Autologous Osteoligamentous Reconstruction of Scaphoid Proximal Pole With Metatarsal Head and Collateral Ligament: Cadaver Anatomic Description of Novel Surgical Technique.

Background: Historically, scaphoid nonunion has been surgically treated with vascularized bone graft taken from multiple different anatomic sites. However, none of these grafts fully recapitulate the unique osteoligamentous anatomy of the proximal pole of the scaphoid and the attachment of the scapholunate ligament (SLIL). We studied the anatomy of the vascularized second metatarsal head with its lateral collateral ligament as a potential novel treatment of proximal pole scaphoid nonunion with collapse. Methods: Scaphoids and second metatarsal heads were harvested from bilateral upper and lower extremities of 18 fresh frozen cadavers (10 male, 8 female) for a total of 36 scaphoids and 36 second metatarsal heads. The ipsilateral second metatarsal head was harvested with its lateral collateral ligament and its blood supply from the second dorsal metatarsal artery (SDMA). Measurements of the scaphoid, the SLIL, the second metatarsal head, and lateral collateral ligaments were compared to matched limbs from the same cadaver. Results: The anatomic dimensions of the second metatarsal head with its lateral collateral ligament are similar to the scaphoid proximal pole and the SLIL in matched cadaveric specimen. Conclusions: This anatomic cadaver study reveals that the second metatarsal head with its associated lateral collateral ligament is a well-matched donor to reconstruct the proximal pole of the scaphoid and SLIL. This anatomic similarity may be well suited to treat nonunion of the scaphoid proximal pole with or without avascular necrosis with simultaneous reconstruction of the SLIL. The authors describe a technique of vascularized reconstruction of the osteoligamentous proximal pole of the scaphoid with its attached SLIL utilizing autologous second metatarsal head with its attached lateral collateral ligament. Based on this cadaver study, this technique merits consideration.

Evaluation of the Intact Anterior Talofibular and Calcaneofibular Ligaments, Injuries, and Repairs With and Without Augmentation: A Biomechanical Robotic Study.

BACKGROUND: Acute ankle sprains are common injuries. The anterior talofibular (ATFL) and calcaneofibular ligaments (CFL) are the most injured lateral structures. However, controversy exists on the optimal surgical treatment when the injury is both acute and severe or becomes chronic and unstable. Studies have evaluated the biomechanics of these ligaments, but no studies have robotically evaluated injury effects and surgical treatment of ATFL or ATFL and CFL injuries. PURPOSE: To quantitatively evaluate biomechanical effects of ATFL and CFL lesions, ATFL repair, ATFL and CFL repair, and augmentation of ATFL on ankle stability. STUDY DESIGN: Controlled laboratory study. METHODS: Ten nonpaired cadaveric ankles were tested using a 6 degrees of freedom robot. Each ankle underwent testing in the following states sequentially: (1) intact, (2) ATFL cut, (3) CFL cut, (4) ATFL repair + CFL cut, (5) ATFL repair + CFL repair, and (6) ATFL repair with augmentation with suture tape + CFL repair. Testing included 88 N anterior drawer and 5 N·m varus talar tilt tests at 0° and 30° of plantarflexion, and 88 N Cotton test at 0° of plantarflexion. RESULTS: After all surgical treatments ankles still had increased laxity compared with intact state testing, except after augmented ATFL repair + CFL repair in anterior drawer testing at 30° of plantarflexion (P = .393). Sectioning the CFL caused a significant increase in talar tilt compared with the ATFL cut state at 0° (P < .001) and 30° of plantarflexion (P < .001), but no increase in anterior drawer or Cotton tests. CONCLUSION: Complete native stability may not be attainable at time zero repair with the tested treatments. The option that best returned stability in anterior translation was augmented ATFL repair with nonaugmented CFL repair. The importance of the CFL as a primary ligamentous stabilizer for talar tilt was confirmed. CLINICAL RELEVANCE: Evaluating lateral ankle stability and treatment with a 6 degrees of freedom robot should help delineate optimal treatment options. Findings in this study show that none of the repair methods at time zero restored kinematics to the intact state. Of the tested states, the augmented ATFL repair with CFL repair was the best option for controlling anterior translation at time zero. The importance of addressing the CFL to correct talar tilt instability was suggested as was the importance of a period of immobilization before beginning protected rehabilitation. The benefit of ATFL repair augmentation with suture tape is in limiting the postoperative motion in an anterior drawer motion to just 0.5 to 1 mm, but there was no significant improvement to talar tilt even with CFL repair, suggesting that further consideration should be given to CFL augmentation in future studies.

A prospective evaluation of platelet function in patients on antiplatelet therapy with traumatic intracranial hemorrhage.

BACKGROUND: Platelet transfusion is increasingly used in patients with traumatic intracranial hemorrhage (ICH) on aspirin therapy to minimize the progression of ICH. We hypothesized (null) that platelet transfusion in this cohort of patients does not improve platelet function. METHODS: We performed a prospective interventional trail on patients with traumatic ICH on daily high-dose (325 mg) aspirin therapy. All patients received one pack of apheresis platelets. Blood samples were collected before and 1 hour after platelet transfusion. Platelet function was assessed using Verify Now Platelet Function Assay, and a cutoff of greater than 550 aspirin reaction units was used to define functioning platelets (FP). RESULTS: Twenty-eight patients were enrolled in the study. On presentation, 79% (22 of 28) of the patients had nonfunctioning platelets (NFPs), and transfusion of platelets did not improve platelet function as 81% (18 of 22) still had NFP. Of the 22 patients, 4 converted from NFP to FP after transfusion. There was no difference in the progression of ICH (37.5% vs. 30%, p = 0.7) or neurosurgical intervention (12.5% vs. 15%, p = 0.86) between patients with FP and NFP after platelet transfusion. CONCLUSION: Administration of one pack of apheresis platelet did not improve platelet function. In our study, progression of ICH and the need for neurosurgical intervention were independent of platelet function. Further randomized clinical trials are required to assess both the dose dependence effect and role of platelet transfusion in patients on antiplatelet therapy with traumatic ICH. LEVEL OF EVIDENCE: Therapeutic study, level III.