Meniscal allograft transplantation.

PURPOSE: Meniscal allograft transplantation (MAT) has become an accepted treatment option for patients undergoing meniscectomy with recalcitrant pain in the corresponding compartment. Whether MAT can oppose cartilage degeneration is unclear. Our purpose was to perform a systematic review of available literature to answer the following: (1) Does MAT prevent advancing chondrosis? (2) Who is the ideal candidate for MAT? (3) What is the survival time for allograft in a stable knee? (4) Can MAT be successful when performed with concomitant procedures? (5) Is there an outcome difference between medial and lateral meniscal allograft transplants? (6) What is the expected function of a knee that has undergone MAT? METHODS: Two authors performed a systematic review of the literature pertaining to MAT. Included in the review are studies with at least 2 years' follow-up, studies with validated outcome measures, and studies in which the allograft meniscal horns were secured with bony fixation. RESULTS: We identified 14 clinical articles that satisfied our inclusion and exclusion criteria. Thirteen of the articles provided Level IV evidence, and one article provided Level III evidence. CONCLUSIONS: MAT can result in alleviation of knee pain, improvement in knee function, and good patient satisfaction if performed in the optimal candidate. Improvements in both objective and subjective outcome measures were shown in relatively young patients without significant chondromalacia who underwent concomitant procedures for cartilage defects, limb malalignment, and/or knee instability. We detected no significant difference in outcomes when comparing medial and lateral meniscal allograft transplants. We detected no significant difference when comparing isolated MAT with MAT performed with concomitant procedures. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Suture loosening and its effect on tendon fixation in knotless double-row rotator cuff repairs.

PURPOSE: We have occasionally observed suture loosening in initial suture legs after final fixation of adjacent suture legs in the lateral row of rotator cuff repairs during arthroscopic rotator cuff repair with transosseous-equivalent suture-bridge constructs. We sought to determine how this occurred and what effects it had on tendon fixation stability. METHODS: Six pairs of fresh-frozen human shoulders were prepared with a simulated cuff defect. A suture-bridge repair was performed in each specimen with one of each pair randomized to one type of "knotless" lateral-row screw-in anchor and the other of the pair to a knotless push-in type. The repairs were cyclically loaded with 100 N for 1,000 cycles. Suture leg tensions were measured during the repair and after cycling. Lateral tendon laxity was measured before and after cycling. A pilot study on the effect of suture tension on the tendon contact footprint was also performed. RESULTS: The initial suture legs did not show a decrease in tension after the second lateral-row anchor was secured. Tension of the suture legs after cycling showed that no one leg loosened more than another; however, they all loosened when compared with total suture tensions before cycling (0.1 to 1.0 mm, P = .008). There was no significant difference between suture tension changes for the 2 anchor types after cycling (P = .140). Although the lateral tendon laxity increased slightly (0.04 mm) after cycling, this was not significant (P = .245), nor was there a difference between anchor types. CONCLUSIONS: Suture loosening occurred after cycling these rotator cuff repairs, but this did not appear to affect lateral tendon laxity for the 2 lateral anchor types studied, although medial tendon movement was observed. CLINICAL RELEVANCE: Suture loosening after cycling the 2 transosseous-equivalent suture-bridge repairs studied could affect the area and pressure of tendon-bone contact.

Arthroscopic coracoclavicular ligament reconstruction using biologic and suture fixation.

Presented in this report is a modified arthroscopic approach to acromioclavicular joint reconstruction via suture and allograft fixation. An arthroscopic approach is used to expose the base of the coracoid by use of electrocautery. After an open distal clavicle excision is performed, clavicular and coracoid tunnels are created under arthroscopic visualization as previously described by Wolf and Pennington. The myotendinous end of a semitendinosus allograft is sutured to a Spider plate (Kinetikos Medical, San Diego, CA). The tendinous end of the graft is prepared with a running baseball stitch. A Nitinol wire with a loop end (Arthrex, Naples, FL) is used to pass 2 free FiberTape sutures (Arthrex) and the leading sutures from the tendinous end of the graft through the clavicular and coracoid tunnels, exiting out the anterior portal. One of the FiberTape sutures is retrieved with a grasper and passed over the anterior aspect of the distal clavicle. The second FiberTape suture and the allograft are passed over the distal end of the resected clavicle. While the acromioclavicular joint is held reduced, the FiberTape sutures are tied to the plate and the allograft is tensioned medially until the plate is embedded against the superior surface of the clavicle. The tendinous end of the graft is secured to the superior surface of the clavicle with a Bio-tenodesis screw (Arthrex) medial to the clavicular tunnel.

Sternoclavicular joint reconstruction--a systematic review.

BACKGROUND: Dislocation of the sternoclavicular joint is a rare injury that has a low incidence of signifcant long-term symptoms. Surgical reconstruction of the joint is indicated in patients with symptomatic, chronic anterior instability or with irreducible or recurrent posterior instability. There have been many reported techniques for stabilization of the joint, but few investigators have reported more than several cases. The ideal reconstruction has not been identifed. PURPOSE: The purpose of this investigation was to perform a systematic review of the available literature with the objective of identifying one technique of sternoclavicular reconstruction that could be recommended. METHODS: A systematic review of literature pertaining to treatment of sternoclavicular joint injuries was performed, focusing on clinical reports with at least six patients and 1 year of follow-up. We also reviewed biomechanical reports pertaining to sternoclavicular reconstruction. RESULTS: Six clinical reports and two biomechanical studies were identifed that met our inclusion criteria. Treatments described in the clinical reports included conservative treatment with a sling, repair of the joint capsule with provisional stabilization, and joint reconstruction with local tissue or graft tissue. One biomechanical study compared the strength of three reconstruction techniques. CONCLUSION: Reconstruction with tendon tissue woven in a figure-of-eight pattern through drill holes in the manubrium and clavicle is stronger than reconstructions with local tissue. The review of clinical reports suggests excellent outcomes with this technique, and it is recommended in cases of chronic instability. In cases of acute instability requiring open reduction or inability to maintain a reduction in a posterior dislocation, there is evidence that repair of the joint capsule is suffcient surgical treatment.

Early fracture of a bioabsorbable tibial interference screw after ACL reconstruction with subsequent chondral injury.

Graft fixation in anterior cruciate ligament (ACL) reconstruction is commonly performed with bioabsorbable devices. This article presents a case of a broken bioabsorbable tibial interference screw (Gentle Threads; Biomet, Warsaw, Indiana) that presented as an intra-articular loose body 4 months after ACL reconstruction with posterior tibialis tendon allograft. A 19-year-old man presented with symptoms of pain and catching for 1 week but reported no history of trauma. The broken screw tip was identified on magnetic resonance imaging examination, and the remaining screw appeared to be overinserted into the tibia. During arthroscopic removal, a 10-mm screw tip was found in the lateral gutter. The ACL graft was found to be well fixed, but small areas of chondral damage were found in the patellofemoral and medial compartment. The patient's symptoms resolved postoperatively. To our knowledge, this is the earliest report of a broken bioabsorbable interference screw and only the second report of subsequent chondral injury due to intra-articular migration. Although rare, late breakage and intra-articular migration of bioabsorbable interference screws should be considered during the postoperative evaluation of any patient with pain or mechanical symptoms, regardless of trauma. This case also supports the importance of both measurement of tibial tunnel length and inspection of the intercondylar notch following interference screw insertion. Orthopedic surgeons performing ACL reconstruction must be aware of this possible complication and its potential for devastating chondral injury.

Treatment of stress fractures: the fundamentals.

This article is an introduction to the fundamentals of stress fracture management. Extrinsic and intrinsic factors, that may play a role in the development of stress fractures, are discussed and incorporated as possible treatment options. Different treatment modalities including ultrasound and electromagnetic fields are addressed, with an emphasis on literature support.