Scapholunate ligament reconstruction using an acellular dermal matrix: a mechanical study.

PURPOSE: Numerous surgical techniques have been described for the treatment of chronic scapholunate ligament instability. We hypothesized that scapholunate ligament reconstruction using an acellular dermal matrix was biomechanically comparable to previously described surgical reconstructions. METHODS: The scaphoid and lunate with the entire scapholunate ligament were harvested from 15 cadaveric specimens. The scapholunate ligament was transected and reconstructed using an acellular dermal matrix (Arthroflex; LifeNet Health, Virginia Beach, VA) and 4 micro suture anchors in 10 specimens. Five specimens were kept with the native scapholunate ligament intact. Five other specimens were reconstructed using a 1.0-mm-thick dermal matrix, and a second cohort of 5 specimens was reconstructed using a 1.5-mm-thick matrix. Tensile testing of all specimens was performed using a servohydraulic material testing system and data acquisition software. The tensile test apparatus applied a distractive load of 10 mm/min (0.17 mm/s) until the specimens reached ultimate failure. Failure force, failure displacement, stiffness, and energy to failure were calculated. RESULTS: All 5 specimens in the intact group failed at the scapholunate ligament midsubstance. The mean ultimate failure force was 172 N, with mean stiffness of 74 N/mm. In the reconstruction group with 1.0-mm dermal matrices, the mode of failure was at the suture-matrix interface in all specimens, whereas the 1.5-mm dermal matrix reconstruction cohort all failed at the bone-suture anchor interface. In the 1.0-mm reconstruction group, the mean ultimate failure force was 77 N, with mean stiffness of 24 N/mm. In the 1.5-mm dermal matrix reconstruction cohort, the mean ultimate failure force was 111 N, with mean stiffness of 30 N/mm. CONCLUSIONS: Scapholunate ligament reconstruction using acellular dermal matrix and suture anchors demonstrated similar biomechanical properties to previously described reconstruction techniques. CLINICAL RELEVANCE: Scapholunate ligament reconstruction using acellular dermal matrix warrants clinical investigation as a potential treatment alternative for chronic scapholunate instability.

Surgical management of posttraumatic elbow arthrofibrosis.

BACKGROUND: Functional loss of motion is a frequent complication after elbow trauma. The purpose of this study was to determine the effectiveness of open elbow release in restoring functional elbow motion. METHODS: A retrospective chart review of 177 adult patients who underwent open elbow release at our institution by the senior surgeon (D.P.H.) from 2003 to 2010 was performed. Seventy-seven of the elbow contracture releases were performed for posttraumatic elbow stiffness, with loss of flexion-extension. Burns and isolated proximal radioulnar exostosis resections were excluded. The mean age of patients was 45 years (range, 20-76 years), with 68 patients demonstrating radiographic evidence of heterotopic ossification (HO). The mean preoperative flexion-extension arc was 51 degrees. All patients were treated with the same surgical protocol, which included circumferential elbow capsulectomy, HO excision, hardware removal, and ulnar nerve neurolysis with submuscular anterior transposition. RESULTS: At a mean follow-up of 12 months (range, 3-56 months), the mean elbow flexion-extension arc was 109 degrees representing a mean gain of 58 degrees. Sixty-nine percent (53 of 77 patients) achieved a minimum 100-degree functional elbow arc of motion. Six patients (8%) developed recurrent HO, with four undergoing secondary HO excision. One additional patient required manipulation under anesthesia in the early postoperative period. Complications included five infections, one postoperative fracture, one postoperative hematoma, and one radial head implant loosening. CONCLUSION: Open elbow contracture release and HO excision is an effective means of restoring functional elbow range of motion with a low complication rate. Furthermore, recurrent HO formation and elbow arthrofibrosis respond well to repeat surgical excision and contracture release. LEVEL OF EVIDENCE: IV, therapeutic study.

Total elbow allografts with collateral ligament reconstruction for posttraumatic elbow injuries.

BACKGROUND: The use of total osteoarticular elbow allografts as a salvage procedure for reconstruction of posttraumatic elbow periarticular defects and bone loss has been previously described. Although the procedure restores bone stock and provides a painless functional joint, it is associated with multiple complications, including infection, nonunion, and instability. METHODS: We report a consecutive series of eight patients with posttraumatic elbow injuries and extensive bone loss treated with massive osteoarticular elbow allografts augmented by collateral ligament reconstruction using hamstring allograft. To improve union rates, bone morphogenetic protein-II was applied to the host-graft junctions of the reconstructed elbow. Patients were evaluated clinically and radiographically. The average age of patients was 43 years (range 30-69 years). RESULTS: At a mean follow up of 32 months (range 18-44 months), the average Mayo Elbow Performance Score was 81. All patients reported no or only minimal pain in the elbow. The average arc of motion was 102°, and the mean rotational arc of motion was 100°. Four of the eight elbows developed a complication. CONCLUSIONS: This procedure may serve as a viable salvage option in selected patients with the potential to provide pain relief and improve function, but it is associated with a high complication rate.

Skeletally mature patients with bilateral distal radius fractures have more associated injuries.

Bilateral distal radius fractures are rare injuries and only a handful of case reports exist. Understanding the demographic variables and associated injuries in patients with these fractures may improve awareness and treatment of concomitant injuries. We determined the differences in mode of trauma and associated injuries between skeletally mature and skeletally immature patients with bilateral distal radius fractures. We retrospectively reviewed the records of 93 patients with bilateral distal radius fractures. We compared demographic data, fracture patterns, mode of injury, treatment modality, and associated injuries for skeletally mature and immature patients. The mean age of all patients sustaining a bilateral injury was 22.5 years and 61 (71%) were male. Of the 51 (55%) skeletally immature patients, 37 (73%) were male, and 44 (86%) sustained a low-energy mechanism of injury. Of the 42 (45%) skeletally mature patients, 29 (69%) were male, and 37 (88%) sustained a high-energy mechanism of injury. Skeletally mature patients had a 38% rate of associated injuries versus 4% found in skeletally immature patients. Skeletally mature patients sustained bilateral distal radius fractures through higher-energy mechanisms and presented with more frequent associated injuries compared with the skeletally immature patients.

Biomechanical and anatomical effects of an external rotational torque applied to the knee: a cadaveric study.

BACKGROUND: External rotational torque is one of the mechanisms that may occur during a pivoting or twisting injury to the knee. HYPOTHESIS: Simulated external rotational injury by applying external rotational torque will increase knee laxity and cause soft tissue damage to the knee. STUDY DESIGN: Controlled laboratory study. METHODS: Six cadaveric knees and a custom testing system were used to produce external rotational torque of 30 degrees , 45 degrees , and 60 degrees with the knee at 30 degrees of flexion. Anterior-posterior, valgus-varus, and rotational knee laxity were quantified. After sequential rotational torque to 60 degrees , the specimens were dissected to identify injured structures. RESULTS: External rotational torque of 45 degrees and 60 degrees significantly increased knee joint laxity in all directions (P < .05). Dissection showed that all posterior cruciate ligaments were intact; all medial collateral and anterior cruciate ligaments revealed either partial or complete tears. The lateral collateral ligaments were torn in all specimens. The popliteus tendon was attenuated in 1 specimen and was completely torn in 1 specimen. The popliteofibular ligament was torn in 3 specimens. CONCLUSION: External rotational torque to 60 degrees increased knee laxity, and dissection revealed a consistent pattern of injury to the medial and lateral collateral and anterior cruciate ligaments and posterolateral corner. CLINICAL RELEVANCE: Because isolated ligament injuries are rare, recognizing these combined ligamentous injuries early is essential for repair in the acute stage.