James L. Chen

Arthroscopic Reduction of Tibial Spine Avulsion: Suture Lever Reduction Technique

Tibial spine avulsion fractures are uncommon knee injuries that predominantly occur in children and young adults. Restoration of anterior cruciate ligament length through surgical reduction and fixation of the fracture is necessary to ensure stability of the knee with suitable range of motion and minimal knee laxity. Arthroscopic repair of tibial spine avulsion fractures is a technically complex procedure, specifically when performing and maintaining the initial anatomic reduction. We describe in this technical note and accompanying video a unique 3-point fixation repair of tibial spine avulsion fractures using an arthroscopic assisted suture lever reduction technique. Our technique is both simple and efficacious in the reduction of tibial spine avulsion fractures to anatomic position by passing the first suture through the anterior cruciate ligament, and subsequently anterior to the avulsion fragment, and then beneath the fragment through a posteriorly placed bone tunnel within the tibial fracture bed.

Arthroscopic Remplissage Using a Double-Pulley System for Hill-Sachs Lesions for Recurrent Shoulder Instability

Hills-Sachs lesions are bony lesions in the humeral head that occur as a result of an anterior shoulder dislocation. These lesions often happen in conjunction with tears of the labrum, and large, engaging lesions must be addressed in order to avoid recurrent instability. Moderate to large (≥3 mm deep) Hill-Sachs defects can be treated using arthroscopic remplissage to reduce the rotator cuff down into the lesion. We describe in this Technical Note and accompanying video an adaptation of the classic arthroscopic remplissage that uses a knotless double-pulley technique with 2 suture anchors, which increases the footprint of fixation, reduces the technical difficulty of the procedure, and minimizes the number of portals that need to be made.

Single Portal Technique for Subscapularis Tendon Repair

The fast and steady development of arthroscopy techniques in the last couple of decades led to a drastic increase of arthroscopic rotator cuff repairs over the open procedure. Supraspinatus tears are the most common of all, but the subscapularis tendon tear is a more common injury than expected. Most of the time it presents as a partial tear or is associated with a subsequent rotator cuff tendon injury, especially the supraspinatus. Nowadays, the standard procedure to repair the subscapularis tendon is performed arthroscopically, even though a real superior result over the open repair it is yet to be reported. Ideally less operative time, less scarring, and postoperative pain would be the expected benefits, but no study has compared the long-term outcome of these 2 procedures yet. To maximize possible improvements, we would like to present an arthroscopic technique: a subscapularis tendon repair performed with the aid of an angled suture passer and using a single anterior working portal.

The Tibial Tug Test: An Intraoperative Test to Assess Tibial Fixation During Anterior Cruciate Ligament Reconstruction

The anterior cruciate ligament (ACL) is commonly injured, especially in athletes performing twisting and pivoting motions. ACL reconstruction is a standard procedure; however, there is no way to intraoperatively assess one of the causes of failure: the lack of adequate graft fixation on the tibial side. Different fixation devices can be used to ensure fixation, but there is as yet no consensus on which is the most effective. Moreover, there is no reliable way to assess their strength in the intraoperative setting. The tibial tug test is meant to be an important resource to help avoid fixation failure by evaluating the tibial fixation device intraoperatively and giving the surgeon the opportunity to revise the tibial fixation if deemed inadequate. The aim of this article is to describe an empirical and simple test that can demonstrate to the surgeon adequate tibial fixation during ACL reconstruction surgery.

Intraosseous Bioplasty for a Chondral Cyst in the Lateral Tibial Plateau

Subchondral lesions are the result of osseous modifications seen in a different array of pathologies such as osteoarthritis, rheumatoid arthritis, calcium pyrophosphate deposition, and osteonecrosis. The physiopathologic changes in all of the aforementioned pathologies are not clear yet. What is clear is that the development of a cystic change in the subchondral bone can cause pain and can lead to modification of the activity of daily life. To provide relief and treatment for such a condition, there are different options with joint replacement as last resort when the cyst develops in communication with the joint; if the cyst is not in communication with the joint, it is possible to perform a bioplasty as we present in this technical report. It is crucial to assess the bone continuity, especially when traumas are reported in the patient history. In our case, the tibial plateau did not have signs of collapse. The technique here presented is a minimally invasive technique that can be reproduced for focal and localized subchondral cysts.

Anterior Shoulder Stabilization Using a Single Portal Technique With Suture Lasso

Open Bankart repair was the standard technique used in the past, but the request for less invasiveness, always pursued by every surgeon, pushed the development of the arthroscopic procedure. Nowadays the stabilization of the anteroinferior labrum is usually performed with an arthroscopic technique that uses the classic posterior portal and 2 anterior working portals. Because arthroscopy is progressing steadily under every aspect, there is now the chance to use only one working portal with the aid of a suture passer. One less portal not only means less invasiveness but also less postoperative pain and possible shorter operative time. This Technical Note is focalized in the description of a Bankart repair technique with a single working portal and the aid of a suture lasso.

Submeniscal Portal for Horizontal Cleavage Tear with Parameniscal Cyst of the Lateral Meniscus

Horizontal cleavage tears of the medial and lateral meniscus can be difficult to treat using the standard anteromedial or anterolateral arthroscopy portals. In this Technical Note, we present a new surgical technique to better manage the inferior leaflet of horizontal cleavage tears of the medial and lateral meniscus and their associated parameniscal cysts.

Anatomic Single-Incision Repair of Distal Biceps Tendon Ruptures Using Intramedullary Soft Anchors

Distal biceps tendon ruptures are uncommon injuries responsible for only 3% of all injuries to the biceps tendon. For most of these cases, unless the patient is elderly or infirm, conservative management should be avoided and the injury should be treated with a surgical procedure to reattach the bicep tendon to the radial tuberosity. In this Technical Note and accompanying video, we describe an anatomic single-incision technique using 2 intramedullary soft anchors, which decreases the likelihood of complications associated with bicortical drilling and metal suspensory fixation.

Arthroscopic Bone Marrow Aspirate Concentrate Harvesting From the Intercondylar Notch of the Knee

Bone marrow aspirate concentrate is commonly harvested to obtain mesenchymal stem cells, progenitor cells, and growth factors. The iliac crest is the most common donor site for bone marrow harvesting and is associated with donor site morbidity of an additional incision and pain from the harvest. Iliac crest harvesting can be cumbersome because it often requires different patient positioning from the surgical procedure and additional sedation or anesthesia for the harvest prior to repositioning. The purpose of this Technical Note and accompanying video is to describe a technique to arthroscopically aspirate bone marrow from the intercondylar femoral notch, reducing the need for iliac crest harvesting.

Graft Retensioning Technique Using an Adjustable-Loop Fixation Device in Arthroscopic Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) tears are an unfortunate and devastating injury in the athletic patient. Surgical reconstruction of the ACL with a taut graft construct is necessary to restore knee stability and help expedite the patients return to an active lifestyle. Arthroscopy-assisted ACL reconstruction can be a technically involved procedure, where strong fixation limits graft motion to allow sufficient healing within the tibial and femoral tunnels at the bone-tendon interfaces. Loss of tension in a graft can cause symptomatic anterior or rotatory instability and potential retear of the ACL graft. We describe in this Technical Note and accompanying video a simple and effective technique to implant and retension a tendon graft during ACL reconstruction using a suspensory fixation device. The technical description uses a simple adjustable-loop device to provide strong cortical fixation, along with the unique ability to retension the graft in ACL reconstruction, not otherwise possible with previously described graft fixation techniques.