Clinical and radiographic outcomes of a transosseous suture technique for displaced lateral clavicle fractures.

BACKGROUND: The purpose of this study was to evaluate the clinical and radiographic outcomes of a transosseous suture fixation technique for the treatment of unstable lateral clavicle fractures. The appropriate treatment for lateral clavicle fractures is controversial. Many authors have argued for nonsurgical treatment of these injuries; however, recent literature has shown a role for the surgical treatment of unstable fractures. The paucity of lateral clavicular bone and the unique anatomy of this area of the shoulder makes surgical treatment of these injuries challenging. This article reports a single-surgeon experience with a transosseous suture fixation technique for the treatment of unstable lateral clavicle fractures. MATERIALS AND METHODS: A retrospective review of all patients with unstable lateral clavicle fractures treated with a transosseous suture technique from 2015-2018 was performed. The indication for surgery was significant displacement between the main medial and lateral clavicle fragments. The surgical technique used was a modification of the technique as described by Levy. Patients were followed postoperatively with active and passive range of motion (ROM) measurements, strength testing, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, visual analog scale score, and standard radiographs. Patients were followed to radiographic union. RESULTS: Twelve patients underwent surgical fixation of unstable lateral clavicle fractures from 2015-2018. All patients had excellent function, full ROM, minimal pain, and improved functional scores at final follow-up. Eleven patients achieved complete union of the fracture. One patient healed with a fibrous union; however, the fracture had maintained alignment and the patient was asymptomatic and satisfied with the result. No patient required a second surgery. CONCLUSION: We found that the transosseous suture technique for fixation is an effective treatment for unstable lateral clavicle fracture. This technique is reproducible, cost effective, and limits the need for revision surgery often encountered with other techniques.

Complications of shoulder arthroscopy.

Over the past 20 to 30 years, arthroscopic shoulder techniques have become increasingly popular. Although these techniques have several advantages over open surgery, surgical complications are no less prevalent or devastating than those associated with open techniques. Some of the complications associated with arthroscopic shoulder surgery include recurrent instability, soft-tissue injury, and neurapraxia. These complications can be minimized with thoughtful consideration of the surgical indications, careful patient selection and positioning, and a thorough knowledge of the shoulder anatomy. Deep infection following arthroscopic shoulder surgery is rare; however, the shoulder is particularly susceptible to Propionibacterium acnes infection, which is mildly virulent and has a benign presentation. The surgeon must maintain a high index of suspicion for this infection. Thromboemoblic complications associated with arthroscopic shoulder techniques are also rare, and studies have shown that pharmacologic prophylaxis has minimal efficacy in preventing these complications. Because high-quality studies on the subject are lacking, minimal evidence is available to suggest strategies for prevention.

Superior labrum anterior-to-posterior repair incidence: a longitudinal investigation of community and academic databases.

BACKGROUND: Superior labrum anterior-to-posterior (SLAP) lesion repair is controversial regarding indications and potential complications. METHODS: Databases were used to determine the SLAP repair incidence compared with all orthopaedic procedures over a period of 10 years. In part A, the New York Statewide Planning and Research Cooperative System ambulatory surgery database was investigated from 2002 to 2009. In part B, the California Office of Statewide Health Planning and Development ambulatory surgery database was investigated from 2005 to 2009. In part C, the American Board of Orthopaedic Surgery (ABOS) database was investigated from 2003 to 2010. RESULTS: In part A, from 2002 to 2009, there was a 238% increase in SLAP repair volume compared with a 125% increase in all orthopaedic procedures. In part B, from 2005 to 2009, there was a 20.17% increase in SLAP repair volume compared with a decrease of 13.64% in all orthopaedic procedures. In part C, among candidates performing at least 1 SLAP repair, there was no statistically significant difference in likelihood of performing a SLAP repair (95% confidence interval, 0.973-1.003) in 2010 as compared with 2003 (P > .10). CONCLUSIONS: There has been a significant increase in the incidence of SLAP repairs in the past 10 years in statewide databases. This pattern was not seen in the ABOS database, in which the annual volume of SLAP repairs remained stable over the same period. This suggests that SLAP lesions have been over-treated with surgical repair but that part II ABOS candidates are becoming more aware of the need to narrow indications. LEVEL OF EVIDENCE: Epidemiology study, database analysis.

General surgical principles of open rotator cuff repair in the management of failed arthroscopic cuff repairs.

Open management of failed rotator cuff repair is currently rare because of the advancements in arthroscopic techniques in rotator cuff surgery. Minimally invasive arthroscopic treatment of rotator cuff injuries has eclipsed the traditional open approach at most institutions around the world. Many residents complete their training in orthopaedic surgery without exposure to traditional open rotator cuff repair. When open repair is chosen, an understanding of the necessary preoperative evaluation, surgical techniques, and postoperative care regimens will provide patients with the best possible outcomes.

Suprascapular neuropathy: what does the literature show?

Suprascapular neuropathy remains a rare, albeit increasingly recognized, diagnosis. Despite its relatively low prevalence, it must be kept in the shoulder surgeon's mind as a potential cause of shoulder pain, particularly in patients where the history, physical examination, and imaging studies do not adequately explain a patient's symptoms or disability. Although challenging to identify, suprascapular neuropathy can be successfully treated. The current literature shows that the location and mechanism of nerve injury are the most important factors guiding management. Different treatment strategies are required, depending on the specific location and type of nerve injury. Controversy regarding if and when to perform an isolated suprascapular nerve release continues. Furthermore, no recommendations regarding suprascapular nerve release in conjunction with rotator cuff repair can be made at this time, and further research is necessary to better delineate the indications in the future.

Acromioclavicular Disk as a Potential Source of Pain in AC Joint Injuries.

BACKGROUND: Injuries of the acromioclavicular joint (ACJ) are common shoulder injuries that often lead to pain and dysfunction of the affected shoulder. Regardless of operative or nonoperative treatment, a relatively large number of patients remain symptomatic and experience pain. However, the specific source of persistent pain in the ACJ remains ambiguous. PURPOSE: To investigate the presence of sensory nerve fibers or pain-generating neurotransmitters within the intra-articular disk of the ACJ to determine its potential role as an independent pain generator in ACJ disorders. STUDY DESIGN: Descriptive laboratory study. METHODS: Twelve paired ACJs from 6 fresh human cadavers (mean age, 56 years; range, 41-82 years) were harvested and freed from surrounding soft tissues, leaving only the ACJ capsule intact. The specimens were placed in 4.5% formaldehyde fixative for a minimum of 48 hours. Coronal plane sections were obtained and demineralized in EDTA for a week, embedded in paraffin for 12 hours, and dehydrated overnight. With a rotation microtome, 2-µm sections were cut and stained with hematoxylin and eosin to investigate tissue architecture and confirm the presence of a fibrocartilaginous intra-articular disk. The sections were immunohistochemically stained with antisera against S100, neuropeptide Y (NPY), and substance P (SP) to detect for neural tissue. Additionally, a nerve fiber count per 10 high-power fields representing an area of 0.2 mm2 was conducted for S100 stains. All sections were examined for the presence of positive immunoreactivity to S100, NPY, and SP. RESULTS: The presence of a fibrocartilaginous intra-articular disk could be observed in all 12 examined ACJs. In all specimens, an immunoreactivity to S100, NPY, and SP could be observed within the superior peripheral region of the intra-articular disk. High-power field nerve counts of the S100 stains revealed a mean ± SD of 7.9 ± 2.28 nerves per 10 high-power fields (range, 4-12). CONCLUSION: The documented immunoreactivity to S100, NPY, and SP indicates the presence of somatic and autonomic nerve fibers within the intra-articular disk of the ACJ. CLINICAL RELEVANCE: Confirming the presence of nerve fibers within the intra-articular disk of the ACJ suggests that the disk itself could be an independent source of pain after injury and thus a possible explanation for recalcitrant pain after treatment.

A monoblock porous tantalum acetabular cup has no osteolysis on CT at 10 years.

BACKGROUND: Aseptic osteolysis has been the single most important factor limiting the longevity of a THA. A great deal of attention has been focused on the development of implants and materials that minimize the development of osteolysis. The monoblock porous tantalum acetabular cup was designed to minimize osteolysis, but whether it does so is unclear. QUESTIONS/PURPOSES: We evaluated the incidence of osteolytic lesions after THA using a monoblock porous tantalum acetabular component. METHODS: We retrospectively reviewed 51 patients who had a THA using a monoblock porous tantalum acetabular cup. At a minimum of 9.6 years postoperatively (average, 10.3 years; SD, 0.2 years; range, 9.6-10.8 years), a helical CT scan of the pelvis using a metal suppression protocol was obtained. This scan was evaluated for the presence of osteolysis. RESULTS: We found no evidence of osteolysis on CT scan at an average of 10.3 years. CONCLUSIONS: Osteolysis appears not to be a major problem at 10 years with this monoblock porous tantalum acetabular component, but longer term followup will be required to determine whether these findings persist. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Radical posterior capsulectomy improves sagittal knee motion in crouch gait.

BACKGROUND: Knee flexion contracture leading to crouch gait is commonly seen in children with myelomeningocele. Progressive increase in knee flexion contracture increases energy cost, which interferes with efficient, functional ambulation. To prevent this, surgical release has been recommended when a knee flexion contracture exceeds 15° to 20°. QUESTIONS/PURPOSES: We therefore asked whether knee flexion contracture release improved dynamic sagittal motion and walking velocity using computerized gait analysis. PATIENTS AND METHODS: We retrospectively studied 11 patients (20 knees) with high-sacral-level or low-lumbar-level myelomeningocele and knee flexion contracture of greater than 15°. All patients underwent dynamic gait analysis pre- and postoperatively. Surgery consisted of selective hamstring lengthening (medial and lateral), gastrocnemius release from the femoral condyles, and posterior knee capsulectomy. RESULTS: We observed improvements postoperatively in clinical measurements and sagittal kinematics. The clinical knee flexion contracture improved from a mean of 24.9° preoperatively to 5.9° postoperatively. The knee flexion at initial contact improved from 37.6° to 9.0°, and minimum knee flexion in single-leg stance improved from 48.2° to 16.4. Walking velocity improved from 72.2% to 80.0% of age-matched normal. CONCLUSIONS: Surgical treatment of knee flexion contracture in patients with myelomeningocele using radical posterior knee capsulectomy leads to improvement in clinical knee flexion contracture, dynamic sagittal kinematics, and walking velocity.

The lateral compartment in knees with isolated medial and patellofemoral osteoarthritis: a histologic analysis of articular cartilage.

The purpose of this study was to examine, at a histologic level, the articular cartilage of the radiographically normal lateral compartment in knees with isolated medial and possibly patellofemoral osteoarthritis. Twenty patients with radiographic evidence of medial compartment osteoarthritis and a radiographically osteoarthritis-free lateral compartment underwent a tricompartmental total knee arthroplasty. The resected lateral femoral condyle and lateral tibial plateau were evaluated by a fellowship-trained musculoskeletal pathologist for the presence, or lack thereof, of osteoarthritis at a microscopic level. Both the tibia and femur showed evidence of mild osteoarthritis at a microscopic level. This study shows that in patients with radiographic evidence of medial osteoarthritis and a radiographically normal lateral compartment, there is mild osteoarthritis in the lateral compartment.

ACL injury and surgical treatment options.

The anterior cruciate ligament (ACL) has been the focus of a substantial amount of research. Thousands of studies have evaluated the structure and function of the intact ACL, as well as the best reconstruction techniques. Despite the amount of literature, many controversies remain regarding the ACL and its surgical reconstruction. This article reviews the anatomy and function of the native ACL, the nature of injury, and aspects of ACL reconstruction, including surgical approach, tunnel positioning, graft choice, and graft fixation.

Compartment syndrome following intraosseous infusion.

Intraosseous infusion is a valuable technique in the resuscitation of critically ill pediatric patients in whom vascular access has proved otherwise impossible. Although it is well established as a safe and reliable means of emergent access, intraosseous infusion is not without danger, nor complication. One of the rare yet most grave complications of intraosseous access is compartment syndrome. We report a case of compartment syndrome as a result of intraosseous infusion that serves to remind of the potential pitfalls of this technique. An otherwise healthy 6-year-old girl presented to our institution's pediatric intensive care unit following emergent resuscitation for a prolonged cardiac arrest. Approximately 1 hour following an uneventful soccer practice, without any antecedent cardiopulmonary symptoms or complaints, the patient collapsed and was unresponsive, not breathing, and pulseless. In the course of resuscitation, right and left tibial intraosseous lines were started. After 30 minutes of resuscitation, with multiple rounds of lidocaine and epinephrine infused through the intraosseous lines, a sustained perfusing rhythm was established. Acute compartment syndrome was diagnosed, and through anterolateral and posteromedial incisions, all 4 fascial compartments were released. While the condition of the patient's extremity improved, the overall clinical condition of the patient did not. This case highlights the fundamental principles regarding the use of intraosseous infusion and the diagnosis and management of compartment syndrome in critically ill patients.

The "Labral Bridge": A Novel Technique for Arthroscopic Anatomic Knotless Bankart Repair.

Arthroscopic Bankart repair with suture anchors is widely considered a mainstay for surgical treatment of anterior shoulder instability after recurrent anterior shoulder dislocations. Traditionally, the displaced capsulolabral complex is restored and firmly attached to the glenoid by placing multiple suture anchors individually from a 5- to 3-o'clock position. A variety of different techniques using different anchor designs and materials have been described. Knotless anchors are widely used nowadays for shoulder instability repair, providing a fast and secure way of labral fixation with favorable long-term outcomes. However, these techniques result in a concentrated point load of the reduced labrum to the glenoid at each suture anchor. We describe a technique, developed by the first author, using a 1.5-mm LabralTape (Arthrex, Naples, FL) in combination with knotless suture anchors (3.5-mm PEEK [polyether ether ketone] PushLock anchors; Arthrex), for hybrid fixation of the labrum. The LabralTape is used to secure the torn labrum to the glenoid between each suture anchor, thus potentially providing a more even pressure distribution.

Influence of Rotator Cuff Tear Size and Repair Technique on the Creation and Management of Dog Ear Deformities in a Transosseous-Equivalent Rotator Cuff Repair Model.

BACKGROUND: Redundancies in the rotator cuff tissue, commonly referred to as "dog ear" deformities, are frequently encountered during rotator cuff repair. Knowledge of how these deformities are created and their impact on rotator cuff footprint restoration is limited. PURPOSE: The goals of this study were to assess the impact of tear size and repair method on the creation and management of dog ear deformities in a human cadaveric model. STUDY DESIGN: Controlled laboratory study. METHODS: Crescent-shaped tears were systematically created in the supraspinatus tendon of 7 cadaveric shoulders with increasing medial to lateral widths (0.5, 1.0, and 1.5 cm). Repair of the 1.5-cm tear was performed on each shoulder with 3 methods in a randomized order: suture bridge, double-row repair with 2-mm fiber tape, and fiber tape with peripheral No. 2 nonabsorbable looped sutures. Resulting dog ear deformities were injected with an acrylic resin mixture, digitized 3-dimensionally (3D), and photographed perpendicular to the footprint with calibration. The volume, height, and width of the rotator cuff tissue not in contact with the greater tuberosity footprint were calculated using the volume injected, 3D reconstructions, and calibrated photographs. Comparisons were made between tear size, dog ear measurement technique, and repair method utilizing 2-way analysis of variance and Student-Newman-Keuls multiple-comparison tests. RESULTS: Utilizing 3D digitized and injection-derived volumes and dimensions, anterior dog ear volume, height, and width were significantly smaller for rotator cuff repair with peripheral looped sutures compared with a suture bridge (P < .05) or double-row repair with 2-mm fiber tape alone (P < .05). Similarly, posterior height and width were significantly smaller for repair with looped peripheral sutures compared with a suture bridge (P < .05). Dog ear volumes and heights trended larger for the 1.5-cm tear, but this was not statistically significant. CONCLUSION: When combined with a standard transosseous-equivalent repair technique, peripheral No. 2 nonabsorbable looped sutures significantly decreased the volume, height, and width of dog ear deformities, better restoring the anatomic footprint of the rotator cuff. CLINICAL RELEVANCE: Dog ear deformities are commonly encountered during rotator cuff repair. Knowledge of a repair technique that reliably decreases their size, and thus increases contact at the anatomic footprint of the rotator cuff, will aid sports medicine surgeons in the management of these deformities.

Bone grafting of humeral head cystic defects during rotator cuff repair.

Cystic bony defects of the humeral head greater tuberosity are often encountered during rotator cuff repair. These defects may be idiopathic, related to a patient's rotator cuff disease, or secondary to suture anchor placement from previous repairs. Some cysts are visible on preoperative magnetic resonance imaging, but most are discovered on footprint exploration or implant removal during revision surgery. These osseous defects reduce biological healing capacity and may decrease repair fixation strength. Bone grafting techniques are needed to address these defects. In this article, we present an arthroscopic allograft compaction technique with concomitant suture anchor rotator cuff repair.

Physical examination of the athlete's elbow.

Elbow injury is encountered less frequently than are other joint conditions. The bony architecture, muscle, ligament, and nerve anatomy are complex, and the forces leading to injury in the athlete's elbow are unique. Appreciating the pathomechanics leading to injury and a detailed knowledge of elbow anatomy are the foundation for conducting a directed history and physical examination that achieves an accurate diagnosis. Recent advances in physical examination have improved our ability to accurately diagnose and treat athletic elbow disorders. This article reviews general and focused physical examination maneuvers of the elbow in a systematic anatomic fashion.

Operative treatment of isolated greater tuberosity fractures: retrospective review of clinical and functional outcomes.

Displaced isolated greater tuberosity fractures are rare injuries that require operative treatment to optimize rotator cuff function and prevent painful subacromial impingement. A lack of consensus exists regarding ideal management of these injuries because of the paucity of literature on the subject.The outcomes of 17 patients treated with open (n=15) or arthroscopic (n=2) fixation at the authors' institution between 2001 and 2009 were retrospectively reviewed. Postoperative range of motion, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score, and overall patient satisfaction were recorded at final follow-up. At a mean of 5.2 years (range 1.5-9.7 years), average postoperative active forward elevation was 150.3° (range, 60°-180°), ASES score was 82.9 (range, 46.7-100), and VAS score was 1.4 (range, 0-5). According to Neer's criteria, the overall outcome was excellent in 11 (65%) patients, satisfactory in 5 (29%) patients, and unsatisfactory in 1 (6%) patient. Final postoperative radiographs were available for 15 patients at a mean of 6.64 months. Radiographic union with near-anatomic position of the greater tuberosity was achieved in 13 (87%) of 15 patients. The presence of rotator cuff and rotator interval tears requiring repair, history of dislocation, age 60 years or older, and delayed time to surgery ≥ 10 days did not significantly (P>.05) influence the patients' final active forward elevation and ASES scores.Favorable patient outcomes can be achieved when fractures with >5 mm of displacement are treated with anatomic reduction and secure fixation. For a specific injury, the ideal surgical approach and method of fixation is dictated by patient characteristics and fracture pattern.

Sources of error in total knee arthroplasty.

The purpose of this study was to identify the procedural steps in a total knee arthroplasty (TKA) in which technical errors occur and to quantify the magnitude of these errors. Forty-nine consecutive TKAs were performed using a traditional exposure and manual instrumentation. An image-free computer navigation system (OrthoPilot; Aesculap AG, Tuttlingen, Germany) was used to measure and compare femoral and tibial alignment at specific procedural points during the TKA; this data was then used to evaluate possible sources of error in the procedure. The femoral cut tended to be made in hyperextension, the tibial cut tended to be made in hyperextension and valgus, and the tibial component tended to be implanted in valgus. This study identified specific points during the performance of a TKA where technical errors occur. This information suggests technical considerations that can help a surgeon achieve more reproducible, durable, and successful outcomes for his or her patients.