Jonathan N. Watson

A Systematic Review of Ulnar Collateral Ligament Reconstruction Techniques

Background: Ulnar collateral ligament (UCL) reconstruction of the elbow has become increasingly more frequent among elite overhead athletes. The purpose of this study was to conduct a systematic review comparing the clinical outcomes and biomechanical results of the Jobe, modified Jobe, docking, modified docking, Endobutton, and interference screw techniques for UCL reconstruction. Hypothesis: The docking technique will have significantly fewer complications and improved return-to-play rate. Study Design: Systematic review; Level of evidence, 4. Methods: Using the Medline PubMed, Cochrane, and EMBASE databases, a search was performed of all published articles, including randomized controlled trials, cohort studies, and case series, examining UCL reconstructions performed using one of the above noted techniques and excluding case reports and hybrid techniques. Statistical analysis was performed using a χ2 test of independence and 2-proportion Z test. Results: A total of 21 studies, 7 biomechanical and 14 clinical, met the inclusion criteria. There were 1368 patients. The overall complication rate was 18.6% (255/1368), further subdivided into 21 for the Jobe technique (29.2%), 203 for the modified Jobe technique (19.1%), 2 for the interference screw technique (10.0%), 2 (4.3%) for the modified docking technique, and 10 for the docking technique (6.0%). The most common complication across all studies was ulnar nerve neurapraxia in 176 patients (12.9%). The overall rate of return to play was 78.9%. Conclusion: Ulnar collateral ligament reconstruction utilizing the docking technique results in a significantly higher rate of return to play and a lower complication rate when compared with the Jobe and modified Jobe techniques. Clinical Relevance: A lower complication rate can lead to increased rates of return to play and better outcomes postoperatively.

Repair Techniques for Acute Distal Biceps Tendon Ruptures A Systematic Review

BACKGROUND There is a lack of consensus regarding the optimal surgical approach and fixation method for distal biceps tendon ruptures. The purpose of this study was to conduct a systematic review comparing the results of the various surgical approaches and repair techniques for acute distal biceps tendon ruptures. METHODS We searched the MEDLINE, Cochrane, and Embase databases for all published randomized controlled trials, prospective cohort studies, or case series that involved primary repairs of acute distal biceps tendon ruptures with use of a cortical button, intraosseous screws, suture anchors, or bone tunnels for fixation. Exclusion criteria included case reports, cadaveric studies, repairs of partial ruptures, revision repairs, and multiple methods of fixation in the same patient. Statistical analysis was performed with use of the chi-square test. RESULTS Twenty-two studies met the inclusion criteria. The total number of patients was 494 (498 elbows). The complication rate was 24.5% (122 of 498 elbows) overall, and it was 23.9% (seventy-eight of 327) for one-incision procedures and 25.7% (forty-four of 171) for two-incision procedures (p = 0.32). The complication rate was 26.4% (seventy-five of 284) for suture anchors, 20.4% (thirty-four of 167) for bone tunnels, 44.8% (thirteen of twenty-nine) for intraosseous screws, and 0% (zero of eighteen) for cortical button fixation. The complication rate for use of bone tunnels was significantly lower than that for intraosseous screws (p < 0.01). Similarly, the cortical button method proved superior to intraosseous screws (p = 0.01). The most common complication was lateral antebrachial cutaneous nerve neurapraxia (9.6% across all studies, 11.6% for one incision, and 5.8% for two incisions). CONCLUSIONS The complication rate did not differ significantly between one and two-incision distal biceps repairs; however, the bone tunnel and cortical button methods had significantly lower complication rates compared with suture anchors and intraosseous screws. Further studies are needed to determine the optimal number of incisions.

Effect of Lower Extremity Fasciotomy Length on Intracompartmental Pressure in an Animal Model of Compartment Syndrome The Importance of Achieving a Minimum of 90% Fascial Release

Background: There has been an increase in minimally invasive surgery for chronic exertional compartment syndrome (CECS), despite the potential for incomplete compartment release and iatrogenic injuries. To our knowledge, no study has examined the effect of the length of fascial release on compartment pressures. Purpose/Hypothesis: The purpose was to explain the high failure rate seen in fascial release for CECS by evaluating the effect of fasciotomy length on intracompartmental pressures. We hypothesized that complete fascial release would need to be performed to return pressures to baseline levels. Study Design: Controlled laboratory study. Methods: Five male swine (10 lower extremities) were anesthetized. A slit catheter, connected to a pressure monitor, was inserted into the anterior compartment and a solution containing 5% swine albumin was injected into the compartment until the compartment pressure was >25 mm Hg for 10 minutes. Pressures were measured at rest, after the injection, and after each 10% incremental fasciotomy release. Results: The mean resting intracompartmental pressure was 3.2 mm Hg (range, 0-6 mm Hg), which increased after the injection to a mean of 37 mm Hg (range, 26-67 mm Hg). After complete fasciotomy, the mean pressure was 1.1 mm Hg (range, 0-4 mm Hg). There was a strong negative correlation (r = −0.693) between fasciotomy length and intracompartmental pressure. In 90% of the specimens, the pressures were <15 mm Hg after 80% fascial release, and after 90% release, all pressures were ≤8 mm Hg. Conclusion: This study demonstrates a strong correlation between fasciotomy length and a reduction in intracompartmental pressures in a swine model. Our study suggests that 90% fascial release may represent a possible watershed zone, returning the intracompartmental pressure to a value at or near baseline values. Clinical Relevance: The results suggest that even in cases with near complete fascial release, intracompartmental pressures may decrease enough to provide symptomatic relief and avoid possible iatrogenic injuries associated with percutaneous release. It is unknown whether the swine model may adequately translate to the clinical setting; thus, recommendations should be taken with caution, and future studies should be performed to examine the correlation in a human model.

Periacetabular osteotomy and arthroscopic labral repair after failed hip arthroscopy due to iatrogenic aggravation of hip dysplasia

AbstractHip arthroscopy can be a successful surgery when properly indicated and performed properly. In the setting of dysplasia, arthroscopy of the hip can lead to devastating consequences. This case presents a patient who underwent hip arthroscopy despite having significant hip dysplasia. The surgery failed and was subsequently revised with a concomitant arthroscopic labral repair and periacetabular osteotomy with good results at 2-year follow-up. Level of evidence Case report, Level IV.

Bioabsorbable interference screw failure in anterior cruciate ligament reconstruction: A case series and review of the literature

BACKGROUND To report a case series of failures of bioabsorbable interference screws with possible identification of a novel failure mechanism. METHODS A retrospective review of ACL reconstructions by the senior author utilizing BioComposite™ Interference Screws (Arthrex, Inc., Naples, FL) was performed. Complications related to screw placement, including fracture, breakage or bending were examined. Our rate and methods of failure were compared to those quoted in the current literature. RESULTS Eighty-seven patients of average age 23.8 years met inclusion criteria. There were eight screw failures in six patients, with femoral failure in seven and tibial failure in one. The femoral screw fractured halfway between the tip and head in five, while the head of the screw broke in one and the screw bent in another. In the case of tibial interference screw fracture, failure occurred halfway between the tip and head. The insertion device that was used was replaced after recognition of material deformation and considered a potential contributor to the breakage risk as no further screw failures have occurred since. CONCLUSIONS We demonstrate a unique failure mechanism of bio-absorbable interference screws. In each case, the reconstruction was salvaged. Regular inspection of materials and implants can ensure optimal outcomes and decrease complications intra-operatively.

Physical examination of the patellofemoral joint.

Examination of the patellofemoral joint can prove to be challenging. Although certain acute injuries such as patella fracture or tendon rupture can be diagnosed quickly, more chronic injuries such as patellar subluxation and patellofemoral pain syndrome are more difficult to diagnose because of the subtlety of the examination findings. The source of the problem can also vary, and must be identified to direct treatment. Adding to the complexity is that other structures around the knee may present with anterior knee pain and can be mistaken for patellofemoral disorder, which is why the patellofemoral examination should be performed in the context of a complete knee examination. For all of these reasons, performing a thorough and systematic examination of the patellofemoral joint can lead to optimal outcomes for patients.

Surgical Management of Acute Distal Biceps Tendon Ruptures

Acute distal biceps tendon ruptures are uncommon injuries that often affect young active males and typically result from an eccentric load on the dominant upper extremity.Surgical treatment may be indicated to prevent substantial weakness in supination and flexion that can occur with nonoperative tr

Acute Upper Extremity Injuries in Pediatric and Adolescent Sports

Pediatric and adolescent sports have been gaining in popularity over the last several years. Along with an increase in participants, there has been an increase in frequency of injuries among these young athletes. The most common acute upper extremity injuries the clinician should be aware of include medial clavicular physeal separations, shoulder instability, ruptures of the ulnar collateral ligament of the elbow, and medial epicondyle fractures. The majority of injuries discussed in this chapter should be treated in a nonoperative manner; however, there are some indications for operative treatment. Proper diagnosis, treatment, and rehabilitation can expedite recovery and return to play in these young athletes.