Mark H. Getelman

Revision anterior cruciate ligament reconstruction surgery

Revision anterior cruciate ligament (ACL) reconstruction is indicated for selected patients with recurrent instability after a failed primary procedure. The cause of the failure must be carefully identified to avoid pitfalls that may cause the revision to fail as well. Associated instability patterns must be recognized and corrected to achieve a successful result. The choice of graft, the problem of retained hardware, and tunnel placement are the major challenges of revision ACL reconstruction. The patient must have reasonable expectations and understand that the primary goal of surgery is restoration of the ability to perform activities of daily living, rather than a return to competitive athletics. The results of revision ACL reconstructions are not as good as those after primary reconstructions; however, the procedure appears to be beneficial for most patients.

Revision anterior cruciate ligamentsurgery: Etiology of failures

Abstract Anterior cruciate ligament (ACL) reconstruction has gained wide acceptance as the treatment of choice for the functionally unstable ACL-deficient knee. Long-term good or excellent results of primary ACL reconstructions with respect to functional stability, relief of symptoms, and return to activity is between 75% and 95%. As much as 8% of the unsatisfactory results after primary ACL reconstructions are secondary to recurrent instability and graft failure. Failed ACL reconstruction with recurrent instability can be classified into the following three categories based on the primary reason for failure: technical errors, biological failure, and traumatic failure. These causes of failure are not mutually exclusive, and more than one may contribute to failure. Technical reasons are the most common cause of failure, and anterior femoral tunnel placement is by far the most prevalent cause of graft failure and recurrent instability after ACL reconstruction. This article reviews the possible causes of recurrent instability after ACL reconstruction to enable the surgeon to thoroughly delineate the cause of failure before proceeding with revision ACL surgery.

Complications and Pitfalls in Anterior Cruciate Ligament Reconstruction with Synthetic Grafts

Anterior cruciate ligament (ACL) reconstruction is now widely accepted and routinely performed. It is estimated that 60,000 to 75,000 surgical procedures are performed annually in the United States.

Revision anterior cruciate ligamentsurgery: Preoperative evaluation and considerations

Abstract An orthopedic surgeon must carefully evaluate each patient before proceeding with revision anterior cruciateligament (ACL) surgery. A concerted effort directed at delineating the reason(s) for failure of the primary reconstruction should be undertaken to prepare an orthopedic surgeon for revision ACL surgery. The evaluation should include a detailed history from the preoperative period of the primary ACL until the present. Physical examination should evaluate the knee for previous scars as well as associated laxity. Diagnostic studies should at a minimum include plain radiographs and magnetic resonance imaging. In addition, the operative surgeon should be experienced in ACL surgical techniques, have the appropriate tools and fixation devices, and have several graft choices. Finally, if there is any question about the ability to place the tunnels appropriately or obtain solid fixation, strong consideration should be given to staging the revision reconstruction.

Arthroscopic Management of SLAP Lesions and Biceps Tendon Injuries

The arthroscope has become a tool routinely used by orthopedic surgeons. It allows the surgeon to visualize the entire glenoid labrum and the intraarticular biceps tendon, advancing our knowledge of these structures dramatically. Consequently, we can now recognize intraarticular pathology which was previously not appreciated with open surgical techniques. Tears of the superior labrum from anterior to posterior, SLAP lesions, are now well recognized. With the improved techniques of magnetic resonance imaging (MRI) and with the advent of magnetic resonance arthrography (MRA), these lesions can be diagnosed more accurately. This understanding has led to improved techniques for treatment. Presently, SLAP lesions can be treated arthroscopically with a high success rate. This chapter reviews the normal and pathologic labral and biceps anatomy, discusses the biomechanics of the labrum and biceps tendon, and outlines the diagnosis, classification, and treatment of SLAP lesions. It also describes the latest information regarding lesions involving the long head of the biceps tendon and outlines our approach to treatment.

Regarding "meta-analysis comparing single-row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears".

To the Editor: We appreciate the work by Xu et al to evaluate the collective clinical and advanced-imaging outcomes in their recent article, ‘‘Meta-analysis comparing single-row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears.’’ There are many factors that can contribute to the success of rotator cuff (RC) repair, including type of anchors, number of anchors, anchor location, suture pattern, suture number, bony preparation, and postoperative protocol. This article brings to light the current controversy surrounding the best repair technique for RC tears. The strength of this meta-analysis is the inclusion of only level I and II studies; however, we believe that the authors failed to evaluate and analyze some essential aspects of repair technique that may also affect the outcome after RC repair. The authors commented on the number of suture anchors, but failed to mention how many sutures were included in each anchor. The most important element for secure RC fixation is not the number of anchors, but rather the number of effective sutures passing from the anchors through the tendon. The authors cite several studies that showed increased biomechanical strength of double-row (DR) repairs, but these studies did not compare DR constructs with single-row (SR) constructs with triple-loaded anchors. Coons et al have shown that a SR repair with triple-loaded anchors and a simple suture construct is significantly more resistant to gap formation than DR constructs. This meta-analysis included 9 studies, 5 of which were level I prospective, randomized controlled trials. In only 2 of the 9 studies was the SR placed medially on the footprint, adjacent to the articular cartilage. The SR in the remaining 7 studies was placed at the lateral footprint; however, lateralizing the insertion of an already shortened