Background:
The transosseous-equivalent (TOE) rotator cuff repair construct has become the gold standard for the repair of medium and large rotator cuff tears. Repair failure, however, continues to ...be a problem. One contributing factor may be the inability of the TOE repair to replicate the native footprint contact characteristics during shoulder movement, especially in rotation. This results in higher strain across the repair, which leads to gapping and predisposes the construct to failure. In an effort to better reproduce the native compression forces throughout the footprint, an augmented TOE construct supplemented with lateral edge fixation is proposed, and the contact characteristics were compared with those of the gold standard TOE construct.
Hypothesis:
The augmented TOE repair will demonstrate improved footprint contact characteristics when compared with the classic TOE repair.
Study Design:
Controlled laboratory study.
Methods:
Ten fresh-frozen cadaveric shoulders underwent supraspinatus repair using both the classic TOE double-row construct and the augmented TOE repair. For the augmented repair, 2 luggage tag sutures were used to secure the lateral edge and incorporated into the lateral row anchors. A Tekscan pressure sensor (Tekscan Inc) placed under the repaired tendon was used to collect footprint contact area, force, peak pressure, and contact pressure data for each construct.
Results:
The augmented construct demonstrated significantly greater contact forces (average difference, 4.9 N) and significantly greater contact pressures (average difference, 23.1 kPa) at all degrees of abduction and all degrees of rotation. At 30° of internal and 30° of external rotation at both 0° and 30° of shoulder abduction, the augmented construct demonstrated significantly greater peak contact pressures.
Conclusion:
The augmented construct showed superior contact characteristics when compared with the classic TOE technique. The addition of lateral edge fixation to the classic TOE repair significantly improves bone-tendon contact characteristics with minimal additional surgical effort.
Clinical Relevance:
The results of this study indicate that lateral augmentation of the classic TOE repair produces a biomechanically superior construct that may optimize tendon healing.
Carpal fractures are uncommon, but if missed, can lead to morbidity and loss of function, especially in an athlete. Early diagnosis through physical examination, plain radiographs, and possibly ...advanced imaging is paramount. Treatment is specific to each fracture type, and return to play varies with each clinical scenario. This article organizes current knowledge of these potentially difficult fractures with a table of diagnoses and treatment guidelines.
Background:
Ulnar collateral ligament (UCL) repair augmented with the “internal brace” construct for the management of acute UCL injuries has recently garnered increasing interest from the sports ...medicine community. One concern with this technique is excessive bone loss at the sublime tubercle, should revision UCL reconstruction be required. In an effort to preserve the bony architecture of the sublime tubercle, an alternative internal brace construct is proposed and biomechanically compared with the gold standard UCL reconstruction.
Hypothesis:
The internal brace repair construct will restore valgus laxity and rotation to its native state and demonstrate comparable load-to-failure characteristics with the 3-strand reconstruction technique.
Study Design:
Controlled laboratory study.
Methods:
For this study, 8 matched pairs of fresh-frozen cadaveric elbows were randomized to undergo either UCL reconstruction with the 3-ply docking technique or UCL repair with a novel internal brace construct focused on augmenting the posterior band of the anterior bundle of the ligament (modified repair-IB technique). Valgus laxity and rotation measurements were quantified through use of a MicroScribe 3DLX digitizer at various flexion angles of the native ligament, transected ligament, and repaired or reconstructed ligament. Laxity testing was performed from maximum extension to 120° of flexion. Each specimen was then loaded to failure, and the method of failure was recorded.
Results:
Valgus laxity was restored to the intact state at all degrees of elbow flexion with the modified repair-IB technique, and rotation was restored to the intact state at both full extension and 30°. In the reconstruction group, valgus laxity was not restored to the intact state at either full extension or 30° of flexion (P < .001 and P = .004, respectively). Laxity was restored at 60° of flexion, but the elbow was overconstrained at 90° and 120° of flexion (P = .027 and P = .003, respectively). In load-to-failure testing, the reconstruction group demonstrated significantly greater yield torque (19.1 vs 9.0 N·m; P < .005), yield angle (10.2° vs 5.4°; P = .007), and ultimate torque (23.9 vs 17.6 N·m; P = .039).
Conclusion:
UCL repair with posterior band internal bracing was able to restore valgus laxity and rotation to the native state. The construct exhibited lower load-to-failure characteristics when compared with the reconstruction technique.
Clinical Relevance:
In selected patients with acute, avulsion-type UCL injuries, ligament repair with posterior band internal bracing is a viable alternative surgical option that, by preserving bone at the sublime tubercle, may decrease the complexity of future revision procedures.
Purpose To provide a cadaveric analysis of 3 surgical approaches (anterior, anterolateral, posterior) used for decompression of the posterior interosseous nerve within the radial tunnel. The aim of ...the study was to determine whether the number of compression sites visualized and safely released differed between approaches. We hypothesized that no single approach is adequate for visualization of all key compression sites. Methods Thirty fresh-frozen cadaveric specimens were used to perform 10 anterior, 10 anterolateral, and 10 posterior approaches to the radial tunnel. For each approach, key anatomical structures and the 5 documented anatomical sites of nerve compression that were clearly visualized within the surgical exposure were recorded. The portion of the supinator that was directly visualized in each approach was released. A second window was then created to expose the remaining uncut portion of the supinator. Measurements were taken from each specimen. Results Statistical analysis demonstrated that the anterior and anterolateral approaches were best for visualizing the fibrous bands of the radial head, the leash of Henry, the origin of the extensor carpi radialis brevis, and the arcade of Frohse. The posterior approach was best for visualizing the distal border of the supinator. The relative uncut supinator distance varied with approach. The anterior approach left a larger relative uncut portion than the posterior approach. Conclusions No single approach was adequate for complete visualization and release of all compression points of the radial tunnel. In cases of radial tunnel release, complete visualization of the posterior interosseous nerve compression sites is best achieved through multiple windows. Type of study/level of evidence Therapeutic IV.
Background:
Anterior tibial stress fractures are associated with high rates of delayed union and nonunion, which can be particularly devastating to a professional athlete who requires rapid return to ...competition. Current surgical treatment strategies include intramedullary nailing, which has satisfactory rates of fracture union but an associated risk of anterior knee pain. Anterior tension band plating is a biomechanically sound alternative treatment for these fractures.
Hypothesis:
Tension band plating of chronic anterior tibial stress fractures leads to rapid healing and return to physical activity and avoids the anterior knee pain associated with intramedullary nailing.
Study Design:
Case series; Level of evidence, 4.
Methods:
Between 2001 and 2013, there were 13 chronic anterior tibial stress fractures in 12 professional or collegiate athletes who underwent tension band plating after failing nonoperative management. Patient charts were retrospectively reviewed for demographics, injury history, and surgical details. Radiographs were used to assess time to osseous union. Follow-up notes and phone interviews were used to determine follow-up time, return to training time, and whether the patient was able to return to competition.
Results:
Cases included 13 stress fractures in 12 patients (9 females, 3 males). Five patients were track-and-field athletes, 4 patients played basketball, 2 patients played volleyball, and 1 was a ballet dancer. Five patients were Division I collegiate athletes and 7 were professional or Olympic athletes. Average age at time of surgery was 23.6 years (range, 20-32 years). Osseous union occurred on average at 9.6 weeks (range, 5.3-16.9 weeks) after surgery. Patients returned to training on average at 11.1 weeks (range, 5.7-20 weeks). Ninety-two percent (12/13) eventually returned to preinjury competition levels. Thirty-eight percent (5/13) underwent removal of hardware for plate prominence. There was no incidence of infection or nonunion.
Conclusion:
Anterior tension band plating for chronic tibial stress fractures provides a reliable alternative to intramedullary nailing with excellent results. Compression plating avoids the anterior knee pain associated with intramedullary nailing but may result in symptomatic hardware requiring subsequent removal.
The gold standard for management of elbow ulnar collateral ligament (UCL) injuries in elite athletes is reconstruction of the UCL with a tendon graft. Over the past several years, UCL repair for ...acute tears, as well as partial tears, in young athletes has gained increasing popularity, with studies reporting good outcomes and high rates of return to sports. Additionally, there is increased interest in ligament augmentation using the InternalBrace concept. A recent technique paper describes a direct repair of the UCL augmented with a spanning suture bridge. Although clinical outcomes for this method are promising, one possible concern when using this technique is bone loss at the ulnar origin of the UCL should revision reconstruction be required. We propose an alternative augmentation method that allows for stress shielding of the healing native ligament while minimizing bone compromise in the face of UCL reconstruction at a later time point.
Abstract The active compression test (O'Brien Sign) is widely used by physicians to aid in the diagnosis of biceps-labrum complex disease. This maneuver has been particularly criticized in the ...literature, however, with regard to interobserver reliability. Criticisms may in fact stem from inaccurate and inconsistent practice of the examination maneuver, stemming from both patient- and physician-related errors. In this Technical Note, we introduce an easy modification to the O'Brien Sign that limits such errors and improves test uniformity.
Objectives:
The internet has an increasing role in both patient and physician education. While several recent studies critically appraised the quality and accuracy of web-based written information ...available to patients, no studies have evaluated such parameters for open access video content designed for provider use. The present study sought to determine utilization of video resources by orthopaedic residents and assess the quality and accuracy of their content
Methods:
Surveys were distributed to orthopaedic surgery residents to to determine their use of open access instructional video content. An assessment of quality and accuracy of said video content was performed using the basic shoulder examination as a suragate for the “best-case scenario” due to its widely accepted components that are stable over time. Three search terms (“shoulder”, “examination” and “shoulder exam”) were entered into the four online video resources most commonly accessed by orthopaedic surgery residents (VuMedi, G9MD, Orthobullets, and YouTube). Videos were captured and independently reviewed by three orthopedic surgeons. Quality and accuracy were assessed in accordance with previously published standards.
Results:
Of the 72 orthopaedic residents surveyed, 70% use open-access videos as a resource monthly and 25% weekly. Over 70% or respondents perceived the video content to be accurate and informative. We reviewed 39 unique video tutorials on physical examination. Of the 39 videos, 61% rated poor (<25% accurate) or fair (<50% accurate). Specific shoulder tests such as Hawkins, O’Brien Sign, and Neer Impingement were accurately demonstrated in only 50%, 36%, and 27% of videos respectively. Inter-rater reliability was excellent (mean Kappa 0.80, range 0.79-0.81).
Conclusion:
We demonstrated that orthopaedic surgery residents often turn to open-access video tutorials as a supplemental education tool. While the majority residents believed the content is accurate, our results suggest an alarming inaccuracy of these video tutorials. Trainee exposure to inaccurate information has far reaching implications on the education process. As such, training programs should help guide their residents to pre-screened or peer-reviewed video resources.
PDF
