Interobserver and intraobserver reliability of radiographic classification of acromioclavicular joint dislocations.

HYPOTHESIS AND BACKGROUND: The classification and treatment of acromioclavicular (AC) joint dislocations remain controversial. The purpose of this study was to determine the interobserver and intraobserver reliability of the Rockwood classification system. We hypothesized poor interobserver and intraobserver reliability, limiting the role of the Rockwood classification system in determining severity of AC joint dislocations and accurately guiding treatment decisions. METHODS: We identified 200 patients with AC joint injuries using the International Classification of Diseases, Ninth Revision code 831.04. Fifty patients met inclusion criteria. Deidentified radiographs were compiled and presented to 6 fellowship-trained upper extremity orthopedic surgeons. The surgeons classified each patient into 1 of the 6 classification types described by Rockwood. A second review was performed several months later by 2 surgeons. A κ value was calculated to determine the interobserver and intraobserver reliability. RESULTS: The interobserver and intraobserver κ values were fair (κ = 0.278) and moderate (κ = 0.468), respectively. Interobserver results showed that 4 of the 50 radiographic images had a unanimous classification. Intraobserver results for the 2 surgeons showed that 18 of the 50 images were rated the same on second review by the first surgeon and 38 of the 50 images were rated the same on second review by the second surgeon. CONCLUSION: We found that the Rockwood classification system has limited interobserver and intraobserver reliability. We believe that unreliable classification may account for some of the inconsistent treatment outcomes among patients with similarly classified injuries. We suggest that a better classification system is needed to use radiographic imaging for diagnosis and treatment of AC joint dislocations.

Proximity of the Triangular Fibrocartilage Complex to Key Surrounding Structures and Safety Assessment of an Arthroscopic Repair Technique: A Cadaveric Study.

PURPOSE: To quantify the distance of the dorsal ulnar sensory branch, floor of the extensor carpi ulnaris (ECU) subsheath, and ulnar neurovascular bundles from the triangular fibrocartilage complex (TFCC), and secondarily to assess the safety of an all-inside arthroscopic repair of the TFCC with a commonly used meniscal repair device with respect to the aforementioned structures. METHODS: A custom K-wire with 1-mm gradation was used to determine the distance of at-risk structures from the periphery of the TFCC in 13 above-elbow human cadaver specimens. An all-inside repair of the TFCC at the location of a Palmer 1B tear was then performed using a commonly employed meniscal repair device. The distance from the deployed devices to the structure in closest proximity was then measured using digital calipers. RESULTS: The mean distance from the deployed device to the nearest structure of concern for iatrogenic injury was 9.4 mm (range, 5-15 mm). The closest structure to iatrogenic injury was usually, but not always, the dorsal ulnar sensory nerve in 9 of 13 wrists (69.2%) at 9.3 mm (range, 5-15 mm); on 3 occasions it was instead the ulnar nerve (23.1%) at 9.5 mm (range, 9-10 mm), and on 1 occasion 6 mm from the flexor digitorum profundus to the little finger (7.7%). Forearm rotation had no significant effect on measured distances (ulnar nerve: P = .98; dorsal sensory: P = .89; ECU: P = .90). The largest influence of forearm rotation was a 0.4-mm difference between pronation and supination with respect to the distance of the TFCC periphery on the ECU subsheath. CONCLUSIONS: An all-inside arthroscopic TFCC repair using a commonly used meniscal repair device appears safe with respect to nearby neurovascular structures and tendons under typical arthroscopic conditions. CLINICAL RELEVANCE: An all-inside arthroscopic TFCC repair using a commonly employed meniscal repair device appears safe in terms of proximity to important structures although further clinical investigation is warranted.

Fractures of the lesser sesamoids: case series.

We present 3 cases of sesamoid fractures involving the index, ring, and little finger metacarpophalangeal joints. These injuries present similar to more common sprains of the finger metacarpophalangeal joint and may be difficult at times to appreciate on standard posteroanterior and lateral x-rays. Oblique images can aid in making the diagnosis at times. Whereas we still recommend immobilization as the initial treatment for these injuries, all 3 of our cases failed nonoperative management and eventually required sesamoid excision.

Thromboembolic phenomena after arthroscopic shoulder surgery.

PURPOSE: The purpose of this study was to review a series of patients who experienced thromboembolic events after shoulder arthroscopy and attempt to identify possible risk factors or associations with thromboembolic phenomena after shoulder arthroscopy. METHODS: After institutional review board approval, a retrospective database review from 2 fellowship-trained surgeons over a 5-year consecutive period was conducted to identify all patients who underwent shoulder arthroscopy (N = 1,908). Six patients were identified as sustaining thromboembolic events after shoulder arthroscopy (5 deep vein thromboses [DVTs] and 4 pulmonary embolisms [PEs]), but there were no deaths. Patient demographics (age, gender, significant medical history, and body mass index), operative detail (concomitant procedures, positioning, and DVT prophylaxis), and diagnosis and treatment of the thromboembolic events (Doppler ultrasound/chest computed tomography, hypercoagulability testing, and treatment with Coumadin [Bristol-Myers Squibb, New York, NY]) were recorded. RESULTS: Over a 5-year period, from 2002 to 2006, there were 6 patients known to have had thromboembolic events (5 documented DVTs and 4 PEs) after shoulder arthroscopy at the 2 institutions participating in the study. The total number of shoulder arthroscopies performed was 1,908. The mean patient age was 47 years (range, 18 to 71 years). All patients were evaluated with Doppler ultrasound, chest radiography, and chest computed tomography. Patients were treated with Coumadin, after bridging with low-molecular weight heparin. For the 5 documented DVTs, all lesions occurred on the same side as the operated extremity. There were 3 upper extremity lesions and 2 lower extremity lesions. CONCLUSIONS: Postoperative DVT and PE are unusual and potentially fatal consequences of arthroscopic shoulder surgery. We report a low prevalence (0.31%), but all patients in this series required hospitalization and subsequent anticoagulation. All patients who had arthroscopic shoulder surgery during this study period-those with and without thromboembolic events-were in the lateral decubitus position with arm traction. Thromboembolic complications included both ipsilateral upper and lower extremity DVTs, as well as a high percentage of PEs (4 of 6 patients). A wide age range was seen in the patients with thromboembolic complications, and 3 of the patients had known identifiable risk factors. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Postoperative infections: prevention and management.

Postoperative infections continue to be a challenging problem. The incidence of bacterial antibiotic resistance such as methicillin-resistant Staphylococcus aureus is rising. There are numerous intrinsic patient factors that should be optimized before surgery to minimize the risk of surgical site infections. When postoperative infections develop, treatment must be individualized. This article outlines the principles that can help guide treatment.

Comparison of autograft vs allograft in opening-wedge high tibial osteotomy.

Opening-wedge high tibial osteotomy (HTO) is used to treat isolated medial knee joint arthritis. A benefit of using allograft instead of autograft is avoiding a second surgical site, thereby decreasing operative time, blood loss, and pain. Our study objective was to evaluate allograft vs autograft in the failure and complication rates of HTO using the same technique and implant system (Arthrex HTO plate system, Arthrex, Inc, Naples, Fla). Seventy knees in 65 patients were evaluated. There was a 6-fold higher failure rate for the allograft group. When there was no lateral cortical breach, construct failure did not occur in 87.8% of the knees (P = .0006); with lateral cortical breach, construct failure occurred 53% of the time (P = .0006). Seventy-six and a half percent of breached cortices and 75% of failures were associated with large wedge sizes (>or=11 mm); this may suggest a role for closing-wedge osteotomy or alternative osteotomies when larger alignment corrections are needed.

Adipose-derived mesenchymal stem cells from the sand rat: transforming growth factor beta and 3D co-culture with human disc cells stimulate proteoglycan and collagen type I rich extracellular matrix.

INTRODUCTION: Adult mesenchymal stem cell therapy has a potential application in the biological treatment of disc degeneration. Our objectives were: to direct adipose-derived mesenchymal stem cells (AD-MSC) from the sand rat to produce a proteoglycan and collagen type I extracellular matrix (ECM) rich in known ECM components of the annulus fibrosis of disc; and to stimulate proteoglycan production by co-culture of human annulus cells with AD-MSC. METHODS: AD-MSC were isolated and characterised by adherence to plastic, appropriate expression of cluster of differentiation (CD) markers, and differentiation to osteoblasts and chondrocytes in vitro. AD-MSC were grown in three-dimensional (3D) culture and treated with or without transforming growth factor beta (TGFbeta) to direct them to produce annulus-like ECM as determined by proteoglycan content and collagen expression. AD-MSC were co-cultured with human annulus cells and grown in 3D culture. RESULTS: AD-MSC produced a proteoglycan and collagen type I rich ECM after treatment with TGFbeta in 3D culture as confirmed by a 48% increase in proteoglycan content assayed by 1,9-dimethylmethylene blue (DMB), and by immunohistochemical identification of ECM components. Co-culture of human annulus and sand rat AD-MSC in 3D culture resulted in a 20% increase in proteoglycan production compared with the predicted value of the sum of the individual cultures. CONCLUSION: Results support the hypothesis that AD-MSC have potential in cell-based therapy for disc degeneration.

A biomechanical comparison of two suture anchor configurations for the repair of type II SLAP lesions subjected to a peel-back mechanism of failure.

PURPOSE: The purpose of this study was to biomechanically compare 2 different suture anchor configurations in the repair of type II SLAP lesions. METHODS: Standardized type II SLAP lesions were created in 8 matched pairs of cadaveric shoulders. Two different suture anchor configurations were used to repair the type II SLAP lesions. Group 1 SLAP lesions were repaired with 1 suture anchor placed at the anterior border and a second suture anchor placed at the posterior border of the biceps tendon. Group 2 SLAP lesions were repaired with 2 suture anchors placed posterior to the biceps tendon. Biomechanical testing was conducted in 1 direction. A posterior-directed force, in the plane of the glenoid, simulated the peel-back mechanism that occurs during the late cocking phase of throwing. Biceps-labral complex displacement from the glenoid was measured with 2 miniature displacement transducers. Repair failure (2 mm of posterior labral displacement), ultimate failure, and construct stiffness were measured for each specimen. RESULTS: The mean load to repair failure was 43.66 N in group 1 and 40.70 N in group 2. The mean load to ultimate failure was 156.28 N in group 1 and 162.06 N in group 2. The mean construct stiffness was 25.91 N/mm in group 1 and 30.28 N/mm in group 2. The differences between the 2 groups were not statistically significant in terms of repair failure, ultimate failure, and construct stiffness. CONCLUSIONS: When repaired type II SLAP lesions were subjected to a posterior vector load to simulate the peel-back mechanism, the 2 suture anchor configurations were biomechanically equivalent. CLINICAL RELEVANCE: Placement of an anterior suture anchor could, theoretically, tension the anterior capsulolabral structures via the superior and middle glenohumeral ligaments to the superior labrum. The results of this study suggest that there is no biomechanical advantage to placing an anterior suture anchor and so the use of 2 posterior suture anchors may be preferable in the repair of type II SLAP lesions.

Advances in the surgical management of pediatric femoral shaft fractures.

PURPOSE OF REVIEW: To provide an update on surgical methods of pediatric femur fracture treatment. RECENT FINDINGS: Multiple studies describe successful results with elastic nail stabilization of pediatric femur fractures. The indications and risk factors for complications are being more clearly defined. Trochanteric entry-locked intramedullary nailing and submuscular bridge plating have also recently been reported to produce excellent outcomes in a high percentage of patients. Older (>11 years) patients, heavier patients and patients with length-unstable fracture patterns may be best treated with locked nailing or plating. SUMMARY: Pediatric femur fractures can be successfully treated by a number of methods. This review examines the recent literature to provide some guidelines for choosing amongst the options for surgical stabilization.

Basicervical versus intertrochanteric fractures: an analysis of radiographic and functional outcomes.

This retrospective study compared the long-term stability and functional outcomes of basicervical versus intertrochanteric fractures, and evaluated the use of an additional derotational screw in the treatment of basicervical fractures. Sixty-six patients (28 with basicervical fractures and 38 treated for stable and unstable intertrochanteric fractures) were identified. All intertrochanteric fractures were treated with a sliding hip screw. Basicervical fractures were treated with a sliding hip screw with or without a derotational screw. Radiographically measured fracture collapse and tip-apex distance were measured at least 6 weeks after surgery; SF-36 score and Functional Recovery Score data was collected at least 1 year after surgery. The proportion of fractures with > 10% collapse was significantly greater in the basicervical group than the subset of stable intertrochanteric fractures (P = .009), but not than the subset of unstable intertrochanteric fractures. The mean SF-36 bodily pain section domain was greater (less pain) in the basicervical group than the unstable intertrochanteric group (P = .02). No other significant differences in SF-36 scores were noted between the basicervical and either intertrochanteric group. Basicervical fractures collapse more than stable intertrochanteric fractures, suggesting that they may have greater biomechanical instability. This instability, however, does not translate into clinically significant decreases in functional outcome. Using a derotational screw with a sliding hip screw does not affect fracture stability or clinical outcome.