Marc Tompkins

Complications Related to Anatomic Reconstruction of the Coracoclavicular Ligaments

Background: Anatomic reconstruction of the coracoclavicular (CC) ligaments has become a popular surgical treatment for high-grade acromioclavicular (AC) dislocations, but little has been reported about complications related to these newer surgical techniques. Purpose: We sought to review the complications related to several new techniques for the anatomic reconstruction of the CC ligaments for the treatment of AC separations. Study Design: Case series; Level of evidence, 4. Methods: We conducted a retrospective review of the operative treatment of AC separation utilizing anatomic reconstruction of the CC ligaments by reviewing the case logs of 3 fellowship-trained orthopaedic surgeons at a single academic sports medicine center for the past 5 years using appropriate current procedural terminology codes. The medical records and postoperative radiographs were assessed for complications. Results: Twenty-seven cases of anatomic reconstruction of the CC ligaments were reviewed. All patients had an autograft or allograft ligament reconstruction utilizing either a coracoid tunnel (10 cases) or a loop around the coracoid base (17 cases). Eight complications (80%) were noted in the coracoid tunnel group including 2 coracoid fractures (20%), 5 patients with some loss of reduction (more than 5-mm increased CC interval displacement on subsequent postoperative radiographs) (50%), and 1 patient with an intraoperative failure of the coracoid button fixation (10%). Six patients developed complications in the coracoid loop group (35%) including 3 clavicle fractures (18% within group, 11% overall), 1 patient with loss of reduction (6%), 1 patient with loss of reduction and an infection (6% within group, 4% overall), and 1 patient with adhesive capsulitis postoperatively (6% within group, 4% overall). Conclusion: Newer techniques for the anatomic reconstruction of the CC ligaments may have steep learning curves associated with complications such as coracoid and clavicle fractures. Loss of reduction continues to be associated with the operative treatment of high-grade AC separations. Further refinement of surgical technique and experience with the operative treatment of AC separation is warranted.

Anatomic Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction Use of an Accessory Medial Portal Versus Traditional Transtibial Drilling

Background: During anatomic anterior cruciate ligament (ACL) reconstruction, we have found that the femoral footprint can best be visualized from the anteromedial portal. Independent femoral tunnel drilling can then be performed through an accessory medial portal, medial and inferior to the standard anteromedial portal. Purpose: To compare the accuracy of independent femoral tunnel placement relative to the ACL footprint using an accessory medial portal versus tunnel placement with a traditional transtibial technique. Study Design: Controlled laboratory study. Methods: Ten matched pairs of cadaveric knees were randomized such that within each pair, one knee underwent arthroscopic transtibial (TT) drilling, and the other underwent drilling through an accessory medial portal (AM). All knees underwent computed tomography (CT) both preoperatively and postoperatively with a technique optimized for ligament evaluation (80 keV with maximum mAs). Computed tomography was performed with a dual-energy scanner. Commercially available third-party software was used to fuse the preoperative and postoperative CT scans, allowing anatomic comparison of the ACL footprint to the drilled tunnel. The ACL footprint was marked in consensus by an orthopaedic surgeon and a musculoskeletal radiologist and then compared with the tunnel aperture after drilling. The percentage of tunnel aperture contained within the native footprint as well as the distance from the center of the tunnel aperture to the center of the footprint was measured. Results: The AM technique placed 97.7% ± 5% of the tunnel within the native femoral footprint, significantly more than 61.2% ± 24% for the TT technique (P = .001). The AM technique placed the center of the femoral tunnel 3.6 ± 1.2 mm from the center of the native footprint, significantly closer than 6.0 ± 1.9 mm for the TT technique (P = .003). Conclusion: This study demonstrates that use of an accessory medial portal will facilitate more accurate placement of the femoral tunnel in the native ACL femoral footprint. Clinical Relevance: More accurate placement of the femoral tunnel in the native ACL femoral footprint should improve the ability to achieve more anatomic positioning of the ACL graft.

Preliminary results of a novel single-stage cartilage restoration technique: Particulated juvenile articular cartilage allograft for chondral defects of the patella

PURPOSE To evaluate outcomes and magnetic resonance imaging (MRI) findings after use of particulated juvenile cartilage for the treatment of focal Outerbridge grade 4 articular cartilage defects of the patella. METHODS From 2007 to 2011, 16 patients (2 bilateral) underwent a novel single-stage articular cartilage restoration procedure using particulated juvenile articular cartilage allograft. We enrolled 15 knees (13 patients) in this study. The mean age at surgery was 26.4 ± 9.1 years, and the mean postoperative follow-up was 28.8 ± 10.2 months. A musculoskeletal radiologist evaluated each knee with postoperative MRI for the International Cartilage Repair Society cartilage repair assessment score, graft hypertrophy, bony changes around the graft, and percent fill of the defect. All patients also completed the Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Evaluation, and Kujala clinical outcome survey (scale, 0 to 100), as well as the Tegner activity scale and visual analog pain scale (scale, 0 to 10). RESULTS The mean International Cartilage Repair Society cartilage repair assessment score on MRI was 8.0 ± 2.8, a nearly normal assessment. Of 15 knees, 11 (73%) were found to have normal or nearly normal cartilage repair. Three patients had mild graft hypertrophy whereas 2 had gross graft hypertrophy, 2 of whom required arthroscopic debridement because of symptoms. The mean fill of the defect at follow-up was 89% ± 19.6%, with 12 of 15 knees (80%) showing at least 90% defect coverage. The mean clinical outcome score at follow-up was 73.3 ± 17.6 for the International Knee Documentation Committee evaluation, and the mean scores for each subdomain of the Knee Injury and Osteoarthritis Outcome Score were as follows: 84.2 ± 14.2 for pain, 85.0 ± 12.3 for symptoms and stiffness, 88.9 ± 12.9 for activities of daily living, 62.0 ± 25.1 for sports and recreation, and 60.8 ± 28.6 for quality of life. The median score for the Kujala survey was 79 (range, 55 to 99). The median score on the Tegner activity scale was 5 (range, 3 to 9), and the mean score on the visual analog scale was 1.9 ± 1.4, indicating minimal pain. CONCLUSIONS Preliminary results suggest that cartilage restoration using particulated juvenile articular cartilage allograft offers a viable option for patients with focal grade 4 articular cartilage defects of the patella.

Spinal Epidural Abscess

BACKGROUND Spinal epidural abscess is an uncommon disease with a relatively high rate of associated morbidity and mortality. The most important determinant of outcome is early diagnosis and initiation of appropriate treatment. OBJECTIVES We aim to highlight the clinical manifestations, describe the early diagnostic evaluation, and outline the treatment principles for spinal epidural abscess in the adult. DISCUSSION Spinal epidural abscess should be suspected in the patient presenting with complaints of back pain or a neurologic deficit in conjunction with fever or an elevated erythrocyte sedimentation rate. Gadolinium-enhanced magnetic resonance imaging is the diagnostic modality of choice to confirm the presence and determine the location of the abscess. Emergent surgical decompression and debridement (with or without spinal stabilization) followed by long-term antimicrobial therapy remains the treatment of choice. In select cases, non-operative management can be cautiously considered when the risk of neurologic complications is determined to be low. CONCLUSION Patients with a spinal epidural abscess often present first in the emergency department setting. It is imperative for the emergency physician to be familiar with the clinical features, diagnostic work-up, and basic management principles of spinal epidural abscess.

Patellar Instability Factors in Isolated Medial Patellofemoral Ligament Reconstructions—What Does the Literature Tell Us? A Systematic Review

Background: Many studies have demonstrated good results after medial patellofemoral ligament (MPFL) reconstruction for patients with patellar instability. The applicability of published studies to the clinical decision-making process for the individual patient with patellar instability, however, is not well elucidated. Hypothesis: There is inconsistency in the reporting of preoperative and postoperative variables, which limits the applicability of current studies to patients with patellar instability. Study Design: Systematic review. Methods: A systematic review of the literature was conducted using the search term medial patellofemoral ligament reconstruction to identify studies with cohorts of patients with isolated MPFL reconstruction. A combination of inclusion and exclusion criteria resulted in 24 studies being reviewed for a variety of preoperative demographics, physical examination findings, and imaging findings, as well as postoperative outcomes, including redislocation and responses to subjective questionnaires. Results: A physical examination of lateral patellar translation was reported in 42% of studies, by reporting an apprehension sign (n = 9), reporting quadrant translation (n = 7), or both. For patellar instability factors on imaging, patellar height was reported as a preoperative variable in 75% of studies, and trochlear dysplasia was reported in 83% of studies. The tibial tubercle–trochlear groove distance was reported as a preoperative variable in 42% of studies. The rate of redislocation after index surgery was reported in 92% of studies. Patient-related outcome measures were reported in all of the studies; the Kujala score was the most common. A homogeneous population was selected as part of the authors’ surgical indications for “isolated” MPFL in 67% of studies, and a heterogeneous population was selected in 33% of studies. Conclusion: Current literature on MPFL reconstruction contains diverse methods of recording preoperative and postoperative variables. Most studies report on a homogeneous population, with inconsistent applicability to the broad spectrum of patients with patellar instability. Outcomes reporting in our current literature needs more clarity and consistency regarding reporting methodology to be of value for the treating clinician.

Anatomic and Radiographic Comparison of Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis Sites

Background: Arthroscopic suprapectoral and open subpectoral surgical techniques are both commonly utilized approaches for proximal biceps tenodesis of the long head of the biceps brachii. A central limitation to the widespread use of an arthroscopic approach for biceps tenodesis is that the tendon may be tenodesed too proximally in the bicipital groove, leading to persistent pain and tendinopathy. Purpose/Hypothesis: The purpose of this study was to determine the in vivo tenodesis location using arthroscopic suprapectoral and open subpectoral techniques for proximal biceps tenodesis in relation to clinically pertinent anatomic and radiographic landmarks. The null hypothesis was that arthroscopic suprapectoral biceps tenodesis would not be significantly different in terms of the location from open subpectoral biceps tenodesis. Study Design: Controlled laboratory study. Methods: A total of 20 matched pairs of cadaveric shoulder specimens were randomized such that within each pair, 1 shoulder underwent a standard open subpectoral biceps tenodesis and the other underwent an arthroscopic suprapectoral tenodesis. Limited dissection and exposure of the surgical tunnel site and reference landmarks were subsequently performed, and anteroposterior and lateral radiographs were obtained. Direct measurements were performed anatomically using a digital caliper and radiographically using picture archiving and communication system (PACS) software from the proximal lip of the humeral tunnel to regional landmarks. Results: Both techniques were able to place the humeral tunnel distal to the bicipital groove in all specimens. On average, the open subpectoral approach placed the tunnel 2.2 cm distal to the arthroscopic suprapectoral approach. Conclusion: The arthroscopic suprapectoral biceps tenodesis technique used in this study consistently placed the tenodesis tunnel distal to the bicipital groove, which may allay concerns about the bicipital groove as a pain source after this procedure. Clinical Relevance: This anatomic study provides new information on tunnel placement in 2 biceps tenodesis techniques. In addition, it provides clinically relevant anatomic and radiographic guidelines using clinically pertinent landmarks. This information may be useful in preoperative planning, intraoperative technique, and postoperative assessment of both open subpectoral and arthroscopic suprapectoral biceps tenodesis.

Incidence of Secondary Intra-articular Injuries With Time to Anterior Cruciate Ligament Reconstruction

Background: Precise locations of chondral and meniscal damage with increased time to anterior cruciate ligament reconstruction (ACLR) have not been well described. Purpose/Hypothesis: The purpose of the study was to determine the relationship between delay in primary ACLR and incidence of secondary intra-articular injury. The hypothesis was that patients with increased time between initial injury and ACLR will exhibit greater incidence of secondary intra-articular injury when compared with those who receive surgical intervention promptly after injury. A second hypothesis was that patients with higher preinjury activity levels or older age will exhibit greater secondary injury when compared with those with minimal preinjury activity levels and younger age. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on 1434 patients with an anterior cruciate ligament deficiency who underwent primary ACLR at a single institution between 2009 and 2013. Patients were grouped according to time to surgery after initial injury: 0-3, 4-12, and >12 months. Operative notes were used to analyze 10 variables across time-to-surgery groups: cartilage damage in the patella, trochlea, medial femoral condyle, lateral femoral condyle, medial tibial plateau, and lateral tibial plateau; medial and lateral meniscal injury; and the incidence of procedures involving either the meniscus or cartilage. Patient age and preinjury activity level were also analyzed for the 10 variables based on time-to-surgery groups. Results: An association was noted between time to surgery and increased incidence of injury in the trochlea, lateral femoral condyle, medial tibial plateau, and medial meniscus (P < .001). Different significant findings within each age group were observed, but overall positive findings were seen in the same 4 locations described above. On the basis of preinjury activity level, the less active patients were most at risk for medial meniscal and trochlear injury, while the more active patients were most at risk for medial tibial plateau injury with increased time from injury to ACLR. Conclusion: Increasing time from injury to ACLR was associated with increased incidence of secondary injury seen in the trochlea, lateral femoral condyle, medial tibial plateau, and medial meniscus. Separate analyses of patient age and preinjury activity level showed similar findings, thus supporting the primary analysis.

Anatomic Femoral Tunnels in Posterior Cruciate Ligament Reconstruction Inside-Out Versus Outside-In Drilling

Background: During posterior cruciate ligament (PCL) reconstruction, the placement and orientation of the femoral tunnel is critical to postoperative PCL function. Purpose: To compare the ability of outside-in (OI) versus inside-out (IO) femoral tunnel drilling in placing the femoral tunnel aperture within the anatomic femoral footprint of the PCL, and to evaluate the orientation of the tunnels within the medial femoral condyle. Study Design: Controlled laboratory study. Methods: Ten matched pairs of cadaver knees were randomized such that within each pair, 1 knee underwent arthroscopic OI drilling and the other underwent IO drilling. All knees underwent computed tomography (CT) both pre- and postoperatively with a technique optimized for ligament evaluation (80 keV with maximum mAs). Commercially available third-party software was used to fuse the pre- and postoperative CT scans, allowing comparison of the PCL footprint to the drilled tunnel. The percentage of tunnel aperture contained within the native footprint, as well as the distance from the center of the tunnel aperture to the center of the footprint, were measured. In addition, the orientation of the tunnels in the coronal and axial planes was evaluated. Results: The OI technique placed 70.4% ± 23.7% of the tunnel within the native femoral footprint compared with 79.8% ± 16.7% for the IO technique (P = .32). The OI technique placed the center of the femoral tunnel 4.9 ± 2.2 mm from the center of the native footprint compared to 5.3 ± 2.0 mm for the IO technique (P = .65). The femoral tunnel angle in the coronal plane was 21.0° ± 9.9° for the OI technique and 37.0° ± 10.3° for the IO technique (P = .002). The tunnel angle in the axial plane was 27.3° ± 4.8° for the OI technique and 39.1° ± 11.5° for the IO technique (P = .01). Conclusion: This study demonstrates no difference in the ability of the OI and IO techniques to place the femoral tunnel within the PCL femoral footprint during PCL reconstruction. With the technique parameters used in this study, the IO technique created femoral tunnels with a more vertical and anterior orientation than the OI technique. Clinical Relevance: Either technique can be used to place the femoral tunnel within the anatomic footprint. Consideration should be given to tunnel orientation following each technique, and what effect it has on graft bending angles, as these characteristics may affect graft strain and, ultimately, graft failure. In this regard, the IO technique likely produces gentler graft bending angles.

Complications in patellofemoral surgery

The complexity of patellofemoral morphology, combined with its injuries and degenerative patterns, leads to varied pathologic diagnoses, as well as surgical procedures to address these problems. Surgical procedures in the patellofemoral joint include tibial tubercle osteotomy, medial patellofemoral ligament surgery, soft tissue procedures on the lateral aspect of the patella, trochleoplasty, and patellofemoral arthroplasty. Understanding potential complications related to the various surgical procedures in the patellofemoral joint is critical to successful surgery. The purpose of this article is to discuss potential surgical complications in procedures performed to address patellofemoral pathology and describe ways to avoid these pitfalls.

Rotator cuff: biology and current arthroscopic techniques.

AbstractThe present article summarizes current trends in arthroscopic rotator cuff repairs focusing on the used repair technique, potential influencing factors on the results, and long-term outcome after reconstruction of the rotator cuff. Moreover, different treatment options for the treatment for irreparable rotator cuff ruptures were described, and the results of additional augmentation of the repairs with platelet-rich plasma were critically analyzed. Based on the current literature, double-row repairs did not achieve superior clinical results compared to single-row repairs neither in the clinical results nor in the re-rupture rate. Multiple factors such as age, fatty infiltration, and initial rupture size might influence the results. If the rupture is not repairable, various options were described including cuff debridement, partial repair, tuberoplasty, or tendon transfers. The additional augmentation with platelet-rich plasma did not reveal any significant differences in the healing rate compared to conventional rotator cuff repairs. Level of evidence IV.