An In Vitro Study Demonstrating the Significance of Acromioclavicular Ligament Repair in Restoring Horizontal and Rotational Acromioclavicular Joint Stability.

BACKGROUND: The principle of joint reconstruction surgery is to try to recreate the native joint biomechanics and stability. With respect to acromioclavicular joint (ACJ) surgery, much focus to date has been on restoring the superoinferior stability. There is concern that persistent horizontal instability following ACJ reconstruction could lead to poorer patient outcomes; therefore, we evaluated whether acromioclavicular (AC) ligament repair offers improved horizontal stability in conjunction with ACJ reconstruction. METHODS: A whole-body human cadaver was used. The ACJ was exposed and subjected to a constant 70N load on the lateral end of the clavicle to test the anteroposterior (AP), superoinferior (SI), and horizontal pivot angle (HPA) around the ACJ. The AC and coracoclavicular (CC) ligaments were subsequently divided, and the above three parameters were re-tested. Ligament augmentation and reconstruction system (Corin Group, Cirencester, UK), LockDown (LockDown Medical Limited, Redditch, UK), Endobutton (Smith and Nephew Inc., London, UK), and Neoligament implant (Xiros Ltd., Leeds, UK) were used to reconstruct the CC ligaments and tested with and without AC repair. RESULTS: The native ACJ allowed an average 2.48 mm AP and 3.88 mm SI translation with a 27° HPA. All synthetic implants significantly improved the vertical stability of the ACJ but allowed up to a four-fold increase in AP translation. Coupled with ACJ repair, all the reconstructions were far superior, especially in restoring horizontal stability. CONCLUSION: The implants varied in their approach to fixation and concentrated primarily on the reconstruction of CC ligaments. Our study was able to demonstrate that AC repair significantly improves the stability of the construct and significantly reduces vertical and horizontal instability.

Guided Growth of the Distal Posterior Tibial Physis and Short Term Results: A Potential Treatment Option for Children With Calcaneus Deformity.

BACKGROUND: We present our experience of using tension band plates to achieve guided growth in children for correction of calcaneus deformity around the ankle. METHODS: Our study included 9 consecutive patients (11 ankles) with calcaneus deformity, over a period of 4 years. Surgical treatment with extra periosteal application of flexible 2 hole plate and screws on posterior aspect of distal tibial physis was carried out.The indications for treatment were residual clubfoot deformity in 9, posttraumatic in 1, and neurologic in 1. The average age of the patients was 10 years (range, 4 to 13 y). There were 7 males and 2 females.Serial preoperative and postoperative radiographs were used to measure deformity correction and anterior distal tibia angle (ADTA), lateral distal tibial angle (LDTA), and Screw Divergence Angle (angle subtended by lines passing through the screws) were measured. A 2-tailed student t test was used to determine statistical significance. RESULTS: The ADTA showed mean correction of 8.41 degrees (range, 3.1 to 16.6 degrees) this was statistically significant with P-value of 0.0003.The change in LDTA was not statistically significant (P-value=0.05) reinforcing the aptness of the procedure and that the procedure did not result in coronal plane deformities. Six ankles required revision of fixation: 4 due to metalwork reaching its maximum limit of divergence at an average of 1 year, 1 ankle had screw pull-out, and another ankle was revised due to technical error in screw selection. In our study there were no cases of infection. CONCLUSIONS: We report satisfactory short-term results of correction of calcaneus deformity using flexible tension band plates and screws. In our opinion this is an effective alternative providing gradual correction with easy and minimally invasive surgical technique. It does not violate the physis and is easy to remove and revise. It is safe and well tolerated and can be grouped with other procedures with ease. LEVEL OF EVIDENCE: Level IV­case series.

Elbow arthroscopy: a new setup to avoid visual paradox and improve triangulation.

Elbow arthroscopy is a useful diagnostic and therapeutic tool for various conditions. Conventional arthroscopy with the patient in the prone or lateral position where the screen is placed on the opposite side makes it difficult to interpret the image, results in visual paradox, and is associated with difficult triangulation. We present a modified setup for the operating room to help eliminate these problems and improve triangulation.

Locked superior dislocation of the acromioclavicular joint.

Acromioclavicular (AC) joint injuries account for approximately 3-5% of shoulder girdle injuries (Rockwood et al., 1998). Depending on severity of injury and direction of displacement these are classified using Rockwood classification system for AC joint dislocation. We present an unusual case presenting with locked superior dislocation of the AC joint highlighting the presentation and subsequent successful surgical management of such case. To our knowledge this has not been reported previously in literature.

Fibular lengthening for malunited ankle fractures.

BACKGROUND: Malunited ankle fractures are uncommon. They produce symptoms of persistent pain, joint effusion, limitation of dorsiflexion and eventually lead to ankle arthritis. We feel that correction of the ankle alignment can improve the final outcome and present our results. MATERIALS AND METHOD: From May 2004 to April 2006, seven patients with a malunited fibular fracture aged 25 to 62 years (male:female ratio, 5:2) were treated in our institute. All patients were referred for persistent pain. The delay between injury and the operative intervention was 3 to 16 months. All patients were assessed with a clinical examination, AOFAS ankle hindfoot score and plain radiographs. A transverse fibular osteotomy was made just above the ankle joint and below the tibiofibular syndesmosis. A tricortical iliac bone graft and a lateral fibular plate were applied. RESULTS: Fibular length and restoration of the ankle mortise was successful in all the cases. All patients showed radiological evidence of bony union on followup. The average AOFAS score was 82 (pain: 31, function: 41, and alignment: 10). Patients were followed up for an average period of 11 (range, 6 to 24) months after the surgery. CONCLUSION: We present our early experience with a simpler fibular osteotomy to correct the ankle joint alignment for malunited fibular fractures which was successful at short-term followup.

Need for an urgent ultrasound examination for neck lump.

Thromboembolic phenomenon is rare but serious consequence of ovarian hyperstimulation syndrome (OHSS) and in vitro fertilization (IVF) treatment. We present a case of thrombosis of the right internal jugular vein presenting as a neck lump to the ENT department. Ultrasonography of the neck and upper extremity revealed thrombosis of right internal jugular vein. The patient was started on low molecular weight heparin, which resulted in resolution of her clinical condition. Interestingly, the majority of cases after OHSS involve thrombosis of the upper extremities. ENT surgeons, general physicians, and infertility experts should consider this in the differential diagnosis of neck swellings, particularly after OHSS and IVF treatment, and in this case report, we emphasis the need for an urgent ultrasound of the neck in such patients.