Arthroscopic Repair of the Bankart Lesion Using Dual-Row Labral Repair

Background: The most common technique described for bankart repair is the single-row labral repair. Recent interest has been the use of a dual-row, double pulley technique, first described by Zhang et al and popularized by Millett et al as the “bony Bankart bridge” technique. The aim of this study is to report a double-row all-suture labral fixation technique using knotless anchors. Technique: Step 1: glenohumeral debridement, and preparation of the glenoid labral and Bankart. The patient is first placed in the beach-chair position and surface landmarks are created. The standard posterior portal is first created and the glenohumeral joint is evaluated. Once the lesion is identified, the relevant working anterosuperior and anteroinferior portals are established using the outside-in technique. The synovitis is debrided to allow visualization and the labrum is liberated from the anterior glenoid. The Bankart lesion fragment is liberated, and partial fragments are osteotomized. With the anterolateral portal as the viewing portal, the anterior rim of the glenoid is now decorticated using a motorized shaver and rasp to create a bleeding bony surface. Step 2: the low rim anchor (5:30 o’clock). At the anterior-inferior aspect of the glenoid, the drill guide is positioned as low as possible (5:30 o’clock position for the right shoulder) and about 7 to 10 mm medial to the rim of the glenoid. The first 1.8 mm single-loaded suture anchor (Q-FIX All-Suture Anchor) is then inserted via the posterior portal. Step 3: the anterior-inferior-medial (AIM) anchor (4 o’clock). Step 4: the knotless high rim anchor (3 o’clock). Step 5: tying of sutures. The sutures from each anchor are tied in a mattress configuration, eventually creating a suture bridge over the labral repair Discussion/Conclusion: This dual row labral repair technique allows for maximum compression and contact between the fragment and the glenoid bed, allowing healing over a contact area rather than just the rim. The other added advantage is the use of curved tip anchors which allow negotiation of difficult corners, especially in the 5 to 6 o’clock position.

Ultrasound-guided arthroscopic communication enlargement surgery may be an ideal treatment option for popliteal cysts – indications and technique

Purpose Several studies have shown an excellent success rate of communication enlargement surgery for popliteal cysts (Baker’s cysts). Ultrasound-guided surgery can improve the accuracy of this procedure and may lead to better outcomes. This study describes a simple ultrasound-guided arthroscopic technique to manage popliteal cysts and reduce postoperative pain. Methods After routine arthroscopic observation with a standard 2-portal approach, the arthroscope is redirected toward the posteromedial compartment from the anterolateral portal through the intercondylar notch. A posteromedial portal is then placed at this view. Subsequently, a contrast dye (indigo carmine) is injected into the popliteal cyst percutaneously using ultrasonography. This procedure makes it easier to find a capsular fold or valvular opening. The valvular opening between the semimembranosus and medial gastrocnemius is enlarged with a shaver and radiofrequency ablation. Cystectomy is not performed in any case. Finally, the irrigation fluid is suctioned, and the reduced cyst is visualized by ultrasound. Additionally, a periarticular multimodal drug injection is administered into the septum and inner wall of the cyst under ultrasound guidance. Conclusions Ultrasound-guided arthroscopic surgery for popliteal cysts can ensure reproducibility and be effective for postoperative pain relief. Thus, this combined procedure may be an optimal treatment option.

A Novel Technique of Arthroscopic Ankle Lateral Ligament Repair Using a Knotless Suture Anchor

Background: Although arthroscopic lateral ligament repair (ALLR) with suture anchors for chronic lateral ankle instability has become widely accepted, some complications have been reported as well. Establishment of a new technique is essential for better clinical outcomes after ALLR. Purpose To report a novel technique and good clinical results of ALLR using a knotless suture anchor. Study Design: Case series; Level of evidence, 4. Methods: We examined 30 patients (16 men and 14 women) who underwent ALLR. The mean age of the patients was 30.0 years, and the average period of postoperative monitoring was 21 months. The Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale was used for clinical evaluation postoperatively, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) for patient-reported results. Surgical complications were also examined. Results: The JSSF ankle-hindfoot scale showed a significant improvement from preoperatively to follow-up (from 72.1 to 96.1; P < 0.001), and the SAFE-Q was significantly improved in all subscales (pain and pain-related, physical function and daily living, social function, shoe-related, and general health and well-being; P < 0.004 for all). Complications included residual joint pain due to remaining osteophytes in 1 case, scar pain of the accessory anterolateral portal in 2 cases, and positive Tinel sign indicative of superficial peroneal nerve irritation at the anterolateral portal in 1 case. Conclusion: The clinical results of the novel ALLR technique were overall satisfactory. Knot-related complications, one of the main reasons for postoperative complications, were reduced by using a knotless suture anchor.

Is viewing the femoral footprint end on while drilling the femoral tunnel in an ACL reconstruction more accurate ?

Introduction: Arthroscopic transportal ACL reconstruction traditionally involves viewing from the anterolateral portal and working from a portal on the medial side. This involves seeing the notch from the same side which evades an end on view of the whole lateral notch. Viewing from the medial side gives an end on view of the same. Working and viewing from the same side may create overcrowding of instruments. We overcame this by using a low far medial portal for drilling and viewing with a high anteromedial portal. We compared both techniques using 3D CT scans to analyse whether there was any difference in intended tunnel placements. Hypotheses: Viewing and working from the medial side would give a different tunnel position from viewing from the lateral and working from the medial portal. Methods: 60 patients were recruited , equal numbers underwent transportal ACL reconstruction using semitendinosus and gracilis grafts by Technique A (Viewing from a high anterolateral portal just next to the patellar tendon at the level of the inferior pole of the patella and working from a low far medial portal) and Technique B (Viewing from high medial portal at the level of inferior pole of patella just next to the patellar tendon and working from a low far medial portal). Tunnels were made leaving 5 mm of back wall and just above the equator of the lateral aspect of the notch. 3 D CT scans were done 3 weeks after the surgery and location of the tunnels were studied using A modification of Edwards technique described by P Lertwanich et al,. A rectangle is drawn connecting the highest point of the lateral wall of the notch anteriorly, lowest point inferiorly, anterior and posterior most aspect after digitally subtracting the medial femoral condyle to expose the lateral aspect of notch. The footprint was covered by the best fit circle on a software, that covered all borders of the femoral tunnel. Centre of this circle was marked and perpendiculars bisecting it from the length and breadth of the rectangle were drawn. The centre of the femoral tunnel was expressed as a percentage from anterior and posterior. Results: 60 knees were evaluated 52 right (Technique A: 27 and Technique B: 25) and 8 left knees ( Technique A :3 and Technique B:5 ). The mean age of the patients was 27.3 yrs ( Technique A : 26.7 yrs (Range 19-41yrs) and Technique B 27.6 yrs (Range 18-43yrs). There were 41 male and 19 female patients ( Technique A 18 males and 12 females, Technique B had 23 males and 7 females). Mean graft diameter was 8.8mm (range 7-10) in technique A and 8.6mm (range 8-10) in Technique B. MDS (Mean distance from superior margin)Technique A : 35.28 , Standard deviation (SD)6.7339, Technique B MDS 35.86, Standrad deviation9.4441 Mean Distance from posterior margin (DP) :Technique A 35.83 ,SD:8.2008, Technique B 38.14 SD: 8.6991 The t value for DS calculated is 0.2767, the P value is 0.7830 confidence interval is (-4.825, 3.653) . The t value for DP calculated is 1.060, the p value is 0.2937 confidence interval is (-6.682, 2.056) We concluded after applying the independent student t test that the p value is greater than 0.05. So mean distance of femoral tunnel from superior, posterior border in technique A does not differ significantly from mean distance of femoral tunnel from superior border, posterior border in technique B Conclusion: An end on view while making the femoral tunnel does not give any added benefit in accuracy of femoral tunnel placement in this study.

Anterocentral Portal in Ankle Arthroscopy

Background: The anterocentral portal is not a standard portal in anterior ankle arthroscopy due to its proximity to the anterior neurovascular bundle. However, it provides certain advantages, including a wide field of vision, and portal changes become redundant. The purpose of this study was to evaluate the neurovascular complications after anterior ankle arthroscopy using the anterocentral portal. Methods: We retrospectively identified patients who had undergone anterior ankle arthroscopy with an anterocentral portal at our institution from 2013 to 2018. Medical record data were reviewed and patients were invited for clinical follow-up, where a clinical examination, quantitative sensory testing for the deep peroneal nerve, and ultrasonography of the structures at risk were performed. A total of 101 patients (105 arthroscopies) were identified and evaluated at a mean follow-up of 31.5 ± 17.7 months. Results: Leading indications to surgery were heterogeneous and included anterior impingement (48.6%), osteochondral lesions of the talus (24.8%), chronic ankle instability (14.3%), and fractures (8.6%). The overall complication rate was 7.6%, and no major complications were observed. In 1.9% (2/105) of the cases, the complications were associated with the anterocentral portal and included injury to the medial branch of the superficial nerve (1/105) and to the deep peroneal nerve (1/105). Injury to the deep peroneal nerve was associated with a loss of detection and nociception. There were no injuries to the anterior tibial artery. In 41.9% (44/105) of the cases, only 1 working portal was used in addition to the anterocentral portal, and in 19% (20/105) the anterolateral portal could be avoided. Ultrasonography confirmed the integrity of the deep peroneal nerve, the medial branch of the superficial peroneal nerve, and the anterior tibial artery in all patients. Patients with nerve injuries associated with the anterocentral portal showed no signs of neuroma or pseudoaneurysm. Conclusion: Using a standardized technique, the anterocentral portal in ankle arthroscopy is safe with a low number of neurovascular injuries and can be recommended as a standard portal. The anterolateral portal remains associated with a high number of injuries to the superficial peroneal nerve. Level of Evidence: Level III, retrospective cohort study.

Two-millimetre diameter operative arthroscopy of the ankle is safe and effective

Purpose Technical innovation now offers the possibility of 2-mm diameter operative arthroscopy: an alternative to conventional arthroscopy that no longer uses inner rod-lenses. The purpose of this study was to assess whether all significant structures in the ankle could be visualized and surgically reached during 2-mm diameter operative arthroscopy, without inflicting iatrogenic damage. Methods A novel, 2-mm diameter arthroscopic system was used to perform a protocolled arthroscopic procedure in 10 fresh-frozen, human donor ankles. Standard anteromedial and anterolateral portals were utilized. Visualization and reach with tailored arthroscopic instruments of a protocolled list of articular structures were recorded and documented. A line was etched on the most posterior border of the talar and tibial cartilage that was safely reachable. The specimens were dissected and distances between portal tracts and neurovascular structures were measured. The articular surfaces of talus and tibia were photographed and inspected for iatrogenic damage. The reachable area on the articular surface was calculated and analysed. Results All significant structures were successfully visualized and reached in all specimens. The anteromedial portal was not in contact with neurovascular structures in any specimen. The anterolateral portal collided with a branch of the superficial peroneal nerve in one case but did not cause macroscopically apparent harm. On average, 96% and 85% of the talar and tibial surfaces was reachable respectively, without causing iatrogenic damage. Conclusion 2-mm diameter operative arthroscopy provides safe and effective visualization and surgical reach of the anterior ankle joint. It may hold the potential to make ankle arthroscopy less invasive and more accessible.

Remnant Preserving or Augmentation SB PCL Reconstruction: Tips and Tricks

Injury to the Posterior Cruciate Ligament (PCL) is thought to account for 3% to 20% of all knee ligament injuries. Accurate diagnosis of the PCL injury is the first step in determining appropriate management. Approximately 60% of PCL injuries are associated with tearing of the Posterolateral Corner (PLC) structures. When the surgery, arthroscopy PCL reconstruction, is decided then we have to think how and what the best technique will be used to reconstruct. Various techniques of PCL Reconstruction Arthroscopy are known that based on research. According the position of PCL, the procedure of reconstruction is more difficult than ACL one. If combined with PLC rupture, all the structures will be reconstructed in one step. Will be proposed the tips and tricks how to do arthroscopy remnant preserving or augmentation single bundle PCL reconstruction, such as: how to preserve the remnant, how to find the position of tibial attachment and what the landmark, how to deliver the graft into the tunnels so preventing “killer turn” on the posterior part of joint, and how to do the proper rehabilitation. By using the Posterior Medial Portal, working with Remnant Preserved of PCL Reconstruction will be made easier. Joint line of medial tibial plateau as a landmark to find the tibial tunnel. About 1.5 cm below the joint line, the point of tibial tunnel is made or directly finding the edge of the ‘shelf’ where the tunnel is made on there. The remnant will be split and the graft will be laid in between. A strong suture material is used to pull the graft with all in side technique. The tibial part of the graft goes in first through the anterolateral portal following the suture material, go into between the remnant and go into the tibial tunnel from posterior to anterior (inside out). The femoral part of the graft will go into the joint together with the wire that carrying the distal end of the graft go into the femoral tunnel. After that we make the finalization of procedure. Finally, a special rehab program is needed to get the good result of PCL reconstruction as a whole.

Hip Arthroscopic Portals: A New Approach through Accessory Portals Established Within 3cm around Anterolateral Portal

Background: This new technique an approach through accessory portals established within 3cm around anterolateral portal has more advantageous aspect than any other approach taken during hip arthroscopy. Through this new approach injury to labrum, articular cartilage, neurovascular structures is avoided completely along with that this new approach makes the procedure easy and convenient. Aim: To prove that accessory portals established within 3cm around anterolateral portal makes the procedure and instrumentation facilitation easy and injury to anatomical structure and NVS can be avoided completely. Methods and materials: Anterolateral portal being the safest is established first and in relation to it within 3cm accessory portals are established as many as per need. Results: Every year an average of 40 patients undergo hip arthroscopy and in all cases our approach is through this new technique of accessory portals established within 3cm around anterolateral portal. Conclusion: The accessory portals we establish not only makes the hip arthroscopy easy but also help us avoid use of fluoroscopy and prolonged traction. The visualization within the hip joint of anatomical structure is more precise and accurate, and injury to anatomical structures and NVS is avoided completely.