Faculty Bibliography

Injury to the distal tibiofibular syndesmosis is common and failure to correct instability may lead to inferior outcomes. Recently, suture-button devices have garnered increasing attention for dynamic syndesmotic fixation. However, current constructs and techniques have been consistently associated with complications such as lateral knot irritation and wound breakdown. In addition, knot slippage, loosening, and osteolysis have been described leading to recurrent syndesmotic diastasis. To address these shortcomings, a continuous loop double cortical button technique has been developed for dynamic syndesmotic stabilization. The continuous loop double cortical button technique has been utilized for coracoclavicular ligament stabilization for both acromioclavicular joint dislocation and distal clavicle fractures with excellent clinical outcomes. This procedure has been adapted for fixation of the distal tibiofibular syndesmosis. The technique utilizes 2 cortical buttons linked by a continuous loop of ultra-high molecular weight polyethylene suture for dynamic knotless syndesmotic fixation. The continuous loop double cortical button technique was performed on 4 consecutive cases of distal tibiofibular syndesmosis diastasis. Accurate, stable fixation was achieved in all cases without loosening or diastasis. At the final follow-up, no evidence of button-related osteolysis or migration was observed. One patient with prominent lateral hardware developed a wound infection requiring reoperation for hardware removal and debridement. Otherwise, no complications related to syndesmotic hardware were observed. The continuous loop double cortical button technique is a reproducible and reliable procedure for fixation of the distal tibiofibular syndesmosis. The construct allows for accurate restoration of the dynamic syndesmotic complex without compromising stability. Knot-related complications are minimized. As with all systems, limiting lateral hardware prominence appears to reduce the risk of wound-related complications.Level of Evidence: Diagnostic Level IV - case series. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Although numerous suture-button fixation techniques for acromioclavicular (AC) joint reconstruction have been validated with biomechanical testing in the superior direction, clinical reports continue to demonstrate high rates of construct slippage and breakage. PURPOSE: To compare the stability of a novel closed-loop double Endobutton construct with a commercially available cortical button system in both the axial and superior directions. STUDY DESIGN: Controlled laboratory study. METHODS: Six matched pairs of fresh-frozen cadaveric upper extremities were anatomically dissected and prepared to simulate a complete AC joint dislocation. One side of each pair was reconstructed with the double Endobutton (DE) construct and other side with the dog bone button (DB) construct. The specimens were then tested using a materials testing machine, determining initial superior and axial displacements with a preload, and then cyclically loaded in the axial direction with 70 N for 5000 cycles. Displacement was again measured with the same preloads at fixed cycle intervals. The specimens were then loaded superiorly to failure. RESULTS: At 5000 cycles, the mean axial displacement was 1.7 mm for the DB group and 1.2 mm for the DE group (P = .19), and the mean superior displacement was 1.1 mm for the DB group and 0.7 mm for the DE group (P = .32). Load at failure was similar (558 N for DE, 552 N for DB; P = .96). There was no statistically significant difference in the modes of failure. CONCLUSION: Biomechanical testing of both constructs showed similar fixation stability after cyclical axial loading and similar loads to failure. CLINICAL RELEVANCE: The strength of both constructs after cyclical loading in the axial plane and load-to-failure testing in the superior plane validate their continued clinical use for achieving stability in AC joint reconstruction procedures.

BACKGROUND: Displaced fractures of the distal clavicle are inherently unstable and lead to nonunion in a high percentage of cases. The optimal surgical management remains controversial. HYPOTHESIS: Indirect osteosynthesis with a closed-loop double endobutton construct would result in reliable fracture union and obviate the need for additional surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eight patients with an acute unstable Neer type IIB distal clavicle fracture were treated with a closed-loop double endobutton implant. Mean follow-up averaged 3.4 years (range, 1-9 years). Two patients were lost to follow-up. The remaining 6 patients underwent a detailed functional and radiologic evaluation. RESULTS: Definitive fracture healing was achieved in all patients. There were no complications, and no patients required additional surgery related to the index procedure. The mean Constant score was 97 at final follow-up. CONCLUSION: The closed-loop double endobutton technique was reliable and effective in achieving fracture union in all patients with unstable Neer type IIB fractures of the distal clavicle. This technique obviates the need for late hardware removal that is often necessary when direct osteosynthesis is used and avoids potential complications associated with coracoclavicular cerclage constructs that require knot fixation.

PURPOSE: Recently, many acromioclavicular-coracoclavicular (AC-CC) ligament reconstruction techniques address only the CC ligament. However, many of these techniques are costly, time-consuming, and require the use of allogenic grafts, making them prone to creep and failure or novel devices making them challenging for orthopaedic surgeons. The purpose of this study was to compare the biomechanical characteristics of a double endobutton technique using a standard endobutton CL with those of a coracoid cerclage sling (CS) for reconstruction of the CC ligaments. METHODS: Anterior-posterior (AP) translation and superior-inferior (SI) translation were quantified for eight matched pairs of intact AC joints. One shoulder from each pair underwent a double endobutton repair, using an endobutton CL modified with an additional endobutton (Smith & Nephew, Memphis, Tenn) and placed through holes in the coracoid and clavicle. The contra-lateral shoulder received a coracoid sling reconstruction using an anterior tibialis tendon. Translation testing was repeated after reconstruction, followed by load-to-failure testing. Paired t tests were used for statistical analysis. RESULTS: The CS technique demonstrated a greater SI and AP translation than the double endobutton technique (p < 0.05). Additionally, the double endobutton technique had a greater stiffness (40.2 +/- 11.0 vs. 20.3 +/- 6.4 N/mm, p = 0.005), yield load (168.5 +/- 11.0 vs. 86.8 +/- 22.9 N, p = 0.002), and ultimate load (504.4 +/- 199.7 vs. 213.2 +/- 103.4 N, p = 0.026) when compared to the CS technique. CONCLUSION: The double endobutton technique yielded less translation about the AC joint and displayed stronger load-to-failure characteristics than the CS reconstruction. As such, this technique may be better suited to restore native AC-CC biomechanics, reduce post-operative pain, and prevent recurrent subluxation and dislocation than an allogenic graft construct. The double endobutton technique may be a suitable option for addressing AC-CC injuries.

BACKGROUND: Current anatomic methods for reconstruction of the dislocated acromioclavicular (AC) joint show improved clinical results but continue to be associated with significant rates of fixation loss and complications, limiting more widespread use. PURPOSE: To determine the long-term clinical and radiologic outcomes of a novel surgical technique using a closed-loop double Endobutton device to reconstruct both acute and chronic dislocations. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 2003 and 2012, a total of 35 patients (31 men, 4 women) at a mean age of 42 years (range, 25-70 years) were surgically treated for a Rockwood type III or greater AC joint dislocation with the described technique (26 chronic, 9 acute). Imbrication of the AC joint capsule and deltotrapezial fascia was performed in all patients. Biological bridging across the coracoclavicular (CC) interval was performed in all patients by use of coracoacromial (CA) ligament transfer in 28 patients and primary repair of the CC ligament in 7 patients. Complete follow-up information was obtained for 31 of 35 patients. RESULTS: At a mean follow-up of 5.2 years (range, 27-144 months), the construct remained stable in all but 1 patient. The mean CC interval difference was 1.1 mm (range, -2.5 to 4.0 mm) and was <2 mm in 87% of patients. The mean Constant score was 98; the mean University of California, Los Angeles Shoulder Rating Scale score was 34; and the mean American Shoulder and Elbow Surgeons Shoulder Score was 98. Follow-up MRI evaluation in 10 patients consistently demonstrated a wide band of dense scar tissue between the coracoid and clavicle. No infections, fractures, or perioperative complications occurred. CONCLUSION: Excellent results were obtained and maintained over long-term follow-up. The continuous loop device eliminated the possibility of knot slippage or breakage. MRI confirmed a robust healing response. The described technique resulted in outcomes that were significantly superior to historical reports of nonsurgical outcomes, and the technique can be recommended both for acute and chronic dislocations.

Cyclops lesion was previously described as a fibrous lesion with a granulation tissue core originating from the tibial insertion of the anterior cruciate ligament (ACL) graft. 1 Recently, two case reports described inverted cyclops le - sions, which originated from the femoral aspect of the ACL. 2,3 Both cyclops and inverted cyclops lesions are usually associated with a block to knee extension. Here we present a case of an 18-year-old female who developed a painful inverted cyclops lesion originating from the femoral notch above hamstring autograft without restriction to knee range of motion 20 months after arthroscopically assisted ACL reconstruction. The case is followed by literature review on presentation, diagnosis, and treatment of cyclops and inverted cyclops lesions.

A gold standard for the reconstruction of the coracoclavicular complex has yet to emerge for the treatment of separation of the acromioclavicular joint. Most of the current techniques not only fail to recreate the original anatomy, but also do not use materials that are strong enough to maintain the reduction during the healing process. Using a weak and nonanatomical construct has predictably led to problems with slippage of the initial reduction, as well as implant-related complications. This report introduces a novel technique for the reconstruction of complete acromioclavicular joint separation by using an Endobutton CL that has been modified for use in the shoulder. The device is placed through holes in the coracoid and clavicle reproducing the course of the conoid portion of the coracoclavicular ligament. The Endobutton CL material has been shown to have both strength and stiffness in excess of the native anatomy, ensuring a stable reduction. The procedure is simple, has low morbidity, and can be easily adapted to an arthroscopic technique.

PURPOSE: The source of pain in patients with a stable shoulder and clinical signs of impingement is traditionally thought to be subacromial or outlet impingement, as popularized by Neer. This report introduces the concept of anterior internal impingement in patients with signs and symptoms of classic impingement syndrome and arthroscopic evidence of articular-side partial rotator cuff tear. Contact that occurs between the fragmented undersurface of the rotator cuff and the anterosuperior labrum is the apparent source of pain in these patients. TYPE OF STUDY: Case series. METHODS: Ten patients with a primary symptom of pain and an arthroscopic finding of a partial rotator cuff tear were reviewed. Arthroscopic visualization of the subacromial space revealed no evidence of subacromial impingement or bursitis in any patient. All patients had clinical signs and symptoms of classic impingement. The initial part of the surgical procedure consisted of a complete diagnostic arthroscopy in a low-volume gas medium using a single posterior portal. While performing the Hawkins test, the locations of any areas of abnormal soft-tissue contact and impingement were observed directly. RESULTS: There was anterior internal impingement in all 10 patients with partial-thickness rotator cuff tears. The abnormal and fragmented rotator cuff tissue made contact with the anterior superior labrum when the shoulder was visualized from the posterior portal while performing the Hawkins test. Preoperative magnetic resonance imaging correctly showed a partial-thickness rotator cuff tear in 20% of the cases. CONCLUSIONS: Recognition of anterior internal impingement as a clinical entity is important because magnetic resonance imaging results are often misleading. This is of particular importance in young patients with isolated lesions in whom arthroscopic acromioplasty and capsular reefing procedures would be unnecessary. When anterior internal impingement is recognized as the source of unresolved shoulder pain, patient selection for surgery and procedure selection can be improved.

Subtle instability problems of the glenohumeral joint and patellofemoral joint are difficult to assess and accurately diagnose with current methods of preoperative imaging and physical examination. A simple technique is described that provides objective information for diagnosing dynamic problems of the shoulder and patellofemoral joint. Limited-volume gas arthroscopy avoids many of the potential risks and complications of pressure-based gas arthroscopy. In addition to assessing joint dynamics, it allows for initial arthroscopic inspection of joints during open surgical cases, eliminating the additional morbidity and expense of fluid arthroscopy. Objective intraoperative assessments of completed reconstructions can also be made to insure that stabilizing procedures are adequate but not overzealous. The technique requires no special equipment, adds little time to an arthroscopic procedure, and requires only basic arthroscopic skills.