Treatment of Midshaft Clavicle Fractures: Application of Local Autograft With Concurrent Plate Fixation

Currently, open reduction–internal fixation using contoured plates or intramedullary nails is considered the standard operative treatment for midshaft clavicle fractures because of the immediate rigid stability provided by the fixation device. In addition, autologous iliac crest bone graft has proved to augment osteosynthesis during internal fixation of nonunion fractures through the release of osteogenic factors. The purpose of this article is to describe a surgical technique developed to reduce donor-site morbidity and improve functional and objective outcomes after open reduction–internal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation

The Effect of Suture Caliber and Number of Core Strands on Repair of Acute Achilles Ruptures

Category: Sports Introduction/Purpose: Controversy exists in Achilles rupture management with options ranging from nonoperative care to open surgical repair. Current literature suggests re-rupture rates are lower with operative repair; therefore, surgery is recommended for active populations. The effect of suture caliber or number of core stands has not been studied in Achilles repair. Varying these factors may allow for a construct capable of earlier weight-bearing and rehabilitation. We hypothesized the number of core strands and suture caliber used in Achilles repair would significantly affect strength and gapping during a simulated early rehabilitation protocol. Methods: Sixteen cadaveric human foot and ankle specimens with no prior injuries or surgeries were utilized. Simulated midsubstance Achilles ruptures were created 6 cm proximal to the calcaneal insertion in 13 ankles. Specimens were randomly allocated to 1 of 4 groups: (1) intact Achilles tendon, (2) open repair using No. 2 suture with four core sutures and two 2mm suture-tape core sutures, (3) open repair using No. 2 suture with two core sutures and four 2mm suture-tape core sutures, and (4) open repair using No. 2-0 suture with 12 core sutures. Repairs consisted of three modified Kessler sutures and an epitenon stitch with a 3-0 monofilament suture. Specimens were subjected to a cyclic loading protocol simulating early, progressive postoperative rehabilitation: 250 cycles at 1 Hz for each loading range: 20-100, 20-200, 20-300, and 20-400 N. A 1-way ANOVA was used to test significance among repair groups. Results: During biomechanical testing, all repairs survived the first two loading stages. However, elongation trends during stage 1 (Figure 1) were consistent among subsequent cyclic loading stages. No significant elongation differences were observed between any of the repair groups (Groups 2-4), with mean displacements of 4.94 ± 0.90 mm, 3.93 ± 0.92 mm, and 5.35 ± 0.34 mm, respectively, at the end of the first loading stage. In Group 2, one repair failed during the fourth stage and 4 survived all four stages. In Group 3, one repair failed during the third stage and two repairs during the fourth stage. In Group 4, two repairs failed during the fourth stage and two survived all four stages. The average number of cycles to failure for Groups 2-4 was 967, 783, and 940 cycles, respectively. Conclusion: In this study, all but one repair survived 750 cycles. This was superior to a 6 core strand repair with No. 2 suture similarly evaluated in a previous study (427 cycles). When 4 of 6 strands were substituted with suture-tape, repair gapping decreased initially; yet, these repairs failed earlier. Gapping in Groups 2 and 4 was similar to the previously evaluated repair; however, the number of cycles to failure was higher. Therefore, substituting suture-tape for 2 core strands or doubling the core strands with a smaller caliber suture may be biomechanically superior and allow for earlier return to function

Intraarticular arthrofibrosis of the knee alters patellofemoral contact biomechanics

Abstract Background Arthrofibrosis in the suprapatellar pouch and anterior interval can develop after knee injury or surgery, resulting in anterior knee pain. These adhesions have not been biomechanically characterized. Methods The biomechanical effects of adhesions in the suprapatellar pouch and anterior interval during simulated quadriceps muscle contraction from 0 to 90° of knee flexion were assessed. Adhesions of the suprapatellar pouch and anterior interval were hypothesized to alter the patellofemoral contact biomechanics and increase the patellofemoral contact force compared to no adhesions. Results Across all flexion angles, suprapatellar adhesions increased the patellofemoral contact force compared to no adhesions by a mean of 80 N. Similarly, anterior interval adhesions increased the contact force by a mean of 36 N. Combined suprapatellar and anterior interval adhesions increased the mean patellofemoral contact force by 120 N. Suprapatellar adhesions resulted in a proximally translated patella from 0 to 60°, and anterior interval adhesions resulted in a distally translated patella at all flexion angles other than 15° (p < 0.05). Conclusions The most important finding in this study was that patellofemoral contact forces were significantly increased by simulated adhesions in the suprapatellar pouch and anterior interval. Anterior knee pain and osteoarthritis may result from an increase in patellofemoral contact force due to patellar and quadriceps tendon adhesions. For these patients, arthroscopic lysis of adhesions may be beneficial

Lateral meniscus posterior root and meniscofemoral ligaments as stabilizing structures in the ACL-deficient knee: a biomechanical study

Background: The biomechanical effects of lateral meniscal posterior root tears with and without meniscofemoral ligament (MFL) tears in anterior cruciate ligament (ACL)–deficient knees have not been studied in detail. Purpose: To determine the biomechanical effects of the lateral meniscus (LM) posterior root tear in ACL-intact and ACL-deficient knees. In addition, the biomechanical effects of disrupting the MFLs in ACL-deficient knees with meniscal root tears were evaluated. Study Design: Controlled laboratory study. Methods: Ten paired cadaveric knees were mounted in a 6-degrees-of-freedom robot for testing and divided into 2 groups. The sectioning order for group 1 was (1) ACL, (2) LM posterior root, and (3) MFLs, and the order for group 2 was (1) LM posterior root, (2) ACL, and (3) MFLs. For each cutting state, displacements and rotations of the tibia were measured and compared with the intact state after a simulated pivot-shift test (5-Nm internal rotation torque combined with a 10-Nm valgus torque) at 0, 20, 30, 60, and 90 of knee flexion; an anterior translation load (88 N) at 0, 30, 60, and 90 of knee flexion; and internal rotation (5 Nm) at 0, 30, 60, 75, and 90. Results: Cutting the LM root and MFLs significantly increased anterior tibial translation (ATT) during a pivot-shift test at 20 and 30 when compared with the ACL-cut state (both Ps < .05). During a 5-Nm internal rotation torque, cutting the LM root in ACL-intact knees significantly increased internal rotation by between 0.7 ± 0.3 and 1.3 ± 0.9 (all Ps .2). For an anterior translation load, cutting the LM root in ACL-deficient knees significantly increased ATT only at 30 (P ¼ .007). Conclusion: The LM posterior root was a significant stabilizer of the knee for ATT during a pivot-shift test at lower flexion angles and internal rotation at higher flexion angles. Clinical Relevance: Increased knee anterior translation and rotatory instability due to posterior lateral meniscal root disruption may contribute to increased loads on an ACL reconstruction graft. It is recommended that lateral meniscal root tears be repaired at the same time as an ACL reconstruction to prevent possible ACL graft overload

Lateral meniscus posterior root and meniscofemoral ligaments as stabilizing structures in the ACL-deficient knee: a biomechanical study

Background: The biomechanical effects of lateral meniscal posterior root tears with and without meniscofemoral ligament (MFL) tears in anterior cruciate ligament (ACL)–deficient knees have not been studied in detail. Purpose: To determine the biomechanical effects of the lateral meniscus (LM) posterior root tear in ACL-intact and ACL-deficient knees. In addition, the biomechanical effects of disrupting the MFLs in ACL-deficient knees with meniscal root tears were evaluated. Study Design: Controlled laboratory study. Methods: Ten paired cadaveric knees were mounted in a 6-degrees-of-freedom robot for testing and divided into 2 groups. The sectioning order for group 1 was (1) ACL, (2) LM posterior root, and (3) MFLs, and the order for group 2 was (1) LM posterior root, (2) ACL, and (3) MFLs. For each cutting state, displacements and rotations of the tibia were measured and compared with the intact state after a simulated pivot-shift test (5-N·m internal rotation torque combined with a 10-N·m valgus torque) at 0°, 20°, 30°, 60°, and 90° of knee flexion; an anterior translation load (88 N) at 0°, 30°, 60°, and 90° of knee flexion; and internal rotation (5 N·m) at 0°, 30°, 60°, 75°, and 90°. Results: Cutting the LM root and MFLs significantly increased anterior tibial translation (ATT) during a pivot-shift test at 20° and 30° when compared with the ACL-cut state (both Ps .2). For an anterior translation load, cutting the LM root in ACL-deficient knees significantly increased ATT only at 30° (P = .007). Conclusion: The LM posterior root was a significant stabilizer of the knee for ATT during a pivot-shift test at lower flexion angles and internal rotation at higher flexion angles. Clinical Relevance: Increased knee anterior translation and rotatory instability due to posterior lateral meniscal root disruption may contribute to increased loads on an ACL reconstruction graft. It is recommended that lateral meniscal root tears be repaired at the same time as an ACL reconstruction to prevent possible ACL graft overload