Acromioclavicular Joint Reconstruction Using Peroneus Brevis Tendon Allograft

We describe the use of a double-strand peroneus brevis allograft to reconstruct the coracoclavicular and acromioclavicular (AC) joint ligaments. Through sharp dissection, the distal clavicle, the AC joint, and the torn superior AC and coracoacromial ligaments are identified. The coracoid process and injured coracoclavicular ligaments are identified with blunt dissection. A 1-cm segment of the lateral clavicle is resected. Vertical and connecting horizontal tunnels are created (4.5 mm) in the lateral clavicle and in the medial acromion process. The 5.5- to 6.0-mm-diameter allograft is looped around the coracoid process, and both strands are passed through the vertical clavicle tunnel with a nitinol wire loop. One strand passes through the vertical clavicle tunnel, and the other strand passes through the horizontal tunnel, exiting through the lateral end. The allograft strand passed through the vertical clavicle tunnel is then passed inferiorly through the superior vertical acromion tunnel, and the strand passed completely through the horizontal clavicle tunnel is passed laterally through the medial horizontal acromion tunnel. After both strands exit inferiorly through the vertical acromion tunnel, they are tensioned and sutured with AC joint reduction. Soft tissue closure uses No. 0 and No. 2-0 absorbable sutures with No. 3-0 nylon sutures at the skin.     

Evaluation of BioCorkscrew and Bioknotless RC suture anchor rotator cuff repair fixation: an in vitro biomechanical study

This in vitro biomechanical study used cadaveric specimens to compare the rotator cuff repair fixation provided by BioCorkscrew and Bioknotless RC suture anchors. Three cm wide by 1-cm long full-thickness supraspinatus defects were repaired using either two BioCorkscrew suture anchors with combined vertical and horizontal mattress sutures (n = 7) or three Bioknotless RC suture anchors with simple sutures (n = 7). Therefore, the BioCorkscrew suture anchor group had two sutures per anchor (four total sutures), while the Bioknotless RC suture anchor group had one suture per anchor (three total sutures). Two-phase cyclic (5–100 N, 1,000 cycles and 5–180 N, 2,000 cycles) and load to failure tests (31 mm/s) were performed. Non-parametric statistics were used to compare group differences (P < 0.05). All of the BioCorkscrew group specimens (seven of seven) completed the two phase cyclic test regimen without failure or gapping ≥ 5 mm, compared to only three of seven of the Bioknotless RC group (Fisher’s Exact test = 0.03). Groups did not differ for repair site gapping during the 5–100 N cyclic test phase (Fisher’s Exact test = 0.77), however more of the Bioknotless RC group displayed gapping ≥ 5 mm during the 5–180 N cyclic test phase than the BioCorkscrew group (P = 0.02). The BioCorkscrew group also displayed greater yield load during load to failure testing (492.2 ± 204 N vs. 296.4 ± 155 N, P = 0.03). In this in vitro biomechanical study, the BioCorkscrew group with combined vertical and horizontal mattress sutures displayed greater cyclic test survival, less repair site gapping, and superior yield load compared to the Bioknotless RC group with simple sutures. These results in human cadaveric rotator cuff-humerus specimens suggest better immediate post-operative repair site strength and a reduced need for post-operative restrictions. Clinical studies are needed to determine how these rotator cuff repair modes withstand the forces of early rehabilitation and activities of daily living that potentially influence patient outcomes.     

Health-related quality of life and pressure ulceration assessment in patients treated in the community

Little is known of the impact of pressure ulceration on adult patients' health-related quality of life. The purpose of this study was to determine the impact pressure ulceration has on pressure ulcer patients cared for in the community. A case control study design was used by drawing a random sample from patients receiving community nursing care, stratified by the presence of pressure ulceration. In all, 75 patients with pressure ulcers were compared with 100 controls without ulcers using the four-point ulcer grading scale described by United Kingdom consensus guidelines. Patients were interviewed using the Short Form-36 (SF-36) questionnaire and activities of daily living assessed using the modified Barthel scale. Patients with pressure ulcers had significantly poorer physical function (mean difference (d) = 37.6, 95% CI 28.6-46.6, p < 0.001) and social functioning (d = 33.9, 95 % CI 24.0-43.9, p < 0.001) than published age- and sex-matched normative data from the United Kingdom. The difference between cases and controls was much smaller in these domains, with neither approaching statistical significance. After adjustment for age and gender, scores for bodily pain were poorer in patients with no ulceration (d = -10.5, 95% CI - 20.6 to - 0.4, p = 0.042) indicating greater pain in these patients compared with the cases with ulceration. Activities of daily living determined by the modified Barthel scale showed reduced self-care (d = -7.6, 95% CI -12.5 to - 2.7, p = 0.010) and mobility (d = -9.2, 95% CI -14.6 to - 3.8, p = 0.001) in patients with pressure ulceration. The overall ability to perform these activities was also significantly poorer in this group (d = -16.3, 95% CI -27.3 to -5.3, p = 0.004). While patients with pressure ulceration experience some deficits in their health-related quality of life compared with a normal population, these differences are similar to those experienced by other patients receiving community nursing care.     

Three novel PROC gene lesions causing protein C deficiency

Hallam PJ, Mannucci P, Tripodi A, Bevan D, Laursen B, Tengborn L, Wacey A, Cooper DN. Three novel PROC gene lesions causing protein C deficiency. Clin Genet 1998: 54: 231–233. 0 Munksgaard, 1998
Missense mutations. three of them novel (Am210→Val, Asn248→ Ile, Ah355→Val), were found in the protein c ( PROC ) genes of 7 patients with inherited protein C deficiency associated with venous thrombosis. Comparison with the phenotypic effects of mutations in the analogous residues of factor IX causing hdernophilia B and the use of molecular modelling has provided explanations as to how these lesions might alter either the structure, function or secretion of the protein C molecules encoded.     

Radiographic analysis of femoral tunnel position in anterior cruciate ligament reconstruction

Successful reconstruction of the anterior cruciate ligament (ACL) depends on anatomic placement of a graft ligament substitute. This study examined the accuracy of a plain radiograph in determining femoral tunnel position during ACL reconstruction. Nine cadaveric distal femurs had six separate tunnels made in each specimen: 12:00 (high position), 1:30 (anatomic position), and 3:00 (low position) in the left femora and 12:00 (high), 10:30 (anatomic), and 9:00 (low) in the right femora. At each position on the clock face, two 9-mm tunnels were drilled, leaving 2 mm (correct) and 12 mm (incorrect) of posterior wall intact. With a radiopaque tunnel dilator in each tunnel, a true lateral radiograph, a 10 degree externally rotated lateral radiograph, and a 10 degree internally rotated lateral radiograph were obtained. All radiographs were analyzed for femoral tunnel placement in the anteroposterior plane with the four-quadrant method described by Harner et al and the ratio method described by Aglietti et al. Statistically significant differences could only be distinguished between anatomic (10:30), anterior (12-mm rim), and posterior (2-mm rim) positions. There were no statistically significant differences for any of the other positions when comparing true laterals to true laterals, true laterals to internal or external oblique views, or when comparing internal and external oblique views. A malpositioned anterior tunnel (12-mm rim posterior), which was "low" at 9:00 or "high" at 12:00 in the notch (malplaced), could not be distinguished reliably from an anatomically correct placed tunnel with a single-plane lateral radiograph.