Outcomes of a technique combining diaphyseal impaction grafting and metaphyseal cones for severe bone loss in revision total knee arthroplasty

Aims

Metaphyseal cones with cemented stems are frequently used in revision total knee arthroplasty (TKA). However, if the diaphysis has been previously violated, the resultant sclerotic canal can impair cemented stem fixation, which is vital for bone ingrowth into the cone, and long-term fixation. We report the outcomes of our solution to this problem, in which impaction grafting and a cemented stem in the diaphysis is combined with an uncemented metaphyseal cone, for revision TKA in patients with severely compromised bone.

Methods

A metaphyseal cone was combined with diaphyseal impaction grafting and cemented stems for 35 revision TKAs. There were two patients with follow-up of less than two years who were excluded, leaving 33 procedures in 32 patients in the study. The mean age of the patients at the time of revision TKA was 67 years (32 to 87); 20 (60%) were male. Patients had undergone a mean of four (1 to 13) previous knee arthroplasty procedures. The indications for revision were aseptic loosening (80%) and two-stage reimplantation for prosthetic joint infection (PJI; 20%). The mean follow-up was four years (2 to 11).

Results

Survival free from revision of the cone/impaction grafting construct due to aseptic loosening was 100% at five years. Survival free from any revision of the construct and free from any reoperation were 92% and 73% at five years, respectively. A total of six patients (six TKAs, 17%) required a further revision, four for infection or wound issues, and two for periprosthetic fracture. Radiologically, one unrevised TKA had evidence of loosening which was asymptomatic. In all unrevised TKAs the impacted diaphyseal bone graft appeared to be incorporated radiologically.

Conclusion

When presented with a sclerotic diaphysis and substantial metaphyseal bone loss, this technique combining diaphyseal impaction grafting with a metaphyseal cone provided near universal success in relation to implant fixation. Moreover, radiographs revealed incorporation of the bone graft and biological fixation of the cone. While long-term follow-up will be important, this technique provides an excellent option for the management of complex revision TKAs. Cite this article: Bone Joint J 2020;102-B(6 Supple A):116–122.

Hips With Acetabular Retroversion Can Be Safely Treated With Advanced Arthroscopic Techniques Without Anteverting Periacetabular Osteotomy: Midterm Outcomes With Propensity-Matched Control Group

BACKGROUND

Different options, from reverse (anteverting) periacetabular osteotomy to hip arthroscopy, have been proposed for surgical treatment of femoroacetabular impingement syndrome (FAIS) in the setting of acetabular retroversion.

PURPOSE

(1) To report and analyze midterm patient-reported outcome scores (PROs) in patients with FAIS and labral tears in the setting of acetabular retroversion after isolated hip arthroscopy and (2) to compare these PROs with those of a propensity-matched control group without acetabular retroversion.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Prospectively collected data were retrospectively reviewed for patients who underwent hip arthroscopy for FAIS and labral tear treatment between June 2008 and March 2014. Inclusion criteria were as follows: acetabular retroversion, pre- and postoperative PROs for modified Harris Hip Score (mHHS), Non-arthritic Hip Score, Hip Outcome Score-Sports Specific Scale (HOS-SSS), and visual analog scale (VAS). Propensity score matching was utilized to identify a control group without acetabular retroversion matched 1:1 with similar age, sex, body mass index, acetabular and femoral head Outerbridge grade, preoperative lateral center-edge angle, and labral treatment. Patient acceptable symptomatic state (PASS) and/or minimal clinically important difference (MCID) for the mHHS, HOS-SSS, International Hip Outcome Tool-12, and VAS was calculated.

RESULTS

A total of 205 hips with acetabular retroversion were matched to a control group. The groups showed no difference in demographic variables. The retroversion group was composed of 139 female and 66 male hips, with a mean ± SD age of 23.81 ± 7.28 years and follow-up time of 65.24 ± 20.31 months. Intraoperative diagnostic data and procedures performed were similar between groups, except more femoroplasties were performed in the retroversion group. Significant improvements for the mHHS, Non-arthritic Hip Score, HOS-SSS, and VAS were seen for both groups at a mean 5-year follow-up. The proportion of patients who reached the PASS and MCID were similar.

CONCLUSION

In the setting of FAIS and labral tears, patients with acetabular retroversion can be safely treated with advanced hip arthroscopic techniques without reverse (anteverting) periacetabular osteotomy in a high-volume surgeon's hands. Patients with acetabular retroversion demonstrated favorable PROs at midterm follow-up. Furthermore, the proportion of patients reaching the MCID and PASS for several PROs were comparable with those of a propensity-matched control group without acetabular retroversion.

Rotator cuff tear with joint stiffness: a review of current treatment and rehabilitation

Repair of the rotator cuff tear is a joint-tightening procedure that can worsen joint stiffness. This paradoxical phenomenon complicates treatment of rotator cuff tear with joint stiffness. As a result, there is controversy about how and when to treat joint stiffness. As many treatments have been published, this review discusses the latest findings on treatment of rotator cuff tear with joint stiffness.

Elbow Dislocation

This article is a brief overview of the elbow dislocations focusing on updates in treatment and rehabilitation protocols. The fight between obtaining elbow stability without leading to long-term elbow stiffness has been a continued focus in field of sports medicine. This article highlights advances made to help treat the injuries appropriately and obtain optimal patient outcomes.

No Learning Curve of the Direct Superior Approach in Total Hip Arthroplasty

OBJECTIVES

To assess the learning curve of the direct superior approach (DSA) for total hip arthroplasty (THA) and to compare surgical, clinical, and radiological results with a matched control group using the mini posterior approach (MPA).

METHODS

A prospective cohort study was performed from October 2016 to May 2017 including our first 52 patients undergoing THA using the DSA. Patients with primary osteoarthritis or osteonecrosis and a body mass index (BMI) < 35 who were eligible for surgery were included. As a control group, 52 patients who underwent the MPA were included, matched based on age, BMI, and ASA classification. In the DSA group, damage to the iliotibial tract and the distal external rotators, including the external obturator and quadriceps femoris muscles, was avoided. Outcome measures were collected, including surgical time, blood loss, postoperative pain, length of stay, implant position, use of walking aids, patient reported outcome measures (PROM), and complications. Unpaired t-tests were used to analyze differences between the DSA and the MPA group in surgical time, blood loss, length of stay, and acetabular and femoral component position. χ² -tests were used to analyze mobility and the number of complications. Two-way repeated measures ANOVA was used to analyze pain scores and PROM between the DSA and the MPA groups.

RESULTS

The mean surgical time of 61 min (SD 8) in the DSA group was longer (P < 0.001) compared to that in the MPA group, 46 min (SD 12). No differences were found in blood loss, postoperative pain, or mean length of stay in the hospital. After 6 weeks, 94% of the patients in the DSA group were able to walk inside their home without walking aids compared to 90% in the MPA group. The mobility scores were not different after follow up of 6 weeks and 1 year (P = 0.12 and P = 0.36 respectively). All PROM improved postoperatively in both the DSA and the MPA group (P < 0.01). Acetabular cup and femoral stem position were not compromised by the DSA. Complications included two Vancouver B2 periprosthetic fractures in the DSA group, of which there was one surgical-related fracture and one fracture after a traffic accident. Complications in the MPA group included one periprosthetic fracture, two hip dislocations, and one ischial neuropathy. No infections or thromboembolic events were observed. The 1-year complication rate was not different between the MPA and DSA groups (P = 0.40).

CONCLUSION

The DSA can be safely introduced as no learning curve in the prosthesis position or the complication rate was found.

Influence of coracoid anatomy on the location of glenoid rim defects in anterior shoulder instability: 3D CT-scan evaluation of 51 patients

PURPOSE

Glenoid bony lesions play a role in approximately half of anterior shoulder instability cases. The purpose of this study is to see if the anatomy of the coracoid affects the location of glenoid rim defects. We hypothesized that a prominent coracoid (lower and lateral) would be more likely to cause an anterior-inferior glenoid lesion, and a less prominent coracoid more prone to cause an anterior lesion. The null hypothesis being the absence of correlation.

METHODS

Fifty-one shoulder CT-scans from a prospective database, with 3D reconstruction, were analyzed. The position of glenoid lesions was identified using the validated clock method, identifying the beginning and end time. The size of bony glenoid defects was calculated using the validated glenoid ratio method. The position of the coracoid tip was measured in three orthogonal planes.

RESULTS

Analysis included 25 right shoulders and 26 left shoulders in seven females and 41 males. The vertical position of the coracoid tip relative to the top of the glenoid was highly correlated to the location of the glenoid defect on the profile view (r = -0.625; 95% CI 0.423-0.768; p = 0.001). Thus, higher coracoids were associated with anterior lesions, while lower coracoids were associated with anterior-inferior lesions. A more laterally prominent coracoid was also correlated with anterior-inferior lesions (r = 0.433; 95% CI 0.179-0.633; p = 0.002).

CONCLUSION

This study shows that coracoid anatomy affects the location of bony Bankart defects in anterior shoulder instability. Lower and laterally prominent coracoids are associated with anterior-inferior lesions. This variation in anatomy should be considered during pre-op planning for surgeries involving bone graft.

LEVEL OF EVIDENCE

Level 4 basic science.

Delayed union of a surgically treated fragility fracture of the pelvis: A case report

•

A case of delayed union of type IIIa fragility fracture of the pelvis.

•

Evaluating the progress of bone fusion may be difficult using front and side X-rays.

•

This may be because of the implant position and pelvis shape.

•

CT enables diagnosis of delayed union and non-union in type IIIa pelvis fracture.

INTRODUCTION

There are no universally accepted treatment strategies for fragility fractures of the pelvis (FFPs). The incidence of delayed union or non-union of Type IIIa FFP is still unknown.

PRESENTATION OF CASE

We describe a case of delayed union of a Type IIIa FFP. A 96-year-old female patient who lives independently accidentally fell when exiting a car. The diagnosis of Type IIIa FFP with displaced left ilium and left pubic rami fracture. Surgical repair was performed using an anterior intrapelvic approach with constructs made using two reconstruction contoured plates to bridge the medial edge and middle part of the fracture. This case was revealed delayed union. The periodic CT examinations were performed to determine the progress of bone union. The patient returned to most social activities including living independently and the Modified Majeed score was 94 at 12 months post-operation.

DISCUSSION

For the case of TypeⅢa FFP, soft tissue is spread over a wide area. When the fracture site of ilium was exposed, the cortical bone was found to be thin with poor blood flow. There is a possibility that the blood flow was hindered by subperiosteal elevation of the iliacus muscle from the internal iliac fossa in this case.

CONCLUSION

Non-union of the iliac wings is relatively rare following high-energy pelvic ring fractures. The incidence of delayed union or non-union of Type IIIa FFP remains unknown; therefore, careful follow-up of patients who undergo treatment is necessary to reduce the risk of delayed union.

Analysis of Patterns of Gait Deterioration in Patients with Lumbar Spinal Stenosis

OBJECTIVE

Quantitative gait analysis has been established as a valuable tool for functional assessment and evaluation of intervention efficacy in lumbar spinal stenosis (LSS). We aimed to bolster the limited evidence on the specific aspects of gait that are altered in LSS.

METHODS

Fifteen patients with LSS and 15 healthy subjects performed a 30-m-long walk. Gait was assessed by video recording. Four spatiotemporal parameters were compared between groups: cadence, gait velocity, step length, and step duration.

RESULTS

Compared with healthy subjects, gait of patients with LSS demonstrated significant differences for all spatiotemporal parameters. Differences in mean cadence, step length, gait velocity, and step duration were -14%, -24%, -37%, and +16% between patients with LSS and healthy subjects.

CONCLUSIONS

This study demonstrated significant alterations in clinically measurable gait parameters in patients with LSS compared with healthy subjects. Future studies should assess the value of these gait parameters for objective clinical assessment of functional status and intervention efficacy through correlation with currently used subjective tools and comparison at preoperative and postoperative time points. Specific gait alterations identified in patients with LSS may be valuable for clinical objective assessment of functional status and intervention efficacy.

Ten-Year Surgical Outcomes and Prognostic Factors for French-Door Laminoplasty in the Treatment of Multilevel Cervical Spondylotic Myelopathy

Objective

To analyze the ten-year surgical outcomes and postoperative complications of French-Door laminoplasty (FDL) in the management of multilevel cervical spondylotic myelopathy (MCSM) and analyze the prognostic factors for FDL in treating MCSM.

Methods

64 patients with MCSM, who were operated by FDL, were included in this study and followed up for at least 10 years. Clinical assessments including modified Japanese Orthopaedic Association (mJOA) score, age at surgery, preoperative symptom duration, operative time, blood loss and postoperative complications, radiological assessments including Cobb angle, cervical range of motion (ROM), intramedullary signal intensity on T2W MRI, canal narrowing ratio (CNR), and maximum spinal cord compression (MSCC). mJOA score, Cobb angle, cervical ROM, intramedullary signal intensity on T2W MRI, and CNR were assessed before surgery and at the final follow-up.

Results

The average mJOA score was significantly improved from preoperative 10.32 ± 1.63 points to 15.10 ± 0.62 points at the final follow-up (p < 0.05). The average RR of the mJOA score at the final follow-up was 69.10 ± 7.32%. The cervical Cobb angle and ROM decreased significantly at the final follow-up. Patients with high intramedullary signal intensity of T2W MRI or CNR more than 50% showed a lower RR of the mJOA score. Correlation analysis revealed that preoperative symptom duration and intramedullary signal intensity of T2W MRI, CNR, MSCC, and blood loss were significantly correlated with the RR of the mJOA score. Gender, operative method, and age at surgery were significantly correlated with the preservation rate of ROM. Operative time was significantly correlated with the incidence of axial symptoms.

Conclusions

The ten-year clinical outcomes of FDL were satisfactory. Higher intramedullary signal intensity of T2W MRI and a greater CNR predicted poorer prognoses.

Predictors of Perioperative Vancouver B Periprosthetic Femoral Fractures Associated With the Direct Anterior Approach to Total Hip Arthroplasty

BACKGROUND

There is an association between intraoperative and postoperative femoral fractures and the direct anterior approach (DAA) to total hip arthroplasty (THA). The purpose of our study is to identify risk factors for Vancouver B fractures and to establish a predictable timeline for when these occur.

METHODS

We retrospectively identified patients with Vancouver B periprosthetic femoral fractures (n = 49) after 11,509 elective primary cementless THA procedures through the DAA between 2012 and 2018 at a single institution. Fracture patients were matched to nonfracture patients (n = 267) by date of surgery and surgeon. Clinical and radiographic factors were collected for multivariable analysis to identify predictors of fracture.

RESULTS

Periprosthetic Vancouver B femoral fracture incidence was 0.4%. 48 (98%) fractures were postoperative. Fractures occurred at an average of 44 days after surgery (range: 1 to 653 days) with >85% of fractures occurring in the first 6 weeks postoperatively. Significant variables predictive of fracture included >3 degrees valgus and >5 degrees varus coronal stem malalignment, Dorr B and C femoral geometry, lower canal flare index (2.75 vs 3.20), advanced age, increased comorbidities, greater stem canal fill, and right-sided procedures.

CONCLUSION

Despite an overall low rate of Vancouver B perioperative periprosthetic femoral fractures, it is a devastating complication that typically presents within the first 6 weeks after DAA THA surgery. The risk is increased in patients with unfavorable proximal femoral geometry, coronal stem malalignment, advanced age, increased comorbidities, and right-sided procedures.

Combined ACL and Anterolateral Reconstruction Is Not Associated With a Higher Risk of Adverse Outcomes: Preliminary Results From the SANTI Randomized Controlled Trial

Background

The widespread historical abandonment of lateral extra-articular procedures in anterior cruciate ligament (ACL) injuries occurred as a result of concerns about high rates of adverse events. Recently, the popularity of lateral extra-articular procedures has resurged, warranting an urgent evaluation of their safety profile.

Purpose/Hypothesis

The aim of this study was to perform an interim analysis of the ongoing SANTI randomized controlled trial to determine whether combined ACL and anterolateral ligament reconstruction (ACL + ALLR) is associated with an increased rate of adverse outcomes when compared with isolated ACL reconstruction (ACLR). The hypothesis was that there would be no significant difference between groups at a minimum follow-up of 1 year.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Recruitment commenced in November 2016. Patients scheduled for ACLR were randomized to either isolated ACLR (with bone-patellar tendon-bone [BPTB] autograft) or combined ACL + ALLR (with hamstring tendon autograft). All patients with a minimum follow-up of 1 year by March 2019 were included. The evaluated parameters included complications and reoperations, knee laxity parameters, range of motion, and scores on the Tegner, Lysholm, International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) instruments.

Results

A total of 224 patients (112 in each group) with a mean ± SD follow-up of 12.3 ± 1.9 months (range, 12-19 months) formed the study population. A significantly higher rate of reoperation for cyclops syndrome was noted in the isolated ACLR group compared with the combined ACL + ALLR group (8.9% vs 0%, respectively; P = .0012). No significant differences were found in frequency of graft rupture (ACLR, 5.4%; ACL + ALLR, 0.9%; P = .1191), range of motion deficits, pain, or reoperation for meniscectomy between groups. No cases of postoperative infection, venous thromboembolism, or arthrofibrosis were seen. Subjective IKDC (81.2 vs 86.8; P = .0048), Lysholm (88 vs 92; P = .0131), and some components of the KOOS were significantly better in the combined ACL + ALLR group.

Conclusion

This study demonstrates no evidence of an increased risk of short-term adverse events after combined ACL + ALLR compared with isolated ACLR with BPTB graft.

Registration

NCT03740022 (ClinicalTrials.gov Identifier).

Patient function continues to improve over the first five years following tibial plateau fracture managed by open reduction and internal fixation

Aims

Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients’ long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques.

Methods

In total, 102 patients who sustained a displaced tibial plateau fracture and underwent operative repair by one of three orthopaedic traumatologists at a large, academic medical centre and had a minimum of five-year follow-up were identified. Breakdown of patients by Schatzker classification is as follows: two (1.9%) Schatzker I, 54 (50.9%) Schatzker II, two (1.9%) Schatzker III, 13 (12.3%) Schatzker IV, nine (8.5%) Schatzker V, and 26 (24.5%) Schatzker VI. Follow-up data obtained included: Visual Analogue Scale (VAS) or Numeric Rating Scale (NRS) pain scores, Short Musculoskeletal Functional Assessment (SMFA), and knee range of movement (ROM). Data at latest follow-up were then compared to 12-month data using a paired t-test.

Results

Patient-reported functional outcomes as assessed by overall SMFA were statistically significantly improved at five years (p < 0.001) compared with one-year data from the same patients. Patients additionally reported an improvement in the Standardized Mobility Index (p < 0.001), Standardized Emotional Index (p < 0.001), as well as improvement in Standardized Bothersome Index (p = 0.003) between the first year and latest follow-up. Patient-reported pain and knee ROM were similar at five years to their one-year follow-up. In total, 15 of the patients had undergone subsequent orthopaedic surgery for their knees at the time of most recent follow-up. Of note, only one patient had undergone knee arthroplasty following plateau fixation related to post-traumatic osteoarthritis (OA).

Conclusion

Knee pain following tibial plateau fracture stabilizes at one year. However, PROs continue to improve beyond one year following tibial plateau fracture, at least in a statistical sense, if not also clinically. Patients displayed statistical improvement across nearly all SMFA index scores at their minimum five-year follow-up compared with their one-year follow-up. Cite this article: Bone Joint J 2020;102-B(5):632–637.

Surgeon-Performed High-Dose Bupivacaine Periarticular Injection With Intra-Articular Saphenous Nerve Block Is Not Inferior to Adductor Canal Block in Total Knee Arthroplasty

BACKGROUND

Periarticular injection or anesthesiologist-performed adductor canal block are commonly used for pain management after total knee arthroplasty. A surgeon-performed, intra-articular saphenous nerve block has been recently described. There is insufficient data comparing the efficacy and safety of these methods.

METHODS

This is a retrospective two-surgeon cohort study comparing short-term perioperative outcomes after primary total knee arthroplasty, in 50 consecutive patients with surgeon-performed high-dose periarticular injection and intra-articular saphenous nerve block (60 mL 0.5% bupivacaine, 30 mL saline, 30mg ketorolac) and 50 consecutive patients with anesthesiologist-performed adductor canal catheter (0.25% bupivacaine 6 mL/h infusion pump placed postoperatively with ultrasound guidance). Chart review assessed pain scores through POD #1, opioid use, length of stay, and short-term complications, including local anesthetic systemic toxicity. Statistical analysis was performed with two-tailed Student's T-test.

RESULTS

The high-dose periarticular injection cohort had significantly lower pain scores in the postanesthesia care unit (mean difference 1.4, P = .035), on arrival to the inpatient ward (mean difference 1.7, P = .013), and required less IV narcotics on the day of surgery (mean difference 6.5 MME, P = .0004). There was no significant difference in pain scores on POD #1, total opioid use, day of discharge, or short-term complications. There were no adverse events related to the high dose of bupivacaine.

CONCLUSION

Compared with postoperative adductor canal block catheter, an intraoperative high-dose periarticular block demonstrated lower pain scores and less IV narcotic use on the day of surgery. No difference was noted in pain scores on POD #1, time to discharge, or complications. There were no cardiovascular complications (local anesthetic systemic toxicity) despite the high dose of bupivacaine injected.

LEVEL OF EVIDENCE

III.

Ulnar shortening osteotomy as a treatment of symptomatic ulnar impaction syndrome after malunited distal radius fractures

A malunited distal radius fracture can lead to symptomatic ulnar impaction syndrome, which is a common cause for ulnar-sided wrist pain. If conservative treatment fails and symptoms persist after an arthroscopic ulnocarpal debridement, ulnar shortening osteotomy (USO) is the treatment of choice. Since the first USO described by Milch in 1941 after a malunited Colles fracture, many techniques have been described varying in surgical approach, type of osteotomy and osteosynthesis material used. Many studies demonstrated good to very good functional results after USO, reporting, however, a delayed union or non-union rate up to 18%. A modern, low profile, locking plate showed in our short-term study very good functional results and no implant-associated complications, in particular no non-union.

Treatment of segmental tibial defects by bone transport with circular external fixation and a locking plate

Objective

To evaluate the effectiveness of bone transport involving circular external fixation and locking plate application for the treatment of segmental tibial defects.

Methods

A retrospective review of 12 patients with segmental tibial defects who underwent bone transport with circular external fixation and locking plate application. We evaluated external fixation time, external fixation index, time to achieve union, and complications. Clinical results were assessed using the Association for the Study and Application of the Methods of Ilizarov (ASAMI) score. Generic health-related outcome was assessed using the 36-Item Short-Form Health Survey questionnaire (SF-36).

Results

The mean follow-up was 25.8 months, and the mean defect size was 6.7 cm. All of the patients achieved union at the distraction callus and docking site. The average external fixation time was 299.5 days. The mean external fixation index was 16.5 days/cm, and the mean healing index was 44.9 days/cm. The functional outcomes were excellent in eight cases and good in four. The average SF-36 score was 92.

Conclusion

Bone transport with external fixation and locking plate application may be a promising method for the treatment of segmental tibial defects.

Augmenting posterolateral fusion with transforaminal lumbar interbody fusion cage improves clinical outcome, but not fusion rate, of posterior decompression

Objective

This study was performed to compare fusion rates and clinical outcomes of posterior decompression by posterolateral fusion (PLF) versus transforaminal lumbar interbody fusion (TLIF) for treatment of lumbar spinal stenosis.

Methods

This retrospective cohort study involved 157 patients with lumbar spinal stenosis treated with instrumented PLF alone or instrumented PLF combined with TLIF from 2010 to 2018. The patients were divided into two groups: the PLF group (Group A), in which posterior decompression with instrumented PLF was performed, and the cage-augmented group (Group B), in which TLIF was added to the procedures described for the PLF group. Patient outcomes (Oswestry Disability Index, visual analog scale score, and 36-Item Short-Form Health Survey scores) and fusion rates were compared.

Results

The fusion rate was similar between the two groups. Among patients with two- and three-level fusion, improvements in the clinical outcome scores were significantly greater in Group B than Group A.

Conclusion

Combining TLIF with PLF provides better clinical outcomes than PLF alone when multilevel fusion is indicated. TLIF augmentation does not improve the fusion rates in either single- or multi-level surgery.

Mechanism of posterior malleolar fracture of the ankle: A cadaveric study

Objectives:

Ankle fracture treatment involves reduction of the bone fragments and stabilization of the joint by reversing the mechanics of injury. For posterior malleolar fracture however, the true mechanism is not understood, leading to a lack of consistent guidance on how to best treat this injury.

Methods:

Fifteen cadaver ankles were subjected to fracture loading that replicated the Lauge-Hansen pronation-external rotation mechanism. An axial load was applied to each specimen, which was mounted on a materials testing machine, and the foot was rotated externally to failure. Digital video cameras recorded the failure sequence of specific anatomic structures.

Results:

Posterior malleolar fracture occurred in 7 specimens. Of these, 1 was an intra-articular fracture, another was a fracture involving the entire posterior tibial margin consisting of 2 fragments: that of the posterior tubercle and that of the posteromedial margin of the tibial plafond, with the former judged to be a consequence of avulsion by the posterior inferior tibiofibular ligament and the latter a consequence of axial loading from the talus. In the remaining 5 specimens, the posterior malleolar fracture was a small extra-articular avulsion fracture.

Conclusions:

Fractures at the posterolateral corner of the distal tibia were shown to be avulsion fractures attributed to the posterior inferior tibiofibular ligament and produced by external rotation of the talus. A fracture involving the entire posterior tibial margin consisting of 2 fragments can be produced by a combination of avulsion by the posterior inferior tibiofibular ligament and axial loading from the talus.

Digitalization of the IOM: A comprehensive cadaveric study for obtaining three-dimensional models and morphological properties of the forearm's interosseous membrane

State-of-the-art of preoperative planning for forearm orthopaedic surgeries is currently limited to simple bone procedures. The increasing interest of clinicians for more comprehensive analysis of complex pathologies often requires dynamic models, able to include the soft tissue influence into the preoperative process. Previous studies have shown that the interosseous membrane (IOM) influences forearm motion and stability, but due to the lack of morphological and biomechanical data, existing simulation models of the IOM are either too simple or clinically unreliable. This work aims to address this problematic by generating 3D morphological and tensile properties of the individual IOM structures. First, micro- and standard-CT acquisitions were performed on five fresh-frozen annotated cadaveric forearms for the generation of 3D models of the radius, ulna and each of the individual ligaments of the IOM. Afterwards, novel 3D methods were developed for the measurement of common morphological features, which were validated against established optical ex-vivo measurements. Finally, we investigated the individual tensile properties of each IOM ligament. The generated 3D morphological features can provide the basis for the future development of functional planning simulation of the forearm.

Dynamic compression locking system versus multiple cannulated compression screw for the treatment of femoral neck fractures: a comparative study

BACKGROUND

Femoral neck fractures are one of the problems in clinical treatment. The prognosis is uncertain. Currently, No internal fixation method is superior to other internal fixation methods in the treatment of femoral neck fractures. Therefore, the internal fixation system needs to be further explored. The aim of this study was to compare clinical outcomes of femoral neck dynamic compression locking system (DCLS) and multiple cannulated compression screws(MCCS) in the treatment of femoral neck fractures.

METHODS

A prospective analysis of 54 cases of femoral neck fractures treated with either a DCLS (n = 28) or MCCS (n = 26) was conducted between December 2015 and November 2017 in authors' hospitals. The perioperative and postoperative parameters of the two groups were recorded and evaluated.

RESULTS

Fifty-four patients were followed up for 24-47 months. The etiology was caused by a fall. There was no significant difference in follow-up time, operation time, incision length, surgical blood loss, the incidence of perioperative and postoperative healing complications, and mobility in the two groups (all P > 0.05). The Harris score, fracture healing time, femoral neck shortening, partial weight-bearing time and complete weight-bearing time were significantly better in the DCLS group than in the MCCS group (all P < 0.05). The fracture healing rate in the DCLS group was higher than that in the MCCS group.

CONCLUSIONS

The DCLS and MCCS might be equally effective in terms of operation time, incision length, surgical blood loss, the incidence of perioperative and postoperative healing complications, and mobility in the treatment of femoral neck fractures. However, the DCLS is superior to the MCCS in Harris score, fracture healing time, femoral neck shortening, weight-bearing time and fracture healing rate. So, DCLS deserves further study.

Patellofemoral arthroplasty is cheaper and more effective in the short term than total knee arthroplasty for isolated patellofemoral osteoarthritis: cost-effectiveness analysis based on a randomized trial

AIMS

The aim is to assess the cost-effectiveness of patellofemoral arthroplasty (PFA) in comparison with total knee arthroplasty (TKA) for the treatment of isolated patellofemoral osteoarthritis (OA) based on prospectively collected data on health outcomes and resource use from a blinded, randomized, clinical trial.

METHODS

A total of 100 patients with isolated patellofemoral osteoarthritis were randomized to receive either PFA or TKA by experienced knee surgeons trained in using both implants. Patients completed patient-reported outcomes including EuroQol five-dimension questionnaire (EQ-5D) and 6-Item Short-Form Health Survey questionnaire (SF-6D) before the procedure. The scores were completed again after six weeks, three, six, and nine months, and again after one- and two-year post-surgery and yearly henceforth. Time-weighted outcome measures were constructed. Cost data were obtained from clinical registrations and patient-reported questionnaires. Incremental gain in health outcomes (quality-adjusted life-years (QALYs)) and incremental costs were compared for the two groups of patients. Net monetary benefit was calculated assuming a threshold value of €10,000, €35,000, and €50,000 per QALY and used to test the statistical uncertainty and central assumptions about outcomes and costs.

RESULTS

The PFA group had an incremental 12 month EQ-5D gain of 0.056 (95% confidence interval (CI) 0.01 to 0.10) and an incremental 12 month cost of minus €328 (95% CI 836 to 180). PFA therefore dominates TKA by providing better and cheaper outcomes than TKA. The net monetary benefit of PFA was €887 (95% CI 324 to 1450) with the €10,000 threshold, and it was consistently positive when different measures of outcomes and different cost assumptions were used.

CONCLUSION

This study provides robust evidence that PFA from a one-year hospital management perspective is cheaper and provides better outcomes than TKA when applied to patients with isolated patellofemoral osteoarthritis and performed by experienced knee surgeons. Cite this article: Bone Joint J 2020;102-B(4):449-457.

Complications of surgical approaches for osteosynthesis treatment of acetabular fractures: Analysis of pitfalls and how to avoid them

BACKGROUND

Fractures of the acetabulum are rare injuries. The indication for surgical stabilization depends on the grade of instability and dislocation. Exact knowledge of the different possible surgical approaches is essential for the planning of the surgical treatment. Both, knowledge of anatomical structures and possible risks of the different approaches, are important.

METHODS

Over a period of 15 years, we analyzed all patients with acetabular fractures, treated in our Level I Trauma Center with special interest in surgical and approach-related complications. Based on our complication rates, we describe the used different surgical approaches and the accessible anatomical structures respectively. Finally, we focus on strategies to reduce the risk of approach-related complications in acetabular surgery.

RESULTS

Between January 2003 and December 2017, 523 patients with an acetabular fracture were treated in our Tertiary Referral Hospital. Of these, 101 patients had at least one complication, resulting in an overall complication rate of 19.3%. 296 patients underwent surgical treatment of the acetabular fracture, while 227 patients were treated non-operatively. Surgically treated patients had a significantly higher complication rate of 21.2% (63/296) compared to conservatively treated patients with a complication rate of 16.7% (38/227). Neurovascular and thromboembolic adverse events were the most often complications.

CONCLUSIONS

Patients with acetabular fractures are at a high risk for different kind of complications. The most common risks are neuro-vascular and thromboembolic incidents. The risk of getting a complication is increased in surgically treated patients, therefore both the indication for surgical treatment and the surgical approach should be carried out carefully, including individual patient parameters and fracture types as well as the surgeons expertise.

Fibrous Dysplasia/McCune-Albright Syndrome: A Rare, Mosaic Disease of Gα s Activation

Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) is a rare disorder of striking complexity. It arises from somatic, gain-of-function mutations in GNAS, leading to mosaic Gα s activation and inappropriate production of intracellular cyclic adenosine monophosphate (cAMP). The clinical phenotype is largely determined by the location and extent of affected tissues, and the pathophysiological effects of Gα s activation within these tissues. In bone, Gα s activation results in impaired differentiation of skeletal stem cells, leading to discrete skeletal lesions prone to fracture, deformity, and pain. Extraskeletal manifestations include a variable combination of hyperpigmented macules and hyperfunctioning endocrinopathies. Distinctive age-related changes in disease development has key effects on histologic, radiographic, and clinical features. FD/MAS thus presents along a uniquely broad clinical spectrum, and the resulting challenges in diagnosis and management can be difficult for clinicians. This review presents FD/MAS in the context of a mosaic disorder of Gα s activation, providing an intellectual framework within which to understand, evaluate, and treat this interesting disease. It includes a comprehensive summary of current understanding of FD/MAS pathogenesis, and a detailed discussion of clinical presentation and management. Critical areas of unmet need are highlighted, including discussion of key challenges and potential solutions to advance research and clinical care in FD/MAS.

Clinical application of individualized 3D-printed navigation template to children with cubitus varus deformity

Background

Cubitus varus deformity is a common sequela of elbow fractures in children. Cubitus varus deformity treatment is tending toward 3D correction, which is challenging for orthopedic surgeons. This study aims to explore whether individualized 3D-printed navigation templates can assist with accurate and effective corrective treatment of children with cubitus varus deformity.

Methods

Thirty-five patients were treated for cubitus varus deformity from June 2015 to April 2017, including 21 boys and 14 girls, aged 4.6–13.2 years (average, 7.5 years). Of these cases, 17 deformities were on the left side and 18 were on the right side. All were treated with wedge osteotomy of the lateral distal humerus. 3D-printed navigation templates were used in 16 cases, while traditional surgery was used in 19 cases. All patients underwent computed tomography scans before surgery. Computer software was used to analyze the measurements and design and print individualized navigation templates. The navigation templates were matched, and surgery was initially simulated. Intraoperative individualized navigation templates were used to assist with accurate osteotomy and Kirschner wire fixation. Operation times were recorded in all cases, the carrying angles before and after surgery were assessed by computer, and postoperative elbow joint function was evaluated using Bellemore criteria. All measurement data were presented as means ± SD, and Student’s t test was used to examine differences between groups. All count data between both groups were compared using the chi-square test or Fisher’s exact test analysis.

Results

All individualized navigation templates matched well with the corresponding anatomical markers and were consistent with preoperative planning, simulated surgery, and intraoperative procedures. Average operation times from clear exposure to fixed Kirschner wire were 11.69 min (9.6–13.5 min) for the individualized navigation template group and 22.89 min (17.7–26.8 min) for the traditional operation group (p < 0.001). Average differences in postoperation carrying angles between affected and healthy sides were 1.13° (0–2.0°) and 4.21° (0–7.5°), respectively (p < 0.001). Follow-up 6–12 months postoperation showed that elbow function did not differ significantly between groups using the Bellemore criteria (p > 0.05).

Conclusions

Individualized navigation templates simplify procedures, reduce operation time, and improve accuracy when used in orthopedic surgery to treat children with cubitus varus deformity.

Single Ilioinguinal Approach to Treat Complex Acetabular Fractures with Quadrilateral Plate Involvement: Outcomes Using a Novel Dynamic Anterior Plate-Screw System

Objectives

To evaluate the efficacy and safety of a novel fixation technique referred to as the dynamic anterior plate–screw system for quadrilateral plate (DAPSQ) for complex acetabular fractures with quadrilateral plate involvement through the single ilioinguinal approach.

Methods

A total of 32 patients with acetabular fractures, selected between January 2009 and March 2016, were managed by DAPSQ with “quadrilateral screws” through single ilioinguinal approach. The primary outcomes measure was the reduction quality evaluated according to the Matta radiological criteria, and the functional outcomes were evaluated by the modified Merle d'Aubigné score at the last follow‐up. Secondary outcomes were postoperative complications and intraoperative conditions included, for instance, operation time and blood loss.

Results

Of these 32 consecutive patients, 19, 9, and 4 were classified as both columns, anterior column posterior hemi‐transverse, and T‐shaped fractures, respectively, and with an average of 47 months’ follow‐up. Anatomic reduction was obtained in 19 cases (59%), imperfect reduction in 9 cases (28%), and poor reduction in 4 cases (13%). The modified Merle d'Aubigné scores were excellent in 15 cases (47%), good in 13 cases (41%), fair in 2 cases (6%), and poor in 2 cases (6%). Three cases sustained temporary lateral femoral cutaneous nerve injuries. One patient had a superficial wound infection that resolved after debridement. Five patients had posttraumatic arthritis; one of them underwent total hip arthroplasty at 46 months. No cases had quadrilateral screws entering the hip joint.

Conclusion

The use of DAPSQ with quadrilateral screws is an effective and safe choice for complex acetabular fractures with quadrilateral plate involvement through the single ilioinguinal approach.

Functional outcomes, union rate, and complications of the Anser Clavicle Pin at 1 year: a novel intramedullary device in managing midshaft clavicle fractures

Background

Surgical management of displaced midshaft clavicle fractures in adults leads to better union rates, improved early functional outcomes, and increased patient satisfaction compared with nonoperative treatment. However, both intramedullary fixation and plate osteosynthesis are subject to a specific array of disadvantages and complications. The Anser Clavicle Pin is a novel intramedullary device designed to address these disadvantages and complications. The aim of this study was to evaluate the union rate, functional outcomes, and complications of the Anser Clavicle Pin at 1-year follow-up.

Methods

A prospective explorative case series including 20 patients with displaced midshaft clavicle fractures was performed in 2 hospitals. The primary outcomes were union rate, functional outcomes (Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score), and complications. The secondary outcomes were closed reduction rate, operative time, image-intensifier time, hospital stay, incision length, time to radiologic union, postoperative pain reduction, reoperation rate, health-related quality-of-life score, and patient satisfaction.

Results

There was a 100% union rate. The Constant-Murley score at 1 year was 96.7 (standard deviation [SD], 5). The Disabilities of the Arm, Shoulder and Hand score was 5.1 (SD, 10). There were no infections, neuropathy of the supraclavicular nerve, or hardware irritation requiring removal of hardware. Three device-related complications (15%) occurred, including plastic deformation, protrusion, and hardware failure. The satisfaction score was 8.9 (SD, 1) on the visual analog scale at the 1-year follow-up.

Conclusion

Managing displaced midshaft clavicle fractures with the Anser Clavicle Pin results in a 100% union rate and excellent functional outcomes and patient satisfaction. It has a low non-device-related complication rate, and the device-related complications that occurred in this series may be prevented in the future.

Acute Scaphoid Waist Fracture in the Athlete

Scaphoid fractures are the most common carpal fracture and the most challenging. Although appropriately managing acute scaphoid waist fractures is a priority, it also is of primary importance to make a diagnosis acutely. Scaphoid waist fractures can occur with low-energy trauma and lead to mild symptoms. A tendency to minimize symptoms and low level of initial disability lead to delay in diagnosis. Displaced scaphoid fractures require operative intervention uniformly. Although nondisplaced fractures can heal with nonoperative treatment, management of these injuries is affected by patient demands. In high-level athletes, operative treatment of nondisplaced injuries may lead to earlier return to sport.

Supplementing decompression with instrumented fusion for symptomatic lumbar spinal stenosis-a critical appraisal of available randomized controlled trials

Lumbar spinal stenosis (LSS) is one of the most common indications for surgery in the USA. The addition of instrumented fusion to decompression for the treatment of LSS has become common, but recent randomized controlled trials (RCTs) have produced percieved conflicting results with unclear clinical implications. This review seeks clarity through an analysis of available RCTs. We performed a search of the PubMed database for RCTs that directly addressed decompression vs. decompression and fusion for the surgical treatment of LSS. RCTs were screened and reviewed to compare content such as patient selection, pathology, radiographic criteria, and operative technique. Five RCTs resulted from our search and were included in our analysis. Two studies yielded class I data while three yielded class III data due to study design related issues. Heterogeneity between these studies is emphasized with regard to patient selection, LSS definition, spondylolisthesis, instability, and surgical technique. Efforts to decipher which patients will truly benefit from instrumented fusion for the surgical treatment of LSS are still ongoing. Surgeon judgment will remain a crucial component for surgical decision making until future trials provide clarity. Instrumented fusion should be tailored to the individual patient rather than incorporated as a routine practice.

Arthroscopic Anatomical Repair of Anterior Talofibular Ligament for Chronic Lateral Instability of the Ankle: Medium- and Long-Term Functional Follow-Up

Objective

To evaluate the functional outcomes of arthroscopic anatomical repair of anterior talofibular ligament (ATFL) in the treatment of chronic lateral ankle instability (CLAI) during medium‐ and long‐term follow‐up.

Methods

From September 2014 to August 2017, the data of 37 patients (23 males, 14 females; 12 left ankles, 25 right ankles) aged between 21 and 56 years, with an average age of 32.17 ± 6.35 years, presenting with CLAI, was retrospectively analyzed. Among them, 32 injuries were caused by sprain and five injuries were caused by car accidents. The course of the disease lasted for 12 to 60 months, with an average of 26.07 ± 13.29 months. All patients had intact skin around the ankle and no skin lesions. All patients underwent arthroscopic anatomical repair of ATFL, with the fixation of one to two anchors. Pre‐ and post‐operative visual analogue scales (VAS), the American Orthopaedic Foot and Ankle Society Ankle‐Hindfoot Score (AOFAS), and the Karlsson Ankle Functional Score (KAFS) were compared to evaluate the curative effect of the operation.

Results

The operation was successful in all 37 cases. The operation time ranged from 40 to 75 min, with an average of 51.25 ± 11.49 min. After surgery, all incisions healed in stage I and there were no complications such as nerve, blood vessel and tendon injury, implant rejection, or suture rejection. Hospital stays of postoperative patients were 3 to 5 days, with an average of 3.77 ± 1.36 days. All patients were followed for 24 to 45 months, averaging 33.16 ± 10.58 months. For three patients with CLAI combined with mild limitation of subjective ankle movement, joint activity was normal after rehabilitation function exercise and proprioceptive function training for 2 months. At the final follow‐up, ankle pain had disappeared completely. The ankle varus stress test and ankle anterior drawer test were both negative. Range of joint motion was good. There was no lateral instability of the ankle and all patients returned to normal gait. The mean VAS score decreased to 1.12 ± 0.13, the AOFAS score increased to 92.53 ± 4.87, and the KAFS score increased to 93.36 ± 6.15. All the follow‐up indexes were significantly different from those before surgery.

Conclusion

Arthroscopic anatomical repair of ATFL for CLAI is precise, with less surgical trauma and reliable medium‐ and long‐term effect.

Approach to the Perpendicular Fixation of a Scaphoid Waist Fracture-A Computer Analyzed Cadaver Model

PURPOSE

In scaphoid fracture screw fixation, the screw is commonly placed along the long axis of the bone, without consideration of the fracture plane. This position is not perpendicular to transverse waist fractures or to the more common horizontal oblique fractures. Our aim was to examine the feasibility and describe possible approaches to, placing a screw perpendicular and in the center of the scaphoid waist fracture.

METHODS

Computed tomography of 12 cadaver wrists was performed in 3 positions to examine possible approaches in flexion, neutral, and extension of the wrist. The scans were evaluated using a 3-dimensional model that simulated horizontal oblique (60°) and transverse (90°) fractures. We examined all possible approaches for screw positioning and their deviation from the axis perpendicular to the fracture and in the center of its plane.

RESULTS

The preferred approaches for a perpendicular screw in a horizontal oblique fracture were found to be proximal-dorsal in flexion or transtrapezial in the extended or neutral positions (through the volar-radial trapezium). In transverse fractures, the possible approaches were proximal-dorsal or transtrapezial in the flexed or neutral positions and distal in the extended position (volar to volar-radial trapezium). In these approaches, the screw could be placed perpendicularly (deviating by < 10°) and in the center of the fracture in all specimens.

CONCLUSIONS

According to this model, it appears feasible to place a perpendicular screw in the center of a horizontal oblique waist fracture using a proximal-dorsal approach in flexion or a transtrapezial approach in neutral or extension positions of the wrist. Palpable landmarks may be used as additional guides to direct these approaches according to the clinical setting.

CLINICAL RELEVANCE

Perpendicular screw fixation of horizontal oblique or transverse scaphoid waist fractures is a possible option, if chosen for its biomechanical advantages.

Comparison of three different methods of anterior tibial tendon transfer for relapsed clubfoot: A pilot study

INTRODUCTION

The commonly techniques for anterior tibial tendon transfer (ATTT) for clubfoot are split transfers (Hoffer), whole transfers to cuboid (Garceau) or 3rd cuneiform (Ponseti). We compared these surgical ATTT methods for relapsed clubfoot.

MATERIAL AND METHODS

Thirty relapsed clubfoot (46 feet) patients initially treated with Ponseti casting technique were prospectively randomized for ATTT techniques. The outcome was evaluated in terms of foot inversion, eversion and ankle dorsiflexion.

RESULTS

Average follow up was 5.49 months. Whole transfers had better absolute ankle dorsiflexion than split transfers. Foot inversion was comparable in Hoffer and Ponseti transfers but better with Garceau transfers. For eversion, best values occurred with Ponseti transfers. Absolute values of ankle dorsiflexion, foot inversion and eversion obtained with spilt transfers were less than those obtained with whole transfers (statistically insignificant).

CONCLUSIONS

No significant differences for foot or ankle function could be detected in this study using the various surgical ATTT techniques in short term follow up.

An Intact Ligamentum Teres Predicts a Superior Prognosis in Patients With Borderline Dysplasia: A Matched-Pair Controlled Study With Minimum 5-Year Outcomes After Hip Arthroscopic Surgery

BACKGROUND

Hip arthroscopic surgery in patients with borderline dysplasia continues to be controversial. In addition, it has been suggested that ligamentum teres (LT) tears may lead to inferior short-term patient-reported outcomes (PROs) when compared with a match-controlled group.

PURPOSES

(1) To report minimum 5-year PROs in patients with borderline dysplasia and LT tears who underwent hip arthroscopic surgery and (2) to compare these PROs to those of a matched-pair control group of patients with borderline dysplastic hips without LT tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected for patients who underwent hip arthroscopic surgery between September 2008 and August 2013. Patients were included if they had a preoperative diagnosis of borderline dysplasia (lateral center-edge angle [LCEA], 18°-25°) and had preoperative and minimum 5-year postoperative modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and visual analog scale (VAS) for pain scores. Exclusion criteria were osteoarthritis of Tönnis grade >1, previous hip conditions, any previous ipsilateral hip surgery, or workers' compensation status. There were 2 borderline dysplastic groups created. An LT tear group was matched 1:1 to a control group (no LT tear) with similar age, sex, body mass index (BMI), and laterality via propensity score matching. Significance was set at P < .05.

RESULTS

A total of 24 patients with an LT tear (24 hips) were matched to 24 patients without an LT tear (24 hips). There was no significant difference in age, sex, BMI, or laterality between groups. The mean age was 36.2 ± 17.2 and 34.9 ± 15.9 years for the control and LT tear groups, respectively (P = .783). There were 17 (70.8%) and 16 (66.7%) female patients in the control and LT tear groups, respectively, and the mean preoperative LCEA was 23.3° and 22.2° in the control and LT tear groups, respectively. No differences were observed between groups in baseline PROs, intraoperative findings, or surgical procedures. LT debridement was performed in 17 (70.8%) patients in the LT tear group compared with 0 (0.0%) in the control group. Also, 5-year postoperative PROs were comparable in both groups, with the control group exhibiting superior Veterans RAND 12-Item Health Survey (VR-12) mental (P = .041) and Short Form-12 (SF-12) mental (P = .042) scores. Finally, hips with an intact LT were significantly more likely (P = .022) to achieve the patient acceptable symptomatic state (PASS) for the mHHS (100.0% and 75.0%, respectively). No significant differences were present between the groups for the minimal clinically important difference (MCID) of the mHHS (P = .140), MCID of the Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) (P = .550), or PASS of the HOS-SSS (P = .390).

CONCLUSION

After hip arthroscopic surgery, patients with borderline dysplasia and LT tears demonstrated favorable PROs at a minimum 5-year follow-up. Outcomes were similar to a matched-pair control group without LT tears, with the group with intact LTs showing higher VR-12 mental and SF-12 mental scores. Furthermore, patients with borderline dysplasia and intact LTs were significantly more likely to achieve the PASS for the mHHS.

Paediatric injuries around the knee: Bony injuries

The aim of this article is to discuss the diagnosis, management and pitfalls of bony injuries around the skeletally immature knee. Each within their own right is a relatively uncommon injury but associated with potential complications. Distal femoral physeal fractures can result in growth arrest and vascular injury. Tibial spine avulsions can result in an unstable knee. Tibial tubercle fractures can be associated with compartment syndrome and pose a risk to the extensor mechanism of the knee. Fixation can be complicated by growth arrest and subsequent recurvatum deformity. Finally, patella sleeve injuries are often missed and this can also threaten the extensor mechanism. We discuss the approach to clinical and radiological assessment of these injuries, and evidence based recommendations as to how they are best managed to avoid complications.

Dynamic hip kinematics before and after periacetabular osteotomy in patients with dysplasia

BACKGROUND

We prospectively analyzed the hip kinematics in patients with developmental dysplasia of the hip (DDH) before and after periacetabular osteotomy (PAO) and in healthy subjects while squatting to determine the influence of coverage of the femoral head on hip kinematics.

METHODS

14 hips in 14 patients with DDH and 10 hips in 10 volunteers were included. Continuous radiographs while squatting and computed tomography images were obtained to assess the in vivo kinematics of the hip and the rim-neck distance using density-based 3D-to-2D model-to-image registration techniques.

RESULTS

The maximum hip flexion angles were 100.4° and 94.9° before and after PAO (p = 0.0863), respectively. The maximum hip flexion angles after PAO did not significantly differ from those of normal hips (102.2°; p = 0.2552). The hip abduction angles at maximum hip flexion were 31.7° and 26.2° before and after PAO (p = 0.1256), respectively. The rim-neck distance decreased from averaged 12.2 mm-8.9 mm (p = 0.0044) after PAO. The lateral center edge angle (LCEA) and anterior center edge angle (ACEA) significantly improved 14.7°-42.4° and 50.4°-54.0° after PAO (p < 0.0001, p = 0.0347), respectively; in particular, the ACEA after PAO did not significantly differ from that in the normal hips (p = 0.1917). The ACEA was not correlated with hip flexion, or the rim-neck distance (p = 0.9601, 0.8764). The LCEA was also not correlated with hip abduction (p = 0.1683).

CONCLUSION

Patients after PAO showed no significant difference in maximum hip flexion while squatting compared to before PAO and normal hips. Horizontalized weight-bearing acetabulum with normalized ACEA could be adequate correction of the acetabular fragment to restore hip RoM without coxalgia that induce the inability to perform squats after PAO.

Supramalleolar osteotomy in post-traumatic valgus ankle osteoarthritis

PURPOSE

To assess how the level of the deformity, the stage of the osteoarthritic process, and the role of additional surgeries impact radiographic and clinical outcomes following an extra-articular medial closing supramalleolar osteotomy for treatment of post-traumatic valgus ankle osteoarthritis.

METHODS

About 56 consecutive patients who underwent an extra-articular medial closing wedge osteotomy for post-traumatic valgus ankle osteoarthritis were retrospectively analyzed. Subgroups were formed according to the pre-operative level of deformity and preoperative stage of ankle osteoarthritis. Additional surgical steps required to achieve a properly balanced hindfoot were also noted. Radiographic and clinical outcomes of each subgroup were compared with each other, and the role of additional surgical steps required to achieve a balanced hindfoot was investigated.

RESULTS

Radiographic and clinical outcomes improved significantly between pre-operative assessment and the last follow-up. Patients with a pre-operative supramalleolar deformity showed superior radiographic outcomes compared to patients with an intra-articular deformity. Clinical outcomes did not differ significantly between these two subgroups. The pre-operative stage of ankle osteoarthritis significantly impacted radiographic outcomes but did not influence clinical outcome measures. An additional fibula or calcaneus osteotomy was necessary for 55% and 23% of all patients, respectively.

CONCLUSION

Extra-articular medial closing supramalleolar osteotomies show satisfactory mid- to long-term radiographic and clinical outcomes in patients with post-traumatic valgus ankle osteoarthritis.

Comparison of outcomes following minimally invasive and open posterior cervical foraminotomy: description of minimally invasive technique and review of literature

Although minimally invasive posterior cervical foraminotomy (MIS-PCF) is frequently employed in the treatment of cervical radiculopathy, there are very few studies directly comparing outcomes between MIS-PCF and open posterior cervical foraminotomy and between MIS-PCF and percutaneous endoscopic (full-endoscopic) posterior cervical foraminotomy (FE-PCF). This study includes a description of technique and systematic review of literature and analysis of clinical studies comparing outcomes between MIS-PCF and open posterior cervical foraminotomy and between MIS-PCF and FE-PCF. Six comparative studies, including one randomized controlled trial were included in analysis. Average operative time ranged from 60.5 to 171 minutes in the open group and 77.65 to 115 minutes in the MIS group. Mean intraoperative blood loss ranged from 43.5 to 246 cc in the open group and 42 to 138 cc in the MIS group. Average postoperative length of stay ranged from 58.6 to 304.8 hours in the open group and 20 to 273.6 hours in the MIS group. Two studies reported significantly increased VAS-N (Neck) scores postoperatively in patients undergoing open cervical foraminotomies, however both studies reported that the differences lost statistical significance with longer follow-up. There were no significant differences in complications or reoperations between open and MIS groups. One retrospective cohort study was included in analysis that compared MIS-PCF and FE-PCF. Postoperatively at 24 months, mean NDI and VAS-N were significantly lower after FE-PCF than MIS-PCF. There was no significant change in VAS-A (Arm) between the two groups. Direct comparative studies between MIS-PCF and open cervical foraminotomy are limited in number. Although, there is a significant heterogeneity in studies comparing open and MIS-PCF there appears to be a trend of decreased hospital length of stay and postoperative analgesic usage in the minimally invasive cohort.

Comparison of Ulnar Collateral Ligament Reconstruction Techniques in the Elbow of Sports Players

Ulnar collateral ligament injuries have been increasingly common in overhead throwing athletes. Ulnar collateral ligament reconstruction is the current gold standard for managing ulnar collateral ligament insufficiency, and numerous reconstruction techniques have been described. Although good clinical outcomes have been reported regarding return to sports, there are still several technical issues including exposure, graft selection and fixation, and ulnar nerve management. This review article summarizes a variety of surgical techniques of ulnar collateral ligament reconstructions and compares clinical outcomes and biomechanics.

Femoropatellar Osteoarthritis and Trochlear Femoral Bone Defect due to Giant Cell Tumor of the Knee: A Selected Patellofemoral Joint Arthroplasty and Reconstructive Technique: A Case Report

CASE

A 35-year-old man with a giant cell tumor involving the lateral condyle and trochlea of the right distal femur underwent curettage of the lesion and cement grafting, which resulted in symptomatic patellofemoral osteoarthritis after more than 4 years. A standard follow-up excluded recurrence, whereas infection was ruled out while investigating the symptoms. Finally, a patellofemoral resurfacing prosthesis was implanted while filling the bone defects with tantalum cones.

CONCLUSION

A "tailored" surgical technique with a selected patellofemoral joint arthroplasty could be used in oncologic setting to save further bone stock for possible revisions while permitting full and quick clinical recovery.

Reconstruction of Large Skeletal Defects: Current Clinical Therapeutic Strategies and Future Directions Using 3D Printing

The healing of bone fractures is a well-orchestrated physiological process involving multiple cell types and signaling molecules interacting at the fracture site to replace and repair bone tissue without scar formation. However, when the lesion is too large, normal healing is compromised. These so-called non-union bone fractures, mostly arising due to trauma, tumor resection or disease, represent a major therapeutic challenge for orthopedic and reconstructive surgeons. In this review, we firstly present the current commonly employed surgical strategies comprising auto-, allo-, and xenograft transplantations, as well as synthetic biomaterials. Further to this, we discuss the multiple factors influencing the effectiveness of the reconstructive therapy. One essential parameter is adequate vascularization that ensures the vitality of the bone grafts thereby supporting the regeneration process, however deficient vascularization presents a frequently encountered problem in current management strategies. To address this challenge, vascularized bone grafts, including free or pedicled fibula flaps, or in situ approaches using the Masquelet induced membrane, or the patient’s body as a bioreactor, comprise feasible alternatives. Finally, we highlight future directions and novel strategies such as 3D printing and bioprinting which could overcome some of the current challenges in the field of bone defect reconstruction, with the benefit of fabricating personalized and vascularized scaffolds.

Towards Understanding Therapeutic Failures in Masquelet Surgery: First Evidence that Defective Induced Membrane Properties are Associated with Clinical Failures

The two-stage Masquelet induced-membrane technique (IMT) consists of cement spacer-driven membrane induction followed by an autologous cancellous bone implantation in this membrane to promote large bone defect repairs. For the first time, this study aims at correlating IMT failures with physiological alterations of the induced membrane (IM) in patients. For this purpose, we compared various histological, immunohistochemical and gene expression parameters obtained from IM collected in patients categorized lately as successfully (Responders; n = 8) or unsuccessfully (Non-responders; n = 3) treated with the Masquelet technique (6 month clinical and radiologic post-surgery follow-up). While angiogenesis or macrophage distribution pattern remained unmodified in non-responder IM as compared to responder IM, we evidenced an absence of mesenchymal stem cells and reduced density of fibroblast-like cells in non-responder IM. Furthermore, non-responder IM exhibited altered extracellular matrix (ECM) remodeling parameters such as a lower expression ratio of metalloproteinase-9 (MMP-9)/tissue inhibitor of metalloproteinases (TIMP-1) mRNA as well as an important collagen overexpression as shown by picrosirius red staining. In summary, this study is the first to report evidence that IMT failure can be related to defective IM properties while underlining the importance of ECM remodeling parameters, particularly the MMP-9/TIMP-1 gene expression ratio, as early predictive biomarkers of the IMT outcome regardless of the type of bone, fracture or patient characteristics.

Autologous Iliac Bone Graft Compared with Biphasic Hydroxyapatite and Calcium Sulfate Cement for the Treatment of Bone Defects in Tibial Plateau Fractures: A Prospective, Randomized, Open-Label, Multicenter Study

BACKGROUND

Bone-graft substitutes are commonly used for the augmentation of traumatic bone defects in tibial plateau fractures. However, their clinical performance compared with that of autologous bone-grafting, the gold standard in bone defect reconstruction, still remains under debate. This study investigates the differences in quality of life, pain, and radiographic outcomes in the treatment of tibial plateau fracture-associated bone defects with either autologous bone grafts or a bioresorbable hydroxyapatite and calcium sulfate cement (CERAMENT BONE VOID FILLER [CBVF]; BONESUPPORT).

METHODS

In this study, 135 patients with acute depression and split-depression fractures of the proximal part of the tibia (OTA/AO types 41-B2 and 41-B3) were enrolled in a prospective, controlled, randomized, multicenter trial including 20 hospitals in Germany. Patients were randomized to receive either autologous iliac bone graft or CBVF for reconstruction of the bone defect. The primary outcome measures were the Short Form (SF)-12 version 2 Physical Component Summary (PCS) score at week 26 (the study was designed to show noninferiority of the CBVF with regard to the PCS with a prespecified margin of -5 points) and the pain level at 26 weeks postoperatively measured by a visual analog scale (VAS). The secondary outcomes were the SF-12 version 2 Mental Component Summary (MCS) and SF-12 PCS scores at weeks 1, 6, and 12 and bone-healing on radiographs.

RESULTS

Age, sex, fixation methods, and fracture pattern were comparable in both groups. There were no significant differences (p > 0.05) in the SF-12 PCS or VAS scores at postoperative week 26. There was a significant reduction of blood loss (p = 0.007) and pain levels (p = 0.008) at postoperative day 1 in the CBVF group. The rates of fracture-healing, defect remodeling, and articular subsidence were not significantly different (p > 0.05) in both groups.

CONCLUSIONS

Bioresorbable CBVF was noninferior to autologous bone graft with regard to both patient-reported and radiographic outcomes in tibial plateau fractures of OTA/AO types 41-B2 and 41-B3.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Better outcome for suture button compared with single syndesmotic screw for syndesmosis injury: five-year results of a randomized controlled trial

Aims

In a randomized controlled trial with two-year follow-up, patients treated with suture button (SB) for acute syndesmotic injury had better outcomes than patients treated with syndesmotic screw (SS). The aim of this study was to compare clinical and radiological outcomes for these treatment groups after five years.

Methods

A total of 97 patients with acute syndesmotic injury were randomized to SS or SB. The five-year follow-up rate was 81 patients (84%). The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. Secondary outcome measures included Olerud-Molander Ankle (OMA) score, visual analogue scale (VAS), EuroQol five-dimension questionnaire (EQ-5D), range of movement, complications, reoperations, and radiological results. CT scans of both ankles were obtained after surgery, and after one, two, and five years.

Results

The SB group had higher median AOFAS score (100 (interquartile range (IQR) 92 to 100) vs 90 (IQR 85 to 100); p = 0.006) and higher median OMA score (100 (IQR 95 to 100) vs 95 (IQR 75 to 100); p = 0.006). The SS group had a higher incidence of ankle osteoarthritis (OA) (24 (65%) vs 14 (35%), odds ratio (OR) 3.4 (95% confidence interval (CI) 1.3 to 8.8); p = 0.009). On axial CT we measured a significantly smaller mean difference in the anterior tibiofibular distance between injured and non-injured ankles in the SB group (–0.1 mm vs 1.2 mm; p = 0.016).

Conclusion

Five years after syndesmotic injury treated with either SB or SS, we found better AOFAS and OMA scores, and lower incidence of ankle OA, in the SB group. These long-term results favour the use of SB when treating an acute syndesmotic injury. Cite this article: Bone Joint J 2020;102-B(2):212–219.

Biportal endoscopic versus microscopic lumbar decompressive laminectomy in patients with spinal stenosis: a randomized controlled trial

BACKGROUND CONTEXT

Biportal endoscopic decompressive laminectomy is a widely performed procedure and shows acceptable clinical outcomes. However, the evidence regarding the advantages of biportal endoscopic surgery is weak, a randomized controlled trial is therefore warranted.

PURPOSE

To compare the clinical efficacies of biportal endoscopic and microscopic decompressive laminectomy in patients with lumbar spinal stenosis.

STUDY DESIGN

Randomized controlled trial.

PATIENT SAMPLE

Sixty-four participants suffering from low back and leg pain with single-level lumbar spinal stenosis who required decompressive laminectomy.

OUTCOME MEASURES

Outcomes were assessed with the use of patient-reported outcome measures, visual analog scale (VAS) score for low back and lower extremity radiating pain, Oswestry disability index (ODI), European Quality of Life-5 Dimensions (EQ-5D) score, and painDETECT for neuropathic pain. Surgery-related outcomes including operation time, length of hospital stay, postoperative drainage, and serum creatine phosphokinase were evaluated. Perioperative (<30 days) and late (1-12 months) complications were also noted.

METHODS

All participants were randomly assigned in a 1:1 ratio to undergo biportal endoscopic or microscopic decompressive laminectomy. The primary outcome was the ODI score at 12 months after surgery based on a modified intention-to-treat strategy. The secondary outcomes included VAS score for low back and lower extremity radiating pain, ODI scores, EQ-5D score, and painDETECT score. There were no sources of funding and no conflicts of interest associated with this study.

RESULTS

There was no significant difference between groups in the mean ODI score at 12 months after surgery (30 in the microscopy vs. 29 in the biportal endoscopy group, p=.635). There were also no significant differences in low back and lower extremity pain VAS scores, ODI, EQ-5D scores, and painDETECT scores at the 3-, 6-, or 12-month follow-up. Operation time, length of hospital stay, serum creatine phosphokinase, and perioperative complications, such as durotomies and symptomatic hematoma, showed no significant differences between the groups; however, one participant underwent additional revision surgery 9 months after the index surgery in the microscopy group.

CONCLUSIONS

Despite the study design limitation of relatively short duration of follow-up, this trial suggests that biportal endoscopic decompressive laminectomy is an alternative to and offers similar clinical outcomes as microscopic open surgery in patients with symptomatic lumbar spinal stenosis.

Correlation between the efficacy of stem cell therapy for osteonecrosis of the femoral head and cell viability

Background

Osteonecrosis of the femoral head (ONFH) is a common disease that greatly affects the quality of life of patients. Repair of the necrotic area is key to successful treatment. Currently, the combination of stem cell transplantation and decompression is used clinically to promote the repair of necrotic areas based on the characteristics of stem cells. However, a considerable number of patients do not achieve a satisfactory outcome in terms of repair of the femoral head necrotic area, and it is very important to determine the reasons for the poor curative effect. The aim of this study was to investigate the correlation between stem cell viability and the repair efficacy of stem cell therapy combined with core decompression for early-stage ONFH.

Methods

A total of 30 patients with idiopathic ONFH underwent core decompression combined with autologous stem cell transplantation. The Harris hip score (HHS) and difference in necrosis area before and after surgery were measured. The mean repair ratio was set as the threshold to divide the patients into group A (ratio above the mean) and group B (ratio below the mean). The ultrastructure, proliferative capacity, and multidirectional differentiation ability were compared between the groups.

Results

At 9 months after surgery, the HHS and magnetic resonance imaging (MRI) findings improved by varying degrees. Based on the mean repair ratio of (62.2 ± 27.0)%, the threshold for dividing the patients into groups A and B was set to 62.2%. Better repair (group A) was associated with more rapid proliferation and a healthier ultrastructure. The cells in group A showed stronger specific staining signifying osteogenic and chondrogenic differentiation; alkaline phosphatase (ALP) activity, an indicator of osteogenic differentiation, was higher in group A than in group B (OD, 2.39 ± 0.44 and 1.85 ± 0.52; p <  0.05).

Conclusions

The quality of implanted stem cells is closely related to treatment efficacy and determines whether the defective self-repair in the necrotic area can be corrected to enhance repair and thus achieve the desired therapeutic outcome.

Trial registration

The trial registration number: ChiCTR-ORC-17011698 (retrospectively registered at 2017-06-19).