for access to this region may pose a theoretic risk to the posterior neurovascular structures (outside-in technique) and to the articular cartilage (inside-out technique). The first author (D.N.B.) has devised a new posterior portal that permits direct linear access to the entire inferior glenohumeral recess. The portal is placed higher and more lateral compared with the previously described portals; this places it further away from the posterior neurovascular structures and facilitates linear access to the axillary pouch. The portal is created via an outside-inside technique, with a spinal needle to ascertain the correct portal site and angulation. The portal is placed at a mean distance of 20.45 +/- 4.9 mm (range, 15 to 35 mm) directly inferior to the lower border of the posterolateral acromial angle and 21.3 +/- 2 mm (range, 20 to 25 mm) lateral to the posterior viewing portal. The spinal needle or cannula is angulated medially at a mean of 30.6 degrees +/- 4.7 degrees (range, 25 degrees to 40 degrees ) in the axial plane and slightly inferiorly (mean, 2 degrees ; range, 20 degrees superiorly to 20 degrees inferiorly). Use of 30 degrees and 70 degrees arthroscopes through the axillary pouch portal facilitates visualization of the entire recess and of the humeral attachment of the inferior glenohumeral ligament complex for evaluation of humeral avulsion of the glenohumeral ligament lesions. The portal also permits instrumentation in combination with the standard posterior or anterosuperior viewing portal for removal of loose bodies, synovectomy, capsular shrinkage, capsulotomy, and anchor placement in the posteroinferior glenoid rim.

This report presents my guidelines for surgeon training and development of skills in the art of elbow arthroscopy. As elbow arthroscopy becomes more common, it is important to achieve greater levels of experience that will minimize the risk of complications because indications and techniques are growing in number and complexity. Indications for elbow arthroscopy that require diagnosis before open surgery include evaluation of instability; removal of loose bodies, spurs, and plica; irrigation and debridement of infection or open joints; evaluation for arthrofibrosis (with open nerve protection), lateral epicondylitis, arthritis, osteochondritis dissecans, fracture, bursectomy, synovectomy, stabilization, tendon repair, and nerve release or decompression.

Purpose: The purpose of this study was to investigate whether magnetic resonance imaging (MRI) in patients waiting for knee arthroscopy could reduce arthroscopy rates and improve patient outcome., Methods: A prospective randomized controlled trial was conducted in a teaching hospital setting. All participating patients had knee MRI before arthroscopy. In the intervention group the MRI report was seen by surgeons, and in the control group it was not. The primary outcome measure was the proportion of patients who did not have an arthroscopy. Secondary outcome measures included the Short Form 36, EuroQol EQ-5D, Knee Injury and Osteoarthritis Score, and Knee Society Score., Results: Surgeons changed both their diagnosis and management plan in 47% of patients in the intervention group compared with 1% in the control group, with no difference between groups in the proportion of patients who underwent an arthroscopy. In the intervention group 7 of 125 patients (5.6%) did not have an arthroscopy compared with 8 of 127 patients (6.3%) in the control group. In one instance a surgeon decided against arthroscopy based on the MRI report. There was no significant difference between groups in other outcome measures., Conclusions: We found no effect of MRI on the decision to perform arthroscopy or patient outcome. Performing MRI in patients already on the waiting list for arthroscopy may not be effective in reducing utilization of surgery., Level of Evidence: Level I, therapeutic randomized controlled trial with no statistically significant difference but with narrow confidence intervals.

Impingement syndrome resulting from a partially torn posterior cruciate ligament (PCL) stump has not been reported in the English-language literature. We present 2 cases of impingement caused by the torn stump of a partially ruptured PCL. Both patients suffered from severe knee joint pain during knee flexion over 70 degrees to 90 degrees and medial joint-line tenderness after the injury. Magnetic resonance imaging (MRI) showed the partial rupture of the PCL, mainly in the posteromedial (PM) bundle. In both cases, arthroscopic examination revealed that the rupture of the PCL involved the femoral side of the PM bundle, and the torn stump of the PCL was entrapped in the medial tibiofemoral joint (TFJ). The torn stump was removed completely, and the symptoms improved significantly. Partial ruptures of the PCL occur frequently, and it is anticipated that many patients may suffer from pain arising from impingement of a partially torn PCL entrapped in the medial TFJ. Therefore, studies on this subject should continue.

Arthroscopic subtalar arthrodesis, as reported by Tasto, is done in the lateral decubitus position, and the portal sites are lateral. This report describes a new alternative method in which the patient is in the prone position and a posterior 2-portal approach is used, as described by van Dijk et al. The initial debridement and synovectomy are performed with 4- and 5-mm resectors. Debridement and decortication are done posterior to the interosseous ligament because only the posterior facet is fused. Denudation of the articular surfaces is performed with curettes, as well as 4.5- and 5.5-mm burs, to remove 2 mm of subchondral bone. Stabilization in 5 degrees of hindfoot valgus is accomplished with 2 percutaneous cannulated headless screws from the non-weight-bearing portion of the calcaneal tuberosity directed to a point 5 to 10 mm posterior to the anterior margin of the posterior facet. The advantages of this alternative treatment are better intra-articular visualization, more thorough preparation of the fusion site, and minimal bone removal of the lateral side with better control of the arthrodesis position and with less chance of malunion, as well as the possibility to perform a concomitant surgical fusion or debridement of the ankle joint during the same operative procedure with no need for additional portals or orientation.

Purpose: To determine the incidence and morphologic characteristics of knee chondral lesions found at arthroscopy and their correlation with magnetic resonance imaging (MRI)., Methods: This is a prospective study on 190 consecutive knee arthroscopic procedures performed between March 2003 and February 2004 by the same surgical team. The study group's age average was 34.8 years (14 to 77 years). The indication for surgery included anterior cruciate ligament tears, meniscal tears, and anterior knee pain. Patients without a preoperative MRI study were excluded. MRI reports were performed by qualified radiologists in all the cases. Chondral lesions were classified according to the International Cartilage Repair Society (ICRS) classification and were included in a database along with the MRI reports. The results were analyzed statistically with analysis of variance, Pearson, kappa, and chi-square tests., Results: One hundred fifteen chondral lesions in 82 patients were found during the arthroscopic procedure. Most of them were single lesions (72%) located on the medial femoral condyle (32.2%) or medial patellae (22.6%); 62.6% of the lesions were classified as ICRS type 2 or 3-A, with an average surface of 1.99 cm2. We found a significant direct correlation between the patient's age and the size of the lesion (P = .001). MRI sensitivity was 45% with a specificity of 100%. The sensitivity increased with deeper lesions (direct relation with the ICRS classification). Our results showed a statistical power of 100%., Conclusions: Although unenhanced MRI using a 1.5-Tesla magnet with conventional sequences (proton density-weighted, T1-weighted, and T2-weighted) is most accurate at revealing deeper lesions and defects at the patellae, our study shows that a considerable number of lesions will remain undetected until arthroscopy, which remains the gold standard., Level of Evidence: Level III, diagnostic study of nonconsecutive patients.

We introduce a new, not yet described cord-like structure of the knee of children associated with discoid or enlarged menisci. This structure was responsible for knee pathology (loss of extension) in 3 cases. The patients (5 to 8 years of age) complained of knee pain without skeletal abnormality or trauma. Magnetic resonance imaging revealed enlarged or discoid lateral menisci. The patients showed increasing limp with limited range of motion. Lack of extension was between 10 degrees and 45 degrees and continued under anesthesia. During arthroscopy, the menisci and the anterior and posterior cruciate ligaments (ACL, PCL) showed no abnormality other than the variant of the lateral meniscus described above. A tight cord-like structure was imposed, running laterally along the ACL. This cord-like structure was attached to the lateral femoral intercondylar area and the posterior horn region of the lateral meniscus in a sail-like shape. Two knees showed abnormal mobility of the lateral meniscus, tending to luxate. The ligamentous structure was cut stepwise lateral to the ACL, leaving the entire lateral meniscus undisturbed. Finally, full extension was achieved. Examination 7 to 27 months after surgery showed asymptomatic knees. This ligamentous structure is an important differential diagnosis to symptoms usually referred to as meniscus pathology. The appropriate treatment involves dissection. A loss of meniscal tissue followed by development of osteoarthritis can be prevented.

Purpose: Age-dependent studies about the clinical result after microfracture of cartilage lesions in the knee are still missing. This prospective study was performed to discover age-dependent differences in the results after microfracture over a period of 36 months., Methods: Between 1999 and 2002, 85 patients (mean age, 39 years) with full-thickness chondral lesions underwent the microfracture procedure and were evaluated preoperatively and at 6, 18, and 36 months after surgery. Depending on the patients' age (< or =40 years or >40 years) and the localization of the defects (femoral condyles, tibia, and patellofemoral joint), the patients were assigned to 6 different groups. Exclusion criteria were meniscal pathologic conditions, tibiofemoral malalignment, and ligament instabilities. Baseline clinical scores were compared with follow-up data by use of paired Wilcoxon tests for the modified Cincinnati knee score and the International Cartilage Repair Society (ICRS) score., Results: The scores improved in all groups over the whole study period (P < .05). Patients aged 40 years or younger had significantly better results (P < .01) for both scores compared with older patients. Between 18 and 36 months after microfracture, the ICRS score deteriorated significantly (P < .05) in patients aged over 40 years whereas younger patients with defects on the femoral condyles and on the tibia showed neither a significant improvement nor a significant deterioration in the ICRS score (P > .1). Magnetic resonance imaging 36 months after surgery revealed better defect filling and a better overall score in younger patients (P < .05). The Spearman coefficient of correlation between clinical and magnetic resonance imaging scores was 0.84., Conclusions: The clinical results after microfracture of full-thickness cartilage lesions in the knee are age-dependent. Deterioration begins 18 months after surgery and is significantly pronounced in patients aged older than 40 years. The best prognostic factor was found to be a patient age of 40 or younger with defects on the femoral condyles., Level of Evidence: Level IV, prognostic case series.

Purpose: The anatomic localization of the popliteal artery in the mediolateral plane at the level of the joint line was investigated on axial knee magnetic resonance imaging (MRI) scans to study anatomic variations., Methods: The transverse and central axes were described on axial MRI scans of 334 knees. The distance between the popliteal artery and central axis was measured; the course of the central axis bisected the posterior cruciate ligament in almost all of the cases. The differences in popliteal artery localization according to sex and side were analyzed., Results: Whereas popliteal artery localization was lateral to the central axis in 94.3% of cases, it was on the central axis in 5.7%. The popliteal artery localization was not seen on the medial side of the central axis. There was no significant effect of sex and side., Conclusions: Arthroscopic surgeons performing posterior cruciate ligament reconstruction or interventions on the posterior horns of the menisci should bear in mind that the risk of arterial complication may be greater for cases having the popliteal artery on the central axis. In conclusion, preoperative evaluation of the popliteal artery with MR axial scans, especially in pericapsular arthroscopic procedures, may prevent popliteal artery injuries., Level of Evidence: Level III, diagnostic study of nonconsecutive patients.

Purpose: Hip arthroscopy is growing in importance and relevance in the detection and treatment of various pathologies affecting the hip joint. There are a number of indications, including diagnosis and treatment of labral tears, extraction of loose bodies, and synovial-based diseases. Reports in the literature cite few complications arising from this minimally invasive procedure in a joint that has been difficult to access. The purpose of our study was to assess the efficacy and role of hip arthroscopy in the management of hip joint pathology., Type of Study: Retrospective review of a consecutive series of 22 patients over a 44-month period., Methods: The indications for surgery included ongoing hip pain for more than 6 months. Sixteen patients underwent contrast-enhanced magnetic resonance imaging scans, including all patients with mechanical symptoms. The procedure was performed as day surgery and all the patients were available for follow-up. They were assessed for pain, mechanical symptoms, activity levels, and sporting activities., Results: All patients were assessed by means of a questionnaire and allocated scores out of a maximum of 100 points. The most significant improvement was seen in the group of patients (n = 10) who had mechanical symptoms with definite labral pathology confirmed and treated arthroscopically. Their scores improved from an average of 64 preoperatively to 90 postoperatively. There were no complications in our series., Conclusions: Hip arthroscopy represents an effective tool in treating hip joint pathology with reasonable expectations of success and a minimal complication rate., Level of Evidence: Level IV.

Purpose: To evaluate the results for patients treated arthroscopically for anterolateral soft tissue impingement syndrome, to determine the factors affecting the outcome, and to report on a synovial shelf., Type of Study: Retrospective clinical review., Methods: Forty-one patients underwent operative arthroscopy for anterolateral impingement of the ankle between 1990 and 2001; the mean follow-up was 83.7 months (range, 21 to 152 months). There were 25 men and 16 women with an average age of 33.2 years (range, 15 to 63 years). All patients reported a history of inversion injury to the ankle. The most frequent preoperative complaints were tenderness localized to the anterolateral aspect of the ankle, swelling, crepitation, and pain at weight-bearing. All patients had failed to respond to at least 3 months of conservative treatment. The results were assessed according to Meislin's criteria and the American Orthopaedics Foot and Ankle Society (AOFAS) scoring table. For statistical analysis, the Mann-Whitney U test was used where appropriate and the significance was set at P < .005., Results: According to Meislin's criteria, there were excellent results in 21 patients, good in 16, fair in 2, and poor in 2. The mean AOFAS score was 89.6 points (range, 60-100) at follow-up. Four different soft tissue pathologies causing impingement were described. It has been statistically shown that cartilage damage located at the anterolateral region of the ankle and not advanced to the subchondral bone, and repeated inversion injuries had negative effects on clinical results at long-term follow-up., Conclusions: The arthroscopic diagnosis and treatment of anterolateral soft tissue impingement is a safe and effective method. Any combination of associated intra-articular pathologies, such as a chondral lesion or a new inversion injury of the ankle, after the arthroscopic procedure resulted in a poor outcome., Level of Evidence: Level IV, Therapeutic Study.

Abstract Clinical features of the symptomatic mediopatellar plica (MPP) are nonspecific and the diagnosis has been troublesome for orthopaedic surgeons. We present a diagnostic test for symptomatic MPP.

Purpose: The purpose of this study was to describe a new weight-bearing McMurray's test (Ege's test) and to compare its diagnostic value with McMurray's test and joint line tenderness (JLT). We also aimed to determine if associated lesions had any effect on the diagnostic values of the 3 tests., Type of Study: Prospective controlled trial, clinical study., Methods: The study group consisted of 150 consecutive patients who had had symptoms related to intra-articular knee pathology, and arthroscopic diagnoses were used as the gold standard., Results: There were a total of 211 diagnoses on arthroscopy. A meniscus tear was found in 127 of the 150 patients; 90 had medial, 28 had lateral, and 9 had tears of both menisci. There were no statistically significant differences between the 3 tests in detecting a meniscal tear ( P > .05). However, better accuracy, sensitivity, and specificity rates were obtained with Ege's test for medial meniscal lesions (71%, 67%, and 81%, respectively). JLT also gave superior accuracy rates (71%), but the specificity of Ege's test was apparently higher than JLT (81% v 44%). The highest positive predictive value was also obtained with Ege's test (86%), whereas a superior negative predictive value was obtained with JLT (67%) in medial meniscal tears. Lateral meniscal tears were diagnosed more accurately than medial meniscal tears, and Ege's test gave results superior to the others (84%, 64%, 90% for accuracy, sensitivity, and specificity, respectively). Higher positive predictive values were obtained with McMurray's and Ege's tests than with JLT, but similar negative predictive values were achieved in all. A torn anterior cruciate ligament did not decrease the diagnostic values of the 3 tests, whereas the number of associated lesions in the knee negatively affected the diagnostic capabilities of the tests., Conclusions: Accuracies of traditional clinical meniscus tests may be improved by including Ege's test in the clinical examination., Level of Evidence: Level II, diagnostic.

Lipoma arborescens are rare lesions, typically located in the knee. They have a predilection for the suprapatellar pouch in the knee joint, but can also occur in any area of the knee joint. Magnetic resonance imaging of lipoma arborescens often reveals subchondral bone cyst and/or bone erosions, and there may appear to be a correlation between lipoma arborescens and osteoarthritis. We describe a case of histologically proven lipoma arborescens in the suprapatellar pouch and infrapatellar area of the knee with no damage to the posterior compartment and bone erosion in the proximal tibia without osteoarthritis.

We report the case of a 31-year-old, otherwise healthy man with a large intra-articular meniscal ganglion cyst (27.7 x 13.5 mm) originating from the dorsal horn of the lateral meniscus. Clinically, the patient presented with knee pain in a squatting position. Magnetic resonance imaging revealed a large intra-articular cyst in the posterior compartment. At arthroscopic surgery, the ganglion cyst was found in the intercondylar space posteriorly to the posterior cruciate ligament. After removal of the ganglion cyst, a horizontal tear in the dorsal horn of the lateral meniscus was revealed and treated by partial meniscectomy. To our knowledge, a meniscal ganglion cyst originating from the lateral meniscus and extending into the joint is an extremely rare event, with only two previous reported cases. We review the current literature on the pathogenesis, distribution, and treatment of meniscal ganglion cysts.

Magnetic resonance imaging (MRI) is an effective method to evaluate cystic lesions of the knee. Intra-articular ganglia of the knee joint was considered to be rare before the advent of MRI. However, because an MRI is often used to diagnose knee pathology, the reported prevalence of intra-articular ganglia has increased. We describe two cases of an intra-articular ganglion arising from the posterior joint capsule. Both cysts appeared to be arising from the posterior cruciate ligament by both MRI as well as arthroscopy through a lateral infrapatellar portal. However, arthroscopy through a posteromedial portal revealed the cysts to originate from the posterior joint capsule. It suggests that some of the ganglion arising from the posterior cruciate ligament reported in the literature might actually be from the posterior joint capsule. To prevent recurrence of a ganglion cyst, when preoperative MRI shows the mass to be located posterior to the cruciate ligaments, we recommend that the relationship of the ganglion cyst to the posterior joint capsule be evaluated at arthroscopy through the posteromedial or posterolateral portal.

The management of motion loss of the knee is challenging. A clear understanding of the pathoanatomic causes of motion loss is necessary to establish a careful and rational approach to treatment. Early recognition and physical therapy are effective for the majority of patients, but when these conservative measures fail, operative intervention is indicated. The purpose of this article is to outline a comprehensive approach to the arthroscopic evaluation and treatment of the arthrofibrotic knee. This technique is designed to allow the surgeon to systematically address the numerous causes of motion loss of the knee.

Purpose: Arthrofibrosis represents a severe complication of trauma and reconstructive joint surgery because of generalized connective tissue proliferation resulting in painful joint stiffness. It often appears stereotypical in terms of its clinical and pathologic features, comprising excess deposition of extracellular matrix proteins such as collagen type I, III, and VI and proliferation of fibroblasts. However, trauma and surgery around joints does not always lead to fibrosis, suggesting a genetic predisposition. For a number of autoimmune diseases, strong associations have been described. The objective of the study was to investigate whether an association of HLA (human leukocyte antigen) with primary arthrofibrosis exists., Type of Study: Retrospective cohort study., Methods: Seventeen patients with primary arthrofibrosis after autologous anterior cruciate ligament (ACL) reconstruction were identified and clinically reviewed. Blood samples were taken, and DNA was isolated by column extraction method. DNA samples were typed for the loci HLA-A, -B, -C, -DRB1, and -DQB1. Results were compared with the frequencies of allelic groups as determined for the caucasoid population., Results: HLA-Cw*07 was significantly less often found in the patient group than in the general population (P =.022). The opposite effect was seen for Cw*08, which was found in 17.6% of the patient group but only in 3.8% of the reference group (P =.045). A significant difference was also seen for DQB1*06, because 23.5% of the patients but 48.6% of the reference group possessed an allelic variant of this group (P =.048). However, according to the relatively small number of patients, a statistical bias cannot be excluded., Conclusions: A possible link may exist between arthrofibrosis and HLA-Cw*07- and DQB1*06-negative as well as Cw*08-positive individuals. Further investigation is necesessary to confirm or vitiate the possible association., Level of Evidence: Level IV.

Ochronotic arthropathy is a disorder resulting from the deposition of homogentisic acid derivatives in the articular cartilage and the menisci. Large joints of the appendicular skeleton are preferentially affected. The clinical picture resembles that of degenerative joint disease. We present the arthroscopic findings in the shoulder and the knee in a 40-year-old man with ochronotic arthropathy and discuss the role of arthroscopy in the diagnosis and management of this rare metabolic disorder.

Eugen Bircher was a strong advocate of diagnostic arthroscopy as shown in several papers on the topic of internal derangements of the knee published between 1921 and 1926. During that time, he performed about 60 endoscopic procedures, which usually preceded a meniscectomy. We believe that this was the first time arthroscopy was used in a large scale for clinical purposes. Bircher was the head surgeon of the busy provincial Aarau General Hospital, a right-wing politician, and a highly ranked army officer. His interest in knee surgery was supported by his friend Fritz Steinmann, who was the "man of the pin" and an early promoter of skeletal traction for fracture treatment. Bircher believed in the early surgical treatment of meniscal lesions and, later, in the reconstruction of cruciate ligament lesions. He used the Jacobaeus thoracolaparoscope for arthroscopy, but it had poor endoscopic qualities. The electric lamp at the tip of the optical device was not mechanically protected and was therefore endangered by every manipulation within the joint space. Also, the 90 degrees optical system delivered a dark image. By the late 1920s, Bircher had developed the technique of double-contrast arthrography, and he gave up endoscopy by 1930. In 1935, he left surgery and took a military command in the Swiss army; later he was a representative of the Farmers Party in the National Parliament until his death.

Locking of the knee can present with no history of antecedent injury. We identified impingement of intra-articular tumors in 2 cases. Intra-articular tumors are relatively rare. Mechanical symptoms were present in both cases. On physical examination, there was a palpable mass at the medial region of the patellofemoral joint. The interior had been replaced mainly by amorphous necrotic tissue. The definite diagnosis of a soft-tissue mass of the knee could not be made on histologic examination.

We describe a case of a painful locked knee caused by the torsion of an intra-articular lipoma and review the literature on this unusual condition. There are many cases of locked knee and of intra-articular lipoma but to our knowledge there are no previous documented cases of a torted lipoma being identified as a cause of locking.