A new all-suture tension band tape fixation technique for simple olecranon fractures versus conventional tension band wire fixation: a comparative biomechanics study.

HYPOTHESIS: Simple transverse or short oblique olecranon fractures without articular comminution are classified as Mayo type IIA fractures and are typically treated with a tension band wire construct. Because of the high reoperation rates, frequently because of prominent hardware, all-suture tension band constructs have been introduced. It was the purpose to compare the biomechanical performance of conventional tension band wire fixation with a new all-suture tension band tape fixation for simple olecranon fractures. METHODS: Mayo type IIA olecranon fractures were created in 20 cadaveric elbows from 10 donors. One elbow of each donor was randomly assigned to the tension band wire technique (group TBW) or tension band tape (Arthrex, 1.3-mm SutureTape) technique (group TBT). Both groups were cyclically loaded with 500 N over 500 cycles, after which a uniaxial displacement was performed to evaluate load to failure. Data were analyzed for gap formation after cyclic loading, construct stiffness, and ultimate load to failure, where failure was defined as fracture gap formation greater than 4.0 mm. RESULTS: There was no significant difference in gap formation after 500 cycles between the TBW (1.8 mm ± 1.3 mm) and the TBT (1.9 mm ± 1.1 mm) groups (P = .854). The TBT showed a tendency toward greater construct stiffness compared with the TBW construct (mean difference: 142 N/mm; P = .053). Ultimate load to failure was not significantly different comparing both groups (TBW: 1138 N ± 286 N vs. TBT: 1126 N ± 272 N; P = .928). In both groups, all repairs failed because of >4.0-mm gap formation at the fracture site and none because of tension band construct breakage. CONCLUSIONS: Our study shows that the TBT technique produces equivalent or superior biomechanical performance to the TBW for simple olecranon fractures. The TBT approach reduces the risk of hardware prominence and as a result mitigates against the need for hardware removal. The TBT technique offers a clinically viable alternative to TBW.

Single versus double percutaneous pinning of pediatric distal radius fractures.

The aim of this study was to compare early clinical and radiographic results of single- versus double-pin fixation of unstable pediatric distal radius fractures. A total of 103 consecutive closed distal radius fractures treated with either single or double percutaneous pinning at a tertiary level I pediatric hospital were analyzed. All patients had open physes and had fractures that failed initial closed reduction and casting. Postoperative fracture displacement was assessed by measuring the difference in angulation of the radius in the anteroposterior and lateral views from intraoperative fluoroscopic images to postoperative radiographs taken on the day of pin removal. Complications were identified from the medical record review. In 103 operative distal radius fractures in 101 patients (70 males, 31 females), 52 and 51 distal radius fractures were treated with single and double pinning, respectively. The median [interquartile range (IQR)] age at the time of surgery was 12.1 (9.0-14.0) years, with the single-pinning group being younger by 1.9 years (P < 0.01). Median (IQR) postoperative angulation in the anteroposterior radiograph (coronal plane) was 2° (1-7°) with one pin versus 1° (0-2°) with two pins (P < 0.01). Median (IQR) postoperative angulation in the lateral radiograph (sagittal plane) was 3° (1-10°) with one pin versus 1° (0-2°) with two pins (P < 0.01). There were no significant differences in complications between the single- and double-pinning groups. Double-pin fixation resulted in a statistically significant, but clinically negligible, reduction in postoperative fracture displacement compared with single-pin fixation. Complication rates were similar in both groups. These findings suggest that either single- or double-pinning techniques can be effective, provided appropriate reduction and postoperative immobilization are achieved.

Biomechanical Comparison of Distal Biceps Tendon Repair Techniques: Extracortical Single-Button Inlay Fixation Versus Intracortical Double-Button Onlay Anatomic Footprint Fixation.

BACKGROUND: Extracortical single-button (SB) inlay repair is a commonly used distal biceps tendon technique. However, complications (eg, neurovascular injury) and nonanatomic repairs have led to the development of intracortical fixation techniques. PURPOSE: To compare the biomechanical stability of extracortical SB repair with an anatomic intracortical double-button (DB) repair technique. STUDY DESIGN: Controlled laboratory study. METHODS: The distal biceps tendon was transected in 18 cadaveric elbows from 9 donors. One elbow of each donor was randomly assigned to the extracortical SB or anatomic DB group. Both groups were cyclically loaded with 60 N over 1000 cycles between 90° of flexion and full extension. The elbow was then fixed in 90° of flexion and the repair construct loaded to failure. Gap formation and construct stiffness during cyclic loading and ultimate load to failure were analyzed. RESULTS: When compared with the extracortical SB technique after 1000 cycles, the anatomic DB technique showed significantly less gap formation (mean ± SD, 2.7 ± 0.8 vs 1.5 ± 0.9 mm; P = .017) and significantly more construct stiffness (87.4 ± 32.7 vs 119.9 ± 31.6 N/mm; P = .023). Ultimate load to failure was not significantly different between the groups (277 ± 93 vs 285 ± 135 N; P = .859). The failure mode in the anatomic DB group was significantly different from that of the extracortical SB technique (P = .002) and was due to fracture avulsion of the cortical button in 7 of 9 specimens (vs none in the SB group). CONCLUSION: Our study shows that the intracortical DB technique produces equivalent or superior biomechanical performance to that of the SB technique. The DB technique may offer a clinically viable alternative to the SB repair technique. CLINICAL RELEVANCE: This study suggests, at worst, an equivalent and, at best, a superior biomechanical performance of intracortical anatomic DB footprint repair at the time of surgery. However, the mode of failure suggests that this technique should not be used in patients with poor bone quality.

Anterior inferior iliac spine deformity as an extra-articular source for hip impingement: a series of 10 patients treated with arthroscopic decompression.

PURPOSE: To describe an arthroscopic technique for decompression of a prominent anterior inferior iliac spine (AIIS) leading to extra-articular hip impingement and to provide short-term outcome after this procedure. METHODS: We retrospectively reviewed office charts, imaging studies, operative reports, arthroscopic images, preoperative and postoperative hip flexion range of motion, and preoperative and postoperative modified Harris Hip Scores in a consecutive series of 10 male patients who had arthroscopic decompression of symptomatic AIIS deformities leading to extra-articular hip impingement. The procedure was performed through standard anterolateral and mid-anterior hip arthroscopy portals that were also used to explore the joint and address concomitant intra-articular pathologies. RESULTS: The mean age was 24.9 years, with 8 of 10 patients aged younger than 30 years. In 9 patients, an anterior cam lesion was identified and decompressed before the AIIS decompression. The mean follow-up time was 14.7 months (range, 6 to 26 months). Hip flexion range of motion improved from 99° ± 7° before surgery to 117° ± 8° after surgery (P < .001). The modified Harris Hip Score improved from 64 ± 18 before surgery to 98 ± 2 at latest follow-up after surgery (P < .001). CONCLUSIONS: Arthroscopic decompression of a symptomatic AIIS deformity is a reproducible procedure that can provide excellent outcomes at short-term follow-up. As opposed to using an open approach for decompressing a prominent AIIS, an arthroscopic approach may be of particular value in patients with mixed intra- and extra-articular sources of hip dysfunction, because it enables the surgeon to address all pathologies with a single arthroscopic procedure. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Carpometacarpal Arthrodesis for Traumatic Carpal Boss Among Combative Athletes.

Among professional combat athletes, excessive and repetitive trauma to the carpometacarpal (CMC) joints may cause instability, arthritis, and the development of traumatic carpal boss. If nonoperative management is unsuccessful, CMC joint arthrodesis with iliac crest bone graft and supplemental Kirschner wire fixation is a reliable surgical option that results in pain-free return to full competition. From 2002 to 2015, 15 professional athletes with 17 symptomatic carpal bosses were treated with CMC joint arthrodesis after unsuccessful nonoperative management. The operative technique included decortication of the articular surface of the CMC joints, insertion of iliac cancellous and corticocancellous slot grafts, and secure Kirschner wire fixation. Patient charts and postoperative imaging were retrospectively reviewed. Outcome measures included grip strength, pain relief, fusion rate, return to competition, and complications. Mean age at the time of surgery was 28.2 years (range, 21-39 years). The radiographic fusion rate was 100% and occurred at a mean of 7.5 weeks. Mean return to competition occurred at 6 months. Grip strength at final follow-up increased 32% from preoperative level and was 90% of the grip strength of the contralateral hand. Postoperatively, 2 patients had sagittal band ruptures, and 1 patient had a fifth metacarpal fracture. No revision procedures were performed. All patients undergoing CMC arthrodesis had successful fusion, without the need for revision surgery and with return to full competition. For professional fighters, CMC arthrodesis with iliac crest autograft is a safe and effective surgical method for treating symptomatic traumatic carpal boss. [Orthopedics. 2022;45(1):e17-e22.].

Elbow Osteochondral Allograft Transplantation and Lateral Ulnar Collateral Ligament Repair with Internal Brace: A Case Report.

CASE: A 23-year-old woman with an Osborne-Cotterill lesion and posterolateral rotatory instability (PLRI) of the elbow was treated with osteochondral allograft transplantation (OCA) and lateral ulnar collateral ligament (LUCL) repair with internal brace. Two years after surgery, she reported resolution of pain and returned to all recreational activities. She reported no mechanical symptoms and no episodes of postoperative instability. CONCLUSION: PLRI can present with an Osborne-Cotterill lesion in addition to LUCL injury. The purpose of this case report was to describe the use of OCA to manage bony defects in the capitellum in addition to LUCL repair for patients with PLRI.

Acute Septic Carpal Tunnel Syndrome in a Rock Climber.

INTRODUCTION: Rock climbing is an increasingly popular sport in the United States. Acute and chronic upper extremity injuries related to rock climbing are frequently reported and include flexor pulley ruptures and hamate stress fractures. Deep space hand infections after indoor rock climbing are a sport-related pathology that has yet to be reported. Our purpose is to describe an acute septic carpal tunnel syndrome following rock climbing at an indoor climbing gym in a patient who required urgent irrigation and debridement. CASE REPORT: A 33-year-old Caucasian male presented with an acute septic carpal tunnel syndrome 4 days after rock climbing at an indoor gym. On physical examination, he exhibited numbness over the fingers, significant tenderness to palpation, and pain with passive range of motion. His inflammatory markers were markedly elevated and deep space hand infection was confirmed with computed tomography scans. The patient was taken for urgent exploration, irrigation and debridement, and carpal tunnel release. CONCLUSION: We theorize that the patient had an abrasion on the finger or palm that created an entryway for a pathogen. We are unaware of another report of a deep space hand infection associated with rock climbing activities. This case report will hopefully spread awareness of this clinical entity to improve evaluation and prevention of hand infections in rock climbers, as well as providing guidelines for appropriate and timely treatment of the condition.

Open Reduction and Internal Fixation of Posterior Malleolus Fractures via a Posteromedial Approach.

Ankle fractures with a posterior malleolus component are complex injuries. The most commonly used operative methods include indirect reduction via a percutaneous anterior approach and direct reduction via a posterolateral approach. For large posterior malleolus fractures with medial extension, direct reduction via a posteromedial approach is an alternative operative option. The authors hypothesized that fixation of large posterior malleolus fractures via a posteromedial approach results in anatomic reduction and stable plate fixation. From 2008 to 2015, 22 (9.0%) of 244 consecutive operative ankle fractures were identified as posterior malleolus fractures treated using a posteromedial approach. Patient charts were retrospectively reviewed for demographics, operative details, follow-up time, and any postoperative complications. Postoperative radiographs were reviewed to ensure that anatomic reduction and stable fixation was maintained. Sixteen (72.7%) of 22 patients were female, and the average age at the time of surgery was 54.1 years (range, 26-86 years). The average follow-up time was 13.0 months (range, 2.0-41.4 months). Twenty-one (95.5%) of 22 patients healed on a radiographic and clinical basis. There was an 18.2% (4 of 22) postoperative complication rate: 1 patient had a nonunion, 1 patient had cellulitis, 1 patient had osteomyelitis involving the fibula, and 1 patient had symptomatic heterotopic ossification. Open reduction and internal fixation of posterior malleolus fractures via a posteromedial approach achieved anatomic reduction, stable plate fixation, and complete healing in all but 1 patient. This study demonstrates that the posteromedial approach is a reasonable alternative to other more commonly used methods for treating these fractures. [Orthopedics. 2020;43(3):e166-e170.].

Outcomes of Surgical Treatment of Periprosthetic Acetabular Fractures.

Periprosthetic acetabular fractures sustained following acute trauma after total hip arthroplasty are rare and historically have poor outcomes. This article reviews 5 cases and the treatment algorithm used by a single orthopaedic surgeon specializing in acetabular fracture care with a co-surgeon specializing in arthroplasty. Team-based surgical management with arthroplasty- and fracture-trained surgeon(s) is paramount for optimal outcome. The following approach resulted in satisfactory outcomes without need for revision implants. In fracture patterns with columnar involvement, the columns were restored with plates and screws. In fracture patterns with wall involvement, the acetabular component functioned as a template for wall reconstruction with use of a buttress plate. The acetabular component was revised when deemed loose during stress of the component through the surgical approach used for fracture fixation.

Tension Band Plating for Chronic Anterior Tibial Stress Fractures in High-Performance Athletes.

BACKGROUND: Anterior tibial stress fractures are associated with high rates of delayed union and nonunion, which can be particularly devastating to a professional athlete who requires rapid return to competition. Current surgical treatment strategies include intramedullary nailing, which has satisfactory rates of fracture union but an associated risk of anterior knee pain. Anterior tension band plating is a biomechanically sound alternative treatment for these fractures. HYPOTHESIS: Tension band plating of chronic anterior tibial stress fractures leads to rapid healing and return to physical activity and avoids the anterior knee pain associated with intramedullary nailing. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 2001 and 2013, there were 13 chronic anterior tibial stress fractures in 12 professional or collegiate athletes who underwent tension band plating after failing nonoperative management. Patient charts were retrospectively reviewed for demographics, injury history, and surgical details. Radiographs were used to assess time to osseous union. Follow-up notes and phone interviews were used to determine follow-up time, return to training time, and whether the patient was able to return to competition. RESULTS: Cases included 13 stress fractures in 12 patients (9 females, 3 males). Five patients were track-and-field athletes, 4 patients played basketball, 2 patients played volleyball, and 1 was a ballet dancer. Five patients were Division I collegiate athletes and 7 were professional or Olympic athletes. Average age at time of surgery was 23.6 years (range, 20-32 years). Osseous union occurred on average at 9.6 weeks (range, 5.3-16.9 weeks) after surgery. Patients returned to training on average at 11.1 weeks (range, 5.7-20 weeks). Ninety-two percent (12/13) eventually returned to preinjury competition levels. Thirty-eight percent (5/13) underwent removal of hardware for plate prominence. There was no incidence of infection or nonunion. CONCLUSION: Anterior tension band plating for chronic tibial stress fractures provides a reliable alternative to intramedullary nailing with excellent results. Compression plating avoids the anterior knee pain associated with intramedullary nailing but may result in symptomatic hardware requiring subsequent removal.

Prevalence and preoperative demographic and radiographic predictors of bilateral femoroacetabular impingement.

BACKGROUND: Patients with symptomatic femoroacetabular impingement (FAI) frequently have bilateral deformity and inquire about the prognosis of their contralateral, asymptomatic hip. Idiopathic coxarthrosis has been established as an independent risk factor for joint failure on the other side. PURPOSE: To determine the prevalence of bilateral arthroscopic treatment for FAI and to identify predictive patient demographics and radiographic findings for bilateral, symptomatic disease. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: Over a 2-year period, patients receiving single-sided FAI surgery for pain and radiographic deformity were identified as unilateral. In the same period, patients undergoing their second side were labeled bilateral, regardless of when the first surgery was performed. Proximal femoral alpha angle; lateral center edge angle; sagittal center edge angle; acetabular version at 1, 2, and 3 o'clock; and femoral torsion were measured on preoperative computed tomography scans. RESULTS: The unilateral group included 514 patients, and the bilateral group included 132 patients. Women composed 48% of the unilateral group but only 35% of the bilateral group (P = .006). The mean age of unilateral patients was 30.3 (±10.7) years and 27.6 (±9.7) years for the first side of bilateral patients (P = .010). The bilateral hips had higher alpha angles (63.8° vs 59.8°, P = .004), less acetabular anteversion at the 3-o'clock position (13.0° vs 15.9°, P < .001), and similar femoral torsion (15.1° vs 15.5°, P = .793) compared with unilateral hips. A multivariable logistic regression model found that for every 5 years of younger age, 5° higher alpha angle, and 5° decrease in 3-o'clock acetabular version, patients were more likely to undergo bilateral treatment for FAI, by 13.5%, 14.5%, and 25.5%, respectively. In a side-to-side comparison of both hips in bilateral patients, alpha angle (r = 0.72) and acetabular version at 1 o'clock (r = 0.73) showed high correlation. CONCLUSION: Male sex, younger age, higher alpha angles, and reduced acetabular anteversion at initial presentation are significant risk factors for identifying patients who may ultimately require bilateral surgery for symptomatic FAI. Among bilaterally treated patients, no radiographic parameters were predictive of which side would require treatment first. Patients with FAI requiring surgery should be closely monitored for contralateral hip disease.

The incidence of heterotopic ossification after hip arthroscopy.

BACKGROUND: Minimally invasive techniques to treat femoroacetabular impingement (FAI), snapping hip syndrome, and peritrochanteric space disorder (PSD) were developed to reduce complications and recovery time. Although a multitude of studies have reported on the incidence of heterotopic ossification (HO) after open procedures of the hip, there is little known about the rate of HO after hip arthroscopy. HYPOTHESES: The incidence of HO after hip arthroscopy is comparable with that after open surgical dislocation of the hip and can be reduced with the addition of indomethacin to an existing nonsteroidal anti-inflammatory medication prophylaxis protocol. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between July 2008 and July 2010, 616 primary hip arthroscopies were performed to treat FAI and PSD. In July 2009, indomethacin was added in the acute postoperative period to an existing HO prophylactic protocol of naproxen administered for 30 days postoperatively. Postoperative radiographs were reviewed to detect the presence and classify the size and location of HO. Odds ratios and logistic regression explored predictor variables and their relationships with HO, with P < .05 defined as significant. RESULTS: Twenty-nine (21 male, 8 female) of 616 (4.7%) hip procedures developed HO postoperatively. Brooker classification of HO was 18 grade I, 4 grade II, 6 grade III, and 1 grade IV. Mean follow-up was 13.2 months (range, 2.9-26.5 months). Rate of HO for cases with and without indomethacin for prophylaxis was 1.8% (6/339) and 8.3% (23/277), respectively. This difference was statistically significant (P < .05), and patients who underwent protocol 1 were 4.36 times more likely to develop HO postoperatively than those who had protocol 2. The majority of cases of HO (72.4%) occurred in male patients, and all cases occurred in the setting of osteoplasty performed for symptomatic FAI. We were not able to demonstrate statistically significant clinical risk factors that were predictive for the development of postoperative HO. However, the data clearly demonstrate that the performance of arthroscopic osteoplasty with a capsular cut in male patients represented the majority of cases, who are likely the group at highest risk. Seven cases (~1%) required revision procedures to excise HO. There were no cases of recurrence of HO after excision, whether it was performed open or arthroscopically. CONCLUSION: The addition of indomethacin is effective in reducing the incidence of HO after hip arthroscopy and should be especially considered in male patients who undergo osteoplasty for correction of symptomatic FAI.