Historically, did Cemented Thompson perform better than uncemented Austin Moore hemiarthroplasty for femoral neck fractures? A meta-analysis of available evidence

INTRODUCTION

Thompson and Austin Moore prostheses have been commonly used in hemiarthroplasties for displaced femoral neck fractures. There has been considerable debate about which of these prostheses is preferred. The purpose of this meta-analysis was to compare historical data for clinical outcomes of cemented Thompson and uncemented Austin Moore hemiarthroplasty in displaced femoral neck fractures.

METHODS

We searched Medline via PubMed, Cochrane Central, Scopus, Ovid and Web of Science for relevant articles up to February 2019. The included outcomes measured were hip function, hip pain, implant-related complications, surgical complications, reoperation rate and hospital stay. The data were pooled as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) between the two compared groups in a meta-analysis model.

RESULTS

Ten studies (four RCTs and six observational studies) with a total of 4378 patients were included in the final analysis. The pooled RR showed that the Thompson group was associated with a lower incidence of postoperative hip pain (RR = 0.66, 95% CI [0.54, 0.80]), lesser reoperation rate (RR = 0.46, 95% CI [0.24, 0.88]), lesser intraoperative fractures (RR = 0.15, 95% CI [0.09, 0.25]), but a longer operative time (MD = 12.04 min, 95% CI [2.08, 22.00]) in comparison to the Austin Moore group. The effect estimate did not favour either group in terms of hip function, periprosthetic fractures, prosthetic dislocations, wound infection, mortality and hospital stay.

CONCLUSION

Evidence shows that Thompson hemiarthroplasty is better than Austin Moore hemiarthroplasty in terms of hip pain, reoperation rate and intraoperative fractures. Whereas the postoperative hip function is equivalent, these results could be considered when assessing the outcomes in modern hips.

Posterior Acromial Morphology Is Significantly Associated with Posterior Shoulder Instability

BACKGROUND

The purpose of this paper was to determine whether acromial morphology influences anteroposterior shoulder stability. We hypothesized that a more horizontal and higher position of the acromion in the sagittal plane would be associated with posterior instability.

METHODS

In this retrospective study, patients with unidirectional posterior instability were age and sex-matched to a cohort of patients with unidirectional anterior instability. Both cohorts were compared with a control group of patients with no instability and no degenerative glenohumeral (rotator cuff and/or joint surface) or acromial changes. Measurements on radiographs included posterior acromial tilt, anterior and posterior acromial coverage (AAC and PAC), posterior acromial height (PAH), and the critical shoulder angle (CSA).

RESULTS

The number of patients enrolled in each instability group was 41, based on a priori power analysis. The control group consisted of 53 shoulders. Of the measured anatomic factors, PAH showed the most significant association with posterior instability (odds ratio [OR] = 1.8; p < 0.001) in the logistic regression model. PAH was significantly greater in the posterior instability group compared with the anterior instability group (30.9 versus 19.5 mm; p < 0.001). With a cutoff value of PAH of 23 mm, the OR for posterior instability was 39. Shoulders with posterior instability were also significantly different from normal shoulders with regard to PAH (p < 0.001), AAC (p < 0.001), and PAC (p < 0.001) whereas, in the shoulders with anterior instability, all of these values except the AAC (p = 0.011) did not differ from those of normal shoulders.

CONCLUSIONS

Specific acromial morphology is significantly associated with the direction of glenohumeral instability. In shoulders with posterior instability, the acromion is situated higher and is oriented more horizontally in the sagittal plane than in normal shoulders and those with anterior instability; this acromial position may provide less osseous restraint against posterior humeral head translation. A steep "Swiss chalet roof-type" acromion virtually excluded recurrent posterior instability in an albeit relatively small cohort of patients. Additional investigation is needed to determine the relevance of these findings for future treatment.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Sliding hip screws versus cancellous screws for femoral neck fractures: a systematic review and meta-analysis

PURPOSE

Both sliding hip screws (SHS) and cancellous screws are used in the surgical management of intracapsular femoral neck fracture. However, there is paucity of information as to which is the superior treatment modality. We performed this systematic review and meta-analysis study to compare the clinical outcomes of SHS and cancellous screws for the treatment of femoral neck fractures in adult patients.

METHODS

We searched PubMed, Scopus, Web of Science, and Cochrane CENTRAL, up to December 2017. Randomized controlled trials (RCTs) directly comparing the clinical outcomes of SHS and cancellous screws for femoral neck fractures were retrieved with no language or publication year restrictions. Data retrieved included operative details, nonunion rate, avascular necrosis, reoperation, infection and mortality, hip pain, functional hip scores, and medical complications. These were pooled as risk ratio or mean difference (MD) with their corresponding 95% confidence interval (CI). Heterogeneity was assessed by Chi-square test.

RESULTS

Ten RCTs involving 1934 patients were included in the final analysis. The pooled estimate showed that the SHS group was associated with more intraoperative blood loss (MD = 110.01 ml, 95% CI [52.42, 167.60], p = 0.00002) than the cancellous screws. There was no significant difference in terms of operative time, postoperative hip function, nonunion, avascular necrosis, reoperation rate, infection, fracture healing, hip pain, medical complications, and mortality rate.

CONCLUSION

Based on our study, the cancellous screws group was associated with less intraoperative blood loss in comparison with the SHS group. No other significant differences were found between the two interventions.

Correction to: Contemporary cemented versus uncemented hemiarthroplasty for the treatment of displaced intracapsular hip fractures: a meta-analysis of forty-two thousand forty-six hips

The author name "Muhammad Shawqi" was incorrectly presented as "Muhammad Shawq".

Contemporary cemented versus uncemented hemiarthroplasty for the treatment of displaced intracapsular hip fractures: a meta-analysis of forty-two thousand forty-six hips

INTRODUCTION

Controversy exists regarding the use of cement for hemiarthroplasty to treat displaced intracapsular hip fractures. The aim of this systematic review and meta-analysis was to compare the clinical outcomes between contemporary cemented and contemporary uncemented hemiarthroplasty for the treatment of displaced femoral neck fractures.

METHODS

Literature searches of PubMed, Scopus, Web of Science, and Cochrane Central, up to May 2017, were performed. We included randomized controlled trials (RCTs) and observational studies comparing contemporary cemented with contemporary uncemented hemiarthroplasty. Data were pooled as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) in a meta-analysis model. Studies with the Thompson and Austin Moore prostheses were excluded.

RESULTS

A total of 29 studies (9 RCTs and 20 observational studies), with a total of 42,046 hips, were included. Meta-analysis showed that the cemented group was associated with fewer periprosthetic fractures (RR = 0.44, 95% CI [0.21, 0.91]), longer operative time (MD = 11.25 min, 95% CI [9.85, 12.66]), more intraoperative blood loss (MD = 68.72 ml, 95% CI [50.76, 86.69]), and higher heterotopic ossification (RR = 1.79, 95% CI [1.11, 2.88]) compared with the uncemented group. Meta-analysis showed no significant difference in terms of post-operative hip function, hip pain, reoperation rate, prosthetic dislocations, aseptic loosening, wound infection, and hospital stay.

CONCLUSIONS

This meta-analysis shows that contemporary cemented prostheses have less intra-operative and post-operative fractures, but longer operative time, more intra-operative blood loss, and heterotopic ossifications. Otherwise, there were no significant differences between both groups.

The X-Pulley Technique for Subpectoral Long Head of the Biceps Tenodesis Using All-Suture Anchors

Subpectoral long head of the biceps tenodesis is gaining popularity as a technique for treating patients with various pathologies of the tendon or its anchor to the superior labrum. It has the added advantage of addressing bicipital groove pathologies. Various techniques for performing it have been described, but none is without problems. We present a modification of the previously described techniques that involves 2 all-suture anchors and offers the added advantage of a reduced risk of fracture without sacrificing the biomechanical strength of the construct. We also believe that it may potentiate healing by providing an adequate surface contact area between the tendon and bone with a minimal risk of damage to the tendon and neurovascular structures.

Distal Triceps Rupture Repair: The Triceps Pulley-Pullover Technique

Distal triceps rupture is an uncommon but debilitating injury, and surgical fixation is almost invariably warranted. A number of techniques have been described in the literature in which combinations of transosseous tunnels and bone anchors have been used. We describe a modification to existing techniques-the triceps pulley-pullover technique with all-suture anchors. This technique minimizes bone loss, while maximizing the bone-tendon contact area and creating a double-row repair to optimize strength and healing.

Are commercially-available precontoured anatomical clavicle plating systems offering the purported superior optimum fitting to the clavicle? A cadaveric analysis and review of literature

PURPOSE

The indication for operative treatment of displaced midshaft clavicle fractures remains controversial. However, if plate fixation is considered, implant prominence and skin irritation are the most common causes for re-operation. Low profile implants as well as closely contouring plates to the individual anatomy may reduce these complications. The aim of this study was to compare the fitting accuracy and implant prominence of 3.5mm pelvic reconstruction plates (PRP) with pre-contoured anatomical clavicle plates (PACP) for midshaft clavicle fractures.

METHODS

Three-dimensional data of the largest, median and smallest male and female clavicle of an existing database of 89 cadaveric clavicles were included for analysis. A three-dimensional model of a commercially available PACP was used for digitally positioning of the plate on the segmented clavicles. Three-dimensional printouts of each clavicle were produced and the 3.5mm reconstruction plates were manually bent and positioned by the senior author. Computed tomography scans and three-dimensional reconstructions were then obtained to digitally compare the fitting accuracy and implant prominence.

RESULTS

Pelvic reconstruction plates offered superior fitting accuracy and lower implant prominence compared to PACP. The largest difference in implant prominence was observed in large sized female clavicles and measured 3.6mm.

CONCLUSION

Both, the less costly PRP plates and commercially available PACP for midshaft fractures of the clavicle demonstrated a clinically acceptable fitting accuracy. The manually bent pelvic-reconstruction plates demonstrated reduced implant prominence with superior fitting. Hypothetically this might contribute to a reduced rate of reoperation.

LEVEL OF EVIDENCE

Level IV cadaveric study.

Mechanical properties of Triclosan sutures

To avoid infections and wound healing disorders, Triclosan coated sutures have been invented. Little is known of these sutures regarding their tensile properties. Three different Triclosan coated sutures (Vicryl 1 plus, PDS 0 plus, Monocryl 3-0 plus) were tested at several time points over 42 days regarding load to failure, strain, and stiffness compared to their non-coated versions (Vicryl 1, PDS 0, Monocryl 3-0). Four different measurement points were made. Suture loops were fixed in a material testing machine over two metal bars which were moved apart creating a stress to the fiber. Unpaired, two-tailed t-test were performed for each group (untreated and treated) while level of significance was defined at a level of p < 0.05. Vicryl 1 was significantly stronger on day 14 than Vicryl 1 plus (p = 0.033). On day 28, significant changes were found in PDS 0 which was weaker compared to PDS 0 plus (p = 0.039) and Vicryl 1 which was stronger than Vicryl 1 plus (p = 0.032). We have seen that Vicryl 1 plus sutures are significantly weaker according to loading to failure after 14 and 28 days, which might cause incisional hernias. PDS 0 sutures are used to reconstruct tendons, therefore a longer durableness might be of interest as re-ruptures of tendons are problematic. Our in vitro findings support, the use of Triclosan coated PDS plus sutures and Vicryl sutures as they show a longer resistance. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1777-1782, 2018.

Compressive Stockings After Hindfoot and Ankle Surgery

BACKGROUND

Swelling and pain are common after foot and ankle procedures. We hypothesized that compressive stockings (CS) treatment after hindfoot surgery would positively influence patient outcomes.

METHODS

We undertook this randomized controlled trial in 87 consecutive patients to analyze the clinical effect of CS after hindfoot and ankle surgery and evaluate CS-wearing compliance using sensors that were implanted into CS. Ankle swelling, pain status, quality of life (SF-36 score), and the American Orthopaedic Foot & Ankle Score (AOFAS) were set as the primary end points. The CS wearing time in hours and percentage were investigated as the secondary end points. All participants with CS (group I) were informed about the implanted sensor after the CS were taken off. A subgroup analysis of group I was performed to detect differences between patients with high vs low compliance.

RESULTS

At 12 weeks, the results of ankle swelling (mean 234 mm in group I and 232 mm in group II), pain in the visual analog scale (1.7 group I vs 1.9 in group II), the SF-36 score (38 points in group I vs 30 points in group II), and the AOFAS score (a mean of 76 points in both groups) showed no statistical differences between the 2 groups. The mean wearing time was 136 (range, 0-470) hours, which corresponds to a compliance rate of 65%. Sixteen participants had high compliance (>80%, >170 hours), and 21 patients had low or noncompliance. The clinical results of patients with high wearing compliance were not significantly better compared to the results of patients with low compliance.

CONCLUSION

CS therapy after ankle and hindfoot surgery was associated with a low wearing compliance and did not influence ankle swelling, function, pain, and the quality of life compared to the control group. Furthermore, the clinical results of patients with high compliance were not better compared to the results of patients with low or noncompliance wearing behavior.

LEVEL OF EVIDENCE

Level II, prospective randomized study of lower quality.

Staged Revision With Antibiotic Spacers for Shoulder Prosthetic Joint Infections Yields High Infection Control

BACKGROUND

The treatment of periprosthetic joint infection (PJI) of the shoulder with two-stage revision arthroplasty using an antibiotic-loaded cement spacer is established strategy, but there is sparse information regarding the likelihood of infection control and restoration of shoulder.

QUESTIONS/PURPOSE

(1) What is the likelihood of infection control after two-stage revision using an antibiotic cement spacer for patients with PJI of the shoulder? (2) What are the improvements in Constant and Murley scores at 2 years after these staged revisions?

PATIENTS AND METHODS

Between 2000 and 2013, we treated 48 patients with PJI of the shoulder using two-stage revision including an antibiotic-containing cement spacer during the first stage. Of those, 38 (79%) were available for review at a minimum of 24 months (mean, 52 ± 34 months). Ten patients (21%) were excluded because they were deceased (n = 3), moved abroad (n = 4), or refused followup (n = 3), leaving 38 for analysis in this retrospective study. During the first stage, removal of the prosthesis, débridement, and implantation of a gentamicin and vancomycin-filled cement spacer were performed by four different surgeons followed by antibiotic therapy (2 weeks intravenous plus 10 weeks oral). For the second stage, we generally tried a reverse total shoulder arthroplasty (RTSA; n = 26). In case of severe glenoid destruction, hemiarthroplasty (HA; n = 8) was used as a salvage option. In 14 patients the cement spacer was left in place because the patients refused further surgery or were not operable owing to medical reasons. The primary outcome included the proportion of patients achieving infection control 2 years after the second-stage procedure after implantation of the cement spacer. Infection control was determined as the absence of the Musculoskeletal Infection Society PJI criteria. The clinical outcome assessed with the Constant and Murley scores served as the secondary outcome parameter. A subgroup (RTSA; HA, spacer retention) analysis of the Constant and Murley scores was performed.

RESULTS

Successful infection control was achieved in 36 of 38 patients (95%). Patients who underwent treatment with a cement spacer had increased Constant and Murley scores at latest followup compared with their pretreatment scores (mean ± SD, 27 ± 19 versus 43 ± 20; mean difference, 17; 95% CI, 10-24; p = 0.001). For patients who underwent staged treatment followed by second-stage RTSA (n = 23), the Constant and Murley scores increased (mean ± SD, 31 ± 20 versus 51 ± 20; mean difference, 20; 95% CI, 11-30; p = 0.001). The Constant and Murley scores did not improve in patients who underwent HA (mean ± SD, 22 ±15 versus 24 ± 90; mean difference, 3; 95% CI, -10 to 16; p = 0.509) or who retained the spacer (mean ± SD, 18 ±12 versus 35 ±10; mean difference, 19; 95% CI, -5 to 44; p = 0.093).

CONCLUSION

Revision arthroplasty using an antibiotic-loaded cement spacer provided successful infection control in patients with periprosthetic shoulder infections in this small, retrospective series. Functional improvement was obtained after reimplantation of a reverse total shoulder prosthesis but was not seen after HA and cement spacer; however, baseline differences among patient groups very likely contributed to these differences, and they should not be attributed to implant selection alone.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Long-term results of total elbow arthroplasty in patients with hemophilia

HYPOTHESIS

It was hypothesized that the long-term survivorship and clinical outcome are reasonable, justifying total elbow arthroplasty (TEA) in patients with end-stage hemophilic arthropathy.

METHODS

From 2002 to 2012, 13 primary TEAs (Coonrad-Morrey design) were implanted in 9 consecutive patients with an average age of 55 (range, 39-76) years. Type A hemophilia was diagnosed in 7 patients and type B hemophilia in 2 patients. Clinical and radiographic results of all (11 TEAs) but 1 patient were retrospectively analyzed.

RESULTS

After a mean of 9.1 (range, 5-14) years, the mean visual analog scale score for pain, total Mayo Elbow Performance Score, and subjective elbow value were significantly improved from 5 (standard deviation, ±3) to 2 (±2; P = .007) points, from 64 (±16) to 89 (±11; P = .008) points, and from 47% (±15%) to 81% (±11%; P < .001), respectively. Whereas the flexion arc remained unchanged (P = .279), mean active pronation improved significantly (P = .024). Postoperative complications were recorded in 8 TEAs (62%), whereas 5 TEAs (38%) underwent partial component exchange after a mean of 7.2 (range, 3-10) years: 2 for periprosthetic infection, 2 for polyethylene wear, and 1 for humeral component loosening. Of the living patients after partial component exchange (n = 3), the mean final total Mayo Elbow Performance Score, flexion and rotation arc, visual analog scale score for pain, and subjective elbow value were comparable with the results of the living patients without revision surgery (n = 8).

CONCLUSIONS

TEA for patients with advanced hemophilic arthropathy is associated with a substantial complication and revision rate. However, even after revision without implant removal, it provides good functional and subjective long-term results.

Lateral unicompartmental knee replacement: a systematic review of reasons for failure

PURPOSE

Currently, individual studies lack the power to successively illustrate different failure modes; therefore, we undertook a systematic review to examine lateral unicompartmental knee replacement (lat UKR) failure modes. Furthermore, we compared early with midterm and late failures and fixed-bearing with mobile-bearing implants.

METHODS

A search using the databases of PubMed, EMBASE, Cochrane, and annual registries was performed to search for failed lat UKRs. Studies were included when they reported more than four failures, described failure modes and were minimum level IV studies. Data was analysed based on overall failure modes, fixed- vs. mobile bearing and early (<5 years) vs. midterm (5-10 years) vs. late failures (>10 years).

RESULTS

Fourteen cohort studies and two registry-based studies were included. A total of 336 overall failures, 87 time-dependent failures, and 175 implant-specific failures were identified. The main overall causes of failure were osteoarthritis (OA) progression (30%) and aseptic loosening (22%). These were followed by less common causes such as instability (7%), unexplained pain (5%), infection (5%), polyethylene wear (5%), and bearing dislocation (5%). Bearing dislocation was the most common early failure (29%) and also the most common failure among mobile-bearing implants (27%). In midterm and late failures, OA progression had the highest rates (59% and 78% respectively) and was also the most common type of failure in fixed-bearing implants (44%).

CONCLUSIONS

Progression of OA and aseptic loosening are the major overall failure modes in lat UKR. Bearing dislocation was the main failure mode in early years and in mobile-bearing implants, whereas OA progression caused most failures in late years and in fixed-bearing implants.

LEVEL OF EVIDENCE

Systematic Review of minimum level IV studies.

A systematic review of the concept and clinical applications of bone marrow aspirate concentrate in tendon pathology

Tendon pathologies are a group of musculoskeletal conditions frequently seen in clinical practice. They can be broadly classified into traumatic, degenerative and overuse-related tendinopathies. Rotator cuff tears, Achilles tendinopathy and tennis elbow are common examples of these conditions. Conventional treatments have shown inconsistent outcomes and might fail to provide satisfactory clinical improvement. With the growing trend towards the use of mesenchymal stem cells (MSCs) in other branches of medicine, there is an increasing interest in treating tendon pathologies using the bone marrow MSC. In this article, we provide a systematic literature review documenting the current status of the use of bone marrow aspirate concentrate (BMAC) for the treatment of tendon pathologies. We also asked the question on the safety of BMAC and whether there are potential complications associated with BMAC therapy. Our hypothesis is that the use of BMAC provides safe clinical benefit when used for the treatment of tendinopathy or as a biological augmentation of tendon repair. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist while preparing this systematic review. A literature search was carried out including the online databases of PubMed, EMBASE, ClinicalTrial.gov and the Cochrane Library from 1960 to the end of May 2015. Relevant studies were selected and critically appraised. Data from eligible studies were extracted and classified per type of tendon pathology. We included 37 articles discussing the application and use of BMAC for the treatment of tendon pathologies. The Critical Appraisal Skills Program (CASP) appraisal confirmed a satisfactory standard of 37 studies. Studies were sub-categorised into: techniques of extraction, processing and microscopic examination of BMAC (n = 18), where five studies looked at the evaluation of aspiration techniques (n = 5), augmentation of rotator cuff tears (n = 5), augmentation of tendo-achilles tendon (n = 1), treatment of gluteal tendon injuries (n = 1), management of elbow epicondylitis (n = 2), management of patellar tendinopathy (n = 1) and complications related to BMAC (n = 5). Multiple experimental studies investigated the use of BMAC for tendon repair; nonetheless, there are only limited clinical studies available in this field. Unfortunately, due to the scarcity of studies, which were mainly case series, the current level of evidence is weak. We strongly recommend further future randomised controlled studies in this field to allow scientists and clinicians make evidence-based conclusions.

The Tripod-Pulley Technique for Arthroscopic Remplissage in Engaging Hill-Sachs Lesions

Arthroscopic Bankart repair is now a well-established technique for the treatment of shoulder instability. However, failure rates are considerable when significant bony defects are not addressed. Hill-Sachs lesions, present in the vast majority of those with recurrent anterior instability, when of significant dimension and location, may account for some of these failures. The remplissage procedure involves capsulotenodesis of the posterior capsule and the infraspinatus tendon to fill the Hill-Sachs lesion. "Double-pulley" remplissage is a transtendinous technique that has been described elsewhere and that may simplify the procedure. We present a modification of this technique, the "tripod-pulley" technique, which we feel may potentiate healing of the Hills-Sachs lesions of the capsule and infraspinatus by increasing the surface contact area. At the same time, this technique minimizes the risk of potential damage to the infraspinatus as it uses 2.3-mm "all-suture" anchors.

A systematic review of the clinical applications and complications of bone marrow aspirate concentrate in management of bone defects and nonunions

PURPOSE

Fracture healing encompasses a succession of dynamic multifactorial metabolic events, which ultimately re-establishes the integrity of the biomechanical properties of the bone. Up to 10% of the fractures occurring annually will need additional surgical procedures because of impaired healing. The aim of this article is to review the current literature regarding the use of bone marrow aspirate concentrate (BMAC) and its effectiveness in the management of bone defects.

METHODS

We have included all published clinical literature investigating the development, techniques and applications of BMAC. Language, design and risk of bias did not deter the initial inclusion of any study. Our search was exclusively limited to studies involving human subjects. A PRISMA compliant search was carried out as published in 2009. This included the online databases: PubMed, EMBASE, clinical trial.gov and the Cochrane library from 1960 to the end of May 2015. MeSH terms used included: "Bone" AND "Marrow" AND "Aspirate" AND "Concentrate" AND "Bone Defects" AND "NONUNION". Eligible studies were independently appraised by two authors using the Critical Appraisal Skills Program checklist. For the purpose of narrative review, relevant studies were included irrespective of methodology or level of evidence.

RESULTS

Thirty-four of the 103 (48 PubMed and 55 EMBASE) results yielded by the preliminary search were included. Exclusions included three duplicate records, six letters, 17 non-orthopaedics related studies and four records irrelevant to our search topic. The CASP appraisal confirmed a satisfactory standard of 31 studies. They all had clearly defined objectives, were well designed and conducted appropriately to meet them. The published studies reported the use of BMAC in non-union and fracture healing (15 studies), bone defects (nine studies), spine fusion (two studies), distraction osteogensis (two studies) and complications related to the use of BMAC (seven studies).

CONCLUSIONS

Stem cells found in BMAC have the potential to self-renew, undertake clonal expansion and differentiate into different musculoskeletal tissues. The commercial processing of BMAC needs to be optimized in order to achieve a consistent end product, which will provide predicable and translatable results. The future potential of cell characterization in order to determine the optimum cell for repair/regeneration of bone also needs to be explored.

LEVEL OF EVIDENCE

Systematic Review of minimum level IV studies.

Double plating of intra-articular multifragmentary C3-type distal femoral fractures through the anterior approach

INTRODUCTION

In this prospective case series, we report a mean of 12-month follow-up of the utilization of a dual plating of distal femoral fractures. Our technique included a lateral distal femoral locked plate with a low-contact-locked medial plate and bone graft through an extended medial parapatellar anterior approach for the fixation of C3-type distal femoral fractures.

PATIENTS AND METHODS

Sixteen patients (11 males and 5 females) presented with supracondylar femoral fracture type C3, according to Müller long-bone classification system and its revision OA/OTA classification. These were treated using dual plating through extended anterior approach and bone grafting. Our outcomes included clinical and radiological outcomes. Secondary outcomes included postoperative complications.

RESULTS

The mean time of complete radiological union in the studied population was 6.0 ± 3.5 months with a range of 3-14 months. We have not observed postoperative varus or valgus deformity in our cohort. The majority (68.75%) of the studied patients showed significant improvement in range of motion (90°-120°) during follow-up. Eleven out of sixteen patients (68.75%) had well-to-excellent functional outcome. Poor outcome was reported in only two patients (12.50%).

CONCLUSIONS

Dual plating fixation using anterior approach for type C3 distal femoral fractures is an efficient method of management. It has several advantages such as precise exposure, easy manipulation, anatomical reduction and stable fixation. However, operative indications and instructions should be strictly followed. The surgical technique must be rigorous, and the biomechanical qualities of these implants must be understood to prevent the development of major complications.

The "Pull-Over" Technique for All Arthroscopic Rotator Cuff Repair With Extracellular Matrix Augmentation

Despite the vast improvement in techniques for arthroscopic rotator cuff surgery, repairs of massive and large tears remain an issue as they are associated with significantly high failure rates, particularly in the elderly population. As a result, there has been a focus of attention to improve rotator cuff repair healing rates. One of the strategies is augmentation of the repair with a patch. Arthroscopic augmentation is, however, technically demanding with challenges in introduction and stabilization of the patch. The purpose of this Technical Note is to describe a technique for arthroscopic rotator cuff repair with augmentation, which offers additional advantages over previous techniques because it facilitates the passage of the patch as well as providing a more robust medial stabilization of the augment and therefore possibly a stronger construct.

Nerve Transfer Versus Nerve Graft for Reconstruction of High Ulnar Nerve Injuries

PURPOSE

To assess the efficacy of nerve transfer versus nerve grafting in restoring motor and sensory hand function in patients with complete, isolated high ulnar nerve injuries.

METHODS

A retrospective chart review was performed, at a minimum 2 years of follow-up, of 52 patients suffering complete, isolated high ulnar nerve injury between January 2006 and June 2013 in one specialized hand surgery unit. Twenty-four patients underwent motor and sensory nerve transfers (NT group). Twenty-eight patients underwent sural nerve grafting (NG group). Motor recovery, return of sensibility and complications were examined as outcome measures. The Medical Research Council scale was applied to evaluate sensory and motor recovery. Grip and pinch strengths of the hand were measured.

RESULTS

Twenty of 24 patients (83.33%) in the NT group regained M3 grade or greater for the adductor pollicis, the abductor digiti minimi, and the medial 2 lumbricals and interossei, compared with only 16 of 28 patients (57.14%) in the NG group. Means for percentage recovery of grip strengths compared with the other healthy hand were significantly higher for the NT group than the NG group. Sensory recovery of S3 or greater was achieved in more than half of each group with no significant difference between groups.

CONCLUSIONS

Nerve transfer is favored over nerve grafting in managing high ulnar nerve injuries because of better improvement of motor power and better restoration of grip functions of the hand.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A systematic review of the concept and clinical applications of Bone Marrow Aspirate Concentrate in Orthopaedics

Introduction: Mesenchymal stem cells (MSC’s) are believed to have multipotent plasticity with the capability to differentiate along multiple cell lineages such as cartilage, bone, tendon, muscle, and nerve. Such multipotency has the potential to play an important role in the repair and reconstruction of multiple tissues across a number of orthopaedic specialties. Bone marrow and fat are the most abundant and accessible source of MSC’s with bone marrow aspirate the most commonly being reported to stimulate healing.

Methods: This review examines the current reported 20 Q2 clinical applications of bone marrow aspirate concentrate and its effectiveness.

Results: The published studies reported techniques of collection and preparation of BMAC in addition to its applications in a number of orthopaedic sub-specialities. Studies could be sub-categorised into: techniques of extraction, processing and microscopic examination of BMAC (31), reconstruction of osseous defects/non-union (20), treatment of avascular necrosis (9), repair of cartilage defects (8), treatment of sports injuries and tendon injury/repair (9), injection in regenerative therapy (4), treatment of spine conditions (4) including enhancing postoperative fusion and degenerative disc pathology and orthopaedic oncology (4). A few published studies combined the use of platelet-rich plasma (PRP) with BMAC (4) or compared them in different applications (5).

Conclusions: BMAC has been used in bone, cartilage and tendon injuries with encouraging results.

Inverted femoral head graft versus standard core decompression in nontraumatic hip osteonecrosis at minimum 3 years follow-up

PURPOSE

Numerous salvage surgeries were popularised to halt the progression of hip osteonecrosis (ON). We aimed to compare the clinico-radiological outcomes of inverted femoral head graft (IFHG) versus standard core decompression (SCD) in treatment of nontraumatic hip ON at pre-arthritic stage.

METHODS

A case review was performed at a minimum 3 years follow-up of 61 patients (71 hips; mean age 32.96 (19-50) years; mean follow-up 7.86 (3-14) years; mean body mass index 28.58 (19-46); 32 males, 29 females) suffering nontraumatic hip ON at pre-arthritic stage. 38 hips underwent SCD and 33 IFHG. The outcome was assessed by changes in modified Harris Hip Score (MHHS), need for revision surgery and progression of modified Ficat-Arlet staging. Data were analysed including logistic regression and Kaplan-Meier survivorship analysis.

RESULTS

13/34 (38.2%) hips in SCD group were revised at 4.61 ± 2.61 years, while 7/33 (21.2%) in IFHG group at 8.43 ± 4.32 years (p = 0.023). MHHS was significantly higher in IFHG group at 1 and 3 years as well as at last follow-up (p = 0.014, 0.001 and 0.023 respectively). Clinical and radiological significant differences were found in survivorship analysis between both groups, in favor of IFHG. A higher clinical failure was noted among obese patients.

CONCLUSIONS

An IFHG technique offers a better alternative regarding postoperative clinico-radiological outcomes in nontraumatic hip ON at the pre-arthritic stage. A cautious prognosis is recommended in obese patients.