Biomechanical evaluation of the acromioclavicular capsular ligaments and reconstruction with an intramedullary free tissue graft.

BACKGROUND: Multiple techniques have been reported to treat chronic acromioclavicular joint injuries. However, many have failed to restore native stability, and few have addressed reconstructing the acromioclavicular ligaments. HYPOTHESIS: An intramedullary free semitendinosus graft reconstruction of the acromioclavicular ligaments will demonstrate joint stability comparable with that of the intact acromioclavicular joint. STUDY DESIGN: Controlled laboratory study. METHODS: Six matched pairs of cadaveric specimens with only the acromioclavicular capsule/ligament intact were tested at 10 N and 15 N in the anteroposterior and superoinferior directions under acromioclavicular joint compression loads of 10 N, 20 N, and 30 N. One of each pair randomly underwent reconstruction of the acromioclavicular ligaments with an intramedullary free semitendinosus graft, and the translational testing was repeated. Both the intact and reconstructed specimens then underwent load-to-failure testing via superior clavicle distraction at a rate of 50 mm/min. RESULTS: The reconstructed specimens reproduced the stability of the intact specimens during all translational and joint compression load trials. Progressively decreased translation was observed for the reconstructed specimens that reached statistical significance (P <.05) in the anteroposterior direction at 10 N of joint compression under 10-N and 15-N translation loads and in the superoinferior direction at 10 N of joint compression and 10-N translational load. With regard to load-to-failure testing, the reconstructed specimens demonstrated significantly lower (P < .05) values for linear stiffness, yield load, ultimate load, and energy absorbed, ranging from 40% to 48% of the values for the intact specimens. CONCLUSION: Intramedullary free semitendinosus graft reconstruction of the acromioclavicular ligaments reproduced anteroposterior and superoinferior translational stability and partially reproduced load-to-failure characteristics. CLINICAL RELEVANCE: When surgical intervention after higher grade acromioclavicular joint injuries is required, reconstruction of the acromioclavicular ligaments with an intramedullary free semitendinosus graft, in addition to reconstructing the coracoclavicular ligaments, may result in improved stability of the joint complex, improved maintenance of joint reduction, and increased patient satisfaction.

The Ilizarov method for the treatment of resistant clubfoot: is it an effective solution?

The resistant clubfoot deformity presents a significant challenge. Several corrective procedures have been described, with the goal to provide a pain-free, plantigrade foot. The Ilizarov method of external fixation and gradual distraction has been reported as an alternative to conventional techniques. Previous reviews have concluded that this method can provide satisfactory correction and outcome. This study presents a review of 21 resistant clubfeet in 17 patients, who had undergone previous surgery, treated with Ilizarov external fixation and gradual distraction by 1 of 2 surgeons. Outcome measures were graded based on function and presence of residual deformity: (a) excellent (painless, plantigrade foot, with no functional limitations); (b) good (plantigrade foot in a patient able to ambulate long distances with mild pain; (c) fair (mild residual deformity, required bracing, and/or had some functional limitations but an active life); and (d) poor (significant residual deformity, pain, and activity limitations). Radiographic measures of the talocalcaneal and talo-first metatarsal angles were compared preoperatively and postoperatively. At an average follow-up of 6.64 years (range, 2.25-10.50 years), 9.5% (2) achieved an excellent result; 4.8% (1), good; 33.3% (7), fair; and 52.4% (11), poor. All 11 of the feet graded poor required revision surgery at an average of 5.63 years postoperatively (range, 2.67-10.2 years). Only the talo-first metatarsal angle displayed a clinically and statistically significant correction. We conclude that the Ilizarov method for treatment of resistant clubfoot deformities results in poor outcome associated with residual or recurrent deformity, often requiring revision surgery.

Arthroscopic proficiency: a survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs.

PURPOSE: The goal of this study was to evaluate the opinion of sports medicine fellowship directors and orthopaedic surgery department chairpersons on how many repetitions the average resident needs to become proficient in several common arthroscopic procedures. TYPE OF STUDY: A cross-sectional study. METHODS: A questionnaire was mailed to all fellowship directors on a list maintained by the American Academy of Orthopaedic Surgeons and to all department chairpersons on a list maintained by the American Medical Association. Respondents were asked to estimate the number of operations needed for a trainee to reach minimal proficiency (able to perform procedure skin-to-skin with supervision) and proficiency (capable of performing procedure without supervision) for 5 common arthroscopic procedures: diagnostic knee scope, partial medial meniscectomy, anterior cruciate ligament (ACL) reconstruction, diagnostic shoulder scope, and subacromial decompression. RESULTS: A total of 164 of 230 (71%) people responded to the questionnaire. Department chairpersons who did not perform arthroscopy consistently estimated two thirds the number of operations that department chairpersons who did perform arthroscopy and nearly half the number of operations estimated by fellowship directors. Chairpersons who did perform arthroscopy had responses more similar to fellowship directors than to department heads who did not perform arthroscopy. CONCLUSIONS: These results indicate that, in the opinion of physicians involved in the education of residents and fellows, it may take a substantial number of repetitions to become proficient in arthroscopy. Physicians who perform little or no arthroscopy themselves may underestimate its difficulty. Interestingly, there was substantial variability in the number of repetitions estimated to achieve proficiency in all procedures. The results of this study may be helpful in designing arthroscopic training programs for orthopaedic residents or sports medicine fellows; however, the wide variability in opinions may indicate difficulty in reaching a consensus.