Guillaume D. Dumont

Meniscal and Chondral Injuries Associated With Pediatric Anterior Cruciate Ligament Tears Relationship of Treatment Time and Patient-Specific Factors

Background: Anterior cruciate ligament (ACL) tears are commonly associated with meniscal and chondral injuries. Although lateral meniscal tears are commonly associated with acute ACL injuries, the chronically ACL-deficient knee is associated with an increased rate of medial meniscal injury. These associations have been described in the adult knee literature. Purpose: To evaluate the relationship of elapsed time from injury with the incidence of meniscal and chondral injuries noted at the time of surgical treatment for ACL tears in pediatric patients. The effect of age, gender, weight, and mechanism of injury was also evaluated. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective chart review of pediatric patients undergoing primary arthroscopic ACL reconstruction between January 2005 and January 2011 was performed. The presence of meniscal tear, chondral injury, number of days from injury to treatment, age, weight, gender, and mechanism of injury were recorded. The data were analyzed for associations between elapsed time before surgery as well as patient-specific factors with rates of meniscal and chondral injuries. Results: Three hundred seventy pediatric patients who underwent primary ACL reconstruction were included. Two hundred forty-one were treated ≤150 days (early) from injury, and 129 were treated >150 days (delayed) from injury. Ninety-one (37.8%) patients in the early treatment group and 69 (53.5%) patients in the delayed treatment group had medial meniscal tears (MMTs) (P = .014; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.12-2.83). Lateral meniscal tear (LMT) rates were similar (56.0% and 57.4%) in each group. Age >15 years also influenced the presence of MMTs (P = .033; OR, 1.6; CI, 1.04-2.54). Increased patient weight was associated with an increased rate of MMTs and LMTs. Fifty-four of 170 (31.8%) patients weighing ≤65 kg and 106 of 200 (53%) weighing >65 kg had MMTs (P < .001; OR, 2.2; CI, 1.36-3.42). Eighty-two of 170 (48.2%) patients weighing ≤65 kg and 127 of 200 (63.5%) weighing >65 kg had LMTs (P < .018; OR, 1.7; CI, 1.10-2.68). The presence of chondral injury was significantly associated with the presence of meniscal tear in the same compartment of the knee. Conclusion: Pediatric patients treated >150 days after injury for ACL tears have a higher rate of MMT than those treated ≤150 days after injury. Increased age and weight are independently associated with a higher rate of MMT. Patients with ACL tears and an MMT or LMT are more likely to have a chondral injury in that particular compartment than those without meniscal tears.

Anterior shoulder instability: a review of pathoanatomy, diagnosis and treatment

The glenohumeral joint is inherently predisposed to instability by its bony architecture. The incidence of traumatic shoulder instability is 1.7% in the general population. Associated injuries to the capsulolabral structures of the glenohumeral joint have been described and may play a role in predicting recurrent instability. Advanced imaging, computed tomography or MRI may be necessary to adequately evaluate for associated glenohumeral pathology. Treatment algorithms have traditionally included a period of non-operative management in all patients, however young athletic patients may often benefit from early operative treatment. Various open and arthroscopic surgical options exist to address anterior glenohumeral instability. Bony injuries including bony Bankart lesions and Hills Sachs lesion have been implicated in failed surgical management using techniques that address only the soft tissues. An individualized treatment approach, based upon the patient’s injury pattern and expectations, will likely lead to the most successful outcome.

Area-Based Determination of Bone Loss Using the Glenoid Arc Angle

In patients with anterior glenohumeral instability, the most commonly observed osseous defect involves the anterior portion of the inferior glenoid. The amount of glenoid bone loss guides surgical treatment, with progressively larger defects not being amenable to arthroscopic soft-tissue procedures. Currently, there is no universally accepted method of quantifying glenoid bone loss. Two-dimensional area-based methods and 1-dimensional methods of measuring bone loss have both been described but cannot be used interchangeably. The surface area of a glenoid bony defect is a more comprehensive descriptor of its magnitude than the 1-dimensional width of the defect. Calculating surface area can be challenging. We describe a method of quantifying glenoid bone loss using a glenoid arc angle that corresponds to the surface area of the defect. The arc angle is easily measured by use of commonly used imaging software tools and is independent of the size of the glenoid or defect orientation. This method may prove valuable in preoperative planning for patients with anterior glenohumeral instability.

Impact of Tunnels and Tenodesis Screws on Clavicle Fracture: A Biomechanical Study of Varying Coracoclavicular Ligament Reconstruction Techniques

PURPOSE The purpose of this study was to compare the load to fracture of distal clavicles with no tunnels, one tunnel, or 2 tunnels and to evaluate the effect of inserting tenodesis screws in the tunnels on load to fracture of the distal clavicle. METHODS Fifty right sawbone clavicles were obtained and divided into 5 groups (n = 10): group 1, normal clavicle; group 2, one tunnel, no tenodesis screw; group 3, 2 tunnels, no tenodesis screws; group 4, one tunnel with tenodesis screw; and group 5, 2 tunnels with 2 tenodesis screws. Tunnels were created using a 5-mm-diameter reamer, and 5.5 × 10 mm polyethyl ethyl ketone tenodesis screws were used. A 4-point bending load was applied to the distal clavicles. Load to failure was noted for each specimen. RESULTS Load to failure in clavicles without tunnels was significantly higher (1,157.18 ± 147.10 N) than in all other groups (P < .0005). No statistical differences were noted between groups 2, 3, 4, and 5. Load to failure was not statistically different in clavicles with one versus 2 tunnels. In addition, the use of tenodesis screws in the tunnels did not affect the load required to fracture. CONCLUSIONS The use of tunnels in the clavicle for coracoclavicular (CC) ligament reconstruction significantly reduces the load required to fracture the distal clavicle. The addition of tenodesis screws does not appear to significantly increase the strength of the clavicle in this construct. CLINICAL RELEVANCE CC ligament reconstruction techniques commonly use tunnels in the distal clavicle, which may render the clavicle more susceptible to fracture. This study helps quantify the effect of these tunnels on the strength of the distal clavicle.

Open Clavicle Fractures: Patterns of Trauma and Associated Injuries

Objectives: To describe the demographic distribution, mechanism of injury, and associated injuries of patients sustaining open clavicle fractures. Design: Retrospective case series. Setting: Level I trauma center. Patients/Participants: Trauma registry data from all patients who required admission to the hospital from October 1995 through January 2010, specifically patients with open clavicle fractures. Intervention: Not applicable. Main Outcome Measurements: The patterns of open clavicle fractures and their association with severe, nonorthopaedic injuries (head, thoracic, and great vessel). Results: Fifty-three patients with open clavicle fractures were identified, and they were organized by mechanism of injury: 21 sustained blunt injuries, 26 penetrating injuries, and six not specified. No difference between blunt and penetrating injuries existed with respect to age, Injury Severity Score, inpatient days, or mortality rates. Blunt injuries were more likely associated with head injuries (52%) versus penetrating injuries (22%), but penetrating injuries were more likely associated with a great vessel injury (27% vs 7%, respectively), all statistically significant (P = 0.0487). Conclusions: Open clavicle fractures are rare injuries. Patients often have associated head, thoracic, and great vessel injuries. Penetrating injuries have higher rates of great vessel injuries and that blunt force injuries have higher rates of head injuries.

Reverse Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures

Proximal humeral fractures account for approximately 5% of fractures that are seen in the emergency department and can present difficult challenges to the treating physician1. These fractures are most commonly classified according to the system proposed by Neer2. Complex proximal humeral fractures that require operative treatment can be treated with osteosynthesis, hemiarthroplasty, total shoulder arthroplasty, or, more recently, reverse shoulder arthroplasty3. While locked plating may result in improved fixation in osteopenic bone compared with traditional unlocked plating, the outcomes may still be limited by the risk of complications, including stiffness, osteonecrosis, implant failure, and loss of reduction4,5. Hemiarthroplasty traditionally has been performed for the treatment of three or four-part fractures, particularly in patients with osteopenic bone, and can yield good results for low-demand patients6,7. The outcomes of hemiarthroplasty for the treatment of proximal humeral fracture are satisfactory for long-term pain relief but are less predictable in terms of shoulder motion8. Reverse shoulder arthroplasty can be used for the treatment of cuff tear arthropathy and recently has gained popularity for the treatment of severe proximal humeral fractures. The present review of the current literature on the use of reverse shoulder arthroplasty for the treatment of complex proximal humeral fractures focuses on indications, preoperative planning, surgical techniques, …

Beyond the peak of the anterior glenoid rim: A cadaveric study.

Purpose: The purpose of this study was to quantify the width of bone beyond the peak of the anterior glenoid rim and to determine if this anatomic region of the glenoid significantly affects measurement of the anteroposterior glenoid diameter. Materials and Methods: 19 cadaveric scapulae were examined and the width of bone beyond the peak of the anterior glenoid rim was measured. The percent width of this region relative to the anteroposterior diameter of the glenoid was evaluated. Male and female specimens were compared. Measurements of the anteroposterior diameter of the glenoid, both including and excluding this region, were compared. Results: The mean width of bone beyond the peak of the anterior glenoid rim was 3.2 ± 0.7 mm, corresponding to 10.5% of the anteroposterior glenoid diameter. This anatomic region is of similar relative size in males and females (11% vs 10% of the glenoid diameter). Measurement of the anteroposterior diameter of the glenoid is significantly different depending on whether this region is included or not (P = 0.0064). Conclusions: There exists a portion of the anterior glenoid that is beyond the peak of the anterior rim, and is not part of the concave articular surface. The width of this anatomic area comprises a significant percent of the anteroposterior glenoid diameter, and should be understood when quantifying and describing anterior glenoid bone loss in cases of glenohumeral instability. Clinical Relevance: Understanding of anterior glenoid anatomy is important in the evaluation of glenohumeral instability. The portion of glenoid bone beyond the anterior rim peak is likely important for its soft tissue attachments, but its contribution to bony stability may be misunderstood.