Anatomic Acromioclavicular Joint Reconstruction with and without Acromioclavicular Ligament Reconstruction: A Comparative Biomechanical Study.

Background: The purpose of this study was to determine if adding a reconstructed superior acromioclavicular (AC) joint ligament adds significant biomechanical stability to the AC joint over anatomic coracoclavicular (CC) ligament reconstruction alone. Methods: Fourteen cadaver shoulders were used for the comparison of biomechanical stability among the anatomic CC ligament reconstruction alone, CC and AC ligament reconstruction, and the intact groups by measuring the displacement under cyclic loads. A load to failure test was then performed in the vertical direction at a loading rate of 2 mm /sec to determine surgical-repair joints' tolerance to the maximum failure load. Results: The average peak-to-peak displacement induced by cyclic load in the sagittal axis and vertical axis direction was not significantly different between CC ligament reconstruction, CC and AC ligament reconstruction, and intact groups. The maximum failure load for the CC reconstruction (224.9 ± 91.8 N (Mean ± SEM)) was lower than CC/AC reconstruction groups (326.2 ± 123.3 N). The CC/AC reconstruction group failed at a significantly higher load (t test, p = 0.016) than the CC reconstruction group. Conclusion: CC/AC reconstruction surgical technique yielded a better shoulder stability than CC ligament alone reconstruction that may better maintain reduction of the AC joint.Level of Evidence: Level II.

Analysis of Non-Game Injuries in Major League Baseball.

BACKGROUND: Numerous studies have investigated injuries and treatments in the baseball athlete. The majority of these studies have focused on the throwing shoulder and elbow. However, more recent literature is reporting injuries to other regions in this cohort, including the knee, head, hip, and hamstring. PURPOSE/HYPOTHESIS: The purpose of the current study was to determine the number and type of injuries in Major League Baseball (MLB) and Minor League Baseball (MiLB) players that do not occur during the actual game but are related to baseball participation. Our hypothesis was that there would be a substantial number of injuries that occurred in professional baseball players during non-game situations. STUDY DESIGN: Descriptive epidemiological study. METHODS: Deidentified, anonymous data were collected from the 2011 through 2016 seasons from the MLB Health and Injury Tracking System (HITS) medical record database. All injuries that were identified as a primary diagnosis and resulted in at least 1 day out of play from both MLB and MiLB were examined. Injuries were categorized as occurring during the game ("game" injuries) or not during the game. A "non-game" injury was defined as occurring at any time other than during the scheduled game from the first to last pitch. RESULTS: There were 51,548 total injuries in MLB and MiLB players from 2011 to 2016, almost 40% of which were attributed to non-game-related injuries (n = 19,201; 37.2%). The remainder occurred during a game (n = 32,347; 62.8%). A significantly greater percentage of non-game injuries were season ending (10.8%) compared with the percentage of game-related season-ending injuries (8.4%) (P < .0001). Pitchers had significantly more non-game-related injuries than game-related injuries (P < .0001). CONCLUSION: A large number of injuries occur in professional baseball outside of actual games. MiLB players, specifically pitchers, are particularly at risk for these types of injuries. It is feasible that the overall injury rate in professional baseball players could be reduced by analyzing these injuries in more detail to develop prevention strategies.

Radial Tears of the Lateral Meniscus-Two Novel Repair Techniques: A Biomechanical Study.

BACKGROUND: A common treatment for radial tears of the meniscus has historically been partial meniscectomy. Owing to the poor outcomes associated with partial meniscectomy, repair of the meniscus is an important treatment option. It is important to evaluate different repair techniques for radial tears of the meniscus. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate 2 novel techniques to repair radial tears of the lateral meniscus. The 2 techniques were compared biomechanically with the cross-suture method with an inside-out technique. The authors hypothesized that novel repair techniques would result in less displacement after cyclic loading, increased load required to displace the repair 3 mm, greater load to failure, decreased displacement at load to failure, and increased stiffness of the repair, resulting in a construct that more closely re-creates the function of the intact meniscus. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 36 fresh-frozen cadaveric tibial plateaus containing intact menisci were obtained. The menisci were divided into 3 groups (n = 12 in each group), and each meniscus was repaired simulating an inside-out technique. The 3 repairs completed were the hashtag, crosstag, and cross-suture techniques. Radial tears were created at the midbody of the lateral meniscus and repaired via the 3 techniques. The repaired menisci were attached to an axial loading machine and tested for cyclic and failure loading. RESULTS: After cyclic loading, the cross-suture repair displaced 4.78 ± 1.65 mm; the hashtag, 2.42 ± 1.13 mm; and the crosstag, 3.13 ± 1.77 mm. The hashtag and cross-tag repairs both resulted in significantly less displacement (P = .003 and .024, respectively) as compared with the cross-suture repair. The cross-suture technique had a load to failure of 81.43 ± 14.31 N; the hashtag, 86.08 ± 23.58 N; and the crosstag, 62.50 ± 12.15 N. The cross-suture and hashtag repairs both resulted in a greater load to failure when compared with the crosstag (P = .009 and .009, respectively). There was no difference comparing the load required to displace the cross-suture technique 3 mm versus the hashtag or crosstag technique (P = .564 and .094, respectively). However, when compared with the crosstag technique, the hashtag technique required a significantly greater load to displace the repair 3 mm (P = .015). CONCLUSION: This study introduced 2 novel repair techniques-hashtag and crosstag-that did not demonstrate superiority in terms of load to failure or stiffness, but both repairs were statistically superior to the cross-suture repair in terms of displacement after cyclic loading. Considerations that may influence the validity of these techniques include cost, surgical time, and increased technical demand. CLINICAL RELEVANCE: Radial tears of the meniscus are difficult to repair. Further research into more stable constructs is necessary.

Proximity of Lateral Critical Structures to the All-Epiphyseal Outside-In Femoral Tunnels in Pediatric Anterior Cruciate Ligament Reconstruction.

PURPOSE: To describe the proximity of the lateral critical structures (peroneal nerve [PN], popliteus tendon [PT], lateral collateral ligament [LCL], and articular cartilage [AC]) to the femoral tunnel for outside-in all-epiphyseal anterior cruciate ligament (ACL) reconstruction in reference to knee flexion angle. METHODS: All-epiphyseal ACL reconstructions were performed in 12 human cadaveric knees using arthroscopy and outside-in drilling for anatomic femoral tunnel placement that was ensured by identifying the center of the total ACL footprint. Fluoroscopy was used to confirm tunnel position and reconstructions were performed with quadrupled semitendinosus and gracilis autograft with Xtendobutton (Smith & Nephew, Andover, MA) fixation on the femoral side. After reconstruction, the lateral side of the knee was dissected and the LCL, PT, distal and posterior AC, and the PN were identified. The distances of these structures from the center of the exiting femoral tunnel were then measured using a digital caliper at 0°, 30°, 60°, 90°, and 120° of knee flexion. Any gross damage to these structures caused by the femoral drilling was also noted. Data were compiled and the mean and standard deviations (SD) of the distances from the pin to the structures of interest were calculated. The normality of the data at each flexion angle was assessed using Shapiro-Wilk tests (P > .05), and the relationship between flexion angle and average distance was evaluated using repeated measures analysis of variance (P < .05). Any significant relationships were then evaluated using paired t-tests (P < .05) with a Benjamini-Hochberg adjustment for each possible pair of flexion angles. Averages, SD, and P values are reported. A post hoc power analysis was performed. RESULTS: The violation of the LCL was noted in 3 specimens and that of the PT in 1 specimen as a result of femoral tunnel drilling at flexion angles ranging from 90° to 120°. The distance between the PT and the femoral tunnel also decreased significantly (P < .001) with knee flexion with average distances to the center of 8.07 mm at 0°, 7.75 mm at 30°, 6.33 mm at 60°, 4.12 mm at 90°, and 1.89 mm at 120°. The mean ± SD for distances from the femoral tunnel to the center of the PT at 0° was 8.07 ± 7.15, at 30° 7.75 ± 6.66, at 60° 6.33 ± 6.79, at 90° 4.12 ± 5.71, and at 120° 1.89 ± 5.56. As the knee was progressively flexed, the distance between the LCL and the femoral tunnel decreased significantly (P < .001) with an average distance of 6.52 mm at 0°, 6.26 mm at 30°, 4.23 mm at 60°, 2.38 mm at 90°, and 0.4 mm at 120°. The mean ± SD for distances from the femoral tunnel to the center of the LCL at 0° was 6.52 ± 5.93, at 30° 6.26 ± 7.32, at 60° 4.23 ± 7.82, 90° 2.38 ± 7.31, and at 120° 0.4 ± 7.01. The PN was remote from the femoral tunnel at all flexion angles with a mean distance of 42.83 to 59.22 mm. The PN to guide pin distance increased significantly with progressive knee flexion (P < .001). The AC was not damaged in all specimens. CONCLUSIONS: The LCL and PT are at significant risk during percutaneous femoral drilling for all-epiphyseal anatomic ACL reconstruction using an outside-in technique. This risk was maximized at 120° flexion and minimized in full extension. These findings suggest that the optimal position for femoral drilling in all-epiphyseal ACL reconstruction is full or near-full extension of the knee that can be accomplished by placing the knee in 30° of flexion (after using fluoroscopic guidance to pass the guide pin past the lateral critical structures) to visualize the footprint of the ACL. CLINICAL RELEVANCE: Information garnered from this study may help clinicians better understand the risk to the lateral critical structures when an outside-in femoral tunnel is not drilled in the appropriate degree of knee flexion.

The Interaction of Intramuscular Ketorolac (Toradol) and Concussion in a Rat Model.

The purpose of this study was to examine the interaction of a single dose of Toradol and head impact in an in vivo rat model for sport-related concussion using a validated rat concussion model. Thirty-five Sprague-Dawley rats were placed into one of four groups: (1) Control, (2) Impact Only, (3) Toradol Only, (4) Impact and Toradol. Animals in the impact groups were subjected to a single head impact. Animals in the Toradol group received a single intramuscular injection of Toradol prior to impact. We examined magnetic resonance imaging, serum S100-B and cognitive function using a Morris Water Maze. In the control group, latency decreased significantly from day 0 (74.9 s) to 24 h (57.4 s) after anesthesia. There was no statistically significant difference between time zero and 24 h after impact in the Impact only or Impact and Toradol group. Our findings indicate that there were no differences between cognitive ability, MRI findings or S100B in rats that were administered a single dose of Toradol and subjected to a single impact and rats that were subjected to a single impact only. In both impact groups there were transient changes in cognitive ability as measured by the Morris Water Maze.

A Biomechanical Comparison of Isometric and Anatomic Medial Patellofemoral Ligament Reconstruction.

The purpose of this study was to compare two different methods of medial patellar femoral ligament (MPFL) reconstructions: isometric and anatomic. These were then compared with the native MPFL. Fourteen fresh frozen cadaveric knees were carefully dissected to expose the MPFL. The patella was laterally translated 10 mm using an Instron and values were recorded for the intact ligament and the reconstructions. Neither the anatomic nor the isometric reconstructions completely restored the biomechanical properties of the intact MPFL. There were fewer differences between the isometric reconstruction and the intact specimens. The higher forces and stiffer constructs that occurred with the anatomic reconstruction may suggest that this reconstruction technique could overconstrain the patellofemoral joint.

Temperature Change When Drilling Near the Distal Femoral Physis in a Skeletally Immature Ovine Model.

BACKGROUND: The possibility of physeal injury during anterior cruciate ligament reconstruction in the pediatric population is a concern. The purpose of this study was to determine whether drilling at or near the physis could cause a temperature increase that could trigger chondrolysis. METHODS: Skeletally immature cadaveric lamb distal femurs were used for this study and randomly placed in 1 of 6 groups (n=10 in each group). We examined the 8 and 10 mm Flipcutter at a distance of 0.5 mm from the physis and an 8 and 10 mm acorn-tipped reamer at a distance of 0.5 and 3.0 mm from the physis. During drilling, temperature change at the distal femoral physis was continuously measured until the temperature decreased to the original value. RESULTS: An interreamer comparison yielded a significant difference when drilling 0.5 mm from the physis (P=0.001). Pair-wise Mann-Whitney post hoc tests were performed to further evaluate the differences among the groups. The 8 mm FlipCutter had a significantly higher maximum temperature (39.8±1.4°C) compared with the 10 mm FlipCutter (38.0±0.6°C, P=0.001), 8 mm acorn-tipped reamer (38.1±0.9°C, P=0.007), and 10 mm acorn-tipped reamer (37.5±0.3°C, P<0.001). CONCLUSIONS: The risk of thermal-induced injury to the physis is low with an all epiphyseal drilling technique, when a traditional acorn-tipped reamer over a guidepin is utilized, even if the drilling occurs very close to the physis. In addition, the risk of drilling with a FlipCutter is low, but may be greater than a traditional reamer. CLINICAL RELEVANCE: Thermal-induced necrosis is a realistic concern, due to the characteristics of the distal femoral physis, and the propensity for this physis to respond poorly to injury. Our study supports that drilling near the physis can be done safely, although smaller reamers and nontraditional designs may generate higher heat. LEVEL OF EVIDENCE: Level I-basic science.

Load to Failure and Stiffness: Anchor Placement and Suture Pattern Effects on Load to Failure in Rotator Cuff Repairs.

BACKGROUND: Rotator cuff tendinopathy is a frequent cause of shoulder pain that can lead to decreased strength and range of motion. Failures after using the single-row technique of rotator cuff repair have led to the development of the double-row technique, which is said to allow for more anatomical restoration of the footprint. PURPOSE: To compare 5 different types of suture patterns while maintaining equality in number of anchors. The hypothesis was that the Mason-Allen-crossed cruciform transosseous-equivalent technique is superior to other suture configurations while maintaining equality in suture limbs and anchors. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 25 fresh-frozen cadaveric shoulders were randomized into 5 suture configuration groups: single-row repair with simple stitch technique; single-row repair with modified Mason-Allen technique; double-row Mason-Allen technique; double-row cross-bridge technique; and double-row suture bridge technique. Load and displacement were recorded at 100 Hz until failure. Stiffness and bone mineral density were also measured. RESULTS: There was no significant difference in peak load at failure, stiffness, maximum displacement at failure, or mean bone mineral density among the 5 suture configuration groups (P < .05). CONCLUSION: According to study results, when choosing a repair technique, other factors such as number of sutures in the repair should be considered to judge the strength of the repair. CLINICAL RELEVANCE: Previous in vitro studies have shown the double-row rotator cuff repair to be superior to the single-row repair; however, clinical research does not necessarily support this. This study found no difference when comparing 5 different repair methods, supporting research that suggests the number of sutures and not the pattern can affect biomechanical properties.

The effect of continuous interscalene brachial plexus block with 0.125% bupivacaine vs 0.2% ropivacaine on pain relief, diaphragmatic motility, and ventilatory function.

STUDY OBJECTIVE: Outpatient continuous interscalene brachial plexus blocks containing bupivacaine or ropivacaine are commonly used to control pain after shoulder surgery. Interscalene blocks cause hemidiaphragmatic paresis. Because ropivacaine preferentially blocks sensory fibers, it may cause less blockade of the phrenic nerve. The purpose of this study was to evaluate the effects of 2 common continuous interscalene brachial plexus infusions: 0.125% bupivacaine vs 0.2% ropivacaine. The study hypothesis is that respiratory function will be less attenuated using ropivacaine than bupivacaine without affecting pain relief. DESIGN: Study design was a prospective randomized double-blind study, registered (NCT 02059070), with institutional review board approval and written informed consent. SETTING: The setting was the preoperative and postoperative area in an orthopedic teaching hospital. PATIENTS: Outpatients scheduled for shoulder arthroscopic surgery were included. INTERVENTIONS: All patients underwent baseline measurements and interscalene catheter placement, then randomized to receive pumps containing either 0.2% ropivacaine or 0.125% bupivacaine. MEASUREMENTS: Study measurements included preoperative and postoperative bedside spirometry and ultrasonographic evaluations of diaphragmatic excursion, postoperative pain scores, and postdischarge oral opioid (oxycodone) consumption. MAIN RESULTS: There were no statistically significant differences between bupivacaine vs ropivacaine in outcomes of forced expiratory volume at 1 second change (-22% ± 18.3% vs -29% ± 14.9%), diaphragmatic excursion (-81.4% ± 37.95% vs -75.5% ± 35.1%), VAS pain scores at rest (4.9 ± 2.9 vs 3.5 ± 2.8), or oral opioid consumption (33.7 ± 24.3 mg vs 35.1 ± 33.9 mg). CONCLUSIONS: There was no difference in respiratory dysfunction or opioid requirements between interscalene continuous peripheral nerve blocks with 0.125% bupivacaine or 0.2% ropivacaine. Further study is required to identify anesthetic infusates that will control pain while decreasing the attenuation of pulmonary function.

Soccer-Related Injuries in Children and Adults Aged 5 to 49 Years in US Emergency Departments From 2000 to 2012.

BACKGROUND: An increase in soccer-related injuries occurred in the United States between 2000 and 2012; however, most studies of soccer-related injuries have only examined the pediatric population and not adults. HYPOTHESIS: The number of soccer injuries is increasing in both the pediatric and adult populations. There are differences in injury types and counts when comparing male and female players within various age groups. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 4. METHODS: This retrospective analysis surveyed the US Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) database from 2000 to 2012 for soccer-related injuries in children and adults aged 5 to 49 years. RESULTS: From 2000 to 2012, there were an estimated 2,472,066 soccer-related injuries among 5- to 49-year-olds; 629,994 (25.5%) in adults (aged 20-49 years). The overall estimated pediatric injury count increased significantly over the time period (R (2) = 0.764, P < 0.001). In the 20- to 49-year age range, there was also a significant increase in the estimated number of injuries over the 13-year period, from 41,292 injuries in 2000 to 55,743 in 2012 (R (2) = 0.719, P < 0.001). The estimated injury counts for male players were significantly higher than female players in any given year for all age groups (P < 0.001). Girls aged 5 to 19 years were more likely to have lower extremity injuries than boys (odds ratio [OR], 1.256; 95% CI, 1.214-1.299; P < 0.001). The most common injuries reported were strain/sprains (33.3%), fractures (23.7%), and contusions and abrasions (17.4%) within the 5- to 49-year age category. In both sexes, strains and sprains were significantly lower among 5- to 19-year-olds in comparison with 20- to 49-year-olds (OR, 0.740; 95% CI, 0.714-0.766; P < 0.001). CONCLUSION: There are age- and sex-related differences in estimated injury count, body part injured, type of injury, and hospital admissions for soccer. Also, estimated injury count increased over the 2000 to 2012 time period. CLINICAL RELEVANCE: This study demonstrates that there are differences between pediatric and adult injuries, based on sex, body part, type of injury, and hospital admissions.

Biomechanical properties of labral repair: simple versus vertical suture pattern.

The goal of this study was to evaluate contact area and surface pressure as a result of different suture patterns in the treatment of anterior shoulder instability caused by a Bankart lesion. Loads were applied through the humeral head to the glenoid surface in the intact shoulder and after simple suture labral repair (n=10) and vertical mattress labral repair (n=9). Peak contact pressure, mean contact pressure, and contact area were recorded for 0°, 45°, and 90° shoulder abduction, and then the repair was loaded to failure. A significant increase (P<.05) in mean contact pressure and peak contact pressure occurred in both repair groups at 90° abduction. No difference was seen between the 2 repair groups. Total contact area significantly decreased after both repairs at 90° abduction at 220 N force (P<.05). No significant difference occurred in load to failure between the groups. Joint loading properties can be affected by alterations in contact pressure within the glenohumeral joint. In the current study, the authors found no significant difference in contact pressure between the 2 repair groups. However, they found a significant increase in mean contact pressure and peak pressure between the intact specimen and the 2 repair groups. Both simple repair and vertical mattress repair provided similar load to failure for labral repair. Current techniques used to perform Bankart repair may need to be altered to provide the stability of current techniques with more normal glenohumeral joint contact pressure.

Biomechanical evaluation of anatomical double-bundle coracoclavicular ligament reconstruction secured with knot fixation versus screw fixation.

Methods to reconstruct the coracoclavicular ligaments anatomically have been described. No clear advantage of 1 technique has been elucidated. The authors' hypothesis was that the biomechanical properties of a modified knot fixation technique would be similar to the anatomical double-bundle technique. Sixteen matched cadaveric shoulders were used for this study, and 1 additional shoulder was used in the knot fixation group only. Shoulders were randomly assigned to the anatomical double-bundle coracoclavicular ligament reconstruction technique (n=8) or a knot fixation technique (n=9). The intact coracoclavicular ligaments were tested to failure with superior displacement at a rate of 2 mm/s. Reconstruction was performed using a semitendinosus tendon allograft, and load to failure was repeated for each construct. Ultimate failure load, stiffness, and failure mode were compared using a paired t test (P<.05). No significant difference existed in load to failure between native and reconstructed ligaments or between reconstruction techniques. Stiffness decreased significantly after reconstruction in the double-bundle group (from 32.5 to 22.5 N/mm; P=.035) and in the modified knot fixation group (from 35.5 to 21.9 N/mm; P=.043). No significant difference existed in stiffness between the 2 reconstruction groups. A significant difference (P=.003) existed between failure modes between the 2 reconstruction techniques. Although less stiff than the native ligament, either technique used to reconstruct the coracoclavicular ligament can be performed to yield a load to failure similar to the intact ligament. The majority of failures in the double-bundle group were by means of the graft slipping at the screw-tendon interface at 1 of the clavicular drill holes. The modified knot fixation technique failed the majority of the time by graft elongation.

The biomechanical stability of distal clavicle excision versus symmetric acromioclavicular joint resection.

BACKGROUND: Treatment for acromioclavicular (AC) joint pain may include distal clavicle excision (DCE). It is possible that DCE can disrupt the surrounding ligaments, leading to increased AC joint laxity. PURPOSE: To determine the load to failure and stiffness of the AC joint after DCE and symmetric acromioclavicular joint resection (ACJR). STUDY DESIGN: Controlled laboratory study. METHODS: Specimens were randomly assigned to 1 of 2 groups: 1-cm DCE (n = 10) or symmetric (5-mm excision of acromion and distal clavicle) ACJR (n = 10). The specimens were loaded intact in the anterior-posterior plane to determine anteroposterior translation. This was repeated after surgery and compared. The specimens were loaded at 2 mm/s until clinical failure. Force and displacement were recorded, and stiffness was calculated. RESULTS: The peak load to failure for the DCE group was 387.8 N (standard error of the mean [SEM], 31.4 N) and for the ACJR group was 468.5 N (SEM, 30.9 N) (P = .035). The average stiffness for the DCE group was 35.2 N/mm (SEM, 2.5 N/mm) and for the ACJR group was 37.4 N/mm (SEM, 2.3 N/mm) (P = .11). There was no significant difference in the anteroposterior translation before and after resection for either group (P > .05). CONCLUSION: This cadaveric study demonstrates that the anterior-posterior load to clinical failure of the AC joint after 5 mm of resection from the distal clavicle and medial acromion is significantly greater than 1 cm of the resected distal clavicle alone. CLINICAL RELEVANCE: Performing ACJR may improve joint stability, leading to fewer complications when compared with DCE.

Anatomical evaluation of a cortical button for distal biceps tendon repairs.

BACKGROUND: The posterior interosseous nerve (PIN) is at risk for injury during one-incision distal biceps tendon repair using a cortical button. The purpose of this study was to evaluate the proximity of a cortical button to the PIN during one-incision repairs of the distal biceps tendon using human cadaveric models. METHODS: In ten cadaveric elbows the biceps tendon was identified, traced to its insertion, and transected. With the forearm supinated, a guide pin was drilled through the radial tuberosity at a 0°, perpendicular to the table. A dorsal incision was used to identify the PIN. The tendon was repaired with a cortical button, ensuring the device lay in line with the radial shaft. The distance from the device to the PIN was measured using digital calipers. This process was repeated with the guide pin aimed at 20° proximal toward the radiocapitellar joint (RCJ) and 30° distal toward the wrist. The data were compared using a Student's paired t-test. RESULTS: The average distance from the device to the PIN with the straight posterior insertion was 8.94 mm, 11.86 mm with 20° proximal, and 0.55 mm with 30° distal angles. The distance between the button and the PIN was significantly greater when aiming the device 20° toward the RCJ compared to the straight insertion technique (p = 0.0061). CONCLUSIONS: The distance between the PIN and cortical button can be significantly increased by aiming the guide pin between 0° and 20° proximal toward the RCJ and placing the device in line with the radial shaft.

Physeal-sparing technique for femoral tunnel drilling in pediatric anterior cruciate ligament reconstruction using a posteromedial portal.

Pediatric anterior cruciate ligament (ACL) tears present a technical dilemma for orthopaedic surgeons. Multiple surgical techniques have been described to protect the distal femoral and proximal tibial physes. We present an ACL reconstruction technique performed on a 12-year-old girl with open physes who sustained an ACL tear after a noncontact twisting injury while playing soccer. A hamstring autograft reconstruction was performed by use of a posteromedial portal to drill the femoral tunnel in an all-epiphyseal fashion at the anatomic footprint of the native ACL. This case provides a new surgical technique to achieve anatomic fixation for ACL reconstruction in a skeletally immature individual using a posteromedial portal to drill a physeal-sparing lateral femoral tunnel for anatomic ACL reconstruction. This advancement may make drilling the femoral tunnel less technically challenging compared with other proposed methods while maintaining the lateral wall of the distal femur.

A new technique: in vitro suture anchor fixation has superior yield strength to bone tunnel fixation for distal biceps tendon repair.

BACKGROUND: Suture anchor and bone tunnel fixations are used for distal biceps tendon repairs and have not been compared. HYPOTHESIS: Suture anchor fixation is equal or superior to bone tunnel fixation. STUDY DESIGN: Randomized controlled in vitro study. METHODS: A new fixation technique was compared to traditional bone tunnel fixation of distal biceps tendon ruptures between randomly selected sides of nine matched-pair, fresh-frozen elbow specimens from cadaveric donors (mean age = 74.7 years). Bone densities were determined. The distal biceps tendon was attached to the actuator of a servohydraulic load frame and loaded to tensile failure at a constant rate of 4 mm/sec. Bone density, sex, age, side, tuberosity area, repair, failure type, repair stiffness, and yield strength were compared. RESULTS: Superior yield strength of suture anchor fixation (263 N) compared to bone tunnel fixation (203 N) (P = 0.0233) were demonstrated. When suture anchor fixation failure (1 of 9) occurred, the matched pair also failed. CONCLUSION: Suture anchor fixation offers an equal if not superior alternative to bone tunnel fixation for repair of the distal biceps tendon in the specimens tested. CLINICAL RELEVANCE: Suture anchor fixation may be used for distal biceps tendon repairs.