Tibial tubercle fracture with avulsion of the patellar ligament: a case report.

Fractures of the tibial tubercle are infrequent injuries in adolescents. A combined injury of the tibial tubercle and patellar ligament is an even more rare event. The literature includes only a few case reports of this injury pattern. In this article, we describe another case and a repair technique and try to increase awareness of this combined injury.

Anterior cruciate ligament reconstruction: a new technique for Achilles tendon allograft preparation.

We describe a new technique in Achilles tendon allograft preparation for use in anterior cruciate ligament (ACL) reconstruction that allows for secure bony interference fixation on each side of the joint and aperture fixation for all patients. In addition, preparation of the graft in this manner avoids some problems that are frequently encountered with patellar tendon allografts, including graft tunnel mismatch and limited availability. Previous studies have reported successful results with Achilles tendon allograft use in ACL reconstruction with soft tissue fixation in the tibial tunnel. Bony interference fixation on the tibial side can be achieved by suturing a free bone plug to the tendon end of an Achilles allograft. We use a 9-mm circular oscillating saw to harvest a free 30-mm length bone plug from the remaining calcaneal bone block. This is then sutured directly to the tendon end of a bone-Achilles tendon allograft with the use of No. 1 nonabsorbable suture placed through 3 equally spaced drill holes in the free bone plug. Tendon length between the bone plugs can be individually set for each patient at a distance equivalent to the length of the native ACL (intra-articular distance between the femoral and tibial tunnels). After graft passage, the construct is tensioned and secured with interference screws, similar to a traditional bone-patellar tendon-bone graft. The senior author (S.G.) has performed 40 procedures with excellent results and reports no cases of tibial fixation failure. Biomechanical and long-term follow-up studies are in progress.

Financial impact of a dedicated orthopaedic traumatologist on a private group practice.

OBJECTIVE: The purpose of the study was to demonstrate the financial impact of the addition of a dedicated orthopaedic traumatologist to a private group practice at a Level II community-based trauma system. DESIGN: Retrospective review of financial records. SETTING: Level II trauma center and large group practice. METHODS: Office billing and financial data were evaluated for the 12 months before the addition of a dedicated, hospital-based, orthopaedic traumatologist and for a 2-year period after the hiring. Outcomes such as payor mix, collection rates, time to breakeven, days off, call days, evenings worked, durable medical equipment, and x-ray and casting reimbursement were analyzed. RESULTS: The addition of a dedicated traumatologist was financially beneficial for the partnership. Existing practices increased 23% in charges and 32% in collections despite partners taking more vacation days and 14% less call. This was partially the result of increased nontrauma referrals, full clinic templates, and uninterrupted elective operating room schedules. Over a 2-year period, elective arthroplasty cases increased 13.1%, elective arthroscopy cases increased 35.4%, and total patient office visits increased 18.8%. The payor mix for trauma patients was poorer than the group average; however, this was offset by decreased overhead requirements. Collections rate for the trauma partner in evaluation and management, surgery, casting, durable medical equipment, and radiology improved dramatically after the first year to become just slightly less than other clinic-specialized practices. The cost of bringing on a new trauma partner is substantial but regained after 6 months. CONCLUSIONS: A dedicated orthopaedic traumatologist can be extremely beneficial to a group practice and to the traumatologist given the appropriate case volume, payor mix, and a relative value unit-based payment system.