James E. Fleischli

Prospective Evaluation of Thermal Capsulorrhaphy for Shoulder Instability Indications and Results, Two- to Five-Year Follow-up

Background Thermal shrinkage of capsular tissue has recently been proposed as a means to address the capsular redundancyassociated with shoulder instability. Although this procedure has become very popular, minimal peer-reviewed literature isavailable to justify its widespread use. Purpose To prospectively evaluate the efficacy of arthroscopic electrothermal capsulorrhaphy for the treatment of shoulderinstability. Study Design This nonrandomized prospective study evaluated the indications and results of thermal capsulorrhaphy in 84shoulders with an average follow-up of 38 months. Methods Patients were divided into three clinical subgroups: traumatic anterior dislocation (acute or recurrent), recurrent anterioranterior/inferior subluxation without prior dislocation, and multidirectional instability. Patients underwent arthroscopic thermalcapsulorrhaphy after initial assessment, radiographs, and failure of a minimum of 3 months of nonoperative rehabilitation. Results Outcome measures included pain, recurrent instability, return to work/sports, and the American Shoulder and ElbowSurgeons (ASES) Shoulder Assessment score. Overall results were excellent in 33 participants (39%), satisfactory in 20 (24%),and unsatisfactory in 31 (37%). Conclusions The high rate of unsatisfactory overall results (37%), documented with longer follow-up, is of great concern. Theauthors conclude that enthusiasm for thermal capsulorrhaphy should be tempered until further studies document its efficacy.

Dorsiflexion metatarsal osteotomy for treatment of recalcitrant diabetic neuropathic ulcers.

Twenty diabetic patients underwent 22 dorsiflexion metatarsal osteotomies for treatment of chronic persistent or recurrent neuropathic forefoot ulcers. Mean duration of nonoperative treatment was 13 months. The procedure consisted of irrigation and debridement of the ulcer followed by basilar closing wedge metatarsal osteotomy performed through a dorsal approach. At follow-up, complete ulcer healing was noted in 21 cases (95%) at an average of 40 days postoperatively. Complications occurred in 15 cases (68%). The main problems encountered postoperatively were acute Charcot disease (32%) and deep wound infections (14%). Transfer lesions under adjacent metatarsal heads developed in two cases (9%). One ulcer (5%) failed to heal secondary to vascular insufficiency and eventually required a below the knee amputation after a failed revascularization attempt. Loss of screw fixation occurred in one patient (5%) but acceptable metatarsal alignment was maintained and the ulcer healed uneventfully. There were no cases of ulcer recurrence. The results of this study suggest that dorsiflexion metatarsal osteotomy is a reliable salvage procedure for the treatment of recalcitrant neuropathic forefoot ulcers that have failed an adequate trial of nonoperative treatment. This procedure is associated with a high complication rate, as would be expected in this patient population.

Transtibial Versus Anteromedial Portal Technique in Single-Bundle Anterior Cruciate Ligament Reconstruction Outcomes of Knee Joint Kinematics During Walking

Background: In anterior cruciate ligament (ACL) reconstruction, the transtibial (TT) technique often creates a nonanatomically placed femoral tunnel, which is a frequent cause of surgical failure and postsurgical knee instability. Several studies reported that drilling the femoral tunnel through an anteromedial portal (AMP) yields a more anatomic tunnel position compared with the TT technique. Purpose: To compare the effectiveness of these two surgical techniques in restoring the intact knee joint kinematics during a physiological loading situation. Study Design: Controlled laboratory study. Methods: Twenty-four patients (TT, n = 12; AMP, n = 12; sex, weight, and height matched, and half with dominant leg involved) who underwent unilateral single-bundle ACL reconstruction by the same surgeon were recruited. Twenty healthy patients with no history of lower limb injuries were recruited as the control group. Tibiofemoral joint motion in 6 degrees of freedom (3 translations and 3 rotations) was determined during level walking by using a least mean square–based optimization algorithm. A redundant marker set was used to improve the accuracy of the motion analysis. Knee joint kinematics as well as spatiotemporal parameters were compared between these two techniques. Results: The AMP technique restored the anterior-posterior translation of the knee joint, while the TT technique resulted in significantly greater (TT, 22.2 mm vs controls, 13.2 mm; P < .01) anterior femoral translations than in the healthy controls during the swing phase. Excessive femoral external (tibial internal) rotation (3.8°; P < .05) was found at midstance in the knees that were reconstructed using the TT technique; using the AMP technique, the external rotation offset was greatly reduced during the stance phase. However, knees repaired using the AMP technique were significantly less extended (5°; P < .05) compared with the knees of the controls during the late stance phase. Neither surgical technique restored the superior-inferior femoral translation to the intact level during the swing phase. Conclusion: The AMP technique better restores the anterior-posterior translation during the swing phase and femoral external rotation at midstance than the TT technique does. However, the AMP technique is also correlated with an extension loss during the late stance phase. Clinical Relevance: The AMP femoral tunnel drilling technique can improve overall knee joint stability, but the increased difficulty with full extension may need to be considered.

A Biomechanical Evaluation of Ulnar Collateral Ligament Reconstruction Using a Novel Technique for Ulnar-Sided Fixation

Background: Techniques for ulnar collateral ligament (UCL) reconstruction have evolved since its original description. Hypothesis: Ulnar collateral ligament reconstruction using the ZipLoop for ulnar-sided fixation, as combined with the humeral docking technique supplemented with an interference screw, will restore valgus stability similar to that of the Jobe technique and the native ligament. Study Design: Controlled laboratory study. Methods: Kinematic testing was performed on 8 matched pairs of cadaver elbows with an electromagnetic tracking system through an arc of motion for the intact, disrupted, and reconstructed states of the UCL in an unloaded and loaded condition. From each pair, the docking technique using the ZipLoop for ulnar fixation and humeral docking technique supplemented with an interference screw and the traditional Jobe technique were performed with matched gracilis allograft tendons. After kinematic testing, both reconstruction groups were tested to failure at 70° of flexion. Results: Kinematic results for the unloaded condition showed that both reconstruction techniques significantly overcorrected (less valgus angulation) the specimens between 40° and 120° of flexion when compared with the intact ligament (all P values < .027). Under loaded conditions, the ulnar trajectories for both reconstruction techniques exhibited significantly greater valgus angulation (undercorrection) at 20° of flexion (Jobe, P = .0084; ZipLoop, P = .0289) when compared with the intact ligament but were not significantly different over the remaining arc of motion. Failure testing resulted in no significant statistical difference between the 2 reconstruction groups. Failure testing demonstrated that humeral tunnel egress, midsubstance elongation, and ulnar tunnel egress of the ligament were similar between the reconstruction techniques. Conclusion: The docking technique using the ZipLoop for ulnar-sided fixation is biomechanically equivalent to the Jobe technique for UCL reconstruction. Both reconstruction techniques restore valgus stability similar to that of the native UCL ligament. Clinical Relevance: This modification in the docking technique restores elbow kinematics while eliminating the risk of ulnar bone bridge fracture, and it allows for retensioning of the graft after cortical fixation.

Superior Pole Sleeve Fracture of the Patella: A Case Report and Review of the Literature

Patellar fractures in children are uncommon and represent 1% of all pediatric fractures. Of all patellar fractures, less than 2% occur in skeletally immature patients, and over half of these are sleeve fractures. Most reported cases of sleeve fractures involve the inferior patellar pole. There is a particularly high male predominance of this injury, with a ratio of 5:1. The sleeve fracture was first described in 1979 by Houghton and Ackroyd as an avulsion of a small subchondral osseous fragment from the distal pole of the patella together with an extensive sleeve of cartilage and retinaculum pulled from the main body of the patella. To our knowledge, there have been 13 cases reported in the literature of sleeve fractures involving the superior pole of the patella. In reviewing the literature, there is a lack of information pertaining to long-term results. The present case report is of a superior pole sleeve avulsion fracture in an otherwise normal athletic boy, treated operatively and seen back for a 3-year follow-up. The patient and his family were informed that data concerning the case would be submitted for publication, and the study was approved by our institutional review board.

Knee Moment and Shear Force Are Correlated With Femoral Tunnel Orientation After Single-Bundle Anterior Cruciate Ligament Reconstruction

Background: Increasing evidence has shown that anatomic single-bundle anterior cruciate ligament reconstruction (ACLR) better restores normal knee kinematics and functionality than nonanatomic ACLR. Whether anatomic reconstruction results in better knee kinetics during daily activities has not been fully investigated. Purpose: To assess the relationship between femoral tunnel angle and kinetic parameters of the knee joint during walking after single-bundle ACLR and to compare the radiographic and kinetic results of patients who underwent anatomic ACLR with those of patients who underwent nonanatomic ACLR. Study Design: Controlled laboratory study. Methods: Twenty-one patients who underwent unilateral ACLR were recruited, and 20 healthy subjects from a previous study were used as a control group. All surgical procedures were performed by a single surgeon, 11 using the transtibial (TT) technique and 10 using the anteromedial portal (AMP) technique. Femoral tunnel orientation was measured from posterior-to-anterior radiographs. Dynamic knee joint moments and shear forces during gait were evaluated using 3-dimensional motion analysis and inverse dynamics. Relationships between femoral tunnel angles and kinetic results were evaluated via linear regression. Results were compared between 2 ACLR groups and controls using 1-way analysis of variance. Results: Femoral tunnel angle had significant correlations with peak external knee flexion moment and posterior shear force during early stance. The TT group had a significantly smaller (more vertical) mean femoral tunnel angle (19.4° ± 4.1°) than the AMP group (36.4° ± 5.8°). Significant reductions were found in the normalized peak external knee flexion moment (TT, 0.15 ± 0.12 Nm/kg·m; AMP, 0.25 ± 0.12 Nm/kg·m; control, 0.25 ± 0.16 Nm/kg·m) (P = .032) and posterior shear force (TT, 0.64 ± 0.55 N/kg; AMP, 1.10 ± 0.58 N/kg; control, 1.35 ± 0.55 N/kg) (P = .024) in the TT group compared with controls, but not in the AMP group. Moreover, a significantly greater medial shear force was found in the TT group during the late stance phase (TT, 1.08 ± 0.32 N/kg; AMP, 0.89 ± 0.26 N/kg; control, 0.83 ± 0.22 N/kg) (P = .038). A greater peak external knee adduction moment was found in both ACL groups during the early stance phase (TT, 0.25 ± 0.07 Nm/kg·m; AMP, 0.25 ± 0.07 Nm/kg·m; control, 0.19 ± 0.05 Nm/kg·m) (P < .01). Conclusion: Knee joint kinetic changes are seen within months (~10 months) after ACLR. This study revealed significant relationships between femoral tunnel orientation and postoperative knee joint flexion moment and posterior shear force during walking. The AMP technique provides better restoration of these knee kinetic parameters compared with the TT technique at this postoperative time point. Clinical Relevance: The femoral tunnel angle measured from plain radiographs can be used as an important metric of postoperative knee joint kinetics. This information provides a better understanding of the knee joint’s biomechanical environment after ACLR using commonly used single-bundle techniques.

Ulnar collateral ligament reconstruction using the ToggleLoc with ZipLoop for ulnar side fixation.

Dr Starman is from Carolinas Medical Center, and Drs Fleischli and D’Alessandro are from OrthoCarolina Sports Medicine Center, Charlotte, North Carolina; and Dr Morgan is from Resurgens Orthopaedics, Atlanta, Georgia. Drs Starman, Morgan, Fleischli, and D’Alessandro have no relevant fi nancial relationships to disclose. Correspondence should be addressed to: James S. Starman, MD, Department of Orthopedic Surgery, Carolinas Medical Center, 1616 Scott Ave, Charlotte, NC 28203 (jstarman20@msn.com). doi: 10.3928/01477447-20100329-16 In ulnar collateral ligament reconstruction, the Biomet Sports Medicine ToggleLoc with ZipLoop Technology may allow for a more anatomic tunnel position on the ulna and avoidance of tunnel complications associated with other techniques.

The prevalence of rotator cuff pathology in the setting of acute proximal biceps tendon rupture.

BACKGROUND The prevalence and severity of concomitant rotator cuff pathology in the setting of proximal biceps tendon ruptures are poorly understood. Concomitant rotator cuff disease may have important implications in the prognosis and natural history of this shoulder condition. Therefore, an observational cohort of patients with an acute rupture of the long head of the biceps tendon (LHBT) was evaluated to determine the prevalence and severity of concomitant rotator cuff disease. METHODS Thirty consecutive patients diagnosed with acute proximal biceps tendon rupture were prospectively enrolled. Magnetic resonance imaging of the affected shoulder was obtained in 27 patients and reviewed by a fellowship-trained orthopedic surgeon. RESULTS The cohort consisted of 20 men (74%) and 7 women (26%) (mean age, 61.0 years [range, 42-78 years]). The dominant side was involved in 20 injuries (74%), and a low-energy trauma mechanism of injury was involved in 23 (85%). Of the patients, 11 (41%) reported a history of antecedent shoulder pain. Magnetic resonance imaging assessment revealed that 93% of patients had evidence of rotator cuff disease, including 13 full-thickness tears. Of the full-thickness tears, 3 were small, 6 medium, 2 large, and 2 massive. Pathology of the subscapularis tendon was identified in 7 patients (26%). CONCLUSION In this cohort, we found LHBT rupture to be highly correlated with the presence of rotator cuff disease, with the majority of patients presenting with full-thickness tears of the supraspinatus. These findings may have important implications in the treatment and prognosis of patients who present with acute LHBT ruptures.

Biceps Tenodesis: Biomechanical Assessment of 3 Arthroscopic Suprapectoral Techniques.

Biceps tenodesis maintains the cosmetic appearance and length-tension relationship of the biceps with an associated predictable clinical outcome compared with tenotomy. Arthroscopic suprapectoral techniques are being developed to avoid the disadvantages of the open subpectoral approach. This study biomechanically compared 3 arthroscopic suprapectoral biceps tenodesis techniques performed with a suture anchor with lasso loop technique, an interference screw, and a compressive rivet. For a total of 15 randomized paired tests, 15 pairs of human cadaveric shoulders were used to test 1 technique vs another 5 times with 3 customized setups. Biomechanical testing was performed with an electromechanical testing system. The tendon was preloaded with 10 N and cyclically loaded at 0 to 40 N for 50 cycles. Load to failure testing was performed at 1 mm/s until failure occurred. The compressive rivet, interference screw, and suture anchor with lasso loop had mean load to failure of 97.1 N, 146.4 N, and 157.6 N, respectively. The difference in ultimate strength between the suture anchor with lasso loop and the compressive rivet was statistically significant (P=.04). No significant differences were found between the suture anchor with lasso loop and the interference screw (P=.93) or between the interference screw and the rivet (P=.10). When adjusted for sex, the load to failure overall among the 3 constructs was not significantly different. All 3 techniques had a different predominant mechanism of failure. The suture anchor with lasso loop showed superior load to failure compared with the compressive rivet. The minimum load to failure required to achieve clinically reliable biceps tenodesis is unknown. [Orthopedics. 2017; 40(6):e1009-e1016.].

Transtibial Versus Anteromedial Portal ACL Reconstruction: Is a Hybrid Approach the Best?:

Background: Improved biomechanical and clinical outcomes are seen when the femoral tunnels of the anterior cruciate ligament (ACL) are placed in the center of the femoral insertion. The transtibial (TT) technique has been shown to be less capable of this than an anteromedial (AM) portal approach but is more familiar to surgeons and less technically challenging. A hybrid transtibial (HTT) technique using medial portal guidance of a transtibial guide wire without knee hyperflexion may offer anatomic tunnel placement while maintaining the relative ease of a TT technique. Purpose: To evaluate the anatomic and biomechanical performance of the HTT technique compared with TT and AM approaches. Study Design: Controlled laboratory study. Methods: Thirty-six paired, fresh-frozen human knees were used. Twenty-four knees (12 pairs) underwent all 3 techniques (TT, AM, HTT) for femoral tunnel placement, with direct measurement of femoral insertional overlap and femoral tunnel length. The remaining 12 knees (6 pairs) underwent completed reconstructions to evaluate graft anisometry and tunnel orientation, with each technique performed in 4 specimens and tested using motion sensors with a quad-load induced model. Graft length changes and graft/femoral tunnel angle were measured at varying degrees of flexion. Results: Percentage overlap of the femoral insertion averaged 37.0% ± 28.6% for TT, 93.9% ± 5.6% for HTT, and 79.7% ± 7.7% for AM, with HTT significantly greater than both TT (P = .007) and AM (P = .001) approaches. Graft length change during knee flexion (anisometry) was 30.1% for HTT, 12.8% for AM, and 8.5% for TT. When compared with the TT approach, HTT constructs exhibited comparable graft–femoral tunnel angulation (TT, 150° ± 3° vs HTT, 142° ± 2.3°; P < .001) and length (TT, 42.6 ± 2.8 mm vs HTT, 38.5 ± 2.0 mm; P = .12), while AM portal tunnels were significantly shorter (31.6 ± 1.6 mm; P = .001) and more angulated (121° ± 6.5°; P < .001). Conclusion: The HTT technique avoids hyperflexion and maintains femoral tunnel orientation and length, similar to the TT technique, but simultaneously achieves anatomic graft positioning. Clinical Relevance: The HTT technique offers an anatomic alternative to an AM portal approach while maintaining the technical advantages of a traditional TT reconstruction.