The impact of open reduction internal fixation on acute pain management in unstable pelvic ring injuries.

BACKGROUND: The management of unstable pelvic ring injuries is complex. Displacement is a clear indication for surgical intervention. However, reduction of acute pain after stabilization may have substantial clinical benefits and affect management decisions. The purpose of this study was to determine the impact of operative fixation of unstable pelvic ring injuries in diminishing acute pain. METHODS: During a 33-month period, 70 patients with isolated pelvic ring injuries were managed at a Level-1 trauma center and retrospectively reviewed. On the basis of clinical and radiographic instability, 38 patients were managed surgically and formed the study group. Pain was assessed using visual analog scales and narcotic consumption during the index hospitalization. RESULTS: In the operative group, visual analog scale scores decreased 48% after fixation from 4.71 +/- 1.8 preoperatively to 2.85 +/- 0.8 postoperatively (p < 0.001). Concomitantly, narcotic requirements decreased 25% from 2.26 mg morphine per hour preoperatively to 1.71 mg morphine per hour postoperatively (p = 0.024). The mean total length of hospital stay was 5.6 days (SD, 1.2 days), and the postoperative length of hospital stay was 4.7 days (SD, 1.2 days). CONCLUSIONS: Operative reduction and fixation of unstable pelvic ring injuries significantly decreases acute pain. This has substantial physiologic benefits, particularly by improving mobilization, and should be an additional factor when determining surgical indication and timing.

Effects of capsular plication and rotator interval closure in simulated multidirectional shoulder instability.

BACKGROUND: Arthroscopic treatment of multidirectional shoulder instability with use of capsular plication and rotator interval closure has been shown to be effective in several clinical studies; however, the biomechanical effects of these procedures have not been elucidated. The purpose of this study was to assess biomechanically the effect of arthroscopic capsular plication combined with rotator interval closure on rotational range of motion, humeral head position throughout rotation, and glenohumeral translation. METHODS: Seven cadaveric shoulders were stretched to 10% beyond the maximum range of motion in 60 degrees and 0 degrees of glenohumeral abduction. Testing was performed for the intact and stretched conditions and following three sequential capsular repairs: anterior plication, posterior plication, and rotator interval closure. Rotational range of motion, humeral head position throughout the range of motion, and glenohumeral translations were measured in both positions. RESULTS: Stretching increased the total rotational range of motion in 60 degrees and 0 degrees of abduction. After anterior plication alone, total rotation decreased significantly (p < 0.05) in both positions and was restored to the intact state. Total translation with a 20-N load increased significantly in the 60 degrees of abduction position after stretching (p = 0.03). Anterior-posterior translation decreased significantly compared with the stretched state only after all components of the repair were completed in 60 degrees of abduction (p = 0.0003 with a 15-N load and p = 0.0001 with a 20-N load). This decrease was also found to be significantly less than the intact condition (p = 0.008 with a 15-N load and p = 0.001 with a 20-N load). A similar trend in results was found with superior-inferior translations in the 0 degrees of abduction position. CONCLUSIONS: Capsular plication alone reduces range of motion to the intact state. Reductions in translation, however, may require the addition of rotator interval closure. Changes in translation and rotation after repair are dependent on arm position. In some positions, the addition of rotator interval closure may also result in overtightening.

Broken poly-L-lactic acid interference screw after ligament reconstruction.

The interference screw is a reliable method used to secure tendon to bone and bone to bone in ligament reconstruction. Historically, metal interference screws have been used for this purpose in both anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction. However, several problems associated with the use of metal interference screws have led to the increasing use of bioabsorbable implants. Poly-L-lactic acid (PLLA) biodegradable interference screws have been used successfully for graft fixation in ligament reconstruction. Although adverse reactions have been reported with the use of biodegradable implants, late screw breakage is rare. To our knowledge no case exists of late screw breakage with bioabsorbable interference screws used in ligament reconstruction. We present one case in the setting of an ACL reconstruction and one with combined PCL and posterolateral corner reconstruction.