Raffaele Garofalo

Background: Deep vein thrombosis (DVT) has an incidence of 1 case per 1000 inhabitants in the general population and it is very rare after arthroscopy of the shoulder. Therefore, the current guidelines do not advise the administration of DVT prophylaxis in shoulder arthroscopy procedures.Cases presentation: We describe two cases of thrombosis of the arm after shoulder arthroscopy on a total of 10.452 shoulder arthroscopies performed during a period of ten years. One of two patients was further complicated by a bilateral pulmonary microembolism. In these two clinical cases the complication developed despite the absence of risk factors such as a concomitant neoplasm, thrombophilia, smoking habit, or a long duration of the procedure.Conclusions: The DVT after shoulder arthroscopy procedure remain a very rare complication. However, in view of the growing number of patients undergoing this procedure, this figure is expected to rise. The clinician surgeon should take in mind this possible complication that normally appears in the first 3 weeks after surgery, so to perform anti-coagulant treatment. Further clinical studies are therefore warranted to assess the true risk of VTE. In fact, the presence of "minor" predisposing factors that are not routinely studied, as well as the postoperative immobilization period, are potential risk factors that, associated with the invasiveness of the arthroscopy procedure, could trigger a thromboembolism.

The purpose of this study was to investigate the effects of extra corporeal shock waves (ESW) therapy on the metabolism of healthy and osteoarthritic human chondrocytes, and particularly on the expression of IL-10, TNF-alpha and beta1 integrin.

The success of anatomic repair of Bankart lesion diminishes in the presence of a capsule stretching and/or attenuation is reported in a variable percentage of patients with a chronic gleno‐humeral instability. We introduce a new arthroscopic stitch, the MIBA stitch, designed with a twofold aim: to improve tissue grip to reduce the risk of soft tissue tear, particularly cutting through capsular–labral tissue, to and address capsule‐labral detachment and capsular attenuation using a double loaded suture anchor. This stitch is a combination of horizontal mattress stitch passing through the capsular–labral complex in a “south‐to‐north” direction and an overlapping single vertical suture passing through the capsule and labrum in a “east‐to‐west” direction. The mattress stitch is tied before the vertical stitch in order to reinforce the simple vertical stitch, improving grip and contact force between capsular–labral tissue and glenoid bone.

Endoscopic anterior cruciate ligament (ACL) reconstruction can be performed through one-incision or two-incision technique. The current one-incision endoscopic ACL single bundle reconstruction techniques attempt to perform an isometric repair placing the graft along the roof of the intercondylar notch, anterior and superior to the native ACL insertion. However the ACL isometry is a theoretical condition, and has not stood up to detailed testing and investigation. Moreover this type of reconstruction results in a vertically oriented non-anatomic graft, which is able to control anterior tibial translation but not the rotational component of the instability. Femoral tunnel obliquity has a great effect on rotational stability. To improve the obliquity of graft, an anatomical ACL reconstruction should be attempt. Anatomical insertion of ACL on the femur lies very low in the notch, spreading between 11 and 9–8 o'clock position and the center lies lower than at 11 o'clock position. Femoral aiming devices through the tibial tunnel aim at an isometric placement, and they do not aim at an anatomic position of the graft. Also, a placement of tunnel in a position of 11 o'clock is unable to restore rotational stability. The two-incision technique, with the possibility to position femoral tunnel independently by tibial tunnel, allows us to place femoral tunnel entrance in a position of 10 'clock that can most accurately reproduce the anatomic behaviour of the ACL and can potentially improve the response of the graft to rotatory loads. This positioning results in a more oblique graft placement, avoiding problem related to PCL impingement during knee flexion. Further studies are required to understand if this kind of reconstruction can ameliorate proprioception as well as clinical outcome at a long-term follow-up.

Purpose: The purpose of this study was to evaluate the clinical and subjective outcomes after arthroscopic‐assisted double‐bundle posterior cruciate ligament (PCL) reconstruction. Methods: A series of 15 patients with grade III isolated chronic PCL tears underwent double‐bundle PCL reconstruction. Of these patients, 8 (53%) had simultaneous fractures. The mean time from accident to surgery was 10.8 months (range, 8 to 15 months). The mean age at the time of surgery was 28.2 years (range, 17 to 43 years). All of the patients reported knee insecurity during activities of daily living or light sporting activities, with associated anterior knee pain in 5 patients. Preoperatively, posterolateral or posteromedial corner injuries were ruled out through accurate clinical examination. The knees were assessed before surgery and at a mean follow‐up of 3.2 years (range, 2 to 5 years) with a physical examination, 4 different rating scales, and stress radiographs obtained with a Telos device (Telos, Marburg, Germany). Results: Postoperative physical examination revealed a reduction of the posterior drawer and tibial step‐off in all cases, although the posterior laxity was not completely normalized. Nevertheless, the patients were subjectively better after surgery. The subjective International Knee Documentation Committee score was significantly ameliorated. With regard to the objective International Knee Documentation Committee score, 6 knees (40%) were graded as abnormal because of posterior displacement of 6 mm or greater on follow‐up stress radiographs with the Telos device. On the Lysholm knee scoring scale, the score was excellent in 13% of patients and good in 87%. The mean score on the Hospital for Special Surgery knee ligament rating scale was 85.8. The Tegner activity score showed an amelioration after surgery, but no patient resumed his or her preinjury level of activities. The postoperative stress radiographs revealed an improvement in posterior instability of 50% or more in all but 3 knees (20%). Conclusions: Our technique of double‐bundle PCL reconstruction produced a significant reduction in knee symptoms and allowed the patients to return to moderate or strenuous activity, although the posterior tibial translation was not completely normalized and our results appear to be no better than the results of single‐bundle PCL reconstruction. Level of Evidence: Level IV, therapeutic case series.

Purpose: To evaluate the cause of recurrent pathologic instability after anterior cruciate ligament (ACL) surgery and the effectiveness of revision reconstruction using a quadriceps tendon autograft using a 2‐incision technique. Type of Study: Retrospective follow‐up study. Methods: Between 1999 and 2001, 31 patients underwent ACL revision reconstruction because of recurrent pathologic instability during sports or daily activities. Twenty‐eight patients were reviewed after a mean follow‐up of 4.2 years (range, 3.3 to 5.6 years). The mean age at revision surgery was 27 years (range, 18 to 41 years). The average time from primary procedure to revision surgery was 26 months (range, 9 to 45 months). A clinical, functional, and radiographic evaluation was performed. Also magnetic resonance imaging (MRI) or computed tomography (CT) scanning was performed. The International Knee Documentation Committee (IKDC), Lysholm, and Tegner scales were used. A KT‐1000 arthrometer measurement (MEDmetric, San Diego, CA) by an experienced physician was made. Results: Of the failures, 79% had radiographic evidence of malposition of their tunnels. In only 6 cases (21%) was the radiologic anatomy of tunnel placement judged to be correct on both the femoral and tibial side. The MRI or CT showed, in 6 cases, a too‐centrally placed femoral tunnel. After revision surgery, the position of tunnels was corrected. A significant improvement of Lachman and pivot‐shift phenomenon was observed. In particular, 17 patients had a negative Lachman test, and 11 patients had a grade I Lachman with a firm end point. Preoperatively, the pivot‐shift test was positive in all cases, and at last follow‐up in 7 patients (25%) a grade 1+ was found. Postoperatively, KT‐1000 testing showed a mean manual maximum translation of 8.6 mm (SD, 2.34) for the affected knee; 97% of patients had a maximum manual side‐to‐side translation <5 mm. At the final postoperative evaluation, 26 patients (93%) graded their knees as normal or nearly normal according to the IKDC score. The mean Lysholm score was 93.6 (SD, 8.77) and the mean Tegner activity score was 6.1 (SD, 1.37). No patient required further revision. Five patients (18%) complained of hypersensitive scars from the reconstructive surgery that made kneeling difficult. Conclusions: There were satisfactory results after ACL revision surgery using quadriceps tendon and a 2‐incision technique at a minimum 3 years’ follow‐up; 93% of patients returned to sports activities. Level of Evidence: Level IV, case series, no control group.

When a soft tissue tumor is initially misdiagnosed as a simple trauma or a mass, treatment may be adversely affected by the delay in diagnosis or an inappropriate invasive procedure that results in extension of a probable malignant tumor. Patients with soft tissue tumors present a diagnostic challenge to the clinician. A systematic approach to the evaluation and biopsy is necessary in order to minimize diagnostic errors and biopsy complications. With a multidisciplinary approach and adequate surgical management, the prognosis with a five-year survival rate can be excellent.