The Frank Stinchfield Award: Assembly and Dissociation Forces Differ Between Commonly Used Dual Mobility Implants: A Biomechanical Study.

BACKGROUND: Intraprosthetic dissociation (IPD) is a complication unique to dual mobility (DM) implants where the outer polyethylene head dissociates from the inner femoral head. Increasing reports of IPD at the time of closed reduction of large head DM dislocations prompted this biomechanical study evaluating the assembly and dissociation forces of DM heads. METHODS: We tested 17 polyethylene DM heads from 5 vendors. Of the heads, 12 were highly cross-linked polyethylene (4 vendors) and 5 were infused with vitamin E (2 vendors). Heads were between 46 and 47 mm in diameter, accepting a 28 mm-inner ceramic head. Implants were assembled and disassembled using a servohydraulic machine that recorded the forces and torques applied during testing. Dissociation was tested via both axial pull-out and lever-out techniques, where lever-out simulated stem-on-acetabular component impingement. RESULTS: The initial maximum assembly force was significantly different between all vendors (P < .01) and decreased for all implants with subsequent assembly. Vendor 4-E (Link with vitamin E) heads required the highest assembly force (1,831.9 ± 81.95 N), followed by Vendor 3 (Smith & Nephew), Vendor 5 (DePuy Synthes), Vendor 1-E (Zimmer Biomet with vitamin E), Vendor 2 (Stryker), and Vendor 1 (Zimmer Biomet Arcom). Vendor 4-E implants showed the greatest dissociation resistance in both pull-out (2,059.89 N, n = 1) and lever-out (38.95 ± 2.79 Nm) tests. Vendor 1-E implants with vitamin E required higher assembly force, dissociation force, and energy than Vendor 1 heads without vitamin E. CONCLUSIONS: There were notable differences in DM assembly and dissociation forces between implants. Diminishing force was required for assembly with each additional trial across vendors. Vendor 4-E DM heads required the highest assembly and dissociation forces. Vitamin E appeared to increase the assembly and dissociation forces. Based on these results, DM polyethylene heads should not be reimplanted after dissociation, and there may be a role for establishing a minimum dissociation energy standard to minimize IPD risk.

Biomechanical Stability of Diaphyseal Ulnar Shaft Fractures and Ulnar Shortening Osteotomies After Fixation.

BACKGROUND: To determine the amount of micromotion during forearm rotation after diaphyseal ulnar shaft fracture or osteotomy. METHODS: This was a biomechanical study using 7 paired-matched cadavers. The upper extremity was mounted in a custom rig and the forearm brought through full pronation and supination. A Hall effect sensor was placed at the fracture ends to measure micromotion for all tested conditions. There were 4 conditions tested: (1) intact ulnar shaft with plate to act as a control; (2) transverse fracture/osteotomy without stabilization; (3) fracture/osteotomy with cortical apposition stabilized with plate fixation; and (4) 50% comminuted fracture stabilized with plate. RESULTS: There was a significantly greater amount of fracture site motion in the fracture/osteotomy model without stabilization compared with all other tested conditions (P < .001, .0001, .0003, respectively). The fracture/osteotomy site with cortical apposition and the comminuted fracture models showed no statistically significant differences in the amount of micromotion compared with each another (P = .952) or compared with the intact ulnar shaft (P = .997, .889, respectively). CONCLUSIONS: There was no significant difference in the amount of motion between an intact ulnar shaft, an ulnar shaft fracture with cortical apposition stabilized with a plate, and a plated comminuted fracture. These findings may help surgeons decide on their type of postoperative immobilization in the setting of isolated ulnar shaft fractures or ulnar shaft osteotomies stabilized with plate fixation.

Shear wave elastography demonstrates different material properties between the medial collateral ligament and anterolateral ligament.

BACKGROUND: Anterolateral ligament and medial collateral ligament injuries could happen concomitantly with anterior cruciate ligament ruptures. The anterolateral ligament is injured more often than the medial collateral ligament during concomitant anterior cruciate ligament ruptures although it offers less restraint to knee movement. Comparing the material properties of the medial collateral ligament and anterolateral ligament helps improve our understanding of their structure-function relationship and injury risk before the onset of injury. METHODS: Eight cadaveric lower extremity specimens were prepared and mechanically tested to failure in a laboratory setting using a hydraulic platform. Measurements of surface strains of superficial surface of each medial collateral ligament and anterolateral ligament specimen were found using three-dimensional digital image correlation. Ligament stiffness was found using ultrasound shear-wave elastography. t-tests were used to assess for significant differences in strain, stress, Young's modulus, and stiffness in the two ligaments. FINDINGS: The medial collateral ligament exhibited greater ultimate failure strain along its longitudinal axis (p = 0.03) and Young's modulus (p < 0.0018) than the anterolateral ligament. Conversely, the anterolateral ligament exhibited greater ultimate failure stress than the medial collateral ligament (p < 0.0001). Medial collateral ligament failure occurred mostly in the proximal aspect of the ligament, while most anterolateral ligament failure occurred in the distal or midsubstance aspect (P = 0.04). INTERPRETATION: Despite both being ligamentous structures, the medial collateral ligament and anterolateral ligament exhibited separate material properties during ultimate failure testing. The weaker material properties of the anterolateral ligament likely contribute to higher rates of concomitant injury with anterior cruciate ligament ruptures.

Optimal Distal Tendon Insertion Point for Elbow Flexion in Free-Functioning Gracilis Muscle Transfer for Panbrachial Plexus Injuries: A Cadaveric Study.

PURPOSE: Following pan-brachial plexus injuries, restoration of elbow flexion is widely accepted as the reconstructive priority. A gracilis free functioning muscle transfer (FFMT) can be used to restore elbow flexion alone with insertion into the biceps brachii (BIC) or brachioradialis (BRD) tendons or restore combined elbow and finger flexion with a more distal insertion into the flexor digitorum profundus (FDP) tendons. Using cadaveric experiments, we determined the peak instantaneous moment arm for each insertion option. METHODS: Six simulated gracilis transfer surgeries were performed using both arms of three fresh-frozen full body cadaveric specimens (age: 79 + 10 years. 2 female). The gracilis muscles from both legs were harvested and transferred to the contralateral upper extremity. The elbow was manually moved through three flexion-extension cycles while the instantaneous moment arm was calculated from measurements of gracilis excursion and elbow joint angle for the three distal insertion sites. RESULTS: Peak instantaneous moment arm for all three insertions occurred at an elbow angle between 83° to 92° with a magnitude ranging from 33 mm to 54 mm. The more distal (FDP/BRD) insertions produced a significantly greater (∼1.5 times) peak elbow flexion instantaneous moment arm compared to the BIC insertion. CONCLUSIONS: Based on the instantaneous moment arm, the gracilis FFMT distal insertion locations could result in greater reconstructed elbow flexion strength. In addition, direct measurement of the shape and magnitude of the moment arm curve for differing insertion sites allows high resolution surgical planning and model testing. CLINICAL RELEVANCE: This study presents the first direct experimental quantification of the gracilis FFMT instantaneous moment arm. The experimental evidence supports the use of FDP/BRD insertion locations by providing a quantitative explanation for the increased elbow flexion torque observed clinically in patients with a gracilis FFMT and distal FDP insertion.

Precise Limb Tourniquet Arterial Occlusion Pressure Determination using Real-Time Ultrasonography and a Capacitive-Based Force Sensor.

BACKGROUND: Hemorrhage control prior to shock onset is increasingly recognized as a time-critical intervention. Although tourniquets (TQs) have been demonstrated to save lives, less is known about the physiologic parameters underlying successful TQ application beyond palpation of distal pulses. The current study directly visualized distal arterial occlusion via ultrasonography and measured associated pressure and contact force. METHODS: Fifteen tactical officers participated as live models for the study. Arterial occlusion was performed using a standard adult blood pressure (BP) cuff and a Combat Application Tourniquet Generation 7 (CAT7) TQ, applied sequentially to the left mid-bicep. Arterial flow cessation was determined by radial artery palpation and brachial artery pulsed wave doppler ultrasound (US) evaluation. Steady state maximal generated force was measured using a thin-film force sensor. RESULTS: The mean (95% CI) systolic blood pressure (SBP) required to occlude palpable distal pulse was 112.9mmHg (109-117); contact force was 23.8N [Newton] (22.0-25.6). Arterial flow was visible via US in 100% of subjects despite lack of palpable pulse. The mean (95% CI) SBP and contact force to eliminate US flow were 132mmHg (127-137) and 27.7N (25.1-30.3). The mean (95% CI) number of windlass turns to eliminate a palpable pulse was 1.3 (1.0-1.6) while 1.6 (1.2-1.9) turns were required to eliminate US flow. CONCLUSIONS: Loss of distal radial pulse does not indicate lack of arterial flow distal to upper extremity TQ. On average, an additional one-quarter windlass turn was required to eliminate distal flow. Blood pressure and force measurements derived in this study may provide data to guide future TQ designs and inexpensive, physiologically accurate TQ training models.

Does proximal versus distal injury location of the medial ulnar collateral ligament of the elbow differentially impact elbow stability? An ultrasound-guided and robot-assisted biomechanical study.

BACKGROUND: The location (proximal vs. distal) of elbow medial ulnar collateral ligament (MUCL) tears impacts clinical outcomes of nonoperative treatment. The purposes of our study were to (1) determine whether selective releases of the MUCL could be performed under ultrasound (US) guidance without disrupting overlying soft tissues, (2) assess the difference in medial elbow stability for proximal and distal releases of the MUCL using stress US and a robotic testing device, and (3) elucidate the flexion angle that resulted in the greatest amount of medial elbow laxity after MUCL injury. METHODS: Sixteen paired, fresh-frozen elbow specimens were used. Valgus laxity was evaluated with both US and robotic-assisted measurements before and after selective MUCL releases. A percutaneous US-guided technique was used to perform proximal MUCL releases in 8 elbows and to perform distal MUCL releases in their matched pairs. The robot was used to determine the elbow flexion angle at which the maximum valgus displacement occurred for both proximally and distally released specimens. Open dissection was then performed to assess the accuracy of the percutaneous releases. RESULTS: Percutaneous US-guided releases were successfully performed in 15 of 16 specimens. The proximal release resulted in greater valgus angle displacement (11° ± 2°) than the distal release (8° ± 2°) between flexion angles of 30° and 70° (P < .0001 at 30°, P < .0001 at 40°, P = .001 at 50°, P = .005 at 60°, and P = .020 at 70°). Valgus displacement between release locations did not reach the level of statistical significance between 80° and 120° (P = .051 at 80°, P = .131 at 90°, P = .245 at 100°, P = .400 at 110°, and P = .532 at 120°). When we compared the values for the mean increase in US delta gap (stressed - supported state) from before to after MUCL release, the proximally released elbows had larger increases than the distally released elbows (5.0 mm proximal vs. 3.7 mm distal, P = .032). After MUCL release, maximum mean valgus displacement occurred at 49° of flexion. CONCLUSIONS: US-guided selective releases of the MUCL can be performed reliably without violating the overlying musculature. Valgus instability is not of greater magnitude for distal releases when compared with proximal releases. This findings suggests there must be alternative factors to explain the difference in clinical prognosis between distal and proximal tears. The observed flexion angle for maximum valgus laxity could have important implications for elbow positioning during US or fluoroscopic stress examination, as well as surgical repair or reconstruction of the MUCL.

Prospective Study Assessing Impact of Ethylene Oxide Sterilization on Endoscopic Ultrasound Image Quality.

BACKGROUND & AIMS: Duodenoscope-associated transmission of infections has raised questions about efficacy of endoscope reprocessing using high-level disinfection (HLD). Although ethylene oxide (ETO) gas sterilization is effective in eradicating microbes, the impact of ETO on endoscopic ultrasound (EUS) imaging equipment remains unknown. In this study, we aimed to compare the changes in EUS image quality associated with HLD vs HLD followed by ETO sterilization. METHODS: Four new EUS instruments were assigned to 2 groups: Group 1 (HLD) and Group 2 (HLD + ETO). The echoendoscopes were assessed at baseline, monthly for 6 months, and once every 3 to 4 months thereafter, for a total of 12 time points. At each time point, review of EUS video and still image quality was performed by an expert panel of reviewers along with phantom-based objective testing. Linear mixed effects models were used to assess whether the modality of reprocessing impacted image and video quality. RESULTS: For clinical testing, mixed linear models showed minimal quantitative differences in linear analog score (P = .04; estimated change, 3.12; scale, 0-100) and overall image quality value (P = .007; estimated change, -0.12; scale, 1-5) favoring ETO but not for rank value (P = .06). On phantom testing, maximum depth of penetration was lower for ETO endoscopes (P < .001; change in depth, 0.49 cm). CONCLUSIONS: In this prospective study, expert review and phantom-based testing demonstrated minimal differences in image quality between echoendoscopes reprocessed using HLD vs ETO + HLD over 2 years of clinical use. Further studies are warranted to assess the long-term clinical impact of these findings. In the interim, these results support use of ETO sterilization of EUS instruments if deemed clinically necessary.

Mechanical Assessment of Tissue Properties During Tourniquet Application.

INTRODUCTION: Successful tourniquet application increases survival rate of exsanguinating extremity hemorrhage victims. Tactile feedback during tourniquet application training should reflect human tissue properties in order to increase success in the field. This study aims to understand the mechanical properties of a human limb during tourniquet application. METHOD: Six cadaveric extremities-three uppers and three lowers-were tested from three body mass index groups: low (<19) healthy (19-24), and overweight (>24). Each specimen donned with a tourniquet and mounted to a servo-hydraulic testing machine, which enabled controlled tightening of the tourniquet while recording the tourniquet tension force and strap displacement. A thin-film pressure sensor placed between the specimen and the tourniquet recorded contact pressure. Each limb was tested with the tourniquet applied at two different sites resulting in testing at the upper arm, forearm, thigh, and shank. RESULTS: The load displacement curves during radial compression were found to be nonlinear overall, with identifiable linear regions. Average contact pressure under the tourniquet strap at 200N and 300N of tension force was 126.3 (σ = 41.2) mm Hg and 205.3 (σ = 75.3) mm Hg, respectively. There were no significant differences in tissue stiffness or contact pressure at 300N of tension force between limb (upper vs. lower) or body mass index. At 200N of tension, the upper limb had significantly higher contact pressure than the lower limb (P = 0.040). Relative radial compression was significantly different between upper (16.74, σ = 4.16%) and lower (10.15, σ = 2.25%) extremities at 200N tension (P = 0.005). CONCLUSIONS: Simulation of tissue compression during tourniquet application may be achieved with a material exhibiting elastic properties to mimic the force-displacement behavior seen in cadaveric tissue or with different layers of material. Different trainers for underweight, healthy, and overweight limbs may not be needed. Separate tourniquet training fixtures should be created for the upper and lower extremities.

Intrinsic Tendon Regeneration After Application of Purified Exosome Product: An In Vivo Study.

BACKGROUND: Tendons are primarily acellular, limiting their intrinsic regenerative capabilities. This limited regenerative potential contributes to delayed healing, rupture, and adhesion formation after tendon injury. PURPOSE: To determine if a tendon's intrinsic regenerative potential could be improved after the application of a purified exosome product (PEP) when loaded onto a collagen scaffold. STUDY DESIGN: Controlled laboratory study. METHODS: An in vivo rabbit Achilles tendon model was used and consisted of 3 groups: (1) Achilles tenotomy with suture repair, (2) Achilles tenotomy with suture repair and collagen scaffold, and (3) Achilles tenotomy with suture repair and collagen scaffold loaded with PEP at 1 × 1012 exosomes/mL. Each group consisted of 15 rabbits for a total of 45 specimens. Mechanical and histologic analyses were performed at both 3 and 6 weeks. RESULTS: The load to failure and ultimate tensile stress were found to be similar across all groups (P ≥ .15). The tendon cross-sectional area was significantly smaller for tendons treated with PEP compared with the control groups at 6 weeks, which was primarily related to an absence of external adhesions (P = .04). Histologic analysis confirmed these findings, demonstrating significantly lower adhesion grade both macroscopically (P = .0006) and microscopically (P = .0062) when tendons were treated with PEP. Immunohistochemical staining showed a greater intensity for type 1 collagen for PEP-treated tendons compared with collagen-only or control tendons. CONCLUSION: Mechanical and histologic results suggested that healing in the PEP-treated group favored intrinsic healing (absence of adhesions) while control animals and animals treated with collagen only healed primarily via extrinsic scar formation. Despite a smaller cross-sectional area, treated tendons had the same ultimate tensile stress. This pilot investigation shows promise for PEP as a means of effectively treating tendon injuries and enhancing intrinsic healing. CLINICAL RELEVANCE: The production of a cell-free, off-the-shelf product that can promote tendon regeneration would provide a viable solution for physicians and patients to enhance tendon healing and decrease adhesions as well as shorten the time required to return to work or sports.

Bankart repair alone in combined Bankart and superior labral anterior-posterior lesions preserves range of motion without compromising joint stability.

HYPOTHESIS: The purpose was to investigate joint stability and range of motion after a Bankart repair without superior labral anterior-posterior (SLAP) repair (termed "Bankart repair") and after combined Bankart and SLAP repairs (termed "combined repair"). METHODS: Eight fresh-frozen shoulders were used. Combined Bankart and SLAP lesions were created (10- to 6-o'clock positions). The labrum and capsule were repaired at the 2-o'clock, 3:30 clock-face, and 5-o'clock positions in the Bankart repair group and at the 11-o'clock, 1-o'clock, 2-o'clock, 3:30 clock-face, and 5-o'clock positions in the combined repair group. The internal- and external-rotation ranges of motion were determined with the arm positioned at 0° and 60° of glenohumeral abduction. The rotation angle was defined when a constant torque of 200 N-mm was applied. Joint stability was measured with a custom stability-testing device. The peak translational force in the anterior-posterior direction was measured with the arm at the end range of external rotation. RESULTS: External rotation angles were greater at 0° and 60° of abduction in the Bankart repair group than in the combined repair group (0° of abduction, P < .01; 60° of abduction, P < .05). The internal rotation angle was greater at 60° of abduction in the Bankart repair group than in the combined repair group (P < .01). The stability between the 2 groups was not significantly different (P = .60). CONCLUSION: In patients with combined Bankart and SLAP lesions and the need for a wide range of motion, a Bankart repair alone may provide a greater range of motion without compromising the joint stability at the end range compared with a combined repair.

The Biomechanical Consequences of Trapeziectomy and Partial Trapezoidectomy in the Treatment of Thumb Carpometacarpal and Scaphotrapeziotrapezoid Arthritis.

PURPOSE: To determine, using a biomechanical cadaveric model, whether, in the treatment of thumb carpometacarpal and scaphotrapeziotrapezoid arthritis, partial trapezoid resection following trapeziectomy causes carpal, specifically lunocapitate and scapholunate, instability. METHODS: Eight fresh-frozen mid-forearm cadaver specimens with type I lunates and devoid of basilar thumb arthritis were used in the study. Specimens were mounted onto a wrist simulator applying cyclical wrist flexion/extension and radial/ulnar deviation motions. Carpal kinematics, specifically lunocapitate and scapholunate joint relationships, were measured at 4 different conditions: (1) a native intact state, (2) after trapeziectomy, (3) after 2-mm partial trapezoid resection, and (4) after 4-mm partial trapezoid resection. RESULTS: During both flexion/extension and radial/ulnar deviation of the wrist, the lunocapitate and scapholunate joint relationship did not show any notable change following any of trapeziectomy, 2-mm, or 4-mm trapezoid resection compared with the intact state. Changes to the lunocapitate and scapholunate angles were clinically insignificant-a maximum of 6° and 4° change, respectively. CONCLUSIONS: This biomechanical cadaveric study shows that performing a trapeziectomy followed by up to 4 mm of proximal trapezoid resection has a negligible effect upon carpal, specifically lunocapitate and scapholunate, stability. Further research is needed to elucidate the long-term clinical consequences of limited trapezoid resection in vivo. CLINICAL RELEVANCE: There may be no clinically relevant effects of resection of up to 4 mm of trapezoid in the surgical management of combined basilar thumb and scaphotrapeziotrapezoid arthritis.

The Effect of Proximal Hamate Osteotomy on Carpal Kinematics for Reconstruction of Proximal Pole Scaphoid Nonunion With Avascular Necrosis.

Background: The purpose of this study is to determine the effects of proximal hamate transfer for proximal pole scaphoid reconstruction upon carpal kinematics. Methods: Eight fresh-frozen cadaveric wrists underwent evaluation of their radiocarpal and midcarpal motion after proximal hamate osteotomy. A wrist simulator was used to apply cyclical tension to the flexor carpi ulnaris (FCU), flexor carpi radialis (FCR), extensor carpi ulnaris (ECU), and extensor carpi radialis longus and brevis stitched together (ECR). Kinematic motion was captured using Moiré Phase Tracking 3-dimensional motion-tracking sensors (MPT, Metria Innovation, Inc, Milwaukee, Wisconsin) to evaluate the lunocapitate and scapholunate angles for each condition. Results: During wrist flexion-extension and radial-ulnar deviation, there were no statistically significant differences about the lunocapitate or scapholunate axis between the intact and post-hamate osteotomy conditions. Conclusions: The harvest of the proximal hamate for proximal pole scaphoid reconstruction does not appear to adversely affect wrist kinematics.

The effect of subscapularis muscle contraction on coaptation of anteroinferior glenohumeral ligament-labrum complex after Bankart repair.

Facilitation of healing is important for the anteroinferior glenohumeral ligament-labrum complex (AIGHL-LC) after Bankart repair in shoulder dislocation. The purpose of this study was to investigate the effect of subscapularis muscle loading on contact area and contact pressure between the subscapularis and AIGHL-LC and between the glenoid bone and the AIGHL-LC following Bankart repair. Twenty-two fresh-frozen cadaveric shoulders were used. They were attached to a shoulder-positioning device to which a compression force was applied. Loads applied to the supraspinatus, infraspinatus, and teres minor tendons were held constant. The loads applied to the subscapularis tendon were set at 0, 10, 20, and 30 Newton (N). Contact pressure and area between the subscapularis and the AIGHL-LC were measured with the arm at 4 rotational positions: 60° and 30° internal, neutral, and 30° external. After the Bankart lesion was created, the contact area and pressure between the AIGHL-LC and glenoid bone were measured while Bankart repair was performed with or without loading of the subscapularis. The contact area and pressures with 10, 20, and 30 N of subscapularis loadings were significantly greater than with 0 N of subscapularis loading at 60° internal rotation and 30° external rotation (P < .05). After Bankart repair, contact area and pressure with subscapularis loading between the AIGHL-LC and glenoid bone were significantly greater than without subscapularis loading (P < .01). We conclude that isometric contraction exercises of the subscapularis might facilitate healing of the AIGHL-LC after Bankart repair.

Articular Contact Area and Pressure in Posteromedial Rotatory Instability of the Elbow.

BACKGROUND: Joint incongruity in posteromedial rotatory instability (PMRI) has been theorized to determine early articular degenerative changes. Our hypothesis was that the articular contact area and contact pressure differ significantly between an intact elbow and an elbow affected by PMRI. METHODS: Seven cadaveric elbows were tested under gravity varus stress using a custom-made machine designed to simulate muscle loads and allow passive elbow flexion (0° to 90°). The mean contact area and contact pressure data were collected and processed using the Tekscan sensor and software. After testing the intact specimen (intact elbow), a PMRI injury was simulated (PMRI elbow) and the specimen was tested again. RESULTS: The PMRI elbows were characterized by initial joint subluxation and significantly elevated articular contact pressure. Both worsened, corresponding with a reduction in contact area, as the elbow was flexed from 0° until the joint subluxation and incongruity spontaneously reduced (at a mean [and standard error] of 60° ± 5° of flexion), at which point the mean contact pressure decreased from 870 ± 50 kPa (pre-reduction) to 440 ± 40 kPa (post-reduction) (p < 0.001) and the mean contact area increased from 80 ± 8 mm to 150 ± 58 mm (p < 0.001). This reduction of the subluxation was also followed by a shift of the contact area from the coronoid fracture edge toward the lower portion of the coronoid. At the flexion angle at which the PMRI elbows reduced, both the contact area and the contact pressure of the intact elbows differed significantly from those of the PMRI elbows, both before and after the elbow reduction (p < 0.001). CONCLUSIONS: The reduction in contact area and increased contact pressures due to joint subluxation and incongruity could explain the progressive arthritis seen in some elbows affected by PMRI. CLINICAL RELEVANCE: This biomechanical study suggests that the early degenerative changes associated with PMRI reported in the literature could be subsequent to joint incongruity and an increase in contact pressure between the coronoid fracture surface and the trochlea.

Contribution of the Ligamentum Teres to Hip Stability in the Presence of an Intact Capsule: A Cadaveric Study.

PURPOSE: To determine the contribution of the ligamentum teres (LT) to hip stability in the presence of an intact capsule with special attention to the change in range of motion and femoral head translation. METHODS: Seven fresh-frozen cadaveric pelvises were used. Following visual inspection of the LT at different hip positions, internal rotation angles were measured at 10° of extension and at 0° of flexion, while external rotation was measured at 60°, 90°, and 110° of flexion with different hip abduction angles using electromagnetic motion tracking sensor. Femoral head translations were measured simultaneously. The tests were repeated after resection of the LT. The capsule was left intact for all test conditions. The results were compared between intact and LT resected conditions when torque of 2 and 4 Nm was applied. RESULTS: Compared with the intact hip, the LT resected hip showed no significant difference when 2 Nm torque was applied in all scenarios. With 4 Nm torque application, significant increase in external rotation was found at 60° and at 90° of flexion (1.7° ± 0.8° and 2.1° ± 1.0°, respectively). Significant difference was also noted at 60°, 90°, and 110° of flexion when the hip was in the adducted position while at 90° in the abducted hip. However, LT resection did not show significant change in internal rotation. There was no significant difference in the translation distance of the femoral head in the intact hip compared with the LT resected hip (0.77-1.11 mm vs 0.79-1.29 mm). CONCLUSIONS: Our results indicate that within the physiologic range of motion, LT can minimally limit external rotation when the hip is in the flexed position but does not contribute to translation stability. CLINICAL RELEVANCE: In the hip with intact capsule, LT deficiency can result in a slight increase in range of motion, but its contribution to stability is questionable.

Experience Influences the Agreement and Reliability of Tibial Component Positioning in Total Knee Arthroplasty.

BACKGROUND: Poor rotation of the tibial component is associated with unfavorable total knee arthroplasty outcomes. Some surgeons utilize the tibial tubercle (TT method), while others utilize the femoral cam (Box method) as a rotational landmark during total knee arthroplasty. Our purpose is to determine the reproducibility of 2 methods for establishing intra-operative tibial component rotation, while also comparing the effect of level of training. METHODS: Twelve surgeons positioned and sized a symmetric tibial component on 7 cadaver knees. Surgeons were allowed to utilize their preferred method for establishing tibial component rotation. Seven surgeons selected the TT method, 4 utilized the Box method, and 1 used both methods depending on the specimen. Repeat measurements were completed by each surgeon after a rest period. The differences between tibial tray positions were assessed using computer-assisted optoelectronic measurements. Intra-class correlation coefficients were calculated to determine inter-observer agreement (IOA) and intra-rater reliability (IRR). RESULTS: Overall, both the Box method and the TT method demonstrated high IRR for tibial component rotation. Experienced surgeons were more consistent at establishing component rotation regardless of technique. Trainees were more consistent when utilizing the Box method (IRR 0.96, IOA 0.94) than the TT method (IRR 0.71, IOA 0.72). CONCLUSION: Surgeon experience influences the agreement and reliability of tibial component position. For less experienced surgeons, the Box method was more effective than the TT method for consistently reproducing tibial component rotation.

Quantifying extensibility of rotator cuff muscle with tendon rupture using shear wave elastography: A cadaveric study.

Surgical repair for large rotator cuff tear remains challenging due to tear size, altered muscle mechanical properties, and poor musculotendinous extensibility. Insufficient extensibility might lead to an incomplete reconstruction; moreover, excessive stresses after repair may result in repair failure without healing. Therefore, estimates of extensibility of cuff muscles can help in pre-surgical planning to prevent unexpected scenarios during surgery. The purpose of this study was to determine if quantified mechanical properties of the supraspinatus muscle using shear wave elastography (SWE) could be used to predict the extensibility of the musculotendinous unit on cadaveric specimens. Forty-five fresh-frozen cadaveric shoulders (25 intact and 20 with rotator cuff tear) were used for the study. Passive stiffness of 4 anatomical regions in the supraspinatus muscle was first measured using SWE. After detaching the distal edge of supraspinatus muscle from other cuff muscles, the detached muscle was axially pulled with the scapula fixed. The correlation between the SWE modulus and the extensibility of the muscle under 30 and 60N loads was assessed. There was a significant negative correlation between SWE measurements and the experimental extensibility. SWE modulus for the anterior-deep region in the supraspinatus muscle showed the strongest correlation with extensibility under 30N (r=0.70, P<0.001) and 60N (r=0.68, P<0.001). Quantitative SWE assessment for the supraspinatus muscle was highly correlated with extensibility of musculotendinous unit on cadaveric shoulders. This technique may be used to predict the extensibility for rotator cuff tears for pre-surgical planning.

Coronoid reconstruction using osteochondral grafts: a biomechanical study.

HYPOTHESIS: The purposes of this study were to test the hypothesis that coronoid deficiency in the setting of posteromedial rotatory instability (PMRI) must be reconstructed to restore articular contact pressures to normal and to compare 3 different osteochondral grafts for this purpose. METHODS: After creation of a anteromedial fracture, six cadaveric elbows were tested under gravity varus stress using a custom-made machine designed to simulate muscle loads and to passively flex the elbow. Mean articular surface contact pressure data were collected and processed using TekScan sensors and software. After testing of the intact specimen (intact condition), a PMRI injury was created (PMRI condition). Testing was repeated after reconstruction of the lateral collateral ligament (LCL) (LCL-only condition), followed by reconstruction of the coronoid with 3 different osteochondral graft techniques (reconstructed conditions). RESULTS: Contact pressure was consistently significantly higher in the PMRI elbow compared with the intact, LCL-only, and reconstructed conditions (P < .006). The LCL-only elbow contact pressure was significantly higher than that of the intact and reconstructed conditions from 5° to 55° of flexion (P = .018). The contact pressure of the intact elbow was never significantly different from that of the reconstructed elbow, except at 5° of flexion (P ≤ .008). No significant difference was detected between each of the reconstructed techniques (P ≥ .15). However, the annular surface of the radial head was the only graft that yielded contact pressures not significantly different from normal at any flexion angle. CONCLUSION: Isolated reconstruction of the LCL did not restore native articular surface contact pressure, and reconstruction of the coronoid using osteochondral graft was necessary. There was no difference in contact pressures among the 3 coronoid reconstruction techniques.

Role of the lateral collateral ligament in posteromedial rotatory instability of the elbow.

BACKGROUND: Posteromedial rotatory instability (PMRI) of the elbow consists of an anteromedial coronoid fracture with lateral collateral ligament (LCL) and posterior bundle of the medial collateral ligament (PMCL) tears. We hypothesized that the LCL tear is required for elbow subluxation/joint incongruity and that an elbow affected by an anteromedial subtype 2 coronoid fracture and a PMCL tear exhibits contact pressures different from both an intact elbow and an elbow affected by PMRI. MATERIALS AND METHODS: Six cadaveric elbows were tested under gravity varus stress using a custom-made machine designed to simulate muscle loads and to passively flex the elbow from 0° to 90° and measure joint contact pressures. After testing of the intact specimen (INTACT-elbow), an anteromedial subtype 2 coronoid fracture with a PMCL tear (COR+PMCL-elbow) and a PMRI injury (PMRI-elbow), after adding an LCL tear, were tested. The highest values of mean contact pressure were used for the comparison among the 3 groups. RESULTS: Neither subluxation nor joint incongruity was observed in the COR+PMCL-elbow. The addition of an LCL detachment consistently caused subluxation and joint incongruity. Mean contact pressures were higher in the COR+PMCL-elbow compared with the INTACT-elbow (P < .03) but lower than in the PMRI-elbow (P < .001). CONCLUSIONS: The LCL lesion in PMRI is necessary for elbow subluxation and causes marked elevations in contact pressures. Even without subluxation, the COR+PMCL-elbow showed higher contact pressures compared with the INTACT-elbow. Treatment of PMRI should be directed toward prevention of joint incongruity, whether by surgical or nonsurgical means, to prevent high articular contact pressures.

Repairing the Capsule to the Transferred Coracoid Preserves External Rotation in the Modified Latarjet Procedure.

BACKGROUND: It is not clear whether the anterior capsule should be repaired to the coracoid process or to the native glenoid during the modified Latarjet procedure. We investigated joint stability and range of motion of the shoulder after the modified Latarjet procedure with both of these methods of capsular repair. METHODS: Eighteen fresh-frozen cadaveric shoulders were used. After a Bankart lesion and 6-mm glenoid defect were created, the coracoid process was transferred to the glenoid and fixed with screws. The anterior capsule was repaired either to the coracoid process (coracoid group) or to the native glenoid (glenoid group). The ranges of internal and external axial rotation were measured with the arm at 0° and 60° of glenohumeral abduction. The range of motion was measured with a constant torque of 200 N-mm. Joint stability was measured using a custom stability testing device. The stability ratio in the anterior-posterior direction was measured with the arm at maximal external rotation and neutral rotation. RESULTS: The range of external rotation was greater at both 0° and 60° of abduction in the coracoid group compared with the glenoid group (p < 0.05). The range of internal rotation was not significantly different between groups. The end-range stability ratio was not significantly different between groups, but the mid-range stability ratio was significantly greater in the glenoid group. CONCLUSIONS: Because the difference in the mid-range stability may not be clinically relevant, we recommend repairing the capsule to the coracoid, as that preserves the range of motion in external rotation. CLINICAL RELEVANCE: Repairing the capsule to the transferred coracoid during the modified Latarjet procedure appears to be beneficial to avoid the limited range of motion in external rotation, but the direct contact of the humeral head and the transferred coracoid might confer a risk of osteoarthritis. Long-term consequences in the clinical setting need to be clarified.