Posterior Rotational and Translational Stability in Acromioclavicular Ligament Complex Reconstruction: A Comparative Biomechanical Analysis in Cadaveric Specimens.

BACKGROUND: Persistent posterior instability of the acromioclavicular (AC) joint is a reported complication after isolated coracoclavicular (CC) reconstruction. Thus, multiple techniques have been proposed attempting to restore biomechanics of the AC ligament complex (ACLC). PURPOSE/HYPOTHESIS: The purpose was to evaluate the posterior translational and rotational stability of an ACLC reconstruction with a dermal allograft (ACLC patch) as compared with 3 suture brace constructs. It was hypothesized that the ACLC patch would better restore AC joint posterior stability. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 28 cadaveric shoulders (mean ± SD age, 57.6 ± 8.3 years) were randomly assigned to 1 of 4 surgical techniques: ACLC patch, oblique brace, anterior brace, and x-frame brace. The force and torque to achieve 10 mm of posterior translation and 20° of posterior rotation of the AC joint were recorded in the following conditions: intact, transected ACLC, ACLC patch/brace repair, ACLC patch/brace repair with dissected CC ligaments, and ACLC patch/brace repair with CC ligament repair. RESULTS: For posterior translation, transection of the ACLC reduced resistance to 16.7% of the native. With the native CC ligaments intact, the ACLC patch (59.1%), oblique brace (54.1%), and anterior brace (60.7%) provided significantly greater stability than the x-frame brace (33.2%; P < .001, P = .008, P < .001, respectively). ACLC patch, oblique brace, and anterior brace continued to have significantly higher posterior translational resistance than the x-frame (35.1%; P < .001, P = .003, P < .001) after transection and subsequent CC ligament repair. For posterior rotation, transection of the ACLC decreased the resistance to 5.4% of the intact state. With the CC ligaments intact, the ACLC patch (77.1%) better restored posterior rotational stability than the oblique (35.3%), anterior (48.5%), and x-frame (23.0%) brace repairs (P < .001, P = .002, P < .001). CC ligament transection and subsequent repair demonstrated the ACLC patch (41.0%) to have improved stability when compared with the oblique (16.0%), anterior (14.0%), and x-frame (12.7%) repairs (P = .006, P = .003, P = .002). CONCLUSION: ACLC reconstruction with a dermal allograft better restored native posterior rotational stability than other brace constructs, with translational stability similar to the oblique and anterior brace technique at the time of surgery. CLINICAL RELEVANCE: Horizontal stability of the AC joint is primarily controlled by the ACLC. Inability to restore AC joint biomechanics can result in persistent posterior instability and lead to functional impairment.

Pediatric Sports Medicine Injuries: Common Problems and Solutions.

The treatment of sports injuries in the skeletally immature has a unique set of complications. Growth deformity may occur after anterior cruciate ligament reconstruction; therefore, skeletal age is used to help guide the choice between physeal sparing and transphyseal techniques. Arthrofibrosis after tibial spine fracture fixation can be reduced by initiating immediate range of motion, and should be treated early and cautiously to avoid iatrogenic fracture. Nonunions of medial epicondyle elbow fractures are more common with nonoperative treatment, but seldom lead to clinical problems outside of certain athletes. Risks of OCD fixation are specific to the material of screw used.

Treatment of ACL Tears in the Skeletally Immature Patient.

The understanding and treatment of anterior cruciate ligament tears in skeletally immature patients continues to evolve. While conservative management was a mainstay of treatment, poor outcomes have led to several surgical techniques aimed at stabilizing the knee, optimizing outcome, and minimizing the chance of growth disturbance. Current techniques have, in large part, accomplished these goals but challenges remain. Looking to the future, different graft options, primary repair techniques, and rigorous prospective studies will help improve outcomes for this challenging patient population.

Risk Factors for Manipulation Under Anesthesia and/or Lysis of Adhesions After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: In the currently published literature, a higher risk for developing arthrofibrosis after anterior cruciate ligament (ACL) reconstruction has been reported for female patients, adolescents, early surgery or concomitant procedures, and the use of a patellar tendon autograft. There is a lack of evidence regarding other graft choices or factors. HYPOTHESIS: Multiple risk factors will play a significant role in the development of arthrofibrosis after ACL reconstruction. Specifically, we hypothesized that the risk of manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) would be affected by graft choice and patient demographic factors. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: The charts of all patients who underwent ACL reconstruction over a 10-year period at a single academic institution were queried from an electronic medical record database and reviewed at a minimum of 6 months after ACL reconstruction, with the collection of demographic and surgical data. The relative risk for undergoing MUA and/or LOA was calculated for each analyzed risk factor. RESULTS: A total of 2424 ACL reconstructions were included, with a chart review at a mean of 56.7 months after surgery (range, 7.6-124.0 months). The rate of MUA and/or LOA for arthrofibrosis was 4.5%. A statistically significantly increased relative risk was found for infection (5.45), hematoma requiring evacuation (3.55), ACL reconstruction with meniscal repair (2.83), use of a quadriceps tendon autograft (2.68), age <18 years (2.39), multiple concomitant procedures (1.69), contact injury (1.62), female sex (1.60), and surgery within 28 days of injury (1.53), and a statistically significantly decreased relative risk was found for revision ACL reconstruction (0.30), age >25 years (0.34), and use of a tibialis anterior allograft (0.36). In the multivariate regression model, the use of a quadriceps tendon autograft (P = .00007), infection (P = .00126), and concomitant meniscal repair (P = .00194) were independent risk factors, whereas revision ACL reconstruction (P = .0024) was an independent protective factor. CONCLUSION: Graft type, infection, concomitant meniscal repair, and primary reconstruction are significant risk factors for undergoing MUA or LOA after ACL reconstruction.

Nonoperative treatment approach to knee osteoarthritis in the master athlete.

CONTEXT: Middle-age and elderly participants in athletic activities frequently encounter the chronic disabling process of osteoarthritis. Knowledge of the treatment of knee osteoarthritis is needed to keep the master athlete active. OBJECTIVE: This article reviews the current scientific evidence regarding recommendations for the maturing athlete, specifically discussing the strengths and weaknesses of dietary and lifestyle modifications, physical therapy, bracing, supplements, pharmacotherapies, and biologics in the management of knee osteoarthritis. LEVEL OF EVIDENCE: Level 4. CONCLUSION: These treatment modalities can help keep the aging athlete active, which in itself plays an important role in reducing the symptoms of knee osteoarthritis.