Kevin J. Campbell

Anterior Talofibular Ligament Ruptures, Part 1 Biomechanical Comparison of Augmented Broström Repair Techniques With the Intact Anterior Talofibular Ligament

Background: The concept of utilizing nonabsorbable suture tape fixed directly to bone to augment Broström repairs of the anterior talofibular ligament (ATFL) has been proposed. No biomechanical studies of this technique are available. Hypothesis: We hypothesized that suture tape augmentation alone and Broström repair with suture tape augmentation would have similar biomechanical properties to the intact ATFL at time zero in a cadaveric model. Study Design: Controlled laboratory study. Methods: Eighteen fresh-frozen cadaveric ankles were randomized into 3 groups of 6 specimens each: (1) intact ATFL, (2) suture tape augmentation, and (3) Broström repair with suture tape augmentation. The specimens were loaded to failure to determine the strength and stiffness of each construct. Results: The mean ultimate load to failure of suture tape augmentation (315.5 ± 66.8 N) was significantly higher than that of the intact ATFL (154.0 ± 63.7 N) (P = .017). The mean ultimate load of the Broström repair with suture tape augmentation (250.8 ± 122.7 N) was not significantly different from that of the intact ATFL. The mean stiffness of augmentation alone (31.4 ± 9.9 N/mm) was significantly higher than that of the intact ATFL (14.5 ± 4.4 N/mm) (P = .008). The mean stiffness of the Broström repair with augmentation (21.1 ± 9.1 N/mm) was not significantly different from that of the intact ATFL. Conclusion: The ATFL with suture tape augmentation is at least as strong and stiff as the native ATFL at time zero in a fresh-frozen cadaveric model. Clinical Relevance: The Broström repair for lateral ankle ligament ruptures is often unsuccessful in circumstances of poor tissue quality. Augmentations, such as with suture tape, have been proposed for these situations. Suture tape used alone or in combination with the Broström repair provided increased strength and stiffness compared with the standard Broström repair, which produced an immediate strength of less than 50% of the intact ATFL. Adding strength to the Broström repair may be valuable in patients with generalized ligamentous laxity, in large patients or elite athletes, or when graft reconstruction is not feasible.

Anatomic Variance of the Iliopsoas Tendon

Background: The iliopsoas tendon has been implicated as a generator of hip pain and a cause of labral injury due to impingement. Arthroscopic release of the iliopsoas tendon has become a preferred treatment for internal snapping hips. Traditionally, the iliopsoas tendon has been considered the conjoint tendon of the psoas major and iliacus muscles, although anatomic variance has been reported. Hypothesis: The iliopsoas tendon consists of 2 discrete tendons in the majority of cases, arising from both the psoas major and iliacus muscles. Study Design: Descriptive laboratory study. Methods: Fifty-three nonmatched, fresh-frozen, cadaveric hemipelvis specimens (average age, 62 years; range, 47-70 years; 29 male and 24 female) were used in this study. The iliopsoas muscle was exposed via a Smith-Petersen approach. A transverse incision across the entire iliopsoas musculotendinous unit was made at the level of the hip joint. Each distinctly identifiable tendon was recorded, and the distance from the lesser trochanter was recorded. Results: The prevalence of a single-, double-, and triple-banded iliopsoas tendon was 28.3%, 64.2%, and 7.5%, respectively. The psoas major tendon was consistently the most medial tendinous structure, and the primary iliacus tendon was found immediately lateral to the psoas major tendon within the belly of the iliacus muscle. When present, an accessory iliacus tendon was located adjacent to the primary iliacus tendon, lateral to the primary iliacus tendon. Conclusion: Once considered a rare anatomic variant, the finding of ≥2 distinct tendinous components to the iliacus and psoas major muscle groups is an important discovery. It is essential to be cognizant of the possibility that more than 1 tendon may exist to ensure complete release during endoscopy. Clinical Significance: Arthroscopic release of the iliopsoas tendon is a well-accepted surgical treatment for iliopsoas impingement. The most widely used site for tendon release is at the level of the anterior hip joint. The findings of this novel cadaveric anatomy study suggest that surgeons should be mindful that more than 1 tendon may be present and require release for curative treatment.

Ankle Syndesmosis A Qualitative and Quantitative Anatomic Analysis

Background: Syndesmosis sprains can contribute to chronic pain and instability, which are often indications for surgical intervention. The literature lacks sufficient objective data detailing the complex anatomy and localized osseous landmarks essential for current surgical techniques. Purpose: To qualitatively and quantitatively analyze the anatomy of the 3 syndesmotic ligaments with respect to surgically identifiable bony landmarks. Study Design: Descriptive laboratory study. Methods: Sixteen ankle specimens were dissected to identify the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), interosseous tibiofibular ligament (ITFL), and bony anatomy. Ligament lengths, footprints, and orientations were measured in reference to bony landmarks by use of an anatomically based coordinate system and a 3-dimensional coordinate measuring device. Results: The syndesmotic ligaments were identified in all specimens. The pyramidal-shaped ITFL was the broadest, originating from the distal interosseous membrane expansion, extending distally, and terminating 9.3 mm (95% CI, 8.3-10.2 mm) proximal to the central plafond. The tibial cartilage extended 3.6 mm (95% CI, 2.8-4.4 mm) above the plafond, a subset of which articulated directly with the fibular cartilage located 5.2 mm (95% CI, 4.6-5.8 mm) posterior to the anterolateral corner of the tibial plafond. The primary AITFL band(s) originated from the tibia 9.3 mm (95% CI, 8.6-10.0 mm) superior and medial to the anterolateral corner of the tibial plafond and inserted on the fibula 30.5 mm (95% CI, 28.5-32.4 mm) proximal and anterior to the inferior tip of the lateral malleolus. Superficial fibers of the PITFL originated along the distolateral border of the posterolateral tubercle of the tibia 8.0 mm (95% CI, 7.5-8.4 mm) proximal and medial to the posterolateral corner of the plafond and inserted along the medial border of the peroneal groove 26.3 mm (95% CI, 24.5-28.1 mm) superior and posterior to the inferior tip of the lateral malleolus. Conclusion: The qualitative and quantitative anatomy of the syndesmotic ligaments was reproducibly described and defined with respect to surgically identifiable bony prominences. Clinical Relevance: Data regarding anatomic attachment sites and distances to bony prominences can optimize current surgical fixation techniques, improve anatomic restoration, and reduce the risk of iatrogenic injury from malreduction or misplaced implants. Quantitative data also provide the consistency required for the development of anatomic reconstructions.

Anterior Talofibular Ligament Ruptures, Part 2: Biomechanical Comparison of Anterior Talofibular Ligament Reconstruction Using Semitendinosus Allografts With the Intact Ligament

Background: Anatomic reconstructions of the lateral ankle ligaments with grafts have been proposed for patients with generalized ligamentous laxity, long-standing instability with attenuated native tissues, varus hindfoot misalignment, or failed prior lateral ligament surgery and for very large patients or elite athletes because of increased demands. Hypothesis: Anatomic reconstruction of the anterior talofibular ligament (ATFL) using a semitendinosus allograft fixed with biocomposite interference fit screws would have similar biomechanical properties to the intact ATFL at time zero in a cadaveric model. Study Design: Controlled laboratory study. Methods: Allograft reconstruction of the ATFL was performed in 6 fresh-frozen cadaveric ankles. The specimens were loaded to failure to determine the strength and stiffness of the reconstruction and compared with data from 6 cadaveric specimens with intact ATFLs. Results: The mean ultimate load to failure of the allograft reconstruction (170.7 ± 54.8 N) was not significantly different from that of the intact ATFL (154.0 ± 63.7 N). The mean stiffness of the allograft reconstruction (23.1 ± 9.3 N/mm) was also not significantly different from that of the intact ATFL (14.5 ± 4.4 N/mm). Conclusion: Anatomic reconstruction of the ATFL with allografts demonstrated similar strength and stiffness to the native ligament at time zero in a fresh-frozen cadaveric model. Clinical Relevance: This technique of anatomic reconstruction of the ATFL with allografts has biomechanical validation for use in clinical situations where a Broström repair of the lateral ankle ligaments is unlikely to be successful or has previously failed.

Influence of Surgeon Volume on Inpatient Complications, Cost, and Length of Stay Following Total Ankle Arthroplasty.

Background: Increased surgeon volume may be associated with improved outcomes following operative procedures. However, there is a lack of information on the effect of surgeon volume on inpatient adverse events and resource utilization following total ankle arthroplasty (TAA). Methods: A retrospective cohort study of TAA patients was performed using the Nationwide Inpatient Sample (NIS) from 2003 to 2009. High-volume surgeons were considered as those with volume ≥90th percentile of surgeons performing TAA. Multivariate regression was used to compare the rates of adverse events, hospital length of stay, and total hospital charges between surgeon volume categories. Results: A total of 4800 TAA patients were identified. The 90th percentile for surgeon volume was 21 cases per year. Mean length of stay was 2.8 ± 2.3 days and mean hospital charges were

Radiographic Identification of the Primary Lateral Ankle Structures

45 963 ±

Arthroscopic Sternoclavicular Joint Resection Arthroplasty: A Technical Note and Illustrated Case Report

43 983. On multivariate analysis, high-volume surgeons had decreased overall complications (OR 0.5, P = .034) and rate of medial malleolus fracture (OR 0.1, P = .043), decreased length of stay (–0.9 days, P < .001), and decreased hospital charges (–

Radiographic Identification of the Deltoid Ligament Complex of the Medial Ankle

20 904, P < .001). Conclusions: Surgeons with volume ≥90th percentile had a decreased rate of complications, decreased length of stay, and reduced hospital charges compared to other surgeons. Level of Evidence: Level III, comparative study.

Involvement of Residents Does Not Increase Postoperative Complications After Open Reduction Internal Fixation of Ankle Fractures: An Analysis of 3251 Cases

Background: Lateral ankle ligament injuries rank among the most frequently observed athletic injuries, requiring repair or reconstruction when indicated. However, there is a lack of quantitative data detailing the ligament attachment sites on standard radiographic views. Purpose: To quantitatively describe the anatomic attachment sites of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL) on standard radiographic views with respect to reproducible osseous landmarks to assist with intraoperative and postoperative assessment of lateral ankle ligament repairs and reconstructions. Study Design: Descriptive laboratory study. Methods: Twelve nonpaired, fresh-frozen cadaveric foot and ankle specimens were dissected to identify the origins and insertions of the 3 primary lateral ankle ligaments. Ligament footprint centers were marked with 2-mm stainless steel spheres shallowly embedded at the level of the cortical bone prior to obtaining standard lateral and mortise radiographs. Measurements were performed twice by 2 blinded raters independently to calculate mean distances and assess reliability via intraclass correlation coefficients (ICCs). Results: Radiographic measurements demonstrated excellent reproducibility between raters (all interobserver ICCs > 0.97) and across trials (all intraobserver ICCs >0.99). On the lateral view, the ATFL fibular attachment (mean ± SD) was 8.4 ± 1.8 mm proximal and anterior to the inferior tip of the lateral malleolus and attached on the talus 13.8 ± 2.0 mm proximal and anterior to the apex of the lateral talar process. The CFL originated 5.0 ± 1.4 mm superior and anterior to the inferior tip of the lateral malleolus and inserted on the calcaneus 18.5 ± 4.6 mm posterior and superior to the posterior point of the peroneal tubercle. On the mortise view, the ATFL origin was 4.9 ± 1.4 mm proximal to the inferior tip of the lateral malleolus and inserted on the talus 9.0 ± 2.1 mm medial and superior of the apex of the lateral talar process and 18.9 ± 3.1 mm inferior and slightly lateral to the superior lateral corner of the talar dome. The fibular CFL origin was 2.9 ± 1.6 mm proximal and slightly medial to the inferior tip of the lateral malleolus and inserted on the calcaneus 18.0 ± 5.1 mm distal to the apex of the lateral talar process. Conclusion: Radiographic parameters quantitatively describing the anatomic origins and insertions of the lateral ankle ligaments were defined with excellent reproducibility and agreement between reviewers. Clinical Relevance: Quantitative radiographic anatomy data will assist in preoperative planning, improve intraoperative localization, and provide objective measures for postoperative assessment of anatomic repairs and reconstructions.

Surgical Release of the Pectoralis Minor Tendon for Scapular Dyskinesia and Shoulder Pain

Open resection arthroplasty of the sternoclavicular (SC) joint has historically provided good long-term results in patients with symptomatic osteoarthritis of the SC joint. However, the procedure is rarely performed because of the risk of injury to vital mediastinal structures and concern regarding postoperative joint instability. Arthroscopic decompression of the SC joint has therefore emerged as a potential treatment option because of many recognized advantages including minimal tissue dissection, maintenance of joint stability, avoidance of posterior SC joint dissection, expeditious recovery, and improved cosmesis. There are, however, safety concerns given the proximity of neurovascular structures. In this article we demonstrate a technique for arthroscopic SC joint resection arthroplasty in a 26-year-old active man with bilateral, painful, idiopathic degenerative SC joint osteoarthritis. This case also highlights the pearls and pitfalls of arthroscopic resection arthroplasty for the SC joint. There were no perioperative complications. Four months postoperatively, the patient had returned to full activities, including weightlifting, without pain or evidence of SC joint instability. One year postoperatively, the patient showed substantial improvements in the American Shoulder and Elbow Surgeons score; Single Assessment Numeric Evaluation score; Quick Disabilities of the Arm, Shoulder and Hand score; and Short Form 12 Physical Component Summary score over preoperative baseline values.