Deficits in Contralateral Limb Strength Can Overestimate Limb Symmetry Index After Anterior Cruciate Ligament Reconstruction.

Purpose: To evaluate whether contralateral limb strength represents a dynamic, rather than static, data point after anterior cruciate ligament reconstruction (ACL-R). Methods: Patients who underwent isolated ACL-R at a single institution were identified. Patients completed an institutional Lower-Extremity Assessment Protocol (LEAP) testing protocol at 6 and 9 months postoperatively. Extension strength and flexion strength of the ipsilateral and contralateral limbs and limb symmetry index (LSI) were compared between the 6- and 9-month testing outcomes. Subgroup analysis compared patients demonstrating less than or greater than 10% change in contralateral limb flexion and extension strength between 6 and 9 months postoperatively. Results: A total of 144 subjects were included in this study. On average, contralateral limb flexion and extension strength increased 2-4% between 6 and 9 months postoperatively. However, the contralateral limb increased >10% from 6 to 9 months in extension and flexion strength in 35/144 (24.3%) and 55/144 (38.2%) of patients, respectively. The cohort with >10% change between 6 and 9 months had significantly weaker contralateral extension and flexion strength at 6 months compared to the cohort that demonstrated <10% change (extension: 2.00 vs 2.39; P < .001; flexion: 0.84 vs 1.08; P < .001), but similar ipsilateral limb performance. Therefore, the >10% change cohort had a significantly greater LSI at 6 months compared to the <10% change cohort (67.3% vs 59.4%; P = .006). No demographic or operative factors correlated with which patients demonstrated >10% flexion or extension strength changes of the contralateral limb. Conclusion: A large percentage of patients demonstrate significant changes in their contralateral limb flexion and extension strength between 6 and 9 months postoperatively that result from an initial contralateral limb strength deficit. This may limit the utility of the contralateral limb as a control for comparison to the operative extremity during return to sport assessment.

Risk Factors, Management, and Prognosis of Brachial Plexopathy Following Reverse Total Shoulder Arthroplasty.

Brachial plexus injuries can have a significant impact on patient outcomes following RTSA by slowing the overall recovery and return of function. Risk factors for brachial plexopathy include traction injury related to arm positioning and exposure during the procedure, direct nerve injury from surgical dissection, and compression injury from retractor placement. Risk of nerve injury can be minimized by limiting the time spent with the arm extended and externally rotated and avoiding excessive traction on the arm during humeral preparation and implant insertion. Prompt identification of postoperative brachial plexopathy is important to optimize the recovery of function.

Motion and Strength Analysis of 2-Tine Staple and K-Wire Fixation in Scapholunate Ligament Stabilization in a Cadaver Model.

Purpose: Previous studies have demonstrated the benefits of 2- and 4-tine staple fixation in scapholunate interosseous ligament (SLIL) reconstruction, including improved rotational control and avoidance of the articular surface. This study compared scaphoid and lunate kinematics after SLIL fixation with traditional Kirschner wire (K-wire) fixation or 2-tine staple fixation. Methods: Eight fresh frozen cadaver arms with normal scapholunate (SL) intervals were included. Infrared motion capture was used to assess kinematics between the scaphoid and lunate as the wrists were moved through a simulated dart-throw motion. Kinematic data were recorded for each wrist in 4 states: SLIL intact, SLIL sectioned, K-wire fixation across SL interval and scaphocapitate joint, and 2-tine Nitinol staple fixation across SL interval. Strength of the SL staple fixation was evaluated using an axial load machine to assess load to failure of the staple construct. Results: Range of motion of the scaphoid and lunate with SLIL intact and SLIL sectioned were similar. K-wire fixation across the SL interval significantly decreased the overall wrist range of motion as well as scaphoid and lunate motion in all planes except for scaphoid flexion. Conversely, scaphoid and lunate motion after staple fixation was similar to that in normal wrists, except for a significant decrease in scaphoid extension. Under axial load simulating a ground-level fall, 3 of 8 arms demonstrated no failure, and none of the failures was due to direct failure of the 2-tine staple. Conclusions: This study demonstrates 2-tine staple fixation across the SL interval is effective in providing initial stability and maintaining physiologic motion of the scaphoid and lunate compared with K-wire fixation after SLIL injury. Clinical relevance: This study demonstrates an alternate technique for the stabilization of the SL interval in repair of acute SLIL injuries using 2-tine staple fixation, which maintains near physiologic motion of the scaphoid and lunate after SLIL injury.

Small, Short, Oblique Patellar Tunnels for Patellar Fixation Do Not Increase Fracture Risk or Complications in MPFL Reconstruction: A Retrospective Cohort Study.

BACKGROUND: Large (4.5 mm) and/or transpatellar bone tunnels have been associated with patellar fracture after medial patellofemoral ligament (MPFL) reconstruction. To avoid this outcome, many surgeons now employ suture anchors to affix the MPFL graft to the patella. PURPOSE: To evaluate the risk of patellar fracture and other outcomes associated with smaller (3.2-mm), short, oblique patellar tunnels as compared with suture anchor fixation in MPFL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A single institution's electronic medical record was queried for all patients undergoing MPFL reconstruction between March 2010 and December 2018. A chart review of operative reports was utilized to identify those who had undergone MPFL reconstruction. Patients undergoing revision MPFL reconstruction or reconstruction with fully transpatellar bone tunnels were excluded. The incidence of patellar fracture and outcomes were evaluated from chart review. The mean duration of follow-up was >2 years. RESULTS: A total of 384 knees in 352 patients undergoing primary MPFL reconstruction were identified. Small (3.2-mm), short, oblique tunnels were used for patellar fixation in 215 cases, and suture anchors were utilized in 169 cases. The small, oblique tunnels and suture anchor techniques both resulted in a low incidence of patellar fracture, with rates of 0.47% and 0%, respectively. The use of suture anchors was associated with an increased risk of subluxation or dislocation compared with small, oblique tunnels (odds ratio, 3.98; P = .028). No significant difference was found in the need for revision MPFL reconstruction surgery with suture anchors (odds ratio, 1.925; P = .66). CONCLUSION: The use of small, oblique tunnels with hamstring autograft is a safe means of patellar fixation in MPFL reconstruction. The use of small, oblique tunnels for patellar fixation versus 2 suture anchors can result in material cost savings with no significantly increased risk for fracture as well as an overall reduction in complication rates.

High Energy Midfoot Fracture-Dislocations: Does Staged Treatment with External Fixation Help?

This study analyzes the outcomes of patients treated for high energy midfoot injuries with temporary stabilization (TS) prior to definitive operative fixation compared to a control group (C) treated initially with splint only. Three Level 1 trauma centers reduced and temporized high energy Lisfranc injuries. A matched control group was compared with the intervention group. Clinical parameters, complications and need for additional surgery were evaluated. There were 15 patients in group C and 29 patients with temporary stabilization (TS). Both the TS and C groups demonstrated no significant difference in the number of additional operations, infection rate, incidence of deep vein thrombosis (DVT), nonunion and need for orthotics postoperatively (p > 0.05). Staged treatment of high energy Lisfranc injuries in the TS group led to a delay in definitive fixation or arthrodesis while having a similar minimal complication rate relative to the controls. This is a Level III, Retrospective Case Control Study. (Journal of Surgical Orthopaedic Advances 29(3):154-158, 2020).

High-Energy Midfoot Fracture-Dislocations: Staged Treatment With an External Fixator.

The purpose of this study was to analyze the clinical outcomes of patients treated for high-energy midfoot (Lisfranc) injuries with initial temporization of an external fixator before definitive fixation. A retrospective chart review at two level 1 trauma centers was completed. Clinical parameters including demographics and comorbidities were evaluated in addition to hospital and clinical data. Time to full weight bearing took an average of 4.4 months, and with the numbers available no significant difference (p < .05) was found between the open reduction and internal fixation (ORIF) group and the arthrodesis group in regard to length of stay, days from initial reduction with an external fixator to definitive fixation, time to full weight bearing, or return to work. Staged treatment of high-energy Lisfranc injuries with external fixation demonstrated minimal soft tissue complications similar to other series reported in the literature. Definitive stabilization with either ORIF or arthrodesis produced similar results in staged treatment of these injuries. (Journal of Surgical Orthopaedic Advances 28(1):24-30, 2019).